Body …

Bryan Pannenberg

Physical Therapy (PT) and Occupational Therapy (OT)

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 - Body …

PDF PG0158 Physical Therapy and Occupational Therapy
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 ­ 12/15/2020


Microsoft Word 2016 Microsoft Word 2016