Physical therapy is a covered service when performed with the expectation of restoring the patient's level of function which has been lost or reduced by injury or illness.

Physical therapy treatment should be provided in accordance with an ongoing, written treatment plan. The treatment plan should include:

• the specific modalities/procedures to be used in treatment
• the patient's diagnosis
• degree of severity of the problem (mild, moderate, severe)
• impairment characteristics
• physical examination findings - X-ray or other pertinent findings
• specific statements of long- and short-term goals
• a reasonable estimate of when the goals will be reached (estimated duration of treatment, e.g. number of weeks)
• the frequency of treatment (e.g., number of times per week)
  

1. A physical therapy session consists of up to one hour of physical therapy or up to three physical therapy modalities/procedures performed on the same date of services.

2. Payment may be made for up to 15 outpatient physical therapy sessions per calendar year (January-December).
3. Claims requesting outpatient physical therapy sessions in excess of 15 sessions are subject to review for the purpose of establishing medical necessity. Providers are required to submit the patient's treatment plan for review. Sessions in excess of 15 without an approved treatment plan will be denied on the basis of medical necessity. A participating, preferred, or network provider cannot bill the member for the denied service. Additional supportive documentation from the provider requesting additional sessions could include the physician's pertinent evaluations (exam findings), progress notes, and opinions about the patient's need for continued therapy services. In addition, the medical history, as it relates to the outpatient physical therapy, must include the date of onset and/or exacerbation of the illness or injury. Any history of treatments from a previous provider is also necessary for patients who have transferred to a new provider for additional treatment. The limitation addressed in this paragraph does not apply to inpatient physical therapy services.
   

   
   

   NOTE:

   Under the UCR and Fee Schedule programs, inpatient physical therapy is covered. However, certain groups under indemnity programs have physical therapy coverage other than inpatient or may not pay for services provided by physical therapists. These situations are identified in the benefits schedule.

   
   

• Documentation indicating whether the patient was in shallow or deep water. An aquatic therapy program undertaken for upper extremity exercises should take place in a depth of water which allows the patient's upper extremities to be submerged. Water depth should be at a level which provides the best postural position for exercise therapy.

• For resistance and strengthening exercises, the provider should document the number of repetitions, the number of sets, the type(s) of equipment, which body area(s) and the specific type(s) of exercise performed by the patient for each therapy session.
  
  NOTE: If a provider cannot substantiate increased resistance experienced as the patient exercises in water, the session will be considered as endurance or conditioning rather than progressive resistance exercises (PRE) to strengthen.

• Specific documented goals regarding decreasing inflammation, decreasing pain, increasing circulation, increasing strength, etc., and the means by which the specific goals will be achieved.
• Periodic re-evaluation documenting the number of times the patient has had rehabilitative aquatic therapy, the patient's pain level before beginning the program, the current pain level and future goals for the patient's care.
• Indication of pool water temperature for each session.
  

Payment for procedure code 97113 includes whirlpool (97022) and/or Hubbard tank (97036). Separate payment will not be made for 97022 or 97036 in addition to 97113 for a single patient encounter.

Procedure code 97116 should be used to report gait training therapy. Gait training is a technique which restores a patient's normal stance, swing, speed, balance and sequence of muscle contractions for walking.

Generally accepted indications for gait training include:

• Foot drop resulting from stroke
• Herniated disc(s)
• Ankle, knee and/or hip replacement
• Traumatic amputations of the toe(s)
  

Procedure code 97116 should not be used to report orthotics or prosthetics training. Orthotics training should be reported using procedure code 97504 and prosthetics training should be reported using procedure code 97520.

NOTE:

Separate payment may not be made for a Physical Therapy Evaluation (codes 97001-97002) or an Athleteic Training Evaluation (97005-97006), and another evaluation and management service on the same day by the same or an affiliated provider.

Muscle Testing (codes 95831-95834), Range of Motion Testing (codes 95851-95852), and Physical Performance Testing (code 97750) are considered to be components of a Physical Therapy Evaluation (codes 97001-97002)or an Athletic Training Evaluation (97005-97006), and are not eligible for separate payment when billed on the same day as a Physical Therapy Evaluation service.

Physical therapy performed repetitively to maintain a level of function is not eligible for payment and is billable by a participating/preferred provider. 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. Maintenance therapy should be reported under procedure code W9700.

NOTE: For information on cognitive rehabilitation and sensory integration techniques, refer to HMPB Y-2.

Physical therapy is covered whether provided by a doctor or a licensed physical therapist.

Managed Care

The entire medical policy outlined above applies to Managed Care programs except points number 2 and 3 (pages 1 and 2) of the outpatient physical therapy guidelines section.

HMO and POS

For HMO and coordinated POS programs, outpatient physical therapy must be coordinated with the member's primary care physician. Therapy type and duration must be approved by the primary care physician and the Plan, prior to the member beginning outpatient physical therapy.

Please note that POS members may self-refer for outpatient physical therapy services.

When the member meets the medical necessity criteria detailed in this medical policy, please refer to the member's specific benefits schedule to determine and approve the duration of outpatient physical therapy services.

PRN References

02/1993, Physical therapy reporting tips
05/1994, Physical therapy quick reference guide
06/1994, Outpatient physical therapy
01/1995, Physical therapy reporting tips
01/1995, Postoperative physical therapy
08/1995, Postoperative physical therapy
10/1996, Aquatic therapy
10/1996, Gait training
10/1996, Manipulation and physical therapy changes
10/1996, Therapy treatment plan
12/1996, Manipulation and physical therapy treatment plan: tips for completing form 3861
12/1996, Therapeutic activities - code 97530 - to remain physical therapy service
02/1997, Physical therapy quick reference guide
02/1998, New physical and occupational therapy coding guidelines adopted