PG0158 – 12/15/2020 Physical Therapy (PT) and Occupational Therapy (OT) Policy Number: PG0158 Last Review: 10/09/2018 GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual
Physical Therapy (PT) and Occupational Therapy (OT) Policy Number: PG0158 Last Review: 10/09/2018 ADVANTAGE | ELITE | HMO INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement. SCOPE X Professional _ Facility DESCRIPTION Physical therapy (PT) is the treatment of disorders or injuries using physical methods or modalities. A PT modality is often defined as any physical agent applied to produce therapeutic changes to biologic tissues. Modalities that are generally accepted for use include exercises, thermal, cold, ultrasonic or electric energy devices. Due to the passive nature of therapeutic modalities, they are generally used to enable the patient to take part in active aspects of therapy. PT may be indicated for treatment of muscle weakness, limitations in the range of motion, neuromuscular conditions, musculoskeletal conditions, lymphedema and for selected training of patients in specific techniques and exercises for their own continued use at home. Therapeutic procedures are intended as a means of effecting change using clinical skills and/or techniques and/or services whose goal is the improvement of function. PT procedures in general include therapeutic exercises and joint mobilization. These have generally been shown to be one set of effective means of treating aspects of many musculoskeletal conditions. Medically necessary PT services must be restorative in nature or for the specific purposes of designing and teaching a maintenance program for the patient to carry out at home. The services must also relate to a written treatment plan and be of the level of complexity that requires the judgment, knowledge and skills of a physical therapist (or medical doctor/doctor of osteopathy) to perform and/or directly supervise. The amount, frequency and duration of PT services must be seen as medically appropriate for the specific treatment regimen and be performed by a physical therapist. The services must not be of a palliative nature or provided for maintenance of the patient's status. A qualified physical therapist for benefit coverage purposes is a person who is licensed as a physical therapist by the state in which he or she is practicing. A physical therapy assistant (PTA) is a person who is licensed as a PTA, if applicable, by the state in which he or she is practicing. The services of a PTA must be supervised by a licensed physical therapist at a level of supervision determined by state law or regulation. The services of a PTA cannot be provided incidental to a physician/appropriately licensed other practitioner as they are not specifically qualified as licensed physical therapists. Occupational therapy (OT) is a form of rehabilitation therapy involving the treatment of neuromuscular and other dysfunction through the use of specific tasks or goal-directed activities to improve an individual's functional performance. This is intended to help a patient regain performance skills lost through injury or illness. Individual PG0158 12/15/2020 patient programs are designed to improve quality of life through the recovery of specific competences, maximizing independence and the prevention of specific illness or disability. OT includes helping patients learn or relearn specific daily living skills (eg, basic activities of daily living or ADLs) such as dressing, eating, personal hygiene, self-care and mobility/transfers. OT also includes specific task oriented therapeutic activities designed to restore physical function of the shoulder, elbow, wrist and/or hand that has been lost as a result of illness or injury. Occupational therapy can include the design, fabrication and fitting/maintenance of orthotics and related self-help devices including the fitting/fabrication of splints for the upper extremity. Medically necessary OT services must be restorative in nature or for the specific purposes of designing and teaching a maintenance program for the patient to carry out at home. The services must also relate to a written treatment plan and be of the level of complexity that requires the judgment, knowledge and skills of an occupational therapist (or medical doctor/doctor of osteopathy) to perform and/or directly supervise these services. The amount, frequency and duration of occupational therapy services must be medically appropriate for the specific treatment regimen and be performed by an occupational therapist. These services must not be of a palliative nature or provided for maintenance of the patient's status. A qualified occupational therapist for benefit coverage purposes is a person who is licensed as an occupational therapist by the state in which he or she is practicing. An occupational therapy assistant (OTA) is a person who is licensed as an OTA, if applicable, by the state in which he or she is practicing. The services of an OTA must be supervised by a licensed occupational therapist at a level of supervision determined by state law or regulation. The services of an OTA cannot be provided incidental to a physician/appropriately licensed other practitioner as they are not specifically qualified as licensed occupational therapists. POLICY Refer to CODING/BILLING INFORMATION below for complete coverage determination. Procedure 97014 is non-covered for Elite/ProMedica Medicare Plan. HCPCS code G0283 should be used for unattended electrical stimulation, to one or more areas for indications other than wound care, in place CPT code 97014 for Elite/ProMedica Medicare Plan. Procedure 97010 is bundled and not eligible for separate reimbursement for all product lines. Kinesio taping is non-covered for all product lines. Refer to PG0036 Vertebral Axial Decompression Therapy for coverage determination for procedure S9090. Refer to PG0150 Chiropractic Services & Spinal Manipulation for coverage determination for procedures 98940-98943. Refer to PG0402 Cognitive Rehabilitation for specific coverage criteria for procedure 97127. COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Refer to specific contract language regarding physical and/or occupational therapy. Most contracts limit the duration or number of visits. NOTE: The new evaluation codes for PT (97161, 97162, & 97163) and OT (97165, 97166, & 97167) are based on patient low, moderate or high complexity and the level of clinical decision-making. The re-evaluation codes for PT (97164) and OT (97168) are reported for an established patient's when a revised plan of care is indicated. These new codes must support the documentation requirements as outlined within the CPT parenthetical. The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered: PG0158 12/15/2020 GO - Services delivered under an outpatient occupational therapy plan of care; or, GP - Services delivered under an outpatient physical therapy plan of care. Physical therapy (PT) Paramount covers a physical therapy evaluation as medically necessary for the assessment of a physical impairment. Paramount covers a prescribed course of physical therapy by an appropriate healthcare provider as medically necessary when ALL of the following criteria are met: The program is designed to improve lost or impaired physical function or reduce pain resulting from illness, injury, congenital defect or surgery. The program is expected to result in significant therapeutic improvement over a clearly defined period of time. The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals. The use of Kinesio taping is unproven and not medically necessary due to insufficient clinical evidence of safety and/or efficacy in published peer-reviewed medical literature. Paramount does not cover physical therapy for the treatment of ANY of the following conditions because it is considered experimental, investigational or unproven: constipation dyspareunia vaginismus vulvodynia/vulvar vestibulitis sexual dysfunction unrelated to musculoskeletal or orthopedic condition scoliosis (e.g., Schroth Method of therapy for scoliosis) Occupational therapy (OT) Paramount covers an occupational therapy evaluation as medically necessary for the assessment of a physical impairment. Paramount covers a prescribed course of occupational therapy by an appropriate healthcare provider as medically necessary when ALL of the following criteria are met: The program is designed to improve or compensate for lost or impaired physical functions, particularly those impacting activities of daily living. The program is expected to result in significant therapeutic improvement over a clearly defined period of time. The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals. For a child, the treatment plan includes active participation/involvement of a parent or guardian. MODALITIES (97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, & G0283) CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention. CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another procedure at the same time. Only the actual time of the provider's direct contact with the patient, providing services requiring the skills of a therapist, is covered for these codes. Modalities chosen to treat the patient's symptoms/conditions should be selected based on the most effective and efficient means of achieving the patient's functional goals. Seldom should a patient require more than one (1) or two (2) modalities to the same body part during the therapy session. Use of more than two (2) modalities on each visit date is unusual and should be carefully justified in the documentation. PG0158 12/15/2020 The use of modalities as stand-alone treatments is rarely therapeutic, and usually not required or indicated as the sole treatment approach to a patient's condition. The use of exercise and activities has proven to be an essential part of a therapeutic program. Therefore, a treatment plan should not consist solely of modalities, but should also include therapeutic procedures. (There are exceptions, including wound care or when patient care is focused on modalities because the acute patient is unable to endure therapeutic procedures.) Use of only passive modalities that exceeds 4 visits should be very well supported in the documentation. Multiple heating modalities should not be used on the same day. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation must support the use of multiple modalities as contributing to the patient's progress and restoration of function. For example, it would not be medically necessary to perform both thermal ultrasound and thermal diathermy on the same area, in the same visit, as both are considered deep heat modalities. When the symptoms that required the use of certain modalities begin to subside and function improves, the medical record should reflect the discontinuation of those modalities, so as to determine the patient's ability to selfmanage any residual symptoms. As the patient improves, the medical record should reflect a progression of the other procedures of the treatment program (therapeutic exercise, therapeutic activities, etc). In all cases, the patient and/or caregiver should be taught aspects of self-management of his/her condition from the start of therapy. Based on the CPT descriptors, these modalities apply to one or more areas treated (e.g., paraffin bath used for the left and right hand is billed as one unit). Hot or cold packs therapy (97010) Code 97010 is bundled. It may be bundled with any therapy code. Regardless of whether code 97010 is billed alone or in conjunction with another therapy code, this code is never paid separately. If billed alone, this code will be denied. Mechanical traction therapy (97012) Traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas. Specific indications for the use of mechanical traction include cervical and/or lumbar radiculopathy and back disorders such as disc herniation, lumbago, and sciatica. This modality is typically used in conjunction with therapeutic procedures, not as an isolated treatment. Documentation should support the medical necessity of continued traction treatment in the clinic for greater than 12 visits. For cervical conditions, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home. The time devoted to patient education related to the use of home traction should be billed under 97012. Only 1 unit of CPT code 97012 is covered per date of service. Equipment and tables utilizing roller systems are not considered true mechanical traction. Services using this type of equipment are non-covered. Supportive documentation should include type of traction and part of the body to which it is applied, etiology of symptoms requiring treatment. Electrical stimulation (unattended) (G0283) Most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment. Code G0283 is classified as a "supervised" modality, even though it is labeled as "unattended." A supervised modality does not require direct (one-on-one) patient contact by the provider. Most electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples of unattended electrical PG0158 12/15/2020 stimulation modalities include Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation). These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement. Note: 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). If unattended electrical stimulation is used for control of pain and swelling, there should be documented objective and/or subjective improvement in swelling and/or pain within 6 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality. Documentation must clearly support the need for electrical stimulation more than 12 visits. Some patients can be trained in the use of a home TENS unit for pain control. Only 1-2 visits should be necessary to complete the training (which may be billed as 97032). Once training is completed, code G0283 should not be billed as a treatment modality in the clinic. THERAPEUTIC PROCEDURES (97110, 97112, 97113, 97116, 97124, 97127, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97763 and 97799) Therapeutic procedures attempt to reduce impairments and restore function through the application of clinical skills and/or services. Use of these procedures is expected to result in improvement of the limitations/deficits in a reasonable and generally predictable period of time. Use of these procedures requires the qualified professional/auxiliary personnel to have direct (one-on-one) patient contact. Only the actual time of direct contact with the patient providing a service which requires the skills of a therapist is considered for coverage. Supervision of a previously taught exercise or exercise program, patients performing an exercise independently without direct contact by the qualified professional/auxiliary personnel, or use of different exercise equipment without requiring the intervention/skills of the qualified professional/ auxiliary personnel are not covered. The patient may be in the facility for a longer period of time, but only the time the qualified professional/auxiliary personnel is actually providing direct, one-on-one, patient contact which requires the skills of a therapist is considered covered time for these procedures, and only those minutes of treatment should be recorded. Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code; there is no separate coverage for time spent on documentation. CPT codes 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97760, 97761, and 97763 describe different types of therapeutic interventions. The expected goals documented in the treatment plan, affected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of these procedures may be used in a treatment plan, documentation must support the use of each procedure as it relates to a specific therapeutic goal. Massage therapy (97124) If massage therapy is not specifically excluded from coverage in the benefit plan, the following condition of coverage applies. Massage therapy may be medically necessary as adjunctive treatment to another therapeutic procedure on the same day, which is designed to reduce edema, improve joint motion, or relieve muscle spasm. Massage therapy is considered a covered service ONLY when provided by a person who is recognized by Medicare as a physical therapy provider. Massage is non-covered as an isolated treatment. Paramount does not cover massage therapy when it is provided in the absence of other covered physical therapy, occupational therapy or chiropractic modalities because it is considered not medically necessary. PG0158 12/15/2020 Paramount covers massage therapy ONLY when provided as one component of a medically necessary and covered comprehensive physical therapy or chiropractic treatment plan. Massage chairs, aqua massage tables and roller beds are not considered massage and are non-covered. CPT code 97124 is non-covered on the same visit date as CPT code 97140 (manual therapy techniques). Do not bill 97124 for percussion for postural drainage. Documentation must clearly support the need for continued massage beyond 6-8 visits, including instruction, as appropriate, to the patient and caregiver for continued treatment. Supportive Documentation Recommendations for 97124: Area(s) being treated Objective clinical findings such as measurements of range of motion, description of muscle spasms and effect on function Subjective findings including pain ratings, pain location, effect on function Unlisted Codes (97039, 97139, 97799) Procedures/services that are billed with an unlisted code must meet medical necessity guidelines appropriate to the procedure/service. Miscellaneous Services (Non-covered) The following are non-covered as skilled therapy services (this list may not be all-inclusive): Iontophoresis, except as indicated for primary focal hyperhidrosis Anodyne Low level laser treatment (LLLT)/cold laser therapy Dry hydrotherapy massage (e.g., aquamassage, hydromassage, or water massage) Massage chairs or roller beds Interactive metronome therapy (Brain Bright Therapy) Loop reflex training Vestibular ocular reflex training Continuous passive motion (CPM) device setup and adjustments Craniosacral therapy Electro-magnetic therapy, except as indicated for chronic wounds Constraint Induced Movement Therapy (CIMT) Driving assessments Work-hardening programs Pelvic Floor Dysfunction (not including incontinence) o Due to the lack of peer reviewed evidence concerning the effect on patient health outcomes, skilled therapy interventions (e.g., ultrasound, electrical stimulation, soft tissue mobilization, and therapeutic exercise) for the treatment of the following conditions is considered investigational and thus noncovered. pelvic floor congestion pelvic floor pain not of spinal origin hypersensitive clitoris prostatitis cystourethrocele enterocele rectocele vulvodynia vulvar vestibulitis syndrome (VVS) PG0158 12/15/2020 CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. CPT CODES COMMERCIAL ADVANTAGE ELITE 97001 Physical therapy evaluation (Deleted code effective 12/31/16) COVER COVER COVER 97002 Physical therapy re-evaluation (Deleted code effective 12/31/16) COVER COVER COVER 97003 Occupational therapy evaluation (Deleted code effective 12/31/16) COVER COVER COVER 97004 Occupational therapy re-evaluation (Deleted code effective 12/31/16) COVER COVER COVER 97010 Application of a modality to one or more areas; hot or cold packs BUNDLE BUNDLE BUNDLE 97012 Application of a modality to 1 or more areas; traction, mechanical COVER COVER COVER 97014 Application of a modality to one or more areas; electrical stimulation (unattended) COVER NC NC 97016 Application of a modality to one or more areas; vasopneumatic devices COVER COVER COVER 97018 Application of a modality to one or more areas; paraffin bath COVER COVER COVER 97022 Application of a modality to one or more areas; whirlpool COVER COVER COVER 97024 Application of modality to one or more areas; diathermy (e.g., microwave) COVER COVER COVER 97026 Application of a modality to one or more areas; infrared COVER NC NC 97028 Application of a modality to one or more areas; ultraviolet COVER NC COVER Application of a modality to one or more 97032 areas; electrical stimulation (manual), each COVER COVER COVER 15 minutes 97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes COVER NC COVER 97034 Application of a modality to one or more areas; contrast baths, each 15 minutes COVER COVER COVER 97035 Application of a modality to one or more areas; ultrasound, each 15 minutes COVER COVER COVER 97036 Application of a modality to one or more areas; Hubbard tank, each 15 minutes COVER COVER COVER 97039 Unlisted modality (specify type and time if constant attendance) BY REVIEW NC BY REVIEW Therapeutic procedure, one or more areas, 97110 each 15 minutes; therapeutic exercises to develop strength and endurance, range of COVER COVER COVER motion and flexibility Therapeutic procedure, one or more areas, 97112 each 15 reeducation minutes; neuromuscular of movement, balance, COVER COVER COVER coordination, kinesthetic sense, posture, PG0158 12/15/2020 97113 97116 97124 97127 97139 97140 97150 97161 97162 and/or proprioception for sitting and/or standing activities Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact (New code effective 01/01/2018) Unlisted therapeutic procedure (specify) Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Therapeutic procedure(s), group (2 or more individuals) Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family. Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body COVER COVER COVER COVER BY REVIEW COVER COVER COVER COVER PG0158 12/15/2020 COVER COVER COVER COVER NC COVER COVER COVER COVER COVER COVER COVER COVER BY REVIEW COVER COVER COVER COVER 97163 97164 97165 structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family. Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family. Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1- 3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem- focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. PG0158 12/15/2020 COVER COVER COVER COVER COVER COVER COVER COVER COVER 97166 97167 Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family. Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. PG0158 12/15/2020 COVER COVER COVER COVER COVER COVER 97168 97530 97532 97533 97535 97537 97542 97545 97546 97750 97755 Typically, 60 minutes are spent face-to-face with the patient and/or family. Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes (Deleted code effective 12/31/17) Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes Wheelchair management (eg, assessment, fitting, training), each 15 minutes Work hardening/conditioning; initial 2 hours Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure) Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes Assistive technology assessment (eg, to restore, augment or compensate for PG0158 12/15/2020 COVER COVER COVER COVER COVER COVER COVER NC NC COVER COVER COVER COVER COVER COVER COVER COVER NC NC NC COVER COVER COVER COVER COVER COVER COVER COVER COVER NC NC COVER COVER existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes Orthotic(s) management and training (including assessment and fitting when not 97760 otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes Prosthetic(s) training, upper and/or lower 97761 extremity(ies), initial prosthetic(s) encounter, each 15 minutes Checkout for orthotic/prosthetic use, 97762 established patient, each 15 minutes (Deleted code effective 12/31/17) Orthotic(s)/ prosthetic(s) management and/or training, upper extremity(ies), lower 97763 extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes (New code effective 01/01/2018) 97799 Unlisted physical medicine/rehabilitation service or procedure HCPCS CODES Occupational therapy services requiring the skills of a qualified occupational therapist, G0129 furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more) Electrical stimulation (unattended), to one G0283 or more areas for indication(s) other than wound care, as part of a therapy plan of care S8940 Equestrian/hippotherapy, per session S8990 Physical or manipulative therapy performed for maintenance rather than restoration S9117 Back school, per visit MODIFIERS GO Services delivered under an outpatient occupational therapy plan of care; or, GP Services delivered under an outpatient physical therapy plan of care. COVER COVER COVER COVER BY REVIEW HMO NC COVER NC NC NC HMO REQUIRED REQUIRED COVER COVER COVER COVER NC ADVANTAGE NC NC NC NC NC ADVANTAGE REQUIRED REQUIRED COVER COVER COVER COVER BY REVIEW ELITE NC COVER NC NC NC ELITE REQUIRED REQUIRED REVISION HISTORY EXPLANATION ORIGINAL EFFECTIVE DATE: 05/30/2008 07/12/16: Changed name from Massage therapy to Physical Therapy (PT) and Occupational Therapy (OT). Added codes 97001, 97002, 97003, 97004, 97010, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97762, 97799, G0129, G0283, S8940, S8990, S9117. Per the Medicare Tactical Team Meeting review and determination, code 97014 is non-covered for Elite per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 02/14/17: Effective 12/31/16 deleted codes 97001-97004. Added effective 01/01/17 new codes 9716197168. Added Modifiers GO & GP. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. PG0158 12/15/2020 10/10/17: Code 97012 added as covered for all product lines with limit of 1 unit per date of service. Kinesio taping added as non-covered for all product lines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 01/09/18: Effective 12/31/17 deleted codes 97532 & 97762. Revised effective 01/01/18 codes 97760 & 97761. Added effective 01/01/18 new codes 97127 & 97763. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 05/24/18: Added Miscellaneous Services (Non-covered) per CMS guidelines that includes Interactive metronome therapy (Brain Bright Therapy). Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG). 09/25/18: Verbiage regarding Advantage limits removed per administrative direction. 10/09/18: Manual therapy (97140) no longer requires prior authorization for children 0-3 years of age for all product lines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG). 12/15/2020: Medical policy placed on the new Paramount Medical Policy Format. REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc. PG0158 12/15/2020Microsoft Word 2016 Microsoft Word 2016