Skip to main content
HealthPartners

Coverage criteria policies

Physical & occupational therapy - habilitative

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for more than 20 visits of habilitative Physical Therapy in a calendar year.

Prior authorization is required for more than 20 visits of habilitative Occupational Therapy in a calendar year.

  • Occupational Therapy (OT) visits count towards Physical Therapy (PT) limits unless modifier ‘GO’ is used when billing.

Coverage

Habilitative PT and OT or habilitative PT and OT with Sensory Integration (SI) therapy, as defined below, are generally covered subject to the following indications and your plan documents.

Habilitative therapy services are covered only when provided in a clinic, office or in an outpatient setting. Occupational therapy must be ordered by either a primary care provider or specialist.

Indications that are covered

  1. For occupational therapy, the member must have written orders from a primary care or specialist physician. Autism diagnoses and treatment recommendations must be made by a psychiatrist, psychologist or developmental pediatrician who has training and expertise in autism spectrum disorder and child development.
  2. To be eligible for habilitative physical or occupational therapy services, evaluations must include standardized age-appropriate tests documenting a condition/developmental delay resulting in ADL, fine motor, or gross motor functionality that is at or below the 10th percentile or 1.5 or greater standard deviations below the norm for the member’s age. When standardized testing resulting in standard deviation or percentile ranking is unable to be completed, age equivalency scores will be accepted to meet this criterion. As age equivalency scores are the least accurate statistical measurement, standard deviation scores or percentile rankings are preferred. The delay must show at least a 25% delay based upon the age of the member in months. For individuals who are unable to complete standardized testing, medical necessity will be determined based on clinical information.
  3. Sensory Integration therapy is covered when part of a covered habilitative therapy treatment plan if the member has definite differences/dysfunction (scores equivalent to 2.0 deviations or greater from the mean) documented in the standardized testing.
  4. Treatment goals should promote achievement of developmental milestones appropriate to the member's age and condition, such as rolling, crawling, pulling to stand, assisted or independent ambulation, dressing and feeding skills.
  5. Evaluations are required at least annually for ongoing treatment and should contain specific documentation regarding progress toward goals. Periodic re-evaluations are required to document measurable functional progress toward treatment goals and the continued medical necessity for therapy.
  6. For continued habilitative therapy coverage, members must continue to demonstrate a significant delay (e.g., 1.5 standard deviations), and must demonstrate measurable functional improvement. A discharge plan, with proposed treatment duration, must be submitted that demonstrates plans to wean services once the above criteria are no longer met.
  7. For members no longer meeting coverage criteria, a weaning process will occur. If regression in function occurs, services will need to be reevaluated for coverage.

Indications that are not covered

  1. Group therapy, except when used in the context of a child diagnosed with autism.
  2. Educational therapy.
  3. Therapy when measurable functional improvement is not expected or progress has plateaued.
  4. Vocational and community reintegration services.
  5. IADL training
  6. Therapy to improve attention, memory, problem solving, organizational skills and time management.
  7. Equine or hippotherapy (horse riding therapy).
  8. Recreational therapy
  9. Metronome therapy
  10. Integration of primitive reflexes as standalone treatment.

Definitions

Activities of daily living (ADLs) - include everyday activities such as eating, bathing, dressing, toileting, transferring, continence, personal hygiene and mobility necessary to achieve these activities.

Educational therapy refers to skills that are typically taught in a school or educational setting.

Functional skills - essential activities of daily life (ADLs) common to all members such as dressing, feeding, ambulation, transfers and fine motor skills. Measurable progress emphasizes mastery of functional skills and independence in the context of the member's potential ability as specified within a care plan or treatment goals.

Measurable functional improvement for habilitative therapy will be assessed by comparison of the progress towards goals as documented in current progress reports. The determination of whether measurable progress is being made is at the sole discretion of the medical director and his or her designee and is made on a case by case basis. In cases where progress is questioned, the medical director and his or her designee will consult with the treating therapist, and/or a Physical or Occupational Therapist consultant when making the coverage determination.

Habilitative occupational therapy (OT) or physical therapy (PT) - care rendered by a licensed physical or occupational therapist for conditions which have significantly limited the successful initiation of normal motor development. To be considered habilitative, measurable functional improvement and measurable progress must be made toward achieving functional goals (ADLs), within a predictable period of time toward a member's maximum potential.

Instrumental activities of daily living (IADLs) - activities related to independent living, such as cleaning, using a telephone, shopping, laundry, managing medications, transportation and managing money.

Recreational therapy - The prescribed use of recreational activities as treatment interventions to improve functional living competence.

Sensory integration/Processing disorder - thought to be a neural system disorder that causes the sensory system to receive incoming information via the senses in a disorganized manner. Sensory integration therapy (SI) is often used with children diagnosed with autism or other pervasive developmental disorder when the disorder is so severe that the patient is not able to take part in the other goals of the habilitative occupational, physical, or speech therapy program.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CPT Code

Description

95831

Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk

95832

Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side

95833

Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands

95834

Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands

95851

Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)

95852

Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side

97012

Application of a modality to 1 or more areas; traction, mechanical

97014

Application of a modality to 1 or more areas; electrical stimulation (unattended)

97016

Application of a modality to 1 or more areas; vasopneumatic devices

97018

Application of a modality to 1 or more areas; paraffin bath

97022

Application of a modality to 1 or more areas; whirlpool

97024

Application of a modality to 1 or more areas; diathermy (e.g., microwave)

97026

Application of a modality to 1 or more areas; infrared

97028

Application of a modality to 1 or more areas; ultraviolet

97032

Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

97033

Application of a modality to 1 or more areas; iontophoresis, each 15 minutes

97034

Application of a modality to 1 or more areas; contrast baths, each 15 minutes

97035

Application of a modality to 1 or more areas; ultrasound, each 15 minutes

97036

Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes

97039

Unlisted modality (specify type and time if constant attendance)

97110

Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112

Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

97113

Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises

97116

Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)

97124

Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

97139

Unlisted therapeutic procedure (specify)

97140

Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

97150

Therapeutic procedure(s), group (2 or more individuals)

97161

Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.

97162

Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.

97163

Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.

97164

Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family.

97165

Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.

97166

Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.

97167

Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.

97168

Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.

97530

Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

97532

Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

97533

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes

97535

Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

97542

Wheelchair management (e.g., assessment, fitting, training), each 15 minutes

97750

Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes

97760

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes

97761

Prosthetic training, upper and/or lower extremity(s), each 15 minutes

97799

Unlisted physical medicine/rehabilitation service or procedure

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 800-233-9645.

References

  1. American Academy of Pediatrics, Committee on Children with Disabilities (2001). Developmental surveillance and screening of infants and young children. Pediatrics, 108(1), 192-196.
  2. American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. (2006). Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics118(1), 405–420. doi:10.1542/peds.2006-123.
  3. Gibson, J., Adams, C., Lockton E., & Green, J. (2013). Social communication disorder outside autism? A diagnostic classification approach to delineating pragmatic language impairment, high functioning autism and specific language impairment. Journal of Child Psychology and Psychiatry, 54(11), 1186-197.
  4. Hall, C. D., Herdman, S. J., Whitney, S. L., Cass, S. P., Clendaniel, R. A., Fife, T. D., … Woodhouse, S. N. (2016). Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline. Journal of Neurologic Physical Therapy, 40(2), 124-55.
  5. Hayes, Inc. Hayes Medical Technology Directory Report. Hippotherapy for neuromusculoskeletal dysfunction. Lansdale, PA: Hayes, Inc.; August, 2009. Reviewed August, 2013. Archived September, 2014.
  6. Hayes, Inc. Hayes Medical Technology Directory Report. Occupational Therapy for Attention-Deficit/Hyperactivity Disorder (ADHD), Lansdale, PA: Hayes, Inc. March 2017.
  7. Hayes, Inc. Hayes Medical Technology Directory Report, Sensory-Based Treatments for Autism Spectrum Disorders, Lansdale, PA: Hayes, Inc. May 2011. Reviewed April 2015, Archived June 2016.
  8. Hayes, Inc. Hayes Medical Technology Directory Report, Sensory Integration Therapy for Non-autistic Children, Lansdale, PA: Hayes, Inc March 2014. Reviewed February, 2017.
  9. Hayes, Inc. Hayes Medical Technology Directory Report, Social Skills Training For Autistic Spectrum Disorders, Lansdale, PA: Hayes, Inc October 2011. Reviewed October 2015, Archived November 2016.
  10. Minnesota Statutes 2016. Public health occupations: physical therapists. Chapter 148,​ §148.76, Subdivision 2.
  11. Simms, M. D., & Jin, X. M. (2015). Autism, language disorder, and social (pragmatic) communication disorder: DSM-V and differential diagnoses. Pediatrics in Review, 36(8), 355-63.
  12. Swineford, L. B., Thurm,A., Baird, G., Wetherby, A. M., & Swedo. S. (2014). Social (pragmatic) communication disorder: a research review of this new DSM-V diagnostic category. Journal of Neurodevelopmental Disorders, 6(1), 41.
  13. Weissman, L., & Bridgemohan, C. Autism spectrum disorder in children and adolescents: behavioral and educational interventions. In: UpToDate, Augustyn, M. & Patterson, M. C. (Eds), UpToDate, Waltham, MA. (Accessed on September 27, 2017.)
  14. Wilkinson, J., Bass, C., Diem, S., Gravley, A., Harvey, L., Maciosek, M. … Vincent, P. Institute for Clinical Systems Improvement. Preventive services for children and adolescents. Updated September 2013.