LCD L33942: Physical Therapy - Home Health

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

N/A