Specific Modality Guidelines G0283, 97012,97016,97018, 97022,97036, 97028, 97032, 97034, 97039

The following clinical guidelines pertain to the specific modalities listed.

G0283 – This modality includes the following types of electrical stimulation:
•    Transcutaneous Electrical Nerve Stimulation (TENS).
•    Microamperage E-Stimulation (MENS).
•    Percutaneous Electrical Nerve Stimulation (PENS).
•    Electrogalvanic stimulation (high voltage pulsed current).
•    Functional electrical stimulation.
•    Interferential current/medium current.

These types of electrical stimulation may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function. Electrical stimulation must be utilized with appropriate therapeutic procedures (e.g., 97110) to effect continued improvement.

Electrical stimulation is typically used in conjunction with therapeutic exercises. It is expected this modality will be used in a clearly adjunctive role and not as a major component of the therapeutic encounter.

When electrical stimulation is used for muscle strengthening or retraining, the nerve supply to the muscle must be intact. It is not medically necessary for completely denervated motor nerve disorders in which there is no potential for recovery or restoration of function.

97012 (mechanical traction) – This modality, when provided by physicians or independent PTs, is typically used in conjunction with therapeutic procedures, not as an isolated treatment; however, it may be used in weaning an acute patient to a self-administered home program.

97016 (vasopneumatic device therapy) – Education for the home use of a lymphedema pump is sometimes provided by the lymphedema pump supplier. If the supplier does not provide this education, limited therapy professional visits for such purposes are allowable. Medicare does not expect to be routinely billed for repeated lymphedema treatments. Medicare expects that documentation in the physician’s medical record must support the necessity of repeated services.

97018 (paraffin bath therapy) – Also known as hot wax treatment, this modality may be medically necessary as an adjunct to other physical/occupational therapy interventions but this service is primarily used for pain relief in chronic joint problems of the wrists, hands or feet. Most patients will be capable of self managing these treatments after education. Therefore, when not used as an adjunct to other physical/occupational therapy interventions, Medicare payment for these services will usually be limited to two or three visits. Documentation supporting the medical necessity for repetitive treatments must be made available to Medicare upon request.

97022 (whirlpool therapy) and 97036 (hydrotherapy) – These modalities involve the use of agitated water to relieve muscle spasms, improve circulation or cleanse wounds (e.g., ulcers, exfoliative skin conditions).

Physician or therapist supervision of the whirlpool modality must be medically necessary for the following indications:
•    The patient’s condition is complicated by:
o    Circulatory deficiency.
o    Areas of desensitization.
o    Impaired mobility or limitations in the positioning of the patient.
o    Concerns about safety, if left unsupervised.
•    Documentation supporting the medical necessity for additional sessions must be made available to Medicare upon request.
•    It is not medically necessary to have more than one form of hydrotherapy during a treatment session.

97028 (ultraviolet therapy) – Ultraviolet must be prescribed by the attending physician. Minimal erythema dosage must be documented and made available to Medicare upon request.

97032 (electrical stimulation) – See procedure code G0283 for clinical guidelines for this procedure.

97034 (contrast bath therapy) and 97035 (ultrasound therapy) – These modalities are generally used as adjuncts to a therapeutic procedure.

97039 – For all claims submitted with an unlisted modality code, a complete narrative description (detailing the service or procedure being performed) must be included on the claim. This code applies only to a procedure in which constant attendance was a requisite.