BlueCross and BlueShield of Montana Medical Policy/Codes
Physical Therapy (PT) and Occupational Therapy (OT) Services
Chapter: Therapies
Current Effective Date: December 27, 2013
Original Effective Date: February 01, 1991
Publish Date: December 27, 2013
Revised Dates: March 12, 2003; April 11, 2007; March 1, 2010; October 1, 2010; April 19, 2012; December 18, 2013
Description

Physical Therapy is the treatment of disease or injury by the use of therapeutic exercise and other interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, functional activities of daily living, and pain relief. Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiological principles.

Physical therapy services include therapeutic interventions tailored to the specific needs of the patient. Such interventions include therapeutic exercise programs to increase strength and endurance, as well as application of various other modalities including, but not limited to, heat, cold, electrical stimulation, ultrasound, hydrotherapy, and massage or mobilization techniques. These services must be rendered under a written plan of care established by a physician or other qualified non-physician practitioner (e.g., physician assistant), and must be performed by a licensed physical therapist, or by assistive personnel under the supervision of a licensed physical therapist; if performed by assistive personnel, such services shall not exceed his or her education, training and/or licensure. To be considered medically necessary, these modalities must also be proven and accepted as effective and/or safe for the treatment of disease or injury.

Durable condition-specific benefit is:

a measurable improvement in or restoration of a functional impairment that resulted from a specific disease, trauma, congenital anomaly or therapeutic intervention; and able to be sustained long-term without significant deterioration.

A few examples of measurable parameters include ROM measurements, wound measurements, distance the patient can ambulate, and amount of support the patient needs to ambulate.

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

Aquatic therapy is therapeutic PT exercises taking place in or on water, most likely in a swimming pool. This involves the therapist doing manipulation, mobilization or manual stretching and strengthening in the water instead of on land. This type of therapy may be useful following intra-articular and ligament reconstruction in the knee, as well as for walking reeducation, strengthening leg muscles, and enhancing joint range of motion. Aquatic therapy may also be a beneficial form of patient treatment for rheumatic disease.

Whirlpool bath is a therapeutic bath in which all or part of the body is exposed to forceful whirling currents of hot water. Whirlpool bath may be used for debridement of traumatic wounds, burns, pressure ulcers or surgical wounds and as an adjunct means to achieve joint mobility.

Contrast bath is immersion of a part of the body alternately in hot and cold water

Hubbard tank is a tank in which a patient may be immersed for the purpose of permitting him to perform underwater exercise.

Hydrotherapy is the application of water, in any form, but usually externally, in the treatment of disease. Any of the above listed forms of water baths or therapy could be called hydrotherapy.

Occupational therapy (OT) is a form of rehabilitation therapy involving the treatment of neuromusculoskeletal and psychological dysfunction through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual.

Occupational therapy involves cognitive, perceptual, safety, and judgment evaluations and training. These services emphasize useful and purposeful activities to improve neuromusculoskeletal functions and to provide training in activities of daily living (ADL). Activities of daily living include: feeding, dressing, bathing, and other self-care activities. Other occupational therapy services include the design, fabrication, and use of orthoses, and guidance in the selection and use of adapted equipment.

Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Physical therapy (PT) and/or occupational therapy (OT) services may be considered medically necessary when PT or OT services fulfill all of the following criteria:

  • Is reasonably expected to restore acute loss of function to an individual who suffers from functional impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention; AND
  • Will provide durable, condition-specific corrective benefit that is not for maintenance or supportive therapy; AND
  • Will achieve durable, condition-specific corrective benefit in a reasonable and predictable period of time (usually four to six months); AND
  • Requires the judgment, knowledge, and skills of a qualified provider of PT or OT services due to the complexity and sophistication of the therapy and the physical condition of the patient, and cannot be reasonably taught to and implemented by the affected individual and/or nonprofessional caregivers; AND
  • Are delivered to the patient individually by a qualified provider* of PT or OT services. [*NOTE: A qualified provider is one who is licensed where required and performs within the scope of licensure. This may include, but is not limited to, Physical Therapists, Occupational Therapists, Chiropractors, etc.]; AND
  • The following documentation from the medical record is provided:
    1. That the patient is under the care of a physician and/or chiropractor and/or other qualified provider** for the diagnosis and/or condition which requires PT or OT services; AND
    2. A written plan of treatment approved by the patient's physician, relating the type, amount, frequency, and duration of the PT or OT services. NOTE: plan of care should be updated as the patient’s condition changes, and recertified by the physician at least every 30 days; AND
    3. Reasonable expectation that PT or OT will achieve measurable improvement in the patient's condition in a reasonable and predictable period of time (usually four to six months); AND
    4. Written evidence demonstrating progress and effectiveness for ongoing PT or OT services.

**NOTE: If a chiropractor or other qualified provider is the attending provider and will also administer the PT or OT treatment, he or she will prepare the written plan of treatment.

In addition to the above criteria, OT services that may be considered medically necessary include treatments that are expected to result in significant functional improvement, and are for the purpose of enabling the patient to perform activities of daily living.

OT services that consist of non-essential, self-help, or recreational tasks are considered not medically necessary, including training to facilitate reintegration into community and/or work environment (i.e., shopping, money management, educational and vocational activities, gardening, driving, etc.)

Physical therapy in Water (i.e., aquatic therapy, aquatic rehabilitation)

Coverage may be allowed for aquatic therapy as with any other PT modality only when there is documentation in the patient's record that the therapy is administered one-to-one (not in a group) by a physical therapist, or other qualified licensed provider of physical therapy (as noted above).

Coverage may be allowed for whirlpool bath, contrast bath, and Hubbard tank as with any other physical therapy (PT) modality.

NOTE:Physical therapy in water is subject to the same contract and medical limitations and guidelines as any other form of physical therapy.

Coverage is not allowed for:

  • Aquatic aerobics and exercise programs that do not meet all of the listed criteria;
  • Group sessions such as exercise or aerobics classes that do not meet all of the listed criteria;
  • Separate charges for a pool or use of a pool.

Physical therapy for athletic training or athletic training evaluation that does not meet the criteria stated above is considered not medically necessary.

Rationale

None

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member's benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: 97001, 97002, 97003, 97004, 97005, 97006, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97537, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97504, 97530, 97532, 97533, 97535, 97537, 97542, 97545, 97546, 97597, 97598, 97602, 97750, 97755, 97799, G0151, G0152, G0157, G0158, G0159, G0160, S8990
References
  1. Texas Insurance Code, Subchapter E, Chapter 21, Article 21.53Q, Health Benefit Plan Coverage for Certain Benefits Related to Brain Injury (House Bill 1676).
  2. Dorland's Illustrated Medical Dictionary, 27th Edition, 1988.
  3. Rheumatic Disease Clinic of North America (1990 November) 16(4):915-29.
  4. Uniform Medical Policy Manual, Blue Cross and Blue Shield Association, September 1991, Allied Health, Physical Therapy, page 97010.0
  5. Department of Health and Human Services, Office of Inspector General, Physical Therapy in the Physician's Office, March 1994.
  6. Journal of Burn Care Rehabilitation (1994 March-April) 15(2):143-6.
  7. Advance for Physical Therapists, Vol. 2 (3), April 18, 1994, Convincing Insurers that Aquatic PT is more than a Splash in the Pool, page 24 through 26.
  8. Sam CD, search completed April 11, 1996, I Exercise, Health, and Sports Medicine, (1994 April) page 1.
  9. Tovin, B.J., Wolf, S.L., et al. Comparison of the Effects of Exercise in Water and on Land on the Rehabilitation of Patients With Intra-articular Anterior Cruciate Ligament Reconstructions. Physical Therapy (1994 August) 74(8).
  10. U.S. Department of Health and Human Services, AHCPR Publication No. 95-0652, (1994 December) Clinical Practice Guidelines, pages 47 through 52.
  11. Carrier Advisory Committee, February 15, 1995, Physical Medicine and Rehabilitation
  12. Special Medicare Newsletter #135, 6/15/95, Helium Neon Laser Bio stimulation.
  13. Ostomy Wound Management (1995 June) 41(5):34, 36-7.
  14. Kelly, B., Roskin, L., et al. Shoulder muscle activation during aquatic and dry land exercises in non-impaired subjects. Journal of orthopedic and sports physical therapy. (2000 April) 30(4):204-10.
  15. Brooks, Paul V. and Denise Brooks. Hydrotherapy. eMedicine Journal (March 29 2002) 3(3) Accessed on 8/12/05 at http://author.emedicine.com .
  16. Physical Therapy. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2002 April) Therapy 8.03.02.
  17. Occupational Therapy. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2004 November) Therapy 8.03.03.
History
October 2010 Revised the policy per Health Care Reform regulations - maximum dollar benefit limitations were removed.
April 2012 Policy updated with current literature. Policy guidelines reordered and revised.
December 2013 Policy formatting and language revised.  Combined the "Physical Therapy" and "Occupational Therapy" policies.  Title changed to "Physical Therapy (PT) and Occupational Therapy (OT)".
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Physical Therapy (PT) and Occupational Therapy (OT) Services