Vasopneumatic Devices (CPT code 97016)
The use of vasopneumatic devices may be considered medically necessary for the application of pressure to an extremity for the purpose of reducing edema.
Specific indications for the use of vasopneumatic devices include:
reduction of edema after acute injury;
lymphedema of an extremity; and/or education on the use of a lymphedema pump for home use.Note: Further treatment of lymphedema by a provider after the educational visits are generally not medically necessary.
Education on the use of a lymphedema pump for home use can typically be completed in no more than three (3) visits.
The use of vasopneumatic devices would not be covered as a temporary treatment while awaiting receipt of ordered Jobst stockings.
97016—Vasopneumatic devices. These devices are used to reduce edema in an extremity or to treat lymphedema. Patient education in the use of a lymphedema pump would be included in this code. Training with the patient must occur in person. Many insurance companies and Medicare contractors allow two to four treatments of this.
Additional treatments may be reimbursed if documentation supports medical necessity of the intervention and why it requires the unique skills of a PT or OT. This could occur if the patient has circulatory deficiencies, areas of impaired sensation, open wounds, or fractures.
97018—Paraffin bath. This superficial heating modality is used primarily for pain reduction in the hands and feet. Instruction to the patient in home use of paraffin must occur face to face with the patient. Many insurance companies and Medicare contractors allow two to four treatments of this. Additional treatments may be reimbursed if documentation supports medical necessity of the intervention and why it requires the unique skills of a PT or OT as outlined above in CPT code 97016.
97022—Whirlpool. This code includes wet and dry whirlpool. Whirlpools agitate water to relieve muscle spasm, reduce pain, and cleanse the wounds. Some Medicare carriers and FIs, as well as other insurance companies, also accept 97022 when billing for fluidotherapy that is considered to be a dry whirlpool.10 A whirlpool may require the skills of a therapist when the patient’s condition is complicated by circulatory deficiencies, areas of impaired sensation, impaired mobility or limitations in the positioning of the patient, safety concerns if left unsupervised, or open wounds. This list is not all inclusive.
Paraffin Bath (CPT code 97018)
Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands, and feet.
Specific indications for the use of paraffin baths include:
the patient has a contracture as a result of rheumatoid arthritis;
the patient has a contracture as a result of scleroderma;
the patient has acute synovitis;
the patient has post-traumatic conditions;
the patient has hypertrophic scarring;
the patient has degenerative joint disease;
the patient has osteoarthritis;
the patient has post-surgical conditions or tendon repairs, or;
the patient who is status post sprains or strains.
Paraffin Bath, also known as hot wax treatment, is primarily used for pain to increase flexibility of soft tissue, and relief in chronic joint problems of the wrists, hands, and feet.
Heat treatments of this type do not ordinarily require the skills of a qualified occupational therapist. However, in a particular case, the skills, knowledge and judgment of a qualified occupational therapist might be required in such treatments or baths, e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications. Also, if such treatments are given prior to but as an integral part of a skilled occupational therapy procedure, the treatments would be considered part of the occupational therapy service.
97016 Application of a modality to one or more areas; vasopneumatic devices
* It may be necessary to reduce edema after acute injury.
* Education for use of lymphedema pump in the home usually requires no more than 2 sessions.
* Further treatment of lymphedema by the provider after the educational visits is generally not medically necessary.
* Supportive documentation for additional visits must be available for review.
97018 Application of a modality to one or more areas; paraffin bath
* Also known as hot wax treatment, this is primarily used for pain relief in chronic joint problems of the wrist, hands, or feet.
* No more than two visits are usually sufficient to educate the patient in home use and to evaluate effectiveness.
* Continued treatment by a provider may require supportive documentation of medical necessity.
97020 Application of a modality to one or more areas; microwave
* Because there is no substantial evidence from published, controlled clinical studies demonstrating the efficacy of this modality, this service will be denied as not proven effective.
97022 Application of a modality to one or more areas; whirlpool
97024 Application of a modality to one or more areas; diathermy
97026 Application of a modality to one or more areas; infrared
* Supervised treatment would not be expected to exceed up to 4 sessions per week for longer than one month. Continued treatment by a provider may require documentation supportive of medical necessity.
* The objective of these treatments is to cause vasodilatation and relieve pain from muscle spasm. Diathermy achieves a greater rise in deep tissue temperature than does infrared. In addition to its use for vasodilatation, whirlpool may also be used for wound debridement.
* It is not medically necessary to have more than one form of hydrotherapy (CPT codes 97022, 97036, 97113) during the same visit.
NOTE: Monochromatic infrared photo energy (MIRE™), anodyne, anodyne therapy, or similar devices are NOT covered services. Therefore, it is not appropriate to bill using 97026 when utilizing monochromatic infrared photo energy (MIRE™), anodyne, anodyne therapy, or similar devices. Please refer to the procedure code 97799 for further instructions.
97028 Application of a modality to one or more areas; ultraviolet
* These services, in addition to all other therapy services, must be prescribed by the attending physician.
Paraffin Bath (CPT code 97018) and Whirlpool Therapy (CPT code 97022)
AOTA objects to the limitation on the number of treatments for these two modalities, i.e., “one or two visits are usually sufficient to educate the patient in home use and to evaluate the effectiveness of the treatment” for paraffin bath and “not performed more than 12 times in one month” for whirlpool therapy.
To enhance the effectiveness of therapeutic procedures, it is often necessary to increase the blood flow and/or decrease muscle spasm. Thermal modalities are use to increase blood flow. Although a hot or cold pack may be effective when treating large body parts, other sources of thermal modalities are more effective for treating small surface areas such as fingers and toes. Both paraffin and whirlpool baths provide an appropriate thermal source for treating small, irregular surface areas. As such, these may be medically necessary modalities for each and every treatment a particular patient requires.
Additionally, AOTA urges the removal of the limitation to 12 treatments per month per our comments on “rules of thumb” described above.
AOTA raises the same issue with regard to the suggestion that these modalities are not appropriate unless the “skills” of a qualified clinician are needed due to a complicated clinical condition such as a “circulatory deficiency, areas of desensitization, open wounds, fractures or other complications.” These may be the only modalities able to create the thermal effects necessary to render the skilled therapeutic procedures. AOTA requests that this limiting language be deleted.
Infrared Application (CPT code 97026)
The application of infrared therapy is considered medically necessary for patients requiring the application of superficial heat in conjunction with other procedures or modalities, to reduce or decrease pain/produce analgesia, reduce stiffness/tension, myalgia, spasm, or swelling.
Effective for services performed on or after October 24, 2006, the Centers for Medicare and Medicaid Services announce a NCS stating the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Medicare beneficiaries. Further coverage guidelines can be found in the National Coverage Determination (Pub. 100-03), Section 270.6. For a list of non-covered ICD-10-CM codes associated with this non-coverage decision is located under ICD-10 Codes that Do Not Support Medical Necessity in the LCD.
Infrared application applied in the absence of associated procedures or modalities, or used alone to reduce discomfort, are considered not medically necessary and therefore, are not covered.
General Modality Guidelines: (97010-97039)
Note: 97010 is bundled into the payment for other services and is not separately reimbursable.
1. Modality codes 97012-97028 require supervision (but not one-on-one) by the provider; and 97032-97039 require direct (one-on-one) contact with the patient by the provider. These services may be provided “incident to” a physician’s services and, if so, must be directly supervised by the physician in his/her office.
2. Modalities 97012 and 97018, are not separately payable when used alone and solely to promote healing, relieve muscle spasm, reduce inflammation and edema, or as analgesia. No more than three visits may be medically necessary to determine the effectiveness of treatment and for patient education. If effective, further treatment may be self-administered in the home and it is not medically necessary to continue treatment by the provider. An exception may be 97012 when used in weaning an acute patient onto a self-administered home program.
3. Generally, adjunctive use of modalities listed in #2 above is required only if the patient cannot tolerate the therapeutic procedures without them. In these circumstances, it may be medically necessary to furnish these modalities in addition to the therapeutic procedures no more than 4 times a week for one month. Continued use of these modalities may be covered if the patient’s record documents that continued use contributed significantly to the patient’s progress.
4. Generally, one heating modality is sufficient during a physical therapy session. Documentation of the medical necessity of multiple heating modalities (97018, 97024, 97026, 97034, 97035) on the same day must be available for review. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired or when dealing with particularly severe hand deformities.
5. Modalities 97022 (whirlpool) and 97036 (Hubbard tank) are subject to the guideline in #4 above when the sole purpose of these modalities is to relieve muscle spasm, inflammation or edema. When 97022 or 97036 are used to treat wounds or other skin conditions, other modalities could be necessary to treat other conditions on the same day.
6. Some of the modalities are considered components of other modalities and procedures and will not be separately reimbursed. Please refer to the National Correct Coding Initiative which can be found on the CMS Website (http://www.cms.hhs.gov/physicians/cciedits/). Documentation must be available supporting the use of multiple modalities as contributing to the patient’s progress and restoration of function.
7. Physical agents and modalities, in the absence of documentation justifying use, and in the absence of other skilled therapeutic or educational interventions, should not be considered physical therapy.
D. Specific Modality Guidelines: The following clinical guidelines pertain to the specific modalities listed below. Please refer to the “ICD-9-CM Codes that Support Medical Necessity” section in this policy for appropriate covered diagnoses to be used with these modalities.
Applicable Outpatient Rehabilitation HCPCS Codes
The CMS identifies the following codes as therapy services, regardless of the presence of a financial limitation. Therapy services include only physical therapy, occupational therapy and speech-language pathology services. Therapist means only a physical therapist, occupational therapist or speech-language pathologist. Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology. Check the notes below the chart for details about each code.
When in effect, any financial limitation will also apply to services represented by the following codes, except as noted below.
NOTE: Listing of the following codes does not imply that services are covered or applicable to all provider settings.
64550+ 90901+ 92506? 92507? 92508 92526
92597 92605**** 92606**** 92607 92608 92609
92610+ 92611+ 92612+ 92614+ 92616+ 95831+
95832+ 95833+ 95834+ 95851+ 95852+ 96105+
96110+9 96111+9 97001 97002 97003 97004
97010**** 97012 97016 97018 97022 97024
97026 97028 97032 97033 97034 97035
97036 97039*? 97110 97112 97113 97116
97124 97139*? 97140 97150 97530 97532+
97533 97535 97537 97542 97597+? 97598+?
97602+****? 97605+? 97606+? 97750 97755 97760**?
97761 97762 97799* G0281 G0283 G0329
0019T+*** 0029T+***
* The physician fee schedule abstract file does not contain a price for CPT codes 97039, 97139, or 97799, since the carrier prices them. Therefore, the FI must contact the carrier to obtain the appropriate fee schedule amount in order to make proper payment for these codes.
