General Guidelines for Therapeutic Procedures 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97545, 97546

•    Therapeutic procedures are procedures that attempt to reduce impairment and improve function through the application of clinical skills and/or services.
•    Use of these procedures requires that the practitioner have direct (one-on-one) patient contact.
•    Codes 97110 (therapeutic exercises), 97112 (neuromuscular re-education), 97113 (aquatic therapy/exercises) and 97530 (therapeutic activities) describe several different types of therapeutic interventions. The expected goals documented in the treatment plan, affected by the use of each of these procedures, will help define whether these procedures are reasonable and medically necessary. Therefore, since any one or a combination of more than one of codes 97110 (therapeutic exercises), 97112 (neuromuscular re-education), 97113 (aquatic therapy/exercises) and 97530 (therapeutic activities) may be used in a treatment plan, documentation must support the use of each code as it relates to specific therapeutic goal(s).
•    Documentation supporting the medical necessity for continued treatment must be made available to Medicare upon request.

Specific Guidelines for Therapeutic Procedures

The following clinical guidelines pertain to the specific listed therapeutic procedures.

Per Change Request 2083

In accordance with established conditions, all rehabilitation services to beneficiaries with a primary vision impairment diagnosis must be provided pursuant to a written treatment plan established by a Medicare physician and implemented by approved Medicare qualified professionals (PTs or OTs) or as “incident to” physician services. Some of the following rehabilitation programs/services for beneficiaries with vision impairment may include Medicare covered therapeutic services.
•    Mobility.
•    Activities of daily living.
•    Other medically necessary services, including low-vision services.

The patient must have a potential for restoration or improvement of lost functions, and must be expected to improve significantly within a reasonable and generally predictable amount of time. Rehabilitation services are not covered if the patient is unable to cooperate in the treatment program or if clear goals are not definable. Most rehabilitation is short-term and intensive, and maintenance therapy – services required to maintain a level of functioning – is not covered. For example, a person with an ICD-9-CM diagnosis of 369.08 (profound impairment in both eyes, i.e., best corrected visual acuity is less than 20/400 or visual field is 10 degrees or less) would generally be eligible for, and may be provided, rehabilitation services under CPT/HCPCS code 97535 (self-care/home management training, i.e., activities of daily living, compensatory training, meal preparation, safety procedures, and instruction in the use of adaptive equipment).

97110 (therapeutic exercises) – Therapeutic exercise to develop strength and endurance, range of motion, and flexibility: active, active-assisted or passive (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening). The exercise may be reasonable and medically necessary for a loss or restriction of joint motion, strength, functional capacity or mobility that has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength or mobility (e.g., degrees of motion, strength grades, levels of assistance). This therapeutic procedure is measured in 15-minute units with therapy sessions frequently consisting of several units.

97112 (neuromuscular re-education) – This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkrais, Bobath, BAP’s boards and desensitization techniques). The procedure may be reasonable and medically necessary for impairments that affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity).

97113 (aquatic therapy) – This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and medically necessary for a loss or restriction of joint motion, strength, mobility or function that has resulted from a specific disease or injury.
•    Documentation must show objective loss of joint motion, strength or mobility (e.g., degrees of motion, strength grades, levels of assistance).
•    Do not use this code for situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).
•    When aquatic therapy is provided in a community pool, the provider must rent or lease at least a portion of the pool for the exclusive use of the patients.

Other forms of exercise therapy may be medically necessary in addition to aquatic therapy when the patient cannot perform land-based exercises effectively to treat their condition without first undergoing the aquatic therapy, or when aquatic therapy facilitates progress to land-based exercise or increased function. Documentation must be available in the record to support medical necessity.

It is not medically necessary to employ hydrotherapy and aquatic therapy during the same treatment session.

Note: Hydrotherapy refers to codes 97022 and 97036.

97116 (gait training therapy) – This procedure may be medically necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.
•    This procedure is not reasonable and necessary or medically necessary when the patient’s walking ability is not expected to improve.
•    Repetitive walk-strengthening exercises for feeble or unstable patients or to increase endurance do not require qualified professional supervision and will be denied as not reasonable and necessary.
•    Generally, CPT code 97116 (gait training therapy) should not be reported with 97760 (orthotic management and training). However, if a service represented by code 97760 (orthotic management and training) was performed on an upper extremity and a service represented by code 97116 (gait training) was also performed, both codes may be billed with the appropriate modifier to denote separate anatomic sites.

97124 (massage therapy) – This procedure may be medically necessary as adjunctive treatment to another therapeutic procedure on the same day, which is designed to restore muscle function, reduce edema, improve joint motion or for relief of muscle spasm.

In most cases, postural drainage and pulmonary exercises can be carried out safely and effectively by ancillary personnel. If the attending physician determines that for the safe and effective administration of these procedures, the professional skills of a PT are required, coverage may be allowed. Documentation of the severity of the pulmonary condition and referral by the physician must be available.

97139 (physical medicine procedure unlisted) – For all claims submitted with an unlisted procedure code, a complete narrative description (detailing the service or procedure being performed) must be included on the claim.
•    For Example: Report phonophoresis with CPT code 97139. However, because there is no evidence from published, controlled clinical studies demonstrating the efficacy of this modality, phonophoresis will be denied as not proven safe and effective, and therefore is not a covered service.

97140 (manual therapy) – Manual therapy such as mobilization, manipulation, manual traction and manual lymphatic drainage.