THERAPY CPT code - 97032, 97035, 97036,

CPT code and description

97032 Electrical stimulation (manual), each 15 minutes

97033 Iontophoresis, each 15 minutes

 97034 Contrast baths, each 15 minutes - Average fee amount $17 - $22

97035 Ultrasound, each 15 minutes

97036 Hydrotherapy, each 15 minutes


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.


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.

 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.

Electrical Stimulation Therapy (CPT code 97032)

Application of a modality to one or more areas, electrical stimulation, manual, each 15 minutes.

CPT code 97032 requires "visual, verbal and/or manual contact" (i.e. constant attendance).


Iontophoresis Application (CPT code 97033)

1. Iontophoresis is a process in which electrically charged molecules or atoms (i. e., ions) are driven into tissue with an electrical field. Voltage provides the driving force. Parameters such as drug polarity and electrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites below the skin.

2. The application of iontophoresis is considered reasonable and necessary for the topical delivery of medications into a specific area of the body.

3. Specific indications for the use of iontophoresis application may include but are not limited to:
a. tendonitis or calcific tendonitis
b. bursitis
c. adhesive capsulitis
d. hyperhidrosis
e. thick adhesive scare


Contrast Baths (CPT code 97034)

1. 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 to decrease edema and inflammation.

2. The use of contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.

3. Specific indications for the use of contrast baths include:
a. The patient having rheumatoid arthritis or other inflammatory arthritis
b. The patient having reflex sympathetic dystrophy
c. The patient having a sprain or strain resulting from an acute injury


4. Heat treatments of this type and whirlpool baths 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. If such treatments were given prior to but as an integral part of a skilled occupational therapy procedure, the treatment would be considered part of the skilled occupational therapy service.

Ultrasound (CPT code 97035)

1. 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.

2. The application of ultrasound is considered reasonable and 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.

3. Specific indications for the use of ultrasound application include:
a. The patient having tightened structures limiting joint motion that require an increase in extensibility
b. The patient having symptomatic soft tissue calcification
c. The patient having neuromas


Note: Ultrasound is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.

GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES :

1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services.

2. Use of these procedures requires that these services be rendered under the supervision of an occupational therapist.

3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented in the written plan of treatment, 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 more than one of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

4. Services provided concurrently by an occupational therapist, physical therapist and speech therapist may be covered, if separate and distinct goals are documented in the written plan of treatment.

5. Requires (one on one) direct patient contact.


Medical Necessity:

Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.

1. Heat Treatment, Including the Use of Diathermy (Procedure  code 97024) and Ultra-Sound (Procedure  code 97035) for Pulmonary Conditions

2. There is no physiological rationale or valid scientific documentation of effectiveness of diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition and for such purpose this treatment cannot be considered reasonable and necessary within the meaning of §1862(a)(1) of the Act.

3. Electrical stimulation (HCPCS code G0283; Procedure  code 97032) is considered not reasonable and necessary and is excluded from Medicare coverage for the following:

a. motor nerve disorders such as Bell’s Palsy. (ICD-9 code 351.0)

b. TENS treatments and related services (i.e. Procedure  code 64550), furnished in physicians/NPP or therapist’s office. (See CMS Pub.100-2 Ch.16 §180, CMS Pub.100-3 §160.3)

c. Electrical Stimulation is not medically necessary for the treatment of strokes when there is no potential for restoration of function.


Electrical Stimulation for NONwound care (CPT 97032, HCPCS G0283)

Transcutaneous electrical nerve stimulation (TENS) is used primarily for pain control. A patient can usually be taught to use a TENS unit for pain control in 1-2 visits. Consequently, it is inappropriate for a patient to continue treatment for pain with a TENS unit in the clinic setting. This service is covered as HCPCS G0283, not CPT 97032.

Neuro-muscular stimulation is used for retraining weak muscles following surgery or injury. Typical treatment is no more than 12 visits when used as muscle re-training. Documentation must support the need for continued treatment beyond 12 visits for muscle re-training. In many instances the patient can be trained in the use of a home muscle stimulator for retraining weak muscles in 1-2 visits. Once training is completed, this procedure should not be billed as treatment modality in the clinic.

Muscle stimulation is a type of stimulation that is taken to the point of visible muscle contraction.

HCPCS G0283 should be used if electrical stimulation units are placed on the patient by the provider and do not require the continued presence and direct one-on-one contact by the provider once set-up is completed. If electrical stimulation is applied manually and direct one-on-one contact is provided by the therapist, CPT 97032 should be used.

Interferential current/medium current (IFC) units use a frequency that allows the current to go deeper into the tissue. IFC is used to control swelling and pain. If no objective and/or subjective improvement in swelling and/or pain is noted after 6 visits, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality. For swelling and pain control, the efficacy of this modality should be met in at most 10-12 visits. Documentation must support the need for continued treatment with this modality for greater than 12 visits.

Non-implantable pelvic floor electrical stimulation is covered for the treatment of stress and/or urge incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.

Utilization of these modalities may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement. A limited number of visits without a therapeutic procedure may be medically necessary for treatment of muscle spasm and swelling, but this should not exceed 2-4 visits. This service is covered by HCPCS G0283.

Specific indications for use include:

Documented dependent peripheral edema with an accompanying reduction in the ability to contract muscles.
Documented reduction in the ability to contract muscles or in the strength of the muscle contraction.
Documented condition that requires an educational program for self-stimulation of denervated muscles.
Documented condition that requires muscle re-education involving a training program, i.e., functional electrical stimulation.

Treatment for disuse atrophy using a specific type of neuromuscular electrical stimulator (NMES), which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. Coverage of NMES to treat muscle atrophy is limited to the treatment of patients with disuse atrophy where the nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves and other non-neurological reasons for disuse atrophy. Examples include 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). Typical treatment duration when electrical stimulation is used as muscle re-training is no more than 12 visits. Documentation must support the need for continued treatment beyond 12 visits for muscle re-training.


Contrast bath therapy (CPT code 97034)

97034 Application of a modality to one or more areas; contrast baths, each 15 minutes

* This modality may be useful to treat extremities affected by reflex sympathetic dystrophy, acute edema resulting from trauma, or synovitis/tenosynovitis. It is generally used as an adjunct to a therapeutic procedure.


*Treatment would not be expected to exceed 4 treatments per week for longer than one month.

Contrast baths provide a unique therapy and are particularly efficacious with certain diagnoses as noted in the draft text. As such, AOTA urges that the limiting language for situations when “the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications” be deleted.



Contrast baths are a form of therapeutic heat and cold applied to distal extremities in an alternating pattern. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold.

Hot and cold baths ordinarily do not require the skills of a therapist. However, the skills, knowledge and judgment of a therapist might be required in the provision of such treatments in a particular case, e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fracture or other complication.

Documentation must indicate the presence of these complicating factors for reimbursement of this code. If there are no complicating factors requiring the skills of a therapist, this modality is non-covered.

CPT Code 97034 is not covered when the services provided are hot and cold packs.

This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment.

No more than 2 visits will generally be covered to educate the patient and/or caregiver in home use, and to evaluate effectiveness. Documentation must support the medical necessity of continued use of this modality for greater than 2 visits. This is a constant attendance code requiring direct, one-on-one patient contact by the provider. Only  the actual time of the provider’s direct contact with the patient is to be billed.


• Rationale requiring the unique skills of a therapist to apply, including the complicating factors

• Area(s) being treated

• Subjective findings to include pain ratings, pain location, effect on function

Utilization Guidelines and Maximum Billable Units per Date of Service Rarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed.


CPT 97035 – Ultrasound Therapy

97035 Application of a modality to one or more areas; ultrasound, each 15 minutes

* This modality is used primarily to treat inflammation of periarticular structures, neuromas, pain, muscle spasms, contractures, and to soften adhesive scars.


* Treatment would not be expected to exceed 4 treatments per week for longer than one month.

For the reasons discussed above, AOTA disagrees with the statement that it is “generally not  medically necessary for a patient to receive more than twelve (12) visits for ultrasound” and for the reasons discussed above, requests that language limiting treatment to three times per week for only twelve visits be deleted.

Additionally, while ultrasound can effectively heat deep tissue, it also has non-thermal effects on
biological tissues. To obtain these benefits when heat is contraindicated (such as with acute inflammation) the ultrasound must be pulsed. AOTA requests that the definition of ultrasound be
expanded to include non-thermal ultrasound.


Billing and Coding Guidelines

Q Several commenters recommended that NGS include phonophoresis, not as a separate service from ultrasound, but as an ultrasound and reimburse for this service under CPT code 97035. 

The LCD has been revised to read,

“Phonophoresis (the use of ultrasound to enhance the delivery of topically applied drugs) will be reimbursed as ultrasound, billable using CPT 97035. Separate payment will not be made for the contact medium or drugs.”



Q Several commenters disagreed with the non-coverage decision of ultrasound for wounds. 

NGS will continue to list ultrasound as a noncovered treatment for wounds. The efficacy of deep thermal or low frequency ultrasound has not been sufficiently proven for wound care. Coverage will not be made for ultrasound for wounds billed under any code, including CPT 97035, Category III CPT code 0183T, or an unlisted code.



When performing ultrasound (CPT® 97035) and electric muscle stimulation, constant, attended (CPT® 97032) the services are duplicate and therefore only the higher reimbursed code is allowed to represent the total service

 • 97035 and 97032 should not be billed together

• Ultrasound/electric muscle stimulation is billed appropriately with CPT® 97035

Heat Treatment, including the Use of Diathermy and Ultrasound for Pulmonary Conditions (CPT codes 97024 and 97035)

Heat treatment, including the use of diathermy and ultrasound for pulmonary conditions are not covered. There is no physiological rationale or valid scientific documentation of effectiveness of diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition and for such purpose this treatment cannot be considered reasonable and necessary.


Billing - CPT Codes: Not Permitted

In the same 15-minute (or other) time period, a therapist cannot bill any of the following pairs of CPT codes for outpatient therapy services provided to the same, or to different patients.

Examples include:

a. Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97542);

b. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032 - 97039);

c. Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) and (b) above -- (CPT codes 97032- 97542). For example: any CPT code for a therapeutic procedure (eg. 97116-gait training) with any attended modality CPT code (eg. 97035-ultrasound);

d. Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110 - 97542) with the group therapy CPT code (97150) requiring constant attendance. For example: group therapy (97150) with neuromuscular reeducation (97112);

e. Any CPT code for modalities requiring constant attendance (CPT codes 97032 - 97039) with the group therapy CPT code (97150). For example: group therapy (97150) with ultrasound (97035);

f. Any untimed evaluation or reevaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 - 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150)


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 may receive as much as 30% greater dosage of ultrasound than tissue not adjacent to bone. 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 tissue may receive a more intense irradiation, ultrasound is an ideal modality for increasing mobility in those tissues with restricted range of motion.

The use of ultrasound is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and for increased flexibility of muscle, tendons, and ligaments.

Specific indications for the use of ultrasound application include but are not limited to:

documented tightened structures limiting joint motion that require an increase in extensibility;

documented symptomatic soft tissue calcification;

documented neuromas.

Non-thermal ultrasound for wound healing may be indicated for non-necrotic wound(s) only after documented standard wound care has been used for a minimum of 30 days with no measurable signs of healing. Billed units should reflect the aggregate one-on-one time spent treating all wounds per day.

Ultrasound application is not considered reasonable and necessary for the treatment of asthma, bronchitis, or any other pulmonary condition.

When phonophoresis is performed, CPT 97035 should be used.

If ultrasound with simultaneous electrical stimulation is used, CPT 97035 should be used. CPT 97035 and any electrical stimulation codes (CPT 97032, HCPCS G0281, G0283) should not be used together to reflect ultrasound with simultaneous electrical stimulation.

This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment.

If no objective and/or subjective improvement noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality.

The efficacy of this modality should be met in at most 12 visits. Documentation must support the need for continued treatment with this modality for greater than 12 visits.

Additional Documentation Requirements

Rationale for use of modality.

Area/Areas being treated.

Frequency and intensity of modality and time applied.

Response of patient to treatment.

Objective clinical findings/measurements of strength, range of motion, and functional deficits/limitations.

Subjective findings to include pain ratings, pain location, effect on function.

Functional progress at reassessment and/or discharge. If no progress, the reason for lack of progress documented and/or alternative treatment strategy.

CPT CODE 97035 – Ultrasound (to one or more areas)

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 may receive as much as 30% greater dosage of ultrasound than tissue not adjacent to bone. 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 tissue may receive a more intense irradiation, ultrasound is an ideal modality for increasing mobility in those tissues.

Covered ultrasound may be pulsed or continuous width, and should be used in conjunction with therapeutic procedures, not as an isolated treatment.

Specific indications for the use of ultrasound application include but are not limited to:
• limited joint motion that requires an increase in extensibility;

• symptomatic soft tissue calcification;

• neuromas.


Ultrasound application is not considered reasonable and necessary for the treatment of:

• asthma, bronchitis, or any other pulmonary condition;

• conditions for which the ultrasound can be applied by the patient without the need for a therapist or other professional to administer, and/or for extended period of time (e.g., devices such as PainShield MD);

• wounds. (see list “ICD-10 Codes that DO NOT Support Medical Necessity”  Phonophoresis (the use of ultrasound to enhance the delivery of topically applied drugs) will be reimbursed as ultrasound, billable using CPT 97035. Separate payment will not be made for the contact medium or drugs.

Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period.

If no objective and/or subjective improvement is noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of ultrasound. Documentation must clearly support the need for ultrasound more than 12 visits.



Supportive Documentation Requirements (required at least every 10 visits) for 97035

• Area(s) being treated

• Frequency and intensity of ultrasound

• Objective clinical findings such as measurements of range of motion and functional limitations to support the need for ultrasound

• Subjective findings to include pain ratings, pain location, effect on function


Utilization Guidelines and Maximum Billable Units per Date of Service

Rarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed.

The following interventions should be reported no more than one unit per code per day per discipline; additional units will be denied: 97001, 97002, 97003, 97004, 97012, 97016, 97018, 97022, 97024, 97028, 97150, 97597, 97605, 97606, G0281, G0283, G0329.

The following timed interventions should be reported no more than 2 (two) units per code per day per discipline; additional units will be denied: 97033, 97034, 97035, 97036.


Physical Therapy Treatment (CPT code 97036)

97036 Application of a modality to one or more areas; Hubbard tank, each 15 minutes

* This modality involves the use of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds e.g., ulcers, exfoliative skin conditions.

* Physician or therapist supervision of the whirlpool modality is already required but especially for the following indications:

The patient’s condition is complicated by circulatory deficiency or

The patient’s condition is complicated by areas of desensitization

* Treatment would not be expected to exceed 4 treatments per week for longer than one month.


* It is not medically necessary to have more than one form of hydrotherapy during a visit (CPT codes 97022, 97036, 97113), during the same visit.


Please refrain from using “physical therapy” as a generic term for physical medicine and  rehabilitation, as this has caused confusion in the past. AOTA requests that this heading be changed to reflect the correct CPT code descriptor (i.e., “Unlisted Modality”).


CPT codes within the code range of 97032-97036 are “Constant Attendance” codes that require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance

UHC - This policy describes reimbursement for timed therapeutic services (Current Procedural Terminology [CPT] codes 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762 and Healthcare Common Procedure Coding System [HCPCS] codes G0237, G0238 and S8948). These services are referred to as “timed codes” within the policy

There may be situations in which therapy services are provided by professionals from different specialties (e.g., physical therapist, occupational therapist) belonging to a multi-specialty group and reporting under the same Federal Tax Identification number. In such cases, UnitedHealthcare Community Plan will allow reimbursement for up to four (4) timed procedures/modalities reported from the list above per date of service for each specialty provider within the group. HCPCS modifiers GN, GO and GP may be reported with the codes listed above to distinguish timed procedures provided by different specialists within a multispecialty group. Refer also to these policies for additional reimbursement limits that may apply: Physical Medicine & Rehabilitation: PT, OT and Evaluation and Management and Physical Medicine & Rehabilitation: Speech Therapy.

Modality codes 97032 & 97035 are generally considered to be an adjunct to a variety of therapies and when billed by an allopathic, osteopathic, or chiropractic physician, these services do not count against the defined benefit limit for PT, ST, OT combined.

Modality CPT Codes 97032 & 97035 will only count as an individual Chiropractic visit if no other chiropractic services are rendered at the same visit.


Optum Policy overview


This policy describes Optum’s requirements for reimbursement of timed therapeutic services (CPT codes 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762).

The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without reimbursing for billing submission or data entry errors or for non-documented services.

Reimbursement Guidelines Optum policy is to allow reimbursement for codes from the list above, in any combination, up to a maximum of four timed units (equivalent to one hour of therapy), per specialty, per date of service.

There may be situations in which a member’s condition warrants therapeutic services that exceed the limit of four timed units per date of service. In such cases, Optum will allow additional reimbursement if records are provided which document the services provided.


Whirlpool (CPT code 97022)/Hubbard Tank (CPT code 97036)

        Whirlpool bath and Hubbard tanks are the most common forms of hydrotherapy. The use of sterile whirlpool is considered medically necessary when used as part of a plan directed at facilitating the healing of an open wound (e.g., burns).

        Specific indications for the use of sterile whirlpools include:
            the patient has a documented open wound which is draining, has a foul odor, or evidence of necrotic tissue; and/or

            the patient has a documented need for wound debridement/bandage removal.General whirlpool therapies (CPT code 97022)/Hubbard tank (CPT code 97036) are considered medically necessary when used to enhance the patientts ability to perform therapeutic exercise.

        Specific indications for the use of general whirlpool therapies include:
            the patient who suffers from generalized weakness in addition to a specific functional limitation, and requires the buoyancy provided in the whirlpool in order to perform the therapeutic exercise, and/or

            the patient who requires joint stretching (joint range of motion) prior to exercise on dry land.General whirlpool therapies/Hubbard tank may be considered medically necessary when the patientts condition is complicated by either circulatory deficiency or areas of desensitization, and the therapeutic goal is to increase circulation or decrease skin sensitivity.

     
        The type of NMES that is used to enhance the ability to walk of SCI patients is commonly referred to as functional electrical stimulation (FES). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Coverage for the use of NMES/FES is limited to SCI patients for walking, who have completed a training program which consists of at least 32 physical therapy sessions with the device over a period of three months. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the personns ability to use these devices frequently and for the long term. Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program. .

        The goal of physical therapy must be to train SCI patients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy. Coverage for NMES/FES for walking will be covered in SCI patients with all of the following characteristics:

        1. Persons with intact lower motor unite (L1 and below) (both muscle and peripheral nerve);
        2. Persons with muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently;
        3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical stimulation sufficient for muscle contraction;
        4. Persons that possess high motivation, commitment and cognitive ability to use such devices for walking;
        5. Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes;
        6. Persons that can demonstrate hand and finger function to manipulate controls;
        7. Persons with at least 6-month post recovery spinal cord injury and restorative surgery;
        8. Persons with hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and
        9. Persons who have demonstrated a willingness to use the device long-term.

        NMES/FES for walking will not be covered in SCI patient with any of the following:

        1. Persons with cardiac pacemakers;
        2. Severe scoliosis or severe osteoporosis;
        3. Skin disease or cancer at area of stimulation;
        4. Irreversible contracture; or
        5. Autonomic dysflexia.

        The only settings where therapists with the sufficient skills to provide these services are employed, are inpatient hospitals; outpatient hospitals; comprehensive outpatient rehabilitation facilities; and outpatient rehabilitation facilities. The physical therapy necessary to perform this training must be part of a one-on-one training program.

        Additional therapy after the purchase of the DME would be limited by our general policies in converge of skilled physical therapy.

 Billing - Procedure  Codes: Not Permitted

In the same 15-minute (or other) time period, a therapist cannot bill any of the following pairs of Procedure  codes for outpatient therapy services provided to the same, or to different patients.

Examples include:

a. Any two Procedure  codes for "therapeutic procedures" requiring direct one-on-one patient contact (Procedure  codes 97110-97542);

b. Any two Procedure  codes for modalities requiring "constant attendance" and direct one-on-one patient contact (Procedure  codes 97032 - 97039);

c. Any two Procedure  codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) and (b) above -- (Procedure  codes 97032- 97542). For example:

any Procedure  code for a therapeutic procedure (eg. 97116-gait training) with any attended modality Procedure  code (eg. 97035-ultrasound);

d. Any Procedure  code for therapeutic procedures requiring direct one-on-one patient contact (Procedure  codes 97110 - 97542) with the group therapy Procedure  code (97150) requiring constant attendance. For example: group therapy (97150) with neuromuscular reeducation (97112);

e. Any Procedure  code for modalities requiring constant attendance (Procedure  codes 97032 - 97039) with the group therapy Procedure  code (97150). For example: group therapy (97150) with ultrasound (97035);

f. Any untimed evaluation or reevaluation code (Procedure  codes 97001-97004) with any other timed or untimed Procedure  codes, including constant attendance modalities (Procedure  codes 97032 - 97039), therapeutic procedures (Procedure  codes 97110-97542) and group therapy (Procedure  code 97150)


Guideline from BCBS

The plan covers up to 30 outpatient sessions combined PT/ ST/ OT visits per plan year. This maximum applies to sessions provided in the home, an outpatient facility or professional office setting. The maximum number of visits included in covered benefits may vary for specific contracts or products. Please refer to the appropriate subscriber contract for the applicable benefit maximum.

Modality codes 97032 & 97035 are generally considered to be an adjunct to a variety of therapies and when billed by an allopathic, osteopathic, or chiropractic physician, these services do not count against the defined benefit limit for PT, ST, OT combined. Modality codes 97032 & 97035 will only count as an individual Chiropractic visit if no other chiropractic services are rendered at the same visit. When other therapeutic techniques (CPT 97110-97535) are billed by any provider (including a chiropractic physician) these services will apply to the defined benefit limit for PT, ST, and

OT combined.

OT services in the Emergency Room apply to the PT, ST, and OT combined defined visit benefit limit.

OT services rendered at an inpatient level of care to members in an acute inpatient or rehabilitation facility, or under hospice care, do not apply to the defined benefit limit.

OT therapists are eligible to provide medically necessary DME, subject to the terms, conditions and limitations of the subscriber’s contract and therapist provider contract. Duplicate therapy occurs when a patient receives both physical and occupational therapy on the same date of service and the services are the same. The two therapies should provide different treatments. Each therapy must have its own goals and treatment plan.

If member visits one provider for OT and another provider for PT – counts as two visits.

If member visits one provider for OT and another provider for OT – counts as two visits. If member visits one individual provider for both OT and PT during a single visit counts as one visit

The following codes will be considered as medically necessary when applicable criteria have been met.

CPT 97003 Occupational therapy evaluation

CPT 97004 Occupational therapy re-evaluation

CPT 97012 Application of a modality to 1 or more areas; traction, mechanical

CPT 97016 Application of a modality to 1 or more areas; vasopneumatic devices

CPT 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Physical medicine and rehabilitation modalities (constant attendance).

For this code range, services are measure in15 minute time units. Time must be documented. Units are required in addition to the code for billing with one unit equaling 15 minutes.

CPT 97035 Application of a modality to 1 or more areas; Ultrasound, each 15 minutes

CPT 97036 Application of a modality to 1 or more areas; Hubbard Tank, each 15 minutes

CPT 97110 Therapeutic procedure, 1 or moreareas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

CPT 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination,  kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

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