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MP 8.03.02 Physical Therapy

Medical Policy
Section
Therapy
Original Policy Date
7/31/96
Last Review Status/Date
Reviewed by consensus/4:2002
Issue
4:2002
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Physical therapy (PT) is the treatment of disease or injury by the use of therapeutic exercise and other interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, a person’s ability to go through the functional activities of daily living, and on alleviating pain.

Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiological principles.


Policy

Physical therapy services are considered medically necessary when performed to meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention.


Policy Guidelines

Physical therapy services must meet all of the following criteria:

  • meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention;
  • achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time;
  • provide specific, effective, and reasonable treatment for the patient’s diagnosis and physical condition;
  • be delivered by a qualified provider of physical therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure;
  • require the judgment, knowledge, and skills of a qualified provider of physical therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.


Benefit Application

 

Plans may wish to review their contract language on physical therapy services to ensure that the contract language is consistent with the Plan’s medical policy on PT.

Many Plans have visit or dollar maximums for PT services, or these services may be provided as a separate contractual benefit.

Qualified providers of PT services may include:

  • M.D. (medical doctor);
  • D.O. (doctor of osteopathy);
  • physical therapist;
  • chiropractor (in some jurisdictions, chiropractors must be licensed to perform PT services);
  • podiatrist (limited by licensure requirements);
  • occupational therapist (limited by certification and licensure).

Charges may appear for the following services under physical therapy. These services should be adjudicated separately:

  • acupuncture (see Policy 7.01.01 ); acupuncture is considered investigational;
  • gait analysis (see Policy 2.01.03 ); gait analysis is considered investigational.

Inpatient benefits are considered not medically necessary if the hospital admission is solely for the purpose of receiving physical therapy.

Sessions

A physical therapy session is defined as up to 1 hour of PT (treatment and/or evaluation) or up to 3 PT modalities provided on any given day. These sessions may include:

  • therapeutic exercise programs, including coordination and resistive exercises, to increase strength and endurance;
  • various modalities including, but not limited to, thermotherapy, cryotherapy, hydrotherapy, and electrical stimulation;
  • massage, traction, or mobilization techniques; and
  • patient and family education in home exercise programs.

Up to 10 physical therapy sessions per year may be covered without prior authorization. All subsequent treatment is subject to individual consideration. Prior authorization is recommended to facilitate claims processing based on a review of the written plan of care.

Plan of Care

The plan of care should include:

  • specific statements of long- and short-term goals;
  • measurable objectives;
  • a reasonable estimate of when the goals will be reached;
  • the specific modalities and exercises to be used in treatment; and
  • the frequency and duration of treatment.

The plan of care should be updated as the patient’s condition changes and should be recertified by a physician at least every 30 days.

Duplicate Therapy

Duplicate therapy is considered not medically necessary. When patients receive both physical and occupational therapy, the therapies should provide different treatments and not duplicate the same treatment. They must also have separate treatment plans and goals (see Occupational Therapy, policy No. 8.03.03 ).

Non-Skilled Services

Certain types of treatment do not generally require the skills of a qualified provider of PT services and are therefore not medically necessary. Services may include:

  • passive range of motion (ROM) treatment, which is not related to restoration of a specific loss of function;
  • any of the following treatments when given alone or to a patient who presents no complications: hot packs; hydrocollator; infrared heat; whirlpool baths; paraffin baths; Hubbard tank; cold packs; ice packs; and contrast baths.

Benefits should be denied for these services.

Maintenance Program

A maintenance program consists of activities that preserve the patient’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.

Benefits for the maintenance program itself, are not covered.


Rationale

A search of literature was completed through the MEDLINE database for the period of January 1980 through December 1995. The search strategy focused on references containing the following Medical Subject Headings:

– Physical Therapy (including review or meta-analysis or practical clinical trial or guidelines) as indexed in the Abridged Index Medicus

– Physical Therapy and Iontophoresis

– Rehabilitation (massage or effleurage or pétrissage or tapotement)

See also:

Occupational Therapy, medical policy No. 8.03.03.

Research was limited to English-language journals on humans.

 

Codes

Number

Description

CPT  97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028  Physical medicine and rehabilitation modalities, supervised, code range. 
  97032, 97033, 97034, 97035, 97036, 97039  Physical medicine and rehabilitation modalities, constant attendance, code range. 
  97110, 97112, 97113, 97116, 97124, 97139  Therapeutic procedures code range. 
ICD-9 Procedure  93.11–93.39  Physical therapy code range 
ICD-9 Diagnosis    Code applicable disease, trauma, congenital anomalies, or prior therapeutic treatment 
HCPCS  Q0086  Physical therapy evaluation/treatment, per visit 
  Q0103  Physical therapy evaluation code range 
Type of Service  Medical 
Place of Service  Inpatient
 
Outpatient
 
Physician’s Office
 
Physical Therapist’s Office
 
Home
 

 


Index

Cryotherapy
Exercise Programs, Therapeutic
Hydrotherapy
Physical Therapy
Therapy, Physical
Thermotherapy  


Policy History

Date Action Reason
07/31/96 Add to Therapy section, Rehabilitation Therapy subsection New Policy
12/18/02 Replace Policy Policy retired


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