Physical Therapy - Home Health

Summary of Evidence Analysis of Evidence General Information Associated Information Sources of Information Bibliography Revision History Information Associated Documents Attachments Related Local Coverage Documents Related National Coverage Documents Public Versions Keywords Local Coverage Determination (LCD) Physical Therapy - Home Health L33942 Expand All | Collapse All  Email Document  Download  Add to basket Contractor Information Contractor Name Contract Type Contract Number Jurisdiction States Delaware District of Columbia Iowa Kansas Maryland Missouri - Entire State Montana Nebraska North Dakota Pennsylvania South Dakota Utah Virginia West Virginia Wyoming LCD Information Document Information LCD ID L33942 LCD Title Physical Therapy - Home Health Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 08/07/2025 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. Current Dental Terminology © 2025 American Dental Association. All rights reserved. Copyright © 2025, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted mat

GENERAL THERAPY GUIDELINES Physical therapy services are part of a constellation of rehabilitative services designed to improve or restore physical functioning following disease, injury, or loss of a body part. Physical therapists use the clinical history, systems review, physical examination, and a variety of evaluations to characterize individuals with impairments, functional limitations and disabilities. Impairments, functional limitations, and disabilities thus identified are then addressed by the design and implementation of a therapeutic intervention tailored to the specific needs of the individual patient. The specific interventions most commonly utilized are exercise, gait and balance training, heat, cold, electricity, ultraviolet light, ultrasound, hydrotherapy, and massage to improve circulation, strengthen muscles, maintain or restore motion, and train or retrain an individual to perform the activities of daily living. Indications The patient must be under the care of and referred for therapy services by a physician who is a doctor of medicine, osteopathy, or podiatric medicine (a doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law). Physical therapy services are covered, provided such services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed qualified physical therapist or licensed physical therapist assistant (LPTA). Services normally considered to be a routine part of nursing care are not covered as physical therapy (e.g., turning patients to prevent pressure injuries or walking a patient in the hallway postoperatively). Physical therapy services are only covered when they relate directly and specifically to a treatment regimen, which is certified/approved by the individual’s physician (after any needed consultation with the qualified therapist), and must be reasonable and necessary to the treatment of the individual’s illness or injury. The plan of treatment should address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency, and duration. The therapist must document the patient’s functional limitations and therapeutic short and long term goals in terms that are objective and measurable. Services related to activities for the general physical welfare of beneficiaries (for example, exercises to promote overall fitness) do not constitute physical therapy for Medicare purposes. In order for the plan of care to be covered, it must address a condition for which physical therapy is an accepted method of treatment, as defined by standards of medical practice. There must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time based on the physician’s assessment of the patient’s rehabilitation potential, after any needed consultation with the qualified physical therapist. The goal for a patient is to return to the highest level of function realistically attainable and within the context of the disability. Services of skilled therapists for the purpose of teaching the patient or the patient’s family or caregivers necessary techniques, exercises, or precautions are covered to the extent that they are reasonable and necessary to treat illness or injury. However, the skills of the therapist may not necessarily be required to attain this goal but may be required initially to ensure safety, proper modality performance, etc. then transferring their care to a caregiver and home exercise plan (HEP). The development, implementation, management, and evaluation of a patient care plan based on the physician’s orders constitute skilled therapy services when, because of the patient’s condition, those activities require the skills of the therapist to manage non-skilled services. Utilization guidelines (i.e. number of visits) mentioned throughout the LCD, serve as only a guideline and DO NOT imply coverage or non-coverage of a service therein. Services must be reasonable and necessary for each individual visit, as supported by the plan of treatment and the therapists’ documentation, based on an assessment of each beneficiary’s individual care needs. The design of a maintenance regimen/HEP required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease may be considered reasonable and necessary. Limited services may be considered reasonable and necessary to establish and assist the patient and/or caregiver with the implementation of a rehabilitation maintenance program/HEP. Generally, no more than 4 visits to instruct in a maintenance program/HEP are considered medically necessary without supporting documentation. Rehabilitation Services for Vision Impairment: the coverage criteria and definition of rehabilitation services for vision impairment (Low Vision) is found in Transmittal AB-02-078, Change Request 2083, dated 5/28/02. This LCD is based on impairments of structure/function and functional limitations. While the pathophysiology is an important factor, the purpose of this LCD is to show the specific functional limitation of the patient. The “ICD-10 Codes that Support Medical Necessity” Section of this LCD is meant to include ‘functional’ diagnoses. The functional diagnoses, not necessarily the clinical diagnoses, may support coverage. Limitations Physical therapy is not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist. Except in cases of maintenance therapy, physical therapy is not covered when the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate. Physical therapy is not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected. The skills of the physical therapist are not required to maintain function. Enhancing already evident/existing functional status is not reasonable and necessary; therefore noncovered. Physical therapy is not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve over time without the services of the physical therapist. It is necessary to determine if individual therapy services are skilled, and whether, in view of the patient’s overall condition, skilled management of the services provided is needed although many or all of the specific services needed to treat the illness or injury do not require the skills of a therapist. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether non-skilled personnel can carry out the services. For example, the patient recovering from a short hospital stay for pneumonia may need only time and the gradual resumption of normal physical activities to regain their strength and function. Physical therapy services provided routinely to identify patients who might need or benefit from physical therapy intervention are not covered. Physical therapy services, which are duplicative of other concurrent rehabilitation services, are not covered. Physical therapy visits would not be routinely covered on a daily basis through discharge. Normally, visit frequency would decrease as the patient's condition improves. Services that are related solely to specific employment opportunities (i.e., on-the-job training, work skills, or work settings) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are not covered. The education component of treatment should begin at the start of care and continue until discharge. Continued visits to exclusively teach the HEP are not covered in the absence of documentation supporting ongoing education throughout the patient's entire course of treatment. This local coverage determination (LCD) does not address any wound debridement services that may be provided by the physical therapist The following services are non-covered (not reasonable and necessary) for physical therapists: Treatment(s) for incontinence, pulsed magnetic neuromodulation, per day Biofeedback training is not a covered service in the home setting. Refer to CMS' NCD 30.1, which states biofeedback services are only covered in the outpatient setting. An evaluation by a therapist is non-covered when the evaluation is for a non-covered service. For example, pre-surgical evaluations for the purpose of teaching a HEP and giving assistive device instruction prior to a scheduled surgical procedure are not covered. This may include but not limited to crutch-walking, donning/doffing of post-surgical immobilizers and/or splints, and performing strengthening exercises Group therapy is not a covered service in the home health setting Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes Work hardening/conditioning; initial 2 hours Each additional hour These services are related solely to specific work skills and will be considered not reasonable and necessary for the diagnosis or treatment of an illness or injury With electrical stimulation Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient; each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) Therapeutic procedures to increase strength or endurance of respiratory muscles, face-to-face, one-on-one, each 15 minutes (including monitoring) Therapeutic procedures to improve respiratory function, other than described by HCPCS G0237, one-on-one, face-to-face, per 15 minutes (including monitoring) Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (including monitoring) Electrical stimulation (unattended), to one or more areas, for wound care other than described in HCPCS G0281 Electrical stimulation modalities (refer to CMS' NCD Section 270 for Wound Treatment) for the treatment of: Stage I or stage II wounds Electrical stimulation and electromagnetic therapy for the treatment of wounds will not be covered as an initial treatment modality for chronic stage III or stage IV wounds. Continued treatment with electrical stimulation and electromagnetic stimulation is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Measurable signs of healing include a decrease in wound size either in surface area or volume, decrease in amount of exudates and decrease in amount of necrotic tissue. Wounds that demonstrate a 100% epithelialized wound bed Patients in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary. Facial nerve paralysis, commonly known as Bell's Palsy (considered investigational). Motor function disorders such as multiple sclerosis (considered investigational) Cerebral vascular accidents or strokes, when determined there is no potential for restoration of function Temporomandibular Joint (TMJ) Pain Currently the medical literature provides no consensus on the requirement of a skilled therapist to perform therapy techniques for TMJ pain/ disorders. Pelvic Floor Dysfunction Due to the lack of peer-reviewed evidence concerning the effect on patient health outcomes, skilled therapy modalities (e.g. ultrasound, electrical stimulation, soft tissue mobilization, and therapeutic exercise) for the treatment of pelvic floor dysfunction are considered investigational and thus non-covered. Pelvic floor dysfunction is a global term which may include, but not limited to the following conditions: Pelvic floor congestion Pelvic floor pain not of spinal origin Hypersensitive clitoris Prostatitis Cystourethrocele Enterocele Rectocele Fecal incontinence Vulvodynia Dyspareunia Pelvic floor relaxation disorders Note: Urinary incontinence is not included in this list, and certain treatment modalities may be covered, per NCD guidelines. NCDs are located on CMS’s Web site, at: www.cms.gov . Miscellaneous Services (This list is not all-inclusive) Constraint Induced Movement Therapy (CIMT) Loop reflex training 'Metronome' therapy Infrared therapy for treatment of diabetic and non-diabetic peripheral sensory neuropathy, wounds and ulcers, and similar related conditions, including symptoms such as pain arising from these conditions. —As of October 24, 2006, CMS has determined that there is sufficient evidence to conclude that the use of infrared devices is not reasonable and necessary for treatment of Medicare beneficiaries for diabetic and non-diabetic peripheral sensory neuropathy, wounds and ulcers, and similar related conditions, including symptoms such as pain arising from these conditions. The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE), is not 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 skin and/or subcutaneous tissues in Medicare beneficiaries. Refer to CMS’ NCD 270.6, “Infrared Therapy Devices,” for additional information. Scar massage Driving assessments Assessments for non-covered items (e.g. DME products) Special Considerations Maintenance Therapy Where repetitive services that are required to maintain function involve the use of complex and sophisticated procedures, the judgment and skill of a physical therapist might be required for the safe and effective rendition of such services. If the judgment and skill of a physical therapist is required to safely and effectively treat the illness or injury, the services may be covered as physical therapy services. For additional information refer to CMS’ Publication 100-2, Chapter 7, Section 402.2E, at: www.cms.gov The establishment of a maintenance program is a skilled physical therapy service where the specialized knowledge and judgment of a qualified physical therapist is required for the program to be safely carried out and the treatment of the physician to be achieved: The design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease may be considered reasonable and necessary Limited services may be considered reasonable and necessary to establish and assist the patient and/or their caregiver with the implementation of a safe and effective rehabilitation maintenance program Infrequent re-evaluations required to assess the patient’s condition and adjust the program may be considered reasonable and necessary In the case where a patient has been under a restorative physical therapy program and reaches a point where no further improvement is likely, a maintenance program would also be appropriate. However, the therapist should have already designed the program and done the appropriate teaching prior to the time the patient shows no further potential to improve. If the maintenance program were not established until after the restorative program has been completed, it would not be considered reasonable and necessary to the treatment of the patient’s condition and would not be covered. Periodic re-evaluations by the physical therapist may be the only required skilled service after a maintenance program has been established The skills of the physical therapist must be necessary to perform a safe and effective maintenance program. Example: Where there is an unhealed, unstable fracture that requires regular exercise to maintain function until the fracture heals, the skills of a physical therapist would be needed to ensure that the fractured extremity is maintained in proper position and alignment during maintenance range of motion exercises. It is not reasonable and necessary for a physical therapist to perform or supervise maintenance programs that do not require the skills of a physical therapist. 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 and 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 Vestibular Rehabilitation Vestibular rehabilitation is a constellation of individualized rehabilitative services used in the management of vestibular disorders. Appropriate selection of patients for vestibular rehabilitation is essential to its success and thus its coverage. Although dizziness is often a core complaint, it is not the functional deficit by which patients are selected for vestibular rehabilitation. Coverage for vestibular rehabilitation will be for those patients with documented vestibular hypofunction or with Benign Paroxysmal Positional Vertigo (BPPV). The goals of vestibular rehabilitation for patients with vestibular hypofunction, although individualized, should be targeted toward enabling the patient to see clearly during head movement; improving static balance and improving dynamic postural stability. The goals of vestibular rehabilitation for patients with BPPV should be targeted toward achieving remission of positional vertigo, improving dynamic postural stability and achieving self-management of the disorder. Prior to the initial evaluation the referring professional should establish the diagnosis of vestibular hypofunction with definitive testing such as caloric testing or the rotary chair test. Appropriately trained referring professionals should perform these definitive tests and forward the results to the treating therapist for review during the initial evaluation. Clinical (bedside) tests that have also shown validity in identifying a vestibular disorder include the Dix-Hallpike Maneuver (for BPPV) and the Head Thrust Test (for vestibular hypofunction). Therapists with specialized training performing these tests should document the results in the medical record. Treatment regimens as well as duration depends on the etiology of the vestibular disorder as follows: BPPV - usually is in remission within 2 visits; beyond 2 visits there should be justification in the medical record for continued treatment; beyond 4 visits with no remission there should be consideration of referral back to the Attending physician Partial or complete unilateral hypofunction (i.e. labyrinthitis, vestibular neuritis) - usually 1 visit/week for up to 6 weeks for optimal recovery in 90% of cases Bilateral vestibular hypofunction - usually requires 1 visit/week for up to 6 weeks but may require a longer treatment duration before maximum improvement The above treatment regimens should only serve as a guide to individual management. There are a few clinical conditions that routinely do not require vestibular rehabilitation unless combined with functional deficits. These include but are not limited to Meniere's disease and Perilymphatic fistula. Compliance with a HEP is essential to the success of vestibular rehabilitation. A noncompliant patient should be considered for discharge. Documentation will be reviewed to determine appropriateness of continuing physical therapy intervention with patients who are noncompliant in their plan of treatment. In order to insure that appropriate patients are selected for vestibular rehabilitation, certain ICD-10-CM codes within H81.XX should be used. The specific ICD-10-CM codes are listed in the appropriate section of the LCD. Gait abnormality alone would not justify the need for vestibular rehabilitation. Additional Documentation Recommendations Diagnostic testing results Home exercise program compliance Risk for falls validation (e.g. Dynamic Gait Index score) Adjunctive testing results (e.g. Activity specific balance confidence scale; Visual Analogue Scale; Tinnetti, etc.) SPECIFIC PROCEDURES AND MODALITIES Peripheral Nerve Neurostimulators Application of surface (transcutaneous) neurostimulator: This code is used for placement of electrodes for home transcutaneous electrical nerve stimulator (TENS) units and instruction for use of home TENS units. Once the patient has been instructed on the use/placement of the home TENS unit, services are no longer covered. This service is generally not covered more than two (2) times in a twelve-month period. Muscle and Range of Motion Testing Testing must be pertinent to the plan of care and the diagnosis It is not reasonable or necessary for these services to be performed on a routine basis or to be routinely used for all patients Evaluations/Re-evaluations Evaluations are required prior to beginning therapy for determining the medical necessity of initiating rehabilitative or maintenance services. Patients must exhibit a significant change from normal functional ability to warrant an evaluation. Components of evaluations include the patient's history, relevant review of systems, pertinent physical assessment, and tests/measurements. Factors that influence the complexity of the evaluation process include the clinical findings, extent of loss of function, social considerations, and the patient's overall function and health status. The evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. If the patient presents with multi-system involvement and/or multiple site involvement, all areas/conditions should be assessed at the initial evaluation (i.e., cervical pain and knee pain; low back pain and rotator cuff; cervical pain and low back pain). Therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, and disability; the living environment; and the social supports (i.e., the potential for effecting an improvement in the patient's functional ability). Initial evaluations may be covered even when it is determined that a skilled level of service is not required if the patient's condition showed a need for the evaluation, even if the goals established by the plan of care are not realized. The patient is not eligible for further treatment if it has been determined that he/she is at maximum therapeutic potential and further therapy would not result in any significant improvement, such as may be the case with many chronic conditions. Initial evaluations from other therapy disciplines performed on the same beneficiary may also be covered, provided that the referral, evaluation and plan of treatment are not duplicative. Continuous evaluation of the patient's progress is a component of the ongoing physical therapy services. Therapy re-evaluations are covered if the documentation shows significant change in the patient's condition that supports the need to perform a formal re-evaluation of the patient's status. When a patient exhibits a demonstrable change in physical functional ability, a re-evaluation is covered to reestablish appropriate treatment goals and interventions. Routine screening, assessments and routine reassessments are not covered. A physical therapy visit for the evaluation of a non-covered service is also not covered. For example, pre-surgical evaluations for the purpose of teaching a HEP and giving assistive device instruction prior to a scheduled surgical procedure are not covered. This may include but is not limited to crutch walking, donning/doffing of post-surgical immobilizers and/or splints, and performing strengthening exercises. Additional Documentation Recommendations The written evaluation should demonstrate the patient's need for skilled therapy based on functional diagnosis, prognosis, and positive prognostic indicators. The therapist should have an expectation that the patient will achieve the established goals. Initial evaluations should contain the following information: Reason for referral and specific treatment requested Diagnosis and functional condition/limitation being treated and onset date Applicable medical history, medications, co-morbidities (complicating or precautionary information) Primary subjective complaint Mechanism of injury (if applicable) Prior diagnostic imaging/testing Prior level of function in the home and community in specific and measurable language Prior therapy history Baseline evaluation data - should be objective and measurable and include all applicable areas. The following list is not intended to be all-inclusive, but to be used as examples: cognition, vision/hearing, vascular signs, sensation/proprioception, edema, posture, active range of motion/passive range of motion, strength, pain, coordination, bed mobility, balance (sit and stand), transfers, ambulation (level and elevated/uneven surfaces), orthotic/prosthetic devices, wheelchair use, durable medical equipment (using or required), activity tolerance, wound description (including incision status), special tests (include the name and scores), and applicable architectural/safety considerations. Assessment by therapist-reason for skilled care. Problems listed The treatment plan is meant to serve as a guide to patient care. Revisions in the plan should be documented as the professional responds to changes in the patient's status. Revisions to the plan of treatment are expected when functional progress is not achieved within a reasonable period of time. The plan of treatment should include: Specific treatment strategies (e.g., specific modalities to be used, specific type of activities and exercises) Areas of the body to be treated Frequency of treatment with the anticipated number of visits per week Duration Patient instruction/home program Caregiver training Short term goals which are appropriate for the patient and the diagnosis and are stated in measurable terms with their expected date of accomplishment Long term goals which are appropriate for the patient and the diagnosis and are stated in measurable terms with their expected date of accomplishment Rehabilitation potential, which is a realistic evaluation of the patient's potential for rehabilitation/restoration using objective terminology Signature and credentials of therapist performing the evaluation The components of the re-evaluation and the documentation requirements are the same as the initial evaluation, but are focused on assessing significant changes from the initial evaluation or progress toward treatment goals. Re-evaluations not addressing any of the functional impairments identified in the initial evaluation will be non-covered. Modalities 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 include therapeutic procedures. Examples of exceptions are wound care or when a patient is unable to endure therapeutic procedures due to the acuteness of the condition. If a patient is unable to endure therapeutic procedures due to the acuteness of the condition, the number of visits for modalities should not exceed 2-4 visits. Greater than two (2) modalities should not be used on each visit date. A balance of supervised and constant attendance modalities should be used. Multiple heating modalities should not be used on the same day. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation must support the medical necessity of multiple heating modalities as contributing to the patient's progress and restoration of function. Supervised Modalities Application of the following modalities does not require direct (one-on-one) patient contact by the physical therapist. Application of a modality to one or more areas; hot or cold packs Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm, and reduce inflammation and edema. Typically cold packs are used for acute, painful conditions, and hot packs for sub acute or chronic painful conditions. Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist. However, the skills, knowledge, and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular case, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are not considered reasonable and necessary and therefore, are not covered. Additional Documentation Recommendations If these modalities are performed, they should be documented. The area/areas treated and the patient's response to treatment should be documented. Application of a modality to one or more areas; traction, mechanical Traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas. Specific indications for the use of mechanical traction include cervical and/or lumbar radiculopathy and back disorders such as disc herniation, lumbago, and sciatica. This modality is typically used in conjunction with therapeutic procedures, not as an isolated treatment. Equipment and tables utilizing roller systems are not considered as true mechanical traction. Services using this type of equipment are non-covered. Vertebral axial decompression (VAX-D) is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, VAX-D is considered non-covered. Supervised mechanical traction is generally not covered for greater than 3-4 visits to determine the efficacy of traction and to instruct the patient and/or caregiver in the use of a home traction unit, if traction is providing benefit. Documentation should support the medical necessity of continued treatment by the provider using this modality for greater than 4 visits. Additional Documentation Recommendations Part of the body to which traction is applied Force of traction applied (pounds) and the angle of pull Amount of time the traction is applied Response of patient to treatment Response of patient and/or caregiver to education Functional progress at reassessment and discharge; If no progress, the reason for lack of progress documented and /or alternative treatment strategy. Application of a modality to one or more areas; vasopneumatic devices Specific indications for the use of vasopneumatic devices include: Reduction of edema after acute injury Lymphedema of an extremity Education on the use of a lymphedema pump No more than 3 visits will generally be covered for educating the patient and/or caregiver in the use of lymphedema pump in the home. Continued treatment by the provider using the vasopneumatic device after the educational visits is generally not medically necessary. If provider treatment is continued for additional visits, the documentation must support the medical necessity. Additional Documentation Recommendations Area of the body being treated, location of edema Objective edema measurements with comparison to the uninvolved side Description of edema (e.g., pitting, non-pitting) Effect of edema on function Type of device used Response of patient to treatment Response of patient and/or caregiver to education Application of a modality to one or more areas; paraffin bath Paraffin bath is primarily used for pain relief in chronic joint problems of the wrists, hands, or feet. Specific indications for the use of paraffin bath include: Contracture as a result of rheumatoid arthritis Contracture as a result of scleroderma Acute synovitis Post-traumatic conditions Hypertrophic scarring Degenerative joint disease Osteoarthritis Post-surgical conditions or tendon repairs Status post sprains or strain No greater 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 treatment and billing of this code by the provider for greater than 2 visits. Additional Documentation Recommendations Area of body treated Response of patient to treatment Response of patient and/or caregiver to education Application of a modality to one or more areas; whirlpool General whirlpool ordinarily does not require the skills of a qualified physical therapist. However, the skills, knowledge, and judgment of a qualified physical therapist may be considered medically necessary when the patient's condition is complicated by either circulatory or areas of desensitization, and the therapeutic goal is to increase circulation or decrease skin sensitivity. No greater than 6-8 visits should be billed. If greater than 8 visits are needed, the documentation must support the medical necessity of continued whirlpool treatment. Whirlpool therapy for the treatment of muscle spasms should not be used since there are other modalities that are more effective. Additional Documentation Recommendations Area/areas being treated If used for weakness or range of motion, objective measurements of strength, range of motion, and/or functional deficits should be documented If used for circulatory or desensitization problems, the description of problem and effect on function should be documented Response of patient to treatment Application of a modality to one or more areas; diathermy In accordance with CMS' NCD 150.5 for “Diathermy Treatment,” located at: www.cms.gov, the use of diathermy is considered reasonable and necessary for the delivery of heat to deep tissues such as skeletal muscle and joints for the reduction of pain, joint stiffness, and muscle spasms. Specific indications for the use of diathermy include: Osteoarthritis, rheumatoid arthritis, or traumatic arthritis A strain or sprain Acute or chronic bursitis Traumatic injury to muscle, ligament, or tendon resulting in functional loss Joint dislocation or subluxation Treatment for a post surgical functional loss Adhesive capsulitis Joint contracture 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. This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment. The efficacy of this modality should be met at most in 10-12 visits. Documentation must support the need of continued treatment with this modality for greater than 12 visits Diathermy is not considered reasonable and necessary for the treatment of asthma, bronchitis, or any other pulmonary condition. Additional Documentation Recommendations Area/areas being treated Response of patient to treatment Objective clinical findings/measurements Subjective findings to include pain ratings, pain location, activities that increase or decrease pain, effect on function, etc. Functional progress at reassessment and discharge. If no progress, the reason for lack of progress and/or alternative treatment strategy should be documented. Application of a modality to one or more areas, infrared As of October 24, 2006, CMS has determined that there is sufficient evidence to conclude that the use of infrared devices is not reasonable and necessary for treatment of Medicare beneficiaries for diabetic and non-diabetic peripheral sensory neuropathy, wounds and ulcers, and similar related conditions, including symptoms such as pain arising from these conditions. The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE), is not 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 skin and/or subcutaneous tissues in Medicare beneficiaries. Refer to CMS’ NCD 270.6, “Infrared Therapy Devices,” for additional information. Superficial heat treatment of this type ordinarily does not require the skills of a qualified, licensed therapist and therefore is considered as a non-skilled service, which is not reimbursable. This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment. Infrared application in the absence of associated therapeutic procedures or modalities, or used alone to reduce discomfort, is considered not medically necessary, and therefore, is not covered. Application of a modality to one or more areas; ultraviolet Treatment of this type is generally used for patients requiring the application of a drying heat. For example, this treatment would be considered reasonable and necessary for the treatment of severe psoriasis where there is limited range of motion. Refer to CMS' NCD 250.1, “Treatment of Psoriasis,” at: www.cms.gov for additional coverage information regarding using ultraviolet for the treatment of psoriasis. Additional Documentation Recommendations Area/areas being treated Minimal erythema dosage should be documented Response of patient to treatment Constant Attendance Modalities Application of the following modalities requires direct (one-on-one) patient contact by the physical therapist. Electrical Stimulation for Non-Wound Care Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care 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. Documentation would need to support the medical necessity of services beyond 1-2 visits. Refer to CMS' NCDs for coverage criteria and definition of electrical stimulation, Section 160, “Nervous System,” at: www.cms.gov 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. Muscle stimulation is a type of stimulation that is taken to the point of visible muscle contraction. 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 are 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. 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. 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. Electrical Stimulation and Electromagnetic Therapy for Wound Care Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care Electromagnetic therapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care Electrical stimulation and electromagnetic therapy for the treatment of chronic stage III or stage IV wounds will be covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Measurable signs of improved healing include a decrease in wound size either in surface area or volume, decrease in amount of exudates and decrease in amount of necrotic tissue. Standard wound care includes optimization of nutritional status; debridement by any means to remove devitalized tissue; maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; and necessary treatment to resolve any infection that may be present. Specific wound care based on type of wound includes frequent repositioning of a patient with pressure ulcers; off-loading of pressure and good glucose control for diabetic ulcers; establishment of adequate circulation for arterial ulcers; and the use of a compression system for patients with venous ulcers. Electromagnetic therapy (e.g. Diapulse ® Wound Treatment System TM , PROVANT ® Wound Closure System) is a form of treatment that involves the production of induced current from the application of electromagnetic fields rather than the application of electrical current directly from electrodes on the skin surface. Energy is delivered by non-contacting means (e.g. coils) rather than by leads and surface electrodes. For additional information on coverage criteria for electrical stimulation for the treatment of wounds, refer to CMS’ NCD 270.1, “Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds, located at: www.cms.gov Additional Documentation Recommendations Type of electrical stimulation used. Area/areas being treated. If used for wounds, the description of wound location, size, drainage, odor, and tissue appearance; parameters used for modality; and precautionary information should be documented. If used for muscle weakness, objective rating of strength and functional deficits should be documented. If used for swelling/edema, location of edema, description of edema, effect of edema on function should be documented. If used for pain, pain rating, location of pain, effect of pain on function should be documented. Response of patient to treatment and/or education. Functional progress at reassessment and discharge. If no progress, the reason for lack of progress and/or alternative treatment strategy should be documented. Application of a modality to one or more areas; iontophoresis, each 15 minutes Iontophoresis is a process in which electrically charged molecules or atoms are driven into tissue with an electrical field. Voltage provides the driving force. The application of iontophoresis is considered medically necessary for the topical delivery of medications into a specific area of the body. If no objective and/or subjective improvements are noted after 8 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 10-12 visits. Documentation must support the need for continued treatment with this modality for greater than 12 visits. This modality should be used in conjunction with therapeutic procedures. Coverage for iontophoresis when delivered by means of a '24 hour patch' is only for the time spent for the initial application and is generally covered for 1-2 visits to establish efficacy. Subsequent visits for reapplication generally do not require the skills of a licensed therapist and therefore are noncovered. Additional Documentation Recommendations Area/areas being treated Medication and dosage information Response of patient to treatment Objective clinical findings/measurements of strength and range of motion and functional deficits/limitations Subjective findings related to pain location, pain rating, effect of pain on function Functional progress at reassessment and discharge. If no progress, the reason for lack of progress and/or alternative treatment strategy should be documented. Application of a modality to one or more areas; contrast baths, each 15 minutes 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. The use of contrast baths is considered medically necessary to desensitize patients to pain. The use of contrast baths may be considered medically necessary for the following: Documented rheumatoid arthritis or other inflammatory arthritis Documented reflex sympathetic dystrophy Documented sprain or strain resulting from an acute injury Hot and cold baths ordinarily do not require the skills of a licensed therapist. However, the skills, knowledge and judgment of a licensed therapist might be required in the giving 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 service. If there were no complicating factors, which would necessitate the skills of a licensed therapist to perform this modality, the modality would be non-covered. However, it could be considered reasonable and necessary for 1-2 visits for instruction to the patient and/or caregivers in the performance of this modality and to assess the patient's response to the modality. This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment. Additional Documentation Recommendations Area/areas being treated. Subjective findings to include pain ratings, pain location, effect on function. Patient response to treatment and/or education. Application of a modality to one or more areas; ultrasound, each 15 minutes 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 fo