Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
The cornerstones of rehabilitative therapy are mobilization, education and therapeutic exercise. The goal of rehabilitative medicine is discernible, functional progress toward the restoration or maximization of impaired neuromuscular and musculoskeletal function. To that end, the dynamic component of therapy, mobilization and patient education should predominate. Passive modalities should be used in the “warm-up” phase of the patient encounter as preparation for or as an adjunct to therapeutic procedures, and in the “cool-down” phase for reduction of pain, swelling and other post-treatment syndromes. Though passive modalities may predominate in the earlier phases of rehabilitation where the patient’s ability to participate in therapeutic exercise is restricted, Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care. Further, Medicare expects the patient’s record to clearly reflect medical necessity for passive modalities, especially those that exceed 25 percent of the cumulative service hours of rehabilitative therapy provided for any beneficiary under a plan of care.
Complicating factors that may influence treatment, e.g., they may influence the type, frequency and/or duration of treatment, may be represented by diagnoses by patient factors such as age, severity, acuity, multiple conditions, co-morbidities, and motivation; or by the patient’s social circumstances, such as the support of a significant other or the availability of transportation to therapy.
In more refractory cases, the practitioner will support the need for continued care with documentation that clearly outlines the factors that affect the rate of recovery and reinforces the anticipation that further functional gain is expected. The contractor recognizes variability in strength, recovery time and the ability to be educated, and allows for a recertification for additional therapy, as long as adequate medical documentation by the supervising physician or therapist is recorded in the medical record and the patient continues to demonstrate progress.
In all cases, whether the duration and intensity of rehabilitative services rendered are limited or extensive, Medicare expects the patient’s medical record to clearly demonstrate medical reasonableness and necessity for all therapy services, both active and passive. If an individual’s expected rehabilitation potential is insignificant, or the patient’s maximum rehabilitation potential have been realized, therapy is not reasonable and necessary and should not be reported to Medicare as a payable service.
Though this LCD establishes limitations to duration and intensity of outpatient rehabilitation, Medicare expects that most patients will not require maximum numbers of services. Providing maximal services as a routine is of concern and will result in Medicare auditing.
General Physical Medicine & Rehabilitation (PM&R) Guidelines
This LCD applies to the therapy services coded with the 97XXX series of CPT codes. Per CMS definitions, therapy services include these services with a few exceptions. Please refer to the documents found at http://www.cms.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage for the complete listing of CPT codes that are “always” considered therapy services and those that are “sometimes” considered therapy services for coverage, requirement for plan of care, and coding purposes.
Intervention with Physical Medicine and Rehabilitation (PM&R) modalities and procedures is indicated when an assessment by a physician, NPP and/or therapist supports utilization of the intervention, there is documentation of objective physical and functional limitations (signs and symptoms), and the written plan of care incorporates those treatment elements that are expected to result in improvement of these limitations in a reasonable and generally predictable period of time. PM&R services must be furnished on an outpatient basis and provided while the patient is or was under the care of a physician or NPP.
Medicare covers therapy services personally performed only by one of the following:
• Licensed therapy professionals: licensed PTs, OTs and SLPs.
• Licensed physical therapy assistants when supervised directly by a licensed PT.
• Licensed occupational therapy assistants when supervised directly by a licensed OT.
• Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
• Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
• Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
• “Qualified” personnel when directly supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met. Qualified personnel have met the educational and degree requirements of a licensed therapy professional (PT, OT, SLP), but are not required to be licensed. Please note that unless these therapy services are performed by a “qualified” person, the services are not covered and must not be reported for Medicare payment.
Other specific requirements include the following:
• Medicare covers therapy services that require the skill of a trained and licensed practitioner to perform or supervise. Medicare does not cover therapy services that do not require the skill of a trained and licensed practitioner to perform even when one of the persons in the list above performs them.
• A written plan of care, consisting of diagnoses (long-term treatment goals and type, amount, duration and frequency of therapy services), must be established by the physician, NPP or therapist providing the services before the services are begun.
o The plan must be periodically reviewed by the physician or NPP.
o A therapist may not significantly alter a plan of care established or certified by the physician or NPP without their documented written or verbal approval.
o The plan must be certified and recertified periodically (see “Documentation Requirements” for details) by the physician or NPP. New or significantly modified plans of care must be certified within 30 calendar days after the initial treatment under that plan, unless delayed certification criteria are met.
o If certification is obtained verbally, it must be followed by a signature within 14 days to be timely.
o Recertifications must be obtained within the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whichever is less.
o Services provided concurrently by a physician, PT and OT may be covered if separate and distinct goals are documented in the treatment plans.
• The type, frequency and duration of services must be medically necessary for the patient’s condition under accepted medical, physical therapy and occupational therapy practice standards and relate directly to a written treatment plan. There must be an expectation that the condition or level of function will improve within a reasonable (and generally predictable) time or the services must be necessary to establish a safe and effective maintenance regimen required in connection with a specific disease.
It is not medically necessary for a qualified professional to perform or supervise maintenance programs that do not require the professional skills of a qualified professional. These situations include:
• Services related to activities for the general good and welfare of patients (i.e., general exercises to promote overall fitness and flexibility).
• Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients.
• Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities.
• Maintenance therapies after the patient has achieved therapeutic goals or for patients who show no further meaningful progress and should become patient- or caregiver-directed.
For all PM&R modalities and therapeutic procedures on a given day, it is usually not medically necessary to have more than one treatment session per discipline. Treatment times per session vary based upon the patient’s medical initial therapy needs and progress to date toward established goals. Treatment times per session typically will not exceed 45–60 minutes. Additional time is sometimes required for more complex and/or slow-to-respond patients. However, documentation of the exceptional circumstances must be maintained in the patient’s medical record and available upon request.
For purposes of this policy, a “service” is defined as a 15-minute billing increment of a specific therapy CPT code. For codes that are defined as per 15 minutes or each 15 minutes, Medicare would not expect to see the qualified professional billing per treatment site. Report these codes based on the actual amount of time spent on a cumulative basis for the specified modality or procedure. For additional information, review unusual length of time issues in the “Documentation Requirements” section of this policy.
• PM&R services in patients’ homes, qualified professionals’ offices, Skilled Nursing Facilities (SNFs), outpatient hospital clinics, Outpatient Rehabilitation Facilities (ORFs) and Comprehensive Outpatient Rehabilitation Facilities (CORFs) are covered when reasonable and medically necessary for the treatment of the patient’s condition (signs and symptoms).
