Physical and Occupational Therapy Services · Musculoskeletal Benefit Management. Physical Therapy...

Physical and Occupational Therapy Services

Effective June 7, 2017

Clinical guidelines for medical necessity review of physical and occupational therapy services. © 2017 eviCore healthcare. All rights reserved.

CLINICAL GUIDELINES

CareCore National, LLC d/b/a eviCore healthcare (eviCore)

Please note the following: CPT Copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Musculoskeletal Benefit Management: Physical and Occupational Therapy Services V1.1.2017

© 2017 eviCore healthcare. All rights reserved. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com

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Dear Provider, This document provides detailed descriptions of eviCore’s basic criteria for musculoskeletal management services. They have been carefully researched and are continually updated in order to be consistent with the most current evidence-based guidelines and recommendations for the provision of musculoskeletal management services from national and international medical societies and evidence-based medicine research centers. In addition, the criteria are supplemented by information published in peer reviewed literature. Our health plan clients review the development and application of these criteria. Every eviCore health plan client develops a unique list of CPT codes or diagnoses that are part of their musculoskeletal management program. Health Plan medical policy supersedes the eviCore criteria when there is conflict with the eviCore criteria and the health plan medical policy. If you are unsure of whether or not a specific health plan has made modifications to these basic criteria in their medical policy for musculoskeletal management services, please contact the plan or access the plan’s website for additional information. eviCore healthcare works hard to make your clinical review experience a pleasant one. For that reason, we have peer reviewers available to assist you should you have specific questions about a procedure. For your convenience, eviCore Customer Service support is available from 7 a.m. to 7 p.m. Our toll free number is (800) 918-8924. Gregg P Allen, M.D. FAAFP EVP and Chief Medical Officer



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Table of Contents Policy Page Physical Therapy Policy ............................................................................................... 6 Occupational Therapy Policy ..................................................................................... 17 General Medical Rehabilitation .................................................................................. 28

Benign Paroxysmal Positional Vertigo ....................................................................... 28 Pelvic Pain Syndrome ................................................................................................ 38 Rheumatoid Arthritis Hip, Knee, Foot, Ankle, Shoulder & Hand ................................ 51 Urinary Incontinence .................................................................................................. 62

Neurological Rehabilitation ........................................................................................ 75 Acquired Brain Injury ................................................................................................. 75 Complex Regional Pain Syndrome (CRPS) ............................................................... 91 Impaired Mobility...................................................................................................... 102 Spinal Cord Injury .................................................................................................... 116

Orthopedic – Cervical Disc-Radicular ..................................................................... 135 Cervical, Brachial Neuritis or Radiculitis .................................................................. 135 Cervical, Intervertebral Disc Syndrome ................................................................... 148 Cervical, Post-Surgical Syndrome ........................................................................... 160 Stenosis – Cervical / Thoracic Spine ....................................................................... 172

Orthopedic – Non Specific ....................................................................................... 184 Head, Neck and Upper Back Dysfunction ................................................................ 184

Orthopedic – General ................................................................................................ 204 Compartment Syndrome .......................................................................................... 204 Musculoskeletal Disorders ....................................................................................... 215 Myofascial Pain Syndrome ...................................................................................... 230 Myositis Ossificans .................................................................................................. 240 Osteitis Pubis ........................................................................................................... 250 Osteoporosis ........................................................................................................... 260 Temporomandibular Joint Dysfunction .................................................................... 271

Orthopedic – Knee .................................................................................................... 282 Anterior Cruciate Ligament (ACL) Reconstruction, Knee ......................................... 282 Knee Pain and Dysfunction ..................................................................................... 293 Knee, Tear, Lateral or Medial Meniscus .................................................................. 308 Tibial Plateau Fractures with ORIF .......................................................................... 320 Total Knee Arthroplasty, Osteoarthritis Knee ........................................................... 331

Orthopedic – Lower Extremity ................................................................................. 343 Ankle/Foot Pain ....................................................................................................... 343 Ankle Ligament, Reconstruction, and Repair ........................................................... 358 Ankle Tendon Repair ............................................................................................... 369 Calcaneus Fracture ................................................................................................. 380 Femoral Shaft Fracture, with ORIF .......................................................................... 391 Hallux Rigidus, Pre- and Post-Surgical .................................................................... 402 Hip Fracture, Closed, With or Without ORIF ............................................................ 413 Hip Pain and Dysfunction ........................................................................................ 424 Hip Total Replacement ............................................................................................ 436



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Lower Extremity, Amputation with Subsequent Prosthesis, AKA & BKA ................. 446 Tarsal Tunnel Syndrome With and Without a Release ............................................ 457 Tarsal/Metatarsal Fracture, Post-Cast Removal or ORIF ........................................ 469 Tibia Fracture, Post-ORIF ........................................................................................ 481 Tri-malleolar, Fracture, Post-Cast Removal ............................................................. 491

Orthopedic – Lumbosacral Disc-Radicular ............................................................. 502 Lumbar Intervertebral Disc Syndrome ..................................................................... 502 Lumbar Post Surgery Syndrome ............................................................................. 514 Lumbar Radiculopathy and Sciatica ........................................................................ 527 Lumbar Spinal Stenosis ........................................................................................... 538

Orthopedic – Lumbrosacral Non Specific ............................................................... 550 Back Pain and Dysfunction ...................................................................................... 550

Orthopedic – Shoulder .............................................................................................. 573 Arthroscopic Procedure of the Shoulder .................................................................. 573 Rotator Cuff Tear Repair, With and Without Distal Clavicle Resection .................... 583 Shoulder Impingement, Release.............................................................................. 594 Shoulder Pain and Dysfunction ............................................................................... 605 Shoulder Total Joint Replacement ........................................................................... 624

Orthopedic – Upper Extremity ................................................................................. 635 Carpal Fracture, Closed and Open, Post-Cast Removal ......................................... 635 Carpal Tunnel Syndrome With and Without Release............................................... 645 Cubital Tunnel, Ulnar Nerve Entrapment ................................................................. 657 Dupuytren’s Contracture, Post-Release .................................................................. 668 Elbow Collateral Ligament Reconstruction .............................................................. 680 Elbow Dislocation .................................................................................................... 690 Elbow Fracture, Closed, Post-Cast Removal ........................................................... 701 Elbow Fracture, with ORIF ....................................................................................... 711 Elbow Radial Nerve Entrapment, With and Without Surgical Release .................... 721 Elbow Sprain/Strain ................................................................................................. 733 Elbow Ulnar Nerve Transposition ............................................................................ 744 Hand, Trigger Finger, With and Without Release .................................................... 754 Lateral Epicondylitis With and Without Fascial Release .......................................... 766 Medial Epicondylitis ................................................................................................. 779 Olecranon Bursitis ................................................................................................... 791 Phalanges Post ORIF, Post Cast Removal, Navicular, Metacarpal ......................... 801 Proximal Humeral Fracture, Open, Post-ORIF ........................................................ 811 Thoracic Outlet Syndrome ....................................................................................... 822 Wrist Fracture, Distal Radius or Ulna (Post-ORIF) .................................................. 834 Wrist Tenosynovitis, Radial Styloid or de Quervain’s............................................... 845 Wrist, Ulnar Nerve Entrapment, Post-op Release ................................................... 856

Pediatric ..................................................................................................................... 866 Autism Spectrum Disorder ....................................................................................... 866 Congenital Muscular Torticollis ................................................................................ 886 Neuromuscular Disorders ........................................................................................ 896

Maximal Complex Motion Necessary for Functional Activities ............................. 913 Diagnosis Codes ....................................................................................................... 918



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Physical Therapy Policy Subject: Physical Therapy

Description: Physical therapy (PT) is the treatment of the complications and sequelae of a disease, or injury by the use of therapeutic exercise and other treatment modalities, that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, an individual's ability to go through the functional activities of daily living (ADL), and on reducing pain. Treatment may include active and passive modalities using a variety of means and techniques, based upon biomechanical and neurophysiologic principles.

Medically Necessary Services To be considered reasonable and necessary the following conditions must each be met:

Services are for the treatment of a covered injury, illness or disease, and are appropriate treatment for the condition

Treatments are expected to result in significant, functional improvement in a reasonable and generally predictable period of time, or are necessary for the establishment of a safe and effective maintenance program. Treatment should be directed toward restoration or compensation for lost function. The improvement potential must be significant in relation to the extent and duration of the therapy required

The services must be currently accepted standards of medical practice, and be specific and effective treatments for the patient’s existing condition

The complexity of the therapy and the patient’s condition must require the judgment and knowledge of a licensed qualified clinician practicing within the scope of practice for that service. Services that do not require the performance or supervision of a qualified clinician are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.

The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.

Services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.



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For these purposes, “generally acceptable standards of practice” means standards that are based on credible scientific evidence published in the peer-reviewed literature generally recognized by the relevant healthcare community, specialty society evidence-based guidelines or recommendation, or expert clinical consensus in the relevant clinical areas.

Coverage Criteria for Providers Several provider specialties utilize various approaches to achieve therapeutic benefit in the treatment of neuromusculoskeletal conditions. Physical therapy services are provided according to the members’ benefit certificates and the health plan’s medical policies. For example, physical therapy must be provided by physical therapists (PT) or physical therapist assistants (PTA). Services billed “incident to” by MDs/DOs/DPMs must meet the Centers for Medicare & Medicaid Services (CMS) “incident to” guidelines for physical therapy and must be rendered by “qualified providers” as defined by CMS. This means that MDs/DOs/DPMs may only bill physical therapy services as “incident to” if provided by an MD, DO, DPM, PA, ARNP, PT and a PTA under supervision of a PT.

Services Not Covered Physical Therapy services will not be covered when provided by athletic trainers, and other providers not recognized by the Health Plan.

Care Classifications

Therapeutic Care Therapeutic care is care provided to relieve the functional loss associated with an injury or condition and is necessary to return the patient to the functioning level required to perform their activities of daily living, instrumental activities of daily living and work activities. Therapeutic care generally occurs within a reasonable period of time and is guided by evidence based practice of physical therapy.

Acute Care Acute care is care of an injury or condition characterized by short and relatively severe symptom complex, generally up to the first month following onset of injury. The condition may be induced by either traumatic or non-traumatic factors and may consist of a new condition or an exacerbation of an existing one. Need for care is proportional to the severity of the signs and symptoms of the particular case, modified by the status of healing tissues. The therapeutic goals of acute care are patient education in the recovery/healing process, reduction of symptoms and minimization of functional loss, in preparation for resolution of the injury or condition. Means and methods include a combination of direct care and a home management program to progress towards recovery of function.

Subacute Care Subacute care is care of an injury or condition characterized by a less severe symptom complex and intermediate course. Typically, it follows an acute injury or exacerbation,



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and can extend up to three months from onset. Subacute care is characterized by a combination of direct care and home management consisting of exercise, symptom management, patient education, and an emphasis on compliance. The therapeutic goal of this phase is to improve functional status by increasing existing range of motion and muscle strength and reducing signs and symptoms associated with the condition or injury. Means and methods include progression of exercise, instruction in self-care, and monitoring patient compliance and motivation. Intensity of care is guided by the condition of healing tissue structures, generally including therapy visits supplemented by a home management program.

Corrective or Rehabilitative Care Corrective or rehabilitative care is the stage of ongoing care beyond the sub-acute phase.T his phase of care may last up to 6 month from onset. It may also refer to treatment of conditions that are chronic in nature and do not occur in conjunction with an acute or subacute phase. The therapeutic goals of this phase are reduction and management of symptoms with a goal of maximizing function over time. Means and methods include progression of exercise, continued patient education, and transition to self-management. Intensity of care is guided by functional status, focusing on home management, supplemented by therapy visits.

Supportive Care Supportive care is that phase of care that occurs following the corrective or rehabilitative phase. The supportive care phase may last up to 12 months from onset. It may apply to chronic conditions or very severe injuries. Treatment is directed towards management of ongoing, unresolved symptoms that may or may not impact functional status. The therapeutic goal of this phase is patient/caregiver education, self-management, and to prevent deterioration of physical or functional status. Means and methods include progression of exercise and continued patient education. Intensity of care is minimal. This is often not covered by the health plan’s benefit.

Palliative Care (Noncovered Service) Palliative care is typically given to alleviate symptoms and does not provide corrective benefit to the condition treated. A patient receiving palliative care, in most instances, demonstrates varying lapses between treatments. If an exacerbation of a condition occurs, care becomes therapeutic rather than palliative, and documentation of the necessity for care (e.g., etiology of exacerbation, objective findings, and desired outcomes) must be obtained.

Skilled Maintenance Care Maintenance care is defined as services required to maintain the member’s current condition or to prevent or slow deterioration of the member’s condition. (Chapter 15, Section 220.2 Subsection D of the Medicare Benefit Policy Manual) Skilled maintenance care for Medicare and Medicaid enrollees is covered if the specialized skill, knowledge and judgment of a qualified therapist are required:



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To establish or design a maintenance program appropriate to the capacity and

tolerance of the member To educate/instruct the member or appropriate caregiver regarding the

maintenance program For periodic re-evaluations of the maintenance program When skilled services are required in order to provide reasonable and necessary

care to prevent or slow further deterioration, coverage will not be denied based on the absence of potential for improvement or restoration as long as skilled care is required.

Skilled Maintenance Programs in an Outpatient and Home Health setting will not be covered if furnished by a Physical Therapist Assistant. (Chapter 15, Section 220.2 Subsection D of the Medicare Benefit Policy Manual) Preventive Care Examinations (Non covered Service) Preventive care includes management of the asymptomatic patient. Preventive care examinations may include pre-participation athletic examination. Habilitation: Physical, occupational and speech therapy services provided in order for a person to attain and maintain a skill or function for daily living, that was never learned or acquired and is due to a disabling condition such as developmental delay, developmental disability, developmental speech or language disorder, developmental coordination disorder and mixed developmental disorder.

Condition Severity Classifications Severity is classified as mild, moderate and severe conditions. Severity is determined by several factors including, but not limited to, mode of onset, duration of care, loss of work days, and functional deficits.

Conditions Severity Criteria Table Criteria Mild

Condition Moderate Condition

Severe Condition

Mode of onset Variable Variable Severe Anticipated duration of care 1-6 weeks 6-10 weeks 10 or more weeks Loss of work days No loss of

work days 0-4 days of work lost

5 or more days of work lost

Work restriction None Possible, depends on occupation; 0-2 weeks

Restriction, depending on occupation; 2 or more weeks

Functional deficits: 1. Range of motion

Mild/no loss

Mild to moderate loss

Considerable loss

2. Muscle Strength Mild/no loss Mild to moderate loss

Considerable loss



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3. Neurologic findings None May be present May be present 4. BADL (Basic daily function such as walking in the home, bathing, dressing, grooming, feeding, positioning, and elimination)

Mild/no loss Mild to moderate Moderate to severe

Criteria/Guidelines for Provision of Physical Therapy

Indications for Coverage 1. Contract limitations for physical therapy services will determine the available benefit

if such therapy is determined to be medically necessary. 2. Physical therapy services must be ordered by a physician (exception in direct-

access states). Each member should be provided with a treatment plan at their start of care

describing appropriate treatment modalities and exercises. The member’s treatment plan must contain objective data, reasonable

expectations, and measurable goals for a specific diagnosis. Re-assessments of member progress should be undertaken as part of every

ongoing PT session; assessments of this nature should be included in the treatment session and should not be performed in a separate treatment session.

The assessment is a part of ongoing care and should occur throughout each treatment session so that therapy continues to be patient- focused to meet the changing needs of the member.

A formal reassessment with objective measures and updated goals should occur at least every 30 days.

Lack of measureable and significant change at reassessments should result in a change in the program or discharge to a home management program.

3. Physical therapy services are reviewed and evaluated by CareCore National periodically during a member’s episode of care based on the provider’s utilization management tier assignment. At each review, the clinical reviewer will evaluate the key objective and subjective

measures of the member’s clinical status, with a focused review on function using a standardized assessment tool.

This information, in the context of the generally accepted natural history of the condition(s) under care, will be used to determine the medical necessity of the care provided to date, and/or the care that is proposed.

Refer to the Evidence-based Guidelines, Patient History and Presentation for information on specific conditions.

Reasonable and Necessary Services Physical therapy (PT) services are considered medically necessary when all of the following criteria are met: 1. Therapy requires 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.



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A qualified provider of physical therapy services is one who is licensed where required and performs within the scope of licensure.

Services provided by PT aides or other non-qualified professionals are not covered.

2. PT services meet the functional needs of the member who suffers from a physical impairment due to illness, disease, or injury and are appropriate treatment for the condition. The patient must have functional deficits that interfere with Activities of Daily Living or return to work (see definitions at the end of policy) Refer to the Evidence-based Guidelines, Admission Criteria, for information on

specific functional losses for specific conditions. 3. PT services achieve a specific diagnosis-related goal for a member, who has a

reasonable expectation of achieving measurable improvement, in a reasonable and predictable period of time. Significant is defined as a measureable and meaningful increase (as

documented in the patient’s record) in the patient’s level of physical and functional abilities that can be attained with short-term therapy, usually within a two month period.

Refer to the Evidence-based Guidelines for expected functional recovery for specific conditions.

4. PT services inherently include the introduction and provision of, and education about a home (self) management program, appropriate for the condition(s) under treatment. In keeping with professional standards, this home management program should be introduced into the course of treatment at the earliest appropriate time; (This may also be applicable to parents, guardians, or caregivers of pediatric patients and adult patients needing assistance.)

5. PT services provide specific, effective, and reasonable treatment for the member’s diagnosis and physical condition. Refer to the Evidence-based Guidelines for a review of specific conditions and their course of recovery.

6. PT services must be described using standard and generally accepted medical/physical therapy/rehabilitation terminology. Such terminology includes objective measurements for ranges of motion, motor ability, and levels of function. Standardized tests for strength, motion, and function are required. Examples of

validated tests include the Oswestry, DASH, TUG, LEFS, etc. Standardized subjective measurements for pain are also expected;

7. Services do not duplicate those provided concurrently by any other therapy, particularly occupational therapy. When a patient receives both occupational and physical or speech therapy, the therapies should provide different interventions and not duplicate the same treatment.T hey must have separate treatment plans and goals with treatment occurring in separate treatment sessions and visits.

Rehabilitative Physical Therapy Services Are Generally Not Considered Medically Necessary Under the Following Circumstances 1. Training in nonessential self-help, recreational tasks, or athletic performance.

Therapeutic care is care provided to relieve the functional loss associated with an injury or condition and is necessary to return the patient to the functioning level required to perform their activities of daily living, instrumental activities of daily living



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and work activities. Therapeutic care generally occurs within a reasonable period of time and is guided by evidence based practice of physical therapy.

2. Maintenance care when palliative procedures are performed that are repetitive or to reinforce previously learned skills or when services performed are related to activities for the good and welfare of member such as a fitness program.

3. Passive modalities that extend beyond the acute phase of recovery. Non-skilled routine, repetitive and reinforced procedures that do not require one-

to-one intervention such as stationary bike riding, progressive resistive exercise after instruction, and passive range of motion.

4. Group exercise/ therapy programs defined as the simultaneous treatment of two or more patients who may or may not be doing the same activities is not a covered benefit.

5. Massage therapy when provided as a stand-alone procedure rather than as part of a comprehensive therapeutic treatment plan

Discharge Criteria Criteria utilized for determining whether a member is eligible for discharge from PT is determined based on the following (objective data) and is available in the Evidence-based Guidelines under Discharge Criteria:

Normative functional range of motion (ROM) for the injured or impaired body part(s). (Examples of these values can be found in Measurement of Joint Motion, a Guide to Goniometry, 3rd Edition, 2003 by Norkin and White as well as other texts and are referenced in the Evidence-based Guidelines.)

1. Satisfactory motor ability of the impaired or injured part(s) such that further improvement can be accomplished with a self-management program. Refer to the Evidence-based Guidelines, Home and Self-Care Techniques.

2. The member is able to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLS).

3. When there is no documented continual progression of function or improvement over the course of treatment, or a negative trend occurs.

4. Member non-compliance with therapy. 5. Physical therapy services are not considered medically necessary for pain mediation

alone.T he goals of PT are for improvement in restoration of function, motor ability, and range of motion as indicated previously.

Definitions:

Skilled Care: The member’s special medical complications require the skills of a therapist to

perform a therapy service or the needed therapy services are of such complexity that the skills of a therapist are required to perform the procedure.

Unskilled Care: Unskilled services are palliative procedures that are repetitive or reinforce

previously learned skills



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They are not covered because they do not involve complex and sophisticated therapy procedures, or require the judgment and skill of a qualified therapist for safety and effectiveness.

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

Services not provided under a therapy plan of care, or are provided by staff not qualified or appropriately supervised, are not covered or payable therapy services. a. Activities of Daily Living (ADL): Activities in which most people take part on a

daily basis. Eating, bathing, dressing, toileting and moving from one place to another are some examples.

b. Instrumental Activities of Daily Living:A ctivities that are often performed by a person who is living independently in a community setting during the course of a normal day, such as managing money, shopping, telephone use, travel in the community, housekeeping, preparing meals, and taking medications correctly. IADLs measure a person’s ability to live independently.

Medicare References 1. Centers for Medicare & Medicaid Services (CMS), Medicare Benefit Policy Manual-

Pub. 100-2: Chapter 15, Section 220, Covered Medical and Other Health Services, Conditions of Coverage and Payment Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

2. Centers for Medicare & Medicaid Services (CMS), Medicare Benefit Policy Manual-Pub. 100-2: Chapter 15, Section 230, Covered Medical and Other Health Services, Practice of Physical Therapy, Occupational Therapy, and Speech Language Pathology. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

3. National Coverage Determination (NCD) for Diathermy Treatment (150.5). http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=58&ncdver=2&DocID=150.5&bc=gAAAAAgAAAAAAA%3d%3d&.

4. National Coverage Determination (NCD) for Neuromuscular Electrical Stimulaton (NMES) (160.12). https://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.12&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced

5. National Coverage Determination (NCD) for Electrotherapy for Treatment of Facial Nerve Paralysis (Bell’s Palsy) (160.15) http://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.15&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced



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http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdfhttp://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=58&ncdver=2&DocID=150.5&bc=gAAAAAgAAAAAAA%3d%3d&http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=58&ncdver=2&DocID=150.5&bc=gAAAAAgAAAAAAA%3d%3d&http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=58&ncdver=2&DocID=150.5&bc=gAAAAAgAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.12&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advancedhttps://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.12&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advancedhttps://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.12&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advancedhttps://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.12&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advancedhttp://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.15&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advancedhttp://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.15&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advancedhttp://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.15&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advancedhttp://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.15&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced

6. National Coverage Determination (NCD) for Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions (240.3). http://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=240.3&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced

7. National Coverage Determination (NCD) for Infrared Therapy Devices (270.6) http://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=270.6&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced

8. Local Coverage Determination (LCD) for Medicine: Physical Therapy-Outpatient (L34310). Cahaba Government Benefit Administrators®.,Alabama, Georgia, Tennessee https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34310&ver=11&Date=03%2f28%2f2017&DocID=L34310&bc=iAAAABAAAAAAAA%3d%3d&

9. Local Coverage Determination (LCD) for Medicine: Physical Therapy- Outpatient (L34308) Cahaba Government Benefit Administrators®.,Alabama, Georgia, Tennessee https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34308&ver=14&Date=03%2f28%2f2017&DocID=L34308&bc=iAAAABAAAAAAAA%3d%3d&

10. Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L34049) CGS Administrators, LLC., Kentucky, Ohio https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34049&ver=18&Date=03%2f28%2f2017&DocID=L34049&bc=iAAAABAAAAAAAA%3d%3d&

11. Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L33631) National Government Services, Inc. Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, Wisconsin https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33631&ver=18&Date=03%2f28%2f2017&DocID=L33631&bc=iAAAABAAAAAAAA%3d%3d&

12. Local Coverage Determination (LCD) for Therapy and Rehabilitation Services (L33413) First Coast Service Options, Inc. Florida https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33413&ver=19&Date=03%2f28%2f2017&DocID=L33413&bc=iAAAABAAAAAAAA%3d%3d&

13. Local Coverage Determination (LCD) for Therapy and Rehabilitation Services (L35036) Novitas Solutions, Inc. Arkansas, Colorado, Delaware, District of Columbia, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, Pennsylvania, Texas https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35036&ver=64&Date=03%2f28%2f2017&DocID=L35036&bc=iAAAABAAAAAAAA%3d%3d&



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References 14. ACOEM Practice Guidelines, American College of Occupational and Environmental

Medicine, 2011 15. APTA, Defining Skilled Maintenance Therapy and Minimizing Denials, April, 2014. 16. Bischel, Margaret D., ‘The Managed Physical/Occupational Therapy and

Rehabilitation Care Manual’ (Apollo Managed Care Consultants, 2002) 17. Braddom R. Physical Medicine & Rehabilitation, 2nd Ed. Saunders, 2000 18. De Carlos MS, Sell KE,T he effects of the number and frequency of Physical

Therapy treatment on selected outcomes of treatment in patients with anterior cruciate ligament reconstruction, J Orthop Sports Phys Ther. 1997, 26 (6): 332-9.

19. Dutton, Mark, Orthopaedic Examination, Evaluation, & Intervention, McGraw-Hill Medial Publishing Division, 2004

20. Gerhardt J, Cocchaiarella L, and Lea R. The Practical Guide to Range of Motion Assessment American Medical Association, 2002

21. Guide to Physical Therapist Practice, Interactive Guide to Physical Therapist Practice, Version 1.0

22. Guides to the Evaluation of Permanent Impairment, 4th Edition (and 5th Edition) AMA Press, 1995

23. Hoppenfeld S, and Murthy V. Treatment & Rehabilitation of Fractures. Lippincott Williams & Wilkins, 2000

24. Jette D, Bacon K, Batty C, et al. Evidence-based practice: Belief, attitudes, knowledge and behaviors of physical therapists. 2003;83(9):86-805

25. Jette AM, Smith K, Haley SM, Davis KD, Physical therapy episodes of care for patients with low back pain. Phys Ther. 1994 Feb;74(2):101-10; discussion 110-5

26. Maxey L and Magnusson J. Rehabilitation for the Postsurgical Orthopedic Patient Mosby, 2001

27. Medicare Part B Reference Manual. October 2001, Revision 050 28. Mitchell, Jean M. and Lissovoy, Gregory de. “A Comparison of Resource Use and

Cost in Direct Access Versus Physician Referral Episodes of Physical Therapy.”P hysical Therapy, Volume 77, No. 1, 1997

29. Myerson M. Foot and Ankle Disorders Saunders, 2000 30. New Jersey Autism and Developmental Disabilities mandate. # A-2238. Effective

02/8/21010 31. Nordeman L Et Al, Early access to physical therapy treatment for subacute low back

pain in PRIMARY Health Care:A prospective randomized clinical trial, Clinical Journal of Pain, 2006, 22 (6)_505-511

32. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions: Overview and Methodology, PT Journal (2001) 81 (10): 1629-1640

33. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Shoulder Pain; PT Journal, Oct 1, 2001, 81: 1719-1730

34. Schenck R (ed). Athletic Training and Sports Medicine (3rd Ed). American Academy of Orthopedic Surgeons, 1999. American Association of Orthopedic Specialties

35. Snider, R (ed). Essentials of Musculoskeletal Care. American Academy of Orthopedic Surgeons and American Academy of Pediatrics, 1997



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36. Swinkels IC, Wimmers RH, Groenewegen PP, van den Bosch WJ, Dekker J, van den Ende CH. What factors explain the number of physical therapy treatment sessions in patients referred with low back pain; a multilevel analysis. BMC Health Serv Res. 2005; 5: 74. Published online before print November 24, 2005.

37. Tepper, Donald E. ReimbursementV ictories: Direst Access and Others, PT Magazine, 2003

38. Van Der Heijdan Et Al, Effects of Interferential Electrotherapy and Pulsed Ultrasound for Soft Tissue Shoulder Disorders, A Randomized Controlled Trial, Ann Rheumatic Diseases, 1999; 58: 530-540



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Occupational Therapy Policy Subject: Occupational Therapy

Description: Occupational therapy (OT) is the treatment of neuromusculoskeletal and psychological dysfunction through the use of specific task or goal-directed activities designed to improve the functional performance of an individual.T hese services emphasize useful and purposeful activities to improve neuromusculoskeletal and cognitive functions, and to teach adaptive skills to accomplish the activities of daily living (i.e., feeding, dressing, bathing, and other self-care activities). Other occupational therapy services include guidance in the selection and use of adaptive equipment.

Medically Necessary Services To be considered reasonable and necessary the following conditions must each be met:

Services are for the treatment of a covered injury, illness or disease, and are appropriate treatment for the condition

Treatments are expected to result in significant, functional improvement in a reasonable and generally predictable period of time, or are necessary for the establishment of a safe and effective maintenance program.T reatment should be directed toward restoration or compensation for lost function. The improvement potential must be significant in relation to the extent and duration of the therapy required

The services must be currently accepted standards of medical practice, and be specific and effective treatments for the patient’s existing condition

The complexity of the therapy and the patient’s condition must require the judgment and knowledge of a licensed qualified clinician practicing within the scope of practice for that service. Services that do not require the performance or supervision of a qualified clinician are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.

The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.

Services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.



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For these purposes, “generally acceptable standards of practice” means standards that are based on credible scientific evidence published in the peer-reviewed literature generally recognized by the relevant healthcare community, specialty society evidence-based guidelines or recommendation, or expert clinical consensus in the relevant clinical areas.

Coverage Criteria for Providers Several provider specialties utilize various approaches to achieve therapeutic benefit in the treatment of neuromusculoskeletal conditions. Occupational therapy services are provided according to the members’ benefit certificates and the health plan’s medical policies. For example, occupational therapy must be provided by occupational therapists (OT) or licensed occupational therapist assistants. Services billed “incident to” by MDs/DOs/DPMs must meet the Centers for Medicare & Medicaid Services (CMS) “incident to” guidelines for occupational therapy and must be rendered by “qualified providers” as defined by CMS. This means that MDs/DOs/DPMs may only bill occupational therapy services as “incident to” if provided by an MD, DO, DPM, PA, ARNP, OT or a COTA under supervision of an OT.

Services Not Covered Occupational Therapy services will not be covered when provided by athletic trainers, and other providers not recognized by Landmark Healthcare or provided beyond the scope of his or her license.

Care Classifications

Therapeutic Care Therapeutic care is care provided to relieve the functional loss associated with an injury or condition and is necessary to return the patient to the functioning level required to perform their daily needs and work activities. Therapeutic care generally occurs within a reasonable period of time and is guided by evidence based practice of physical therapy.

Acute Care Acute care is care of an injury or condition characterized by short and relatively severe symptom complex, generally up to the first month following onset of injury. The condition may be induced by either traumatic or non-traumatic factors and may consist of a new condition or an exacerbation of an existing one. Need for care is proportional to the severity of the signs and symptoms of the particular case, modified by the status of healing tissues. The therapeutic goals of acute care are patient education in the recovery/healing process, reduction of symptoms and minimization of functional loss, in preparation for resolution of the injury or condition. Means and methods include a combination of direct care and a home management program to progress towards recovery of function.



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Subacute Care Subacute care is care of an injury or condition characterized by a less severe symptom complex and intermediate course. Typically, it follows an acute injury or exacerbation, and can extend up to three months from onset. Subacute care is characterized by a combination of direct care and home management consisting of exercise, symptom management, patient education, and an emphasis on compliance. The therapeutic goal of this phase is to improve functional status by increasing existing range of motion and muscle strength and reducing signs and symptoms associated with the condition or injury. Means and methods include progression of exercise, instruction in self-care, and monitoring patient compliance and motivation. Intensity of care is guided by the condition of healing tissue structures, generally including therapy visits supplemented by a home management program.

Corrective or Rehabilitative Care Corrective or rehabilitative care is the stage of ongoing care beyond the sub-acute phase.T his phase of care may last up to 6 month from onset. It may also refer to treatment of conditions that are chronic in nature and do not occur in conjunction with an acute or subacute phase. The therapeutic goals of this phase are reduction and management of symptoms with a goal of maximizing function over time. Means and methods include progression of exercise, continued patient education, and transition to self-management. Intensity of care is guided by functional status, focusing on home management, supplemented by therapy visits.

Supportive Care Supportive care is that phase of care that occurs following the corrective or rehabilitative phase. The supportive care phase may last up to 12 months from onset. It may apply to chronic conditions or very severe injuries. Treatment is directed towards management of ongoing, unresolved symptoms that may or may not impact functional status. The therapeutic goal of this phase is patient/caregiver education, self-management, and to prevent deterioration of physical or functional status. Means and methods include progression of exercise and continued patient education. Intensity of care is minimal.T his is often not covered by the health plan’s benefit.

Palliative Care (Noncovered Service) Palliative care is typically given to alleviate symptoms and does not provide corrective benefit to the condition treated. A patient receiving palliative care, in most instances, demonstrates varying lapses between treatments. If an exacerbation of a condition occurs, care becomes therapeutic rather than palliative, and documentation of the necessity for care (e.g., etiology of exacerbation, objective findings, and desired outcomes) must be obtained.

Skilled Maintenance Care Maintenance care is defined as services required to maintain the member’s current condition or to prevent or slow deterioration of the member’s condition. (Chapter 15, Section 220.2 Subsection D of the Medicare Benefit Policy Manual)



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Skilled maintenance care for Medicare and Medicaid enrollees is covered if the specialized skill, knowledge and judgment of a qualified therapist are required:

To establish or design a maintenance program appropriate to the capacity and tolerance of the member

To educate/instruct the member or appropriate caregiver regarding the maintenance program

For periodic re-evaluations of the maintenance program When skilled services are required in order to provide reasonable and necessary

care to prevent or slow further deterioration, coverage will not be denied based on the absence of potential for improvement or restoration as long as skilled care is required.

Skilled Maintenance Programs in an Outpatient and Home Health setting will not be covered if furnished by a Physical Therapist Assistant. (Chapter 15, Section 220.2 Subsection D of the Medicare Benefit Policy Manual)

Preventive Care Examinations (Noncovered Service) Preventive care includes management of the asymptomatic patient. Preventive care examinations may include pre-vocational or ergonomic assessments.

Habilitation: Physical, occupational and speech therapy services provided in order for a person to attain and maintain a skill or function for daily living, that was never learned or acquired and is due to a disabling condition such as developmental delay, developmental disability, developmental speech or language disorder, developmental coordination disorder and mixed developmental disorder.

Condition Severity Classifications Severity is classified as mild, moderate and severe conditions. Severity is determined by several factors including, but not limited to, mode of onset, duration of care, loss of work days, and functional deficits.

Conditions Severity Criteria Table Criteria Mild

Condition Moderate Condition

Severe Condition

Mode of onset Variable Variable Severe Anticipated duration of care 1-6 weeks 6-10 weeks 10 or more weeks Loss of work days No loss of

work days 0-4 days of work lost

5 or more days of work lost

Work restriction None Possible, depends on occupation; 0-2 weeks

Restriction, depending on occupation; 2 or more weeks

Functional deficits: Mild/no loss Mild to moderate Considerable loss



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1. Range of motion loss 2. Muscle Strength Mild/no loss Mild to moderate

loss Considerable loss

3. Neurologic findings None May be present May be present 4. BADL (Basic daily function such as walking in the home, bathing, dressing, grooming, feeding, positioning, and elimination)

Mild/no loss Mild to moderate Moderate to severe

Criteria/Guidelines for Provision of Occupational Therapy

Indications for Coverage 1. Contract limitations for occupational therapy services will determine the available

benefit if such therapy is determined to be medically necessary. 2. Occupational therapy (OT) services must be ordered by a physician

Each member should be provided with a treatment plan at their start of care describing appropriate treatment modalities and exercises.

The member’s treatment plan must contain objective data, reasonable expectations, and measurable goals for a specific diagnosis.

Re-assessments of member progress should be undertaken as part of every ongoing OT session; assessments of this nature should be included in the treatment session and should not be performed in a separate treatment session.

The assessment is a part of ongoing care and should occur throughout each treatment session so that therapy continues to be patient- focused to meet the changing needs of the member.

A formal reassessment with objective measures and updated goals should occur at least every 30 days.

Lack of measureable and significant change at reassessments should result in a change in the program or discharge to a home management program.

3. Occupational therapy services are reviewed and evaluated by CareCore National periodically during a member’s episode of care. At each review, the clinical reviewer will evaluate the key objective and subjective

measures of the member’s clinical status, with a focused review onf unction. This information, in the context of the generally accepted natural history of the

condition(s) under care, will be used to determine the medical necessity of the care provided to date, and/or the care that is proposed.

Refer to the Evidence Based Guidelines, Patient History and Presentation for information on specific conditions.

Reasonable and Necessary Services Occupational therapy (OT) services are considered medically necessary when all of the following criteria are met:



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1. Therapy requires the judgment, knowledge and skills of a qualified provider of occupational therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient. A qualified provider of occupational therapy services is one who is licensed

where required and performs within the scope of licensure. Services provided by OT aides or other non-qualified professionals are not

covered. 2. OT services meet the functional needs of the member who suffers from a physical

impairment due to illness, disease, or injury and are appropriate treatment for the condition. The patient must have functional deficits that interfere with Activities of Daily

Living Refer to the Evidence Based Guidelines, Admission Criteria, for information on

specific functional losses for specific conditions. 3. OT services achieve a specific diagnosis-related goal for a member, who has a

reasonable expectation of achieving measurable improvement, in a reasonable and predictable period of time. Significant is defined as a measureable and meaningful increase (as

documented in the patient’s record) in the patient’s level of physical and functional abilities that can be attained with short-term therapy, usually within a two month period.

Refer to the Evidence Based Guidelines for expected functional recovery for specific conditions.

4. OT services inherently include the introduction and provision of, and education about a home (self) management program, appropriate for the condition(s) under treatment. In keeping with professional standards, this home management program should be introduced into the course of treatment at the earliest appropriate time; (This may also be applicable to parents, guardians, or caregivers of pediatric patients and adult patients needing assistance.)

5. OT services provide specific, effective, and reasonable treatment for the member’s diagnosis and physical condition. Refer to the Evidence Based Guidelines for a review of specific conditions and their course of recovery.

6. OT services are only considered medically necessary for the restoration of basic functional activities of daily living.

7. OT services must be described using standard and generally accepted medical/occupational therapy/rehabilitation terminology. Such terminology includes objective measurements for ranges of motion, motor ability, and levels of function. Standardized tests for strength, motion, and function are required. Examples of

validated tests include the Oswestry, DASH, TUG, LEFS, etc. Standardized subjective measurements for pain are also expected;

8. Services do not duplicate those provided concurrently by any other therapy. When a patient receives both occupational and physical or speech therapy, the therapies should provide different interventions and not duplicate the same treatment.T hey must have separate treatment plans and goals with treatment occurring in separate treatment sessions and visits.



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Occupational Therapy Services Considered Not Medically Necessary Under Any Of The Following Circumstances: 1. Training in nonessential self-help or recreational tasks such as:

Homemaking, gardening, educational activities and driving, return to sport or recreational activities (e.g., golf, tennis, running, jogging, swimming, basketball, gymnastics, football, baseball, martial arts, dance, etc.), or for the performance of work-related or other specific vocational tasks.

2. Maintenance OT services Maintenance therapy is defined as ongoing therapy after the patient has reached maximum rehabilitation potential, or functional level has shown no significant improvement for 2 weeks, and initial instruction in a maintenance program is completed. This is particularly applicable to patients with chronic, stable conditions where skilled supervision/interventions are no longer required and further clinical improvement cannot reasonably be expected from continuous ongoing care. This includes but is not limited to: Therapy that is supportive rather than corrective in nature Therapy that is intended to maintain a gradual process of healing, or to prevent

deterioration or relapse Ongoing treatment solely to improve endurance, strength, or distance Passive exercises to maintain range of motion that can be carried out by non-

skilled persons A general exercise program to promote overall fitness Treatment that is intended to provide diversion or general motivation Treatment that seeks to prevent disease, promote health, and prolong and

enhance quality of life 3. Ongoing or prolonged treatment for chronic conditions and/or chronic pain is not

considered medically necessary in the absence of measurable improvement that is sustained from treatment visit to treatment visit.T herapy is also not covered when the condition is not expected to improve significantly within a reasonable time period. Therapy is not meant to address ongoing safety issues related to cognitive and

physical impairments that do not appear to be improving. 4. OT treatment must include active, skilled therapy (i.e. that requiring an occupational

therapist or physician) during each session, at intensity and of duration necessary to the condition(s) under treatment. The use of passive modalities should be limited to the acute phase of recovery

and care should quickly transition to active care. Non-skilled therapy includes but is not limited to routine, repetitive and reinforced

procedures that do not require one-to-one intervention such as using a UBE, progressive resistive exercise after instruction, and passive range of motion.T hese procedures do not generally require the skills of a qualified provider of OT services and are therefore not covered.

5. The intensity or frequency of care should not exceed the number of visits necessary for a clinician to provide skilled care. Repetitive care and exercise is not considered skilled and can be transitioned to

a home management program. (For example a member receiving passive exercise following an orthopedic procedure will require a visit for instruction and



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periodic visits to monitor the patient’s progress and update the program.T his normally does not exceed 1 to 2 visits weekly.)

Refer to the Evidence Based Guidelines for examples of treatment progression based on the nature and severity of clinical findings.

6. Group exercise/ therapy programs defined as the simultaneous treatment of two or more patients who may or may not be doing the same activities is not a covered benefit.

7. Occupational therapy is not covered when an individual’s improvement potential is insignificant when compared to the extent and duration of the therapy needed.

8. Occupational therapy is not covered when the member suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of an occupational therapist.

9. Instruction of other agency or professional personnel in the patient’s physical therapy program

10. Collaboration with other agency or professional personnel or with other community resources

11. Emotional support, adjustment to extended hospitalization and/or disability, and behavioral readjustment

Discharge Criteria Criteria utilized for determining whether a member is eligible for discharge from OT is determined based on the following (objective data) and is available in the Clinical Practice Guidelines under Discharge Criteria: 1. Functional range of motion (ROM) for the injured or impaired body part(s). ROM

measurements will be reviewed on an individual basis. ROM values will be compared to standard normative measures that have been

published in the medical/orthopedic literature with respect to functional ability as demonstrated by the member.

These values can be found in Measurement of Joint Motion, a Guide to Goniometry, 3rd Edition, 2003 by Norkin and White as well as other texts and are referenced in the Clinical Practice Guidelines.

2. Satisfactory motor ability of the impaired or injured part(s) such that further improvement can be accomplished with a home exercise (management) program (HEP). Refer to the Clinical Practice Guidelines, Home and Self-Care Techniques.

3. The member is able to perform activities of daily living (ADLs) such as walking in the home, bathing, grooming, feeding, positioning, dressing and elimination.

4. For additional therapy requests to be considered medically necessary, they must include documented objective, measurable clinical data demonstrating the need for continued treatment. Valid and reliable instruments should be used to provide the data. In those instances when there is no documented continual progression of

function or improvement over the course of treatment, or when a negative trend occurs, further OT services generally will not be approved due to lack of medical necessity.



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5. If the member has been non-compliant with therapy as is evidenced by the clinical documentation, and/or the lack of demonstrated progress, OT will be deemed to be not medically necessary and the member should be discharged from OT.

6. Occupational therapy services are not considered medically necessary for pain mediation alone.T he goals of OT are for improvement in restoration of function, motor ability, and range of motion as indicated previously.

Medicare References 1. Centers for Medicare & Medicaid Services (CMS), Medicare Benefit Policy Manual-

Pub. 100-2: Chapter 15, Section 220, Covered Medical and Other Health Services, Conditions of Coverage and Payment Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

2. Centers for Medicare & Medicaid Services (CMS), Medicare Benefit Policy Manual-Pub. 100-2: Chapter 15, Section 230, Covered Medical and Other Health Services, Practice of Physical Therapy, Occupational Therapy, and Speech Language Pathology. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

3. National Coverage Determination (NCD) for Diathermy Treatment (150.5). http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=58&ncdver=2&DocID=150.5&bc=gAAAAAgAAAAAAA%3d%3d&.

4. National Coverage Determination (NCD) for Neuromuscular Electrical Stimulaton (NMES) (160.12). https://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.12&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced

5. National Coverage Determination (NCD) for Electrotherapy for Treatment of Facial Nerve Paralysis (Bell’s Palsy) (160.15) http://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=160.15&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced

6. National Coverage Determination (NCD) for Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions (240.3). http://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=240.3&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced

7. National Coverage Determination (NCD) for Infrared Therapy Devices (270.6) http://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=270.6&bc=IAAAAAAAAAAAAA%3d%3d&&SearchType=Advanced

8. Local Coverage Determination (LCD) for Medicine: Physical Therapy-Outpatient (L34310). Cahaba Government Benefit Administrators®.,Alabama, Georgia, Tennessee https://www.cms.gov/medicare-coverage-database/details/lcd-



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details.aspx?LCDId=34310&ver=11&Date=03%2f28%2f2017&DocID=L34310&bc=iAAAABAAAAAAAA%3d%3d&

9. Local Coverage Determination (LCD) for Medicine: Physical Therapy- Outpatient (L34308) Cahaba Government Benefit Administrators®.,Alabama, Georgia, Tennessee https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34308&ver=14&Date=03%2f28%2f2017&DocID=L34308&bc=iAAAABAAAAAAAA%3d%3d&

10. Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L34049) CGS Administrators, LLC., Kentucky, Ohio https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34049&ver=18&Date=03%2f28%2f2017&DocID=L34049&bc=iAAAABAAAAAAAA%3d%3d&

11. Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L33631) National Government Services, Inc. Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, Wisconsin https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33631&ver=18&Date=03%2f28%2f2017&DocID=L33631&bc=iAAAABAAAAAAAA%3d%3d&

12. Local Coverage Determination (LCD) for Therapy and Rehabilitation Services (L33413) First Coast Service Options, Inc. Florida https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33413&ver=19&Date=03%2f28%2f2017&DocID=L33413&bc=iAAAABAAAAAAAA%3d%3d&

13. Local Coverage Determination (LCD) for Therapy and Rehabilitation Services (L35036) Novitas Solutions, Inc. Arkansas, Colorado, Delaware, District of Columbia, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, Pennsylvania, Texas https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35036&ver=64&Date=03%2f28%2f2017&DocID=L35036&bc=iAAAABAAAAAAAA%3d%3d&

References 14. ACOEM Practice Guidelines, American College of Occupational and Environmental

Medicine, 2011 15. APTA, Defining Skilled Maintenance Therapy and Minimizing Denials, April, 2014. 16. Bischel, Margaret D., ‘The Managed Physical/Occupational Therapy and

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19. Dutton, Mark, Orthopaedic Examination, Evaluation, & Intervention, McGraw-Hill Medial Publishing Division, 2004

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