All Service Codes
420 (REV) - Physical Therapy
421 (REV) - Physical Therapy: Visit charge
422 (REV) - Physical Therapy: Hourly charge
423 (REV) - Physical Therapy: Group rate
424 (REV) - Physical Therapy: Evaluation/re-evaluation
429 (REV) - Physical Therapy: Other physical therapy
97001 (CPT) - Physical therapy evaluation
97002 (CPT) - Physical therapy re-evaluation
97010 (CPT) - Application of a modality to one or more areas; hot or cold packs
97012 (CPT) - Physical Therapy: traction, mechanical
97014 (CPT) - Application of a modality to one or more areas; electrical stimulation (unattended)
97016 (CPT) - Application of a modality to one or more areas; vasopneumatic devices
97022 (CPT) - Physical Therapy: whirlpool
97024 (CPT) - Application of a modality to one or more areas; diathermy (eg, microwave)
97026 (CPT) - Application of a modality to one or more areas; infrared
97028 (CPT) - Application of a modality to one or more areas; ultraviolet
97032 (CPT) - Physical Therapy: electrical stimulation, each 15 min
97033 (CPT) - Physical Therapy: iontophoresis, each 15 min
97034 (CPT) - Application of a modality to one or more areas; contrast baths, each 15 minutes
97035 (CPT) - Physical Therapy: ultrasound, each 15 minutes
97039 (CPT) - Unlisted modality (specify type and time if constant attendance)
97110 (CPT) - Exercises to develop strength and endurance; each area 15 min
97112 (CPT) - Neuromuscular reeducation of movement activities; each area 15 min
97113 (CPT) - Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with
97116 (CPT) - Gait training; each area 15 min
97139 (CPT) - Unlisted therapeutic procedure (specify)
97140 (CPT) - Manual therapy techniques, one or more regions, each 15 min.
97150 (CPT) - Therapeutic procedure(s), group (2 or more individuals)
97750 (CPT) - Physical performance test or measurement (eg, musculoskeletal
Fluidized Therapy for Dry Heat (CPT code 97022)
Fluidized therapy is a high intensity heat modality consisting of a dry whirlpool of finely divided solid particles suspended in a heated air stream, the mixture having properties of a liquid. Use of fluidized therapy dry heat is considered medically necessary when provided as part of a plan of care for patients having acute or subacute traumatic or nontraumatic musculoskeletal disorders of the extremities.
Diathermy (CPT code 97024)
Short wave diathermy is an effective modality for heating skeletal muscle. Because heating is accomplished without physical contact between the modality and the skin, it can be used even if skin is abraded, as long as there is no significant edema. The use of diathermy is considered medically necessary for the delivery of heat to deep tissues such as skeletal muscle and joints for the reduction of pain, joint stiffness, and muscle spasms.
Specific indications for the use of diathermy include:
the patient has osteoarthritis, rheumatoid arthritis, or traumatic arthritis;
the patient has sustained a strain or sprain;
the patient has acute or chronic bursitis;
the patient has sustained a traumatic injury to muscle, ligament, or tendon resulting in functional loss;
the patient has a joint dislocation or subluxation;
the patient requires treatment for a post surgical functional loss;
the patient has an adhesive capsulitis; and/or
the patient has a joint contracture.
Diathermy is not considered medically necessary for the treatment of asthma, bronchitis, or any other pulmonary condition. Please refer to the ICD-10 Codes that Do Not Support Medical Necessity Section of the policy.
Diathermy/Diapulse (CPT code 97024)
High energy pulsed wave diathermy machines have been determined to produce the same therapeutic benefit as standard diathermy; therefore, any reimbursement for diathermy will be made at the same level as standard diathermy.
Diathermy/Microwave (CPT code 97024)
Because there is no evidence from published, controlled clinical studies demonstrating the efficacy of this modality, this service will be denied as not reasonable and necessary.
Ultraviolet Therapy (CPT code 97028)
Photons in the ultraviolet (UV) spectrum are more energetic than those in the visible or infrared regions. Their interaction with tissue and bacteria can produce nonthermal photochemical reactions, the effects of which provide the rationale for ultraviolet treatment. Ultraviolet light is highly bacteriocidal to motile bacteria, and it increases vascularization at the margins of the wounds.
The application of ultraviolet therapy is considered medically necessary for the patient requiring the application of a drying heat. The specific indications for this therapy are:
A patient having an open wound. Minimal erythema dosage must be documented.
Severe psoriasis limiting range of motion.
Electrical Stimulation (Manual) (CPT code 97032)
This modality includes the following types of electrical stimulation:
Transcutaneous electrical nerve stimulation which produces analgesia, strengthening, and functional electrical stimulation. The use of electrical stimulation is considered medically necessary to reduce pain and/or edema and achieve muscular contraction during exercise.
High voltage pulsed current, also called electrogalvanic stimulation, which may be useful for the reduction of swelling and the control of pain.
Neuro-muscular stimulation which is used for retraining weak muscles following surgery or injury and is taken to the point of visible muscle contraction.
Interferential current/medium current units, which use a frequency that allows the current to go deeper. IFC is used to control swelling and pain.
Specific indications for the use of electrical stimulation include:
the patient has documented dependent peripheral edema with an accompanying reduction in the ability to contract muscles;
the patient has a documented reduction in the ability to contract muscles or in the strength of the muscle contraction;
the patient has a condition that requires an educational program for self-stimulation of denervated muscle (educational program should be limited to 5-7 sessions);
the patient has a condition that requires muscle re-education involving a training program (e.g., functional electrical stimulation);
the patient has a painful condition that requires analgesia or a muscle spasm that requires reduction prior to an exercise program; or
the patient is undergoing treatment for disuse atrophy using a specific type of neurostimulator (NMES) which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. 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).
Standard treatment is 3 to 4 sessions a week for one month when used as adjunctive therapy or for muscle retraining. Additional sessions must meet medical necessity requirements.
Electrical stimulation used in the treatment of facial nerve paralysis, commonly known as Bellls Palsy, is considered investigational and noncovered. Please refer to the ICD-10 Codes that Do Not Support Medical Necessity section.
Electrical nerve stimulation used to treat motor function disorders, such as multiple sclerosis, is considered investigational and, therefore, noncovered.
Electrical stimulation should not be reported for wound care of any sort because wound care does not require constant attendance.
See Electrical Stimulation for Indications Other Than Wound Care (G0283) for pelvic floor electrical stimulators.
Iontophoresis Application (CPT code 97033)
Iontophoresis is a process in which electrically charged molecules or atoms (e.g., ions) are driven into tissue with an electric field. Voltage provides the driving force. Parameters such as drug polarity and elecrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites in or below the skin.
The application of iontophoresis is considered medically necessary for the topical delivery of medications into a specific area of the body. The medication and dosage information may be recorded in the plan of treatment or maintained on a separate prescription signed by the health care provider responsible for certifying the plan of treatment.
Specific indications for the use of iontophoresis application include:
the patient has tendonitis or calcific tendonitis;
the patient has bursitis; or
the patient has adhesive capsulitis.
Contrast Baths (CPT code 97034)
Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications are possible, contrast baths often are used in treatment programs for rheumatoid arthritis and reflex sympathetic dystrophy.
The use of contrast baths is considered medically necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.
Specific indications for the use of contrast baths include:
the patient has rheumatoid arthritis or other inflammatory arthritis;
the patient has reflex sympathetic dystrophy; or
the patient has a sprain or strain resulting from an acute injury.
Ultrasound Application (CPT code 97035)
Therapeutic ultrasound is a deep heating modality that produces a sound wave of 0.8 to 3.0 Mhz. In the human body ultrasound has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of ultrasound, as much as 30% more. Because of the increased extensibility ultrasound produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted range of motion.
The application of ultrasound is considered medically necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.
Specific indications for the use of Ultrasound Application include:
the patient has tightened structures limiting joint motion that require an increase in extensibility; or
the patient has symptomatic soft tissue calcification.
Ultrasound Application is not considered to be medically necessary for the treatment of asthma, bronchitis, or any other pulmonary condition. Please see ICD-10 Codes That Do Not Support Medical Necessity section of the policy.
Standard treatment is 3-4 treatments per week for one month. Additional treatments must meet medical necessity requirements.
Hubbard Tank (CPT code 97036):
Please refer to procedure code 97022 for clinical guidelines for procedure code 97036.
Unlisted Therapeutic Procedure (CPT Code 97039)
When using an unlisted service or procedure code, providers must submit documentation to support the medical necessity and rationale for using this treatment modality. Please refer to the Documentation Requirementss section of this LCD.
Therapeutic Exercise (CPT code 97110)
Therapeutic exercise is performed on dry land with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening).
Therapeutic exercise is considered medically necessary if at least one of the following conditions is present and documented:
the patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance, or
the patient needing to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or re-education.
Neuromuscular Reeducation (CPT code 97112)
This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkreis, Bobath, BAPPs boards, and desensitization techniques).
Neuromuscular reeducation may be considered medically necessary if at least one of the following conditions is present and documented:
the patient has the loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs, and/or fingers;
the patient has nerve palsy, such as peroneal nerve injury causing foot drop; or
the patient has muscular weakness or flaccidity as a result of a cerebral dysfunction, a nerve injury or disease, or having had a spinal cord disease or trauma.
Aquatic Therapy with Therapeutic Exercise (CPT code 97113)
This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). Hydrotherapy is useful in post-operative extremity (joint) rehabilitation (e.g., total hip or knee arthroplasty, total shoulder, elbow, wrist arthroplasty).
Aquatic therapy with therapeutic exercise may be considered medically necessary if at least one of the following conditions is present and documented:
the patient has rheumatoid arthritis;
the patient has had a cast removed and requiring mobilization of limbs;
the patient has paraparesis or hemiparesis;
the patient has had a recent amputation;
the patient is recovering from a paralytic condition;
the patient requires limb mobilization after a head trauma; or
the patient is unable to tolerate exercise for rehabilitation under gravity based weight bearing.
Gait Training (CPT code 97116)
This procedure may be medically necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.
Specific indications for gait training include:
the patient has suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation;
the patient has recently suffered a musculoskeletal trauma, either due to an accident or surgery, requiring ambulation education;
the patient has a chronic, progressively debilitating condition for which safe ambulation has recently become a concern;
the patient has had an injury or condition that requires instruction in the use of a walker, crutches, or cane;
the patient has been fitted with a brace prosthesis and requiring instruction in ambulation; and/or
the patient has a condition that requires retraining in stairs/steps or chair transfer in addition to general ambulation.
Neuromuscular Electrical Stimulation (NMES) (CPT code 97116)
Coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins). (See 160.13 for an explanation of coverage of medically necessary supplies for the effective use of NMES.) Use for Walking in Patients with Spinal Cord Injury (SCI).