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The following is from the American ChiropracticAssociation:

Apparently many chiropractic offices are confused about the correct way to bill electrical stimulation to Medicare. Effective January 1, 2003, CPT code 97014-application of a modality to one or more areas; electrical stimulation (unattended)-was assigned a "status indicator" of "I" on the Medicare Physician Fee Schedule Database. This means that this code is considered "not valid" for Medicare billing purposes because Medicare uses another code for the reporting of this service. Therefore, when billing Medicare for electrical stimulation, HCPCS code G0283-electrical stimulation, other than wound care, as a part of a therapy plan-should be utilized. Of course, the -GY modifier will still need to be attached.

Here is the most recent description of G0283:
Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care.

The following is from LCD Y-1BB:

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Note: Throughout this LCD, the term “non-physician practitioner (NPP)”means physician assistants, clinical nurse specialists, and nurse practitioners who may, if state and local laws permit it, and when appropriate rules are followed, provide, certify or supervise therapy services.

Physical therapy (PT) services are rehabilitative services designed to improve or restore physical functioning following disease, injury or loss of a body part. Services are provided in many settings. Physical therapists use the clinical history, systems review, physical examination, and a variety of evaluations to characterize individuals with impairments, functional limitations and disabilities. Impairments, functional limitations and disabilities thus identified are addressed by the design and implementation of a plan of care tailored to the specific needs of the individual patient. The specific interventions most commonly used are exercise, heat, cold, electricity, ultraviolet light, ultrasound, hydrotherapy, manual therapy and massage to improve circulation, strengthen muscles, maintain or restore motion, and train or retrain an individual to perform the activities of daily living. Although there is an overlap in services provided by physical and occupational therapists, this policy addresses only physical therapy services provided to Medicare beneficiaries.

The statutory basis for Medicare payment policy is Federal law. Veritus Medicare Services (VMS) is aware that state laws regarding PT practice, and the individual scope of practice for physical therapists may differ by state. Providers need to be aware of Federal, state, and local requirements.

Physical therapy services may be eligible for coverage provided the services are rendered to patients under the care of a physician or NPP and are considered to be a skilled physical therapy service. That is, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, a physical therapist, physician, or qualified personnel.

Physical therapy services must be considered under accepted standards of medical practice to be specific and effective treatments for the patient's condition. There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe and effective maintenance program. The CORF services benefit does not recognize an NPP for orders and certification.

A condition that does not ordinarily require skilled services may require them because of special medical complications. Under those circumstances, a service that is usually non-skilled (such as those listed in 42CFR 409.33(d)) may be considered skilled because it must be performed or supervised by skilled rehabilitation personnel. The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. The reasons for physical therapy intervention must be clear in the documentation, as well as the patient specific goals.

Patients Receiving Outpatient Therapy Services Must Be Under the Care of a Physician/Non-physician Practitioners (NPP) (Orders/Referrals and Need for Care)

Physical therapy provided to Medicare patients must be done while under the "care of a physician who is a doctor of medicine, osteopathy, podiatric medicine or optometry (low vision rehabilitation only)" or a non-physician practitioner. These physicians or non-physician practitioners provide referrals, certification and recertification of the plan of care for the patient. As defined in Medicare statute, chiropractors and doctors of dental surgery or dental medicine are not considered physicians for these services and are not able to refer patients for rehabilitation services nor establish therapy plans of care.

An order or referral for physical therapy services provides evidence of both the need for care and that the patient is under the care of a physician/NPP as appropriate, however, it is not required for payment purposes. If the signed order includes a plan of care, no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan. Based upon the results of the evaluation, an active treatment plan is developed. Physical therapy services must relate directly and specifically to the active written treatment plan and must be reasonable and necessary to the treatment of the individual's illness or injury.

Physical Therapy Provided by Qualified Professionals

Physical therapy services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services required can be safely and effectively performed by a qualified therapist or under the supervision of a qualified professional. For this policy, a qualified therapist refers only to qualified physical therapists as defined in Pub.100-2, Chapter 15, § 230.1 of the Internet Only Manual.

The following standards apply to physical therapy services:

A. The services must be provided by, or under the direct supervision of, a physician who is legally authorized to practice physical therapy services by the State in which he practices. The patient must be under the care of the physician or non-physician practitioner for a condition that is medically necessary, reasonable and appropriate for physical therapy treatment. The services must be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition.

B. The services must be of a level of complexity that requires that they be performed by or under the direct supervision of the physician.

C. Services must be furnished under a plan of care that has been written and developed by the physician, non-physician practitioner, or physical therapist caring for the patient. Evaluation and treatment may occur on the same day or at the subsequent visit. It is appropriate that treatment begins when the plan is established. Therapy may be initiated by qualified personnel based on a dictated plan and that dictated plan is considered completed on the treatment day that it was dictated. The qualified professional may edit and electronically sign the documentation at a later date, but the date must be relevant for the plan of care. A clinician (physician, nonphysician practitioner or therapist) must personally perform or actively participate in at least one treatment session during the interval of treatment for the active plan of care as verified by the clinician's signature on the Treatment Encounter Note and /or the Progress Report.

1. The plan of care shall contain, at minimum, the following information:

a. Diagnoses;

b. Long term treatment goals; and

c. Type, amount, duration and frequency of therapy services.

2. The plan of care must be reviewed, dated and signed by the physician/NPP every 30 days. Any significant change in the treatment plan must be noted in writing in the patient record and signed by the physician/NPP, the qualified physical therapist, the registered professional nurse or physician/NPP on the staff of the facility pursuant to the oral orders of the physician/NPP or therapist. While the physician/NPP may change a plan of care established by the therapist providing such services, the therapist may not significantly alter a plan of care established or certified by a physician/NPP without their documented written or verbal approval.

3. CORF services must be furnished under a written plan of care established and signed by a physician who has recently evaluated the patient. It is expected that the physician will establish the plan in consultation with the physical therapist who will provide the actual therapy. The CORF physician or the referring physician must review the plan of treatment at least once every 60 days. The 60-day period begins with the first day of skilled rehabilitation therapy. Following the review, the physician must certify that the plan of treatment is being followed and that the patient is making progress in attaining the established skilled rehabilitation goals.

D. The physical therapy services provided to the patient must be restorative or for the purpose of designing and teaching a maintenance program for the patient to conduct at home. There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state. If the patient's expected restoration potential would be insignificant in relation to the extent and duration of physical therapy services required to achieve such potential, the physical therapy would not be considered reasonable and necessary. If at any point in the treatment it is determined that improvement in the patient's condition will not be achieved, the services will no longer be considered reasonable and necessary.

E. Services that are palliative in nature are not considered necessary and reasonable and are not covered services. These services maintain function and generally do not involve complex physical therapy procedures nor do they require physician judgment and skill for safety and effectiveness.

Where there is an identified risk to the patient, the professional skill of a physician may be required to manage and periodically evaluate the appropriateness of a therapy maintenance program. When the knowledge and judgment of the qualified professional is necessary to prevent or minimize deterioration caused by a medical condition, reasonable management and evaluation services may be covered under the following circumstances. A patient who has NOT been under restorative physical therapy may require the services of a qualified therapist to determine the type of exercises that will be effective in maintaining the patient's present functional level. Such a maintenance program, to be covered under Medicare, must include all of the following:

1. an initial patient evaluation;
2. a maintenance program;
3. a care plan appropriate to the capacity and tolerance of the patient;
4. treatment goals/objectives of the physician;
5. instruction of the patient or family members in carrying out the program.

Maintenance programs subject to such re-evaluations may be considered reasonable and necessary.

MODALITIES

Multiple physical therapy modalities may be reasonable and necessary in many clinical situations. Documentation in the patient’s medical record must clearly support the use of multiple modalities as contributing to the patient’s progress and restoration of function and as per the plan of care. When more than one modality is used during an encounter, whether supervised or constant attendance, or any combination, each modality provided should be reported and must be reflected in the documentation. This documentation is expected to be made available to Veritus upon request.
Physical therapy modalities are categorized as either supervised or constant attendance.

Supervised Modalities
Supervised modalities are considered to be the application of a modality that does not require direct (one-on-one) patient contact by the provider. There is no time component that describes supervised codes. The code is reported without regard to the length of time spent performing the service. These services are to be billed only once per encounter regardless of the number of areas treated. The total number of minutes of treatment including untimed codes must be consistent with the documentation that the services were provided for a reasonable amount of time.

Hot or cold packs therapy (CPT 97010)

Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm, and reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs are used for sub acute or chronic painful conditions.

Heat or cold treatments ordinarily do not require the skills of a qualified physical therapist. However, the skills, knowledge and judgment of a qualified physical therapist may be required while providing these treatments in specific cases where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications. Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a qualified physical therapist.

The application of this modality is considered to be an integral part of a service or visit by CMS.

Electrical stimulation other than wound (HCPCS code G0283)

Unattended electrical stimulation means the patient is positioned and the appropriate type of stimulation is applied to an area over a specific period of time. Nerve and muscle stimulation can be useful in any disorder in which the patient has lost voluntary control over skeletal muscle. This modality is often used in conjunction with other modalities, such as passive exercise.

HCPCS code G0283 should be used for unattended electrical stimulation, to one or more areas for indications other than wound care, as part of a physical therapy plan of care. HCPCS code G0283 should not be used to describe the instruction and application process involved with providing a patient with training for independent home use of a TENS device for pain modulation.

Refer to the Constant Attendance Modalities section of this policy under CPT code 97032 for additional information pertaining to electrical stimulation.

Examples of specific types of unattended electrical stimulation are listed below:

TENS (Transcutaneous electrical nerve stimulation) produces analgesia, strengthening, and functional electrical stimulation. The use of electrical stimultion is considered reasonable and necessary to reduce pain and/or edema and achieve muscular contraction during exercise.

NMS (Neuro-muscular stimulation) is used to retrain weak muscles following surgery, soft tissue injury or after weakness occurs.

HVPC (High voltage pulsed current), also called electrogalvanic stimulation, may be useful for the reduction of swelling and the control of pain.

MENS (Microcutaneous electrical stimulation or microcurrent) is used for the relief of pain, improvement of circulation, and/or reduction of edema. These units are similar to a TENS device, but stimulate at a very low level current.

Whirlpool therapy

Baths of this type typically do not require the skills of a qualified physical therapist. However, the skills, knowledge and judgment of a qualified physical therapist may be required in providing such treatments or baths in specific cases where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications.

Whirlpool therapy (CPT Code 97022)

Whirlpool therapy involves the use of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.

Therapist supervision of whirlpool therapy may be medically necessary if the patient’s condition is complicated by a circulatory deficiency, areas of desensitization, or exfoliative skin impairments. It is necessary to have therapist supervision if the patient has a documented open wound that is draining, has a foul odor, or evidence of necrotic tissue or has a documented need for wound debridement or bandage removal.

Generally, whirlpool treatments are not performed more than 12 times in one month. Services beyond this number may require documentation supporting the medical necessity of continued whirlpool treatments. It is not medically necessary to have more than one form of hydrotherapy during a visit (e.g., CPT codes 97022, 97036 or 97113 cannot be billed together).

Diathermy (CPT code 97024)

Short wave diathermy is probably the most effective modality for heating skeletal muscle. Heating is accomplished without physical contact between the modality and the skin, therefore it can be used even if skin is abraded, as long as there is no significant edema. The objective of these treatments is to cause vasodilation and relieve pain from muscle spasm. Diathermy achieves a greater rise in deep tissue temperature than does microwave. However, diathermy is generally being replaced by portable ultrasound.

The use of diathermy is considered reasonable and necessary for the delivery of heat to deep tissues such as skeletal muscle and joints for the reduction of pain, joint stiffness, and muscle spasm. Diathermy is not considered reasonable and necessary for the treatment of asthma, bronchitis, or any other pulmonary condition. High energy pulsed wave diathermy machines have been determined to produce the same therapeutic benefit as standard diathermy; therefore, any reimbursement for diathermy will be made at the same level as standard diathermy.

Constant Attendance Modalities

Constant attendance modalities are considered to be the application of a modality that requires direct (one-on-one) patient contact by the provider. Direct one-on-one contact requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the procedure. The time frames indicated for the constant attendance modalities describe the total time (i.e., pre-service, intra-service and post-service time) spent performing this modality. Documentation in the medical record for constant attendance modalities must ascertain that the total number of minutes of treatment for services represented by timed codes is consistent with the number of units billed for those services.

Electrical stimulation (CPT code 97032)

Electrical stimulation may be necessary during the initial phase of physical therapy treatment. There must be an expectation of improvement in function. Electrical stimulation is generally utilized with other appropriate therapeutic procedures, such as therapeutic exercises, to affect continued improvement.

Electrical stimulation is indicated for the patient who has a documented reduction in the ability to contract muscles or diminished muscle contraction strength with or without dependent peripheral edema. It is indicated for a patient who has a condition that requires an educational program for self-stimulation of denervated muscle or a condition that requires muscle reeducation involving a training program (i.e., functional electrical stimulation). Electrical stimulation is also used for the patient who is undergoing treatment for disuse atrophy using a specific type of neuromuscular electrical stimulator (NMES) which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes.

Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post casting or splinting of a limb, and contracture due to soft tissue scarring).

This modality includes the following types of electrical stimulation in addition to those listed under the supervised modalities section of this policy for HCPCS code G0283:

M-Stim (Muscle stimulation) is a type of stimulation that is taken to the point of visible muscle contraction.

IFC (Interferential current/medium current) units use a frequency that allows the current to go deeper into the tissue. IFC is used to control swelling and pain.

Typical treatment is up to twelve (12) sessions per month when used as adjunctive therapy or for muscle retraining. Services beyond this number may require clear documentation supporting the medical necessity of continued muscle stimulation treatments.

Ultrasound therapy (CPT code 97035)

Therapeutic ultrasound is a deep heat modality that produces a sound wave of 0.8 to 3.0 MHZ. In the human body, ultrasound has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of ultrasound, as much as 30% more. Because of the increased extensibility ultrasound produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted range of motion.

The application of ultrasound is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and to increase the flexibility of muscles, tendons and ligaments.

Specific indications for the use of ultrasound application include but are not limited to the patient having neuromas, symptomatic soft tissue calcification or tightened structures limiting joint motion that require an increase in extensibility.

Ultrasound application is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.

Ultrasound treatments are typically applied three (3) times weekly for four (4) weeks. It is generally not medically necessary for a patient to receive more than twelve (12) visits for ultrasound treatments. Services beyond this number may require clear documentation supporting the medical necessity of continued ultrasound treatments.

Hydrotherapy (CPT code 97036)

This modality involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions. Physician or therapist one-on-one supervision of this modality is required. Documentation in the medical record must clearly note that the skills of a qualified physical therapist were necessary in order to treat the patient with this modality.

Typical treatment duration is 3-4 times weekly for 2-4 weeks. Services beyond this number may require documentation supporting the medical necessity of continued Hubbard tank treatments. It is not medically necessary to have more than one form of hydrotherapy during a visit (e.g., CPT codes 97022, 97036 or 97113 cannot be billed together).

THERAPEUTIC PROCEDURES

Therapeutic procedures are treatments that attempt to reduce impairments and improve function through the application of clinical skills and/or services. Use of these procedures requires that the therapist have direct (one-on-one) patient contact. Common components included as part of the therapeutic procedures include chart reviews for treatment, set up of activities and the equipment area, and review of previous documentation as needed. Also included is communication with other health care professionals (such as a social worker or nurse), discussions with family, and calls to the referring physician for additional information or clarification. Subsequent to providing the therapeutic service, the treatment is recorded, and typically the progress is documented. Although these components may be necessary to establish the plan of care for therapeutic procedures, they are not counted in the therapy minutes.

Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals must be documented in the plan of care, and affected by the use of each of these procedures, in order to define whether these procedures are reasonable and necessary. Therefore, since only one, or a combination of more than one of these modalities may be used in the treatment plan, documentation must support the use of each treatment or modality as it relates to a specific therapeutic goal.

Services provided concurrently by a physician, physical therapist and an occupational therapist may be covered if separate and distinct goals are documented in the treatment plans.

Therapeutic exercises (CPT code 97110)

Therapeutic exercise incorporates rehabilitation principles related to strengthening, endurance, flexibility, and range of motion to one or more areas of the body. Therapeutic exercise may be performed with a patient either actively, actively assisted, or passively participating. Examples of these exercises include treadmill (for endurance), isokinetic exercise (for range of motion), lumbar stabilization exercises (for flexibility), and gymnastic ball (for stretching and strengthening).

Therapeutic exercise is considered reasonable and necessary if the patient is having weakness, pain, contracture, stiffness (secondary to coordination deficits), abnormal posture, muscle imbalance or the patient needs to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance. At least one of these conditions must be present and documented in the medical records. Documentation for therapeutic exercise must show objective functional loss of joint motion, strength and mobility as it relates to functional limitations (e.g., degrees of motion, strength grades, levels of assistance). Medical necessity may also be supported for the documented establishment and design of a maintenance exercise program to fit the patient's level of ADL, function, and any instructions supportive personnel and/or family members need to safely and effectively carry out the program.

Neuromuscular reeducation (CPT code 97112)

This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, motor skill, and proprioception. Examples of these treatments include proprioceptive neuromuscular facilitation (PNF), Feldenkrais, Bobath, BAP’s boards, and desensitization techniques.

Neuromuscular reeducation may be reasonable and necessary for impairments, which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity).

The documentation in the medical records must clearly identify the need for these treatments, be part of the plan of care and reflect the patient’s response to treatments.

Aquatic therapy/exercises (CPT code 97113)

Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercise. This requires direct (one-on-one) patient contact. This code is to be used for any exercise performed in a water environment.

This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and medically necessary for a loss or restriction of joint motion, strength, mobility, or function, which has resulted from a specific disease or injury.

Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees or motion, strength grades, levels of assistance) and reflect the medical necessity of the treatment. Other forms of exercise therapy may be medically necessary in addition to aquatic therapy when the patient cannot perform land based exercises effectively to treat his/her condition without first undergoing the aquatic therapy, or when aquatic therapy facilitates progress to land based exercise or increased function.

Do not code the water modality (e.g. Hubbard tank), whirlpool, and the type of therapeutic exercise (e.g. neuromuscular reeducation) separately. Code only the aquatic therapy with therapeutic exercise. This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers). It is not medically necessary to have more than one form of hydrotherapy during a visit (e.g., CPT codes 97022, 97036 or 97113 cannot be billed together).

Gait training therapy (CPT code 97116)

Gait training is the training of the manner or style of walking, including rhythm and speed. The phases of gait include the stance phase, the swing phase, and the double support phase. This procedure may be reasonable and necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.

Specific indications for gait training include but are not limited to:

the patient having suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation;
the patient having recently suffered a musculoskeletal trauma, requiring ambulating reeducation;
the patient having a chronic, progressively debilitating condition for which safe ambulation has recently become a concern;
the patient having had an injury or condition that requires instruction in the use of an assistive device, e.g., walker, crutches, or cane;
the patient having been fitted with a brace/lower limb prosthesis and requires instruction in ambulation; and
the patient having a condition that requires training in stairs/steps or chair transfer in addition to general ambulation.
Gait training is not considered reasonable and necessary when the patient’s walking ability is not expected to improve. Repetitive walk-strengthening exercises for feeble or unstable patients or to increase endurance do not require professional supervision and will be denied as not reasonable and necessary.

Manual therapy (CPT code 97140)

Manual therapy techniques consist of, but are not limited to, connective tissue massage, joint mobilization and manipulation, manual lymphatic drainage, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. As the code descriptor states, "manual," providers use their hands to administer these techniques. Therefore, code 97140 describes "hands-on" therapy techniques.

Typically, the goals of manual therapy are to modulate pain, increase joint range of motion, and reduce or eliminate soft tissue swelling, inflammation, or restriction. These techniques also induce relaxation and improve contractile and noncontractile tissue extensibility.

Manual therapy techniques may be performed on individuals with symptoms that may include a limited range of motion, muscle spasm, pain, scar tissue or contracted tissue and/or soft tissue swelling, inflammation or restriction.

1. Manual traction

This procedure may be considered reasonable and necessary for cervical radiculopathy.

2. Joint mobilization (peripheral or spinal)

This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

3. Myofascial release/soft tissue mobilization, one or more regions

This procedure may be medically necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, or stretching of shortened muscular or connective tissue. This procedure may be medically necessary as an adjunct to other therapeutic procedures such as 97110, 97112, and 97530.

4. Manipulation

This procedure may be medically necessary for treatment of painful spasm or restricted motion of soft tissues. It may also be used as an adjunct to other therapeutic procedures such as 97110, 97112, and 97530.

Group therapeutic procedures (CPT code 97150)

Group therapy procedures involve the constant attendance of the physician or therapist but by definition do not require one-on-one patient contact by the physician or therapist. Constant attendance is required because it is not possible for the physician or therapist to provide simultaneous one-on-one patient contact in a group setting.

CPT code 97150 should be reported for each group member receiving a type of therapeutic modality when the therapist is working with several patients at the same time. The patients do not need to be receiving the same type of therapeutic modality. The specific type of therapy provided (e.g., 97110) should not be reported in addition to the group therapy code. The individual therapy codes should be reported when the physician or therapist is providing therapy to only one patient.

The ICD-9 codes that are applicable to the individual therapies should be billed with the CPT 97150. These ICD-9 codes will identify the condition for which the individual therapy was provided and the 97150 will identify that the service was provided under the constant attention of the physician or therapist in a group setting.

Documentation in the medical records must clearly identify that the therapy was medically necessary and performed by the physician, therapist or qualified personnel in a group setting (two or more individuals).

Therapeutic activities (CPT code 97530)

Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involves movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a physical therapist and are designed to address a specific functional need of the patient.

In order for therapeutic activities to be covered, all of the following requirements must be met:

The patient has a condition for which therapeutic activities can reasonably be expected to restore or improve functioning; and
The patient’s condition is such that he/she is unable to perform therapeutic activities except under the direct supervision of a physician or physical therapist; and
There is a clear correlation between the type of exercise performed and the patient’s underlying functional deficit(s) for which the therapeutic activities were prescribed.
Therapeutic activities may be medically necessary when the professional skills of a provider are required, and the activity is designed to address a specific need of the patient. These dynamic activities must be part of a documented treatment plan and intended to result in a specific outcome.

Self care management training (CPT code 97535)

This training includes activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment, direct one-on-one contact by the provider. The patient must have a condition for which training in activities of daily living is reasonable and necessary, and such training must be reasonably expected to restore or improve the functioning of the patient. The patient and/or caregiver must have the capacity to learn from instructions.

This procedure is reasonable and necessary only when it requires the skills of a physical therapist, is designed to address specific needs of the patient, and is part of an active treatment plan directed at a specific outcome. Documentation must relate the training to expected functional goals that are attainable by the patient.

Services provided concurrently by physical therapists and occupational therapists may be covered if separate and distinct goals are documented in the treatment plans.

Work hardening (CPT code 97545) and Work hardening add-on (CPT code 97546)

These services relate directly to specific work skills and do not provide any diagnostic or therapeutic benefit for the patient that requires physical rehabilitation. They will be denied as not medically necessary for the diagnosis or treatment of illness or injury.

Coverage Limitations

Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation) do not constitute physical therapy services for Medicare purposes.

The application of hot and cold packs is considered an integral part of a service or visit by CMS and is a bundled code on the Medicare Fee Schedule Data Base (MFSDB).

Heat modalities (97024, 97035) used for the treatment of asthma, bronchitis and other pulmonary conditions are considered not reasonable and necessary and will be denied.

It is not medically necessary to have more than one form of hydrotherapy during a visit. Therefore, CPT codes 97022, 97036 or 97113 cannot be billed together.

Electrical stimulation (97032, G0283) used for the treatment of facial nerve paralysis (e.g., Bell's Palsy), or motor function disorders (e.g., multiple sclerosis) is considered investigational and therefore non-covered by Medicare. Electrical stimulation is not reasonable or necessary for the treatment of strokes when it is determined that there is no potential for restoration of function.

Gait training (97116) is not considered reasonable and necessary when the patient's walking ability is not expected to improve. Repetitive walk-strengthening exercises for feeble or unstable patients or to increase endurance do not require provider supervision and will be denied as not reasonable and necessary.

Work hardening (97545) and work hardening add-on (97546) services relate directly to specific work skills and do not provide any diagnostic or therapeutic benefit for the patient that requires physical rehabilitation. They will be denied as not medically necessary for the diagnosis or treatment of illness or injury.