LCD L34428: Outpatient Physical Therapy

Although there is an overlap in services provided by physical and occupational therapists, this policy addresses only physical therapy (PT).

PT services are part of a constellation of rehabilitative services designed to improve or restore physical functioning, as well as, to prevent injury, impairments, activity limitations, participation restrictions and disability following disease, injury or loss of a body part. Impairments, activity limitations and disabilities are addressed by the examination, evaluation and development of a plan of care (POC) that may include implementation of therapeutic interventions tailored to the specific needs of the individual patient to achieve specific goals and outcomes. The specific interventions that may be utilized are therapeutic exercises to strengthen muscles, maintain or restore motion, integumentary repair and protection techniques, physical agents and mechanical modalities, such as heat, cold, electrotherapeutic modalities, ultrasound (US) and hydrotherapy, manual therapy and functional training or retraining an individual to perform the activities of daily living (ADLs).

All PT services must be performed by or under the supervision of a qualified physical therapist.

For the purposes of this Local Coverage Determination (LCD), the descriptions/definitions of supervision are those given in 42 CFR §410.32(b)(3).

Qualified Physical Therapist: An individual who is licensed as a physical therapist and meets the practice requirements in the state where they are practicing.

For outpatient settings, references to “physicians” throughout this policy include nonphysician practitioners (NPPs), such as nurse practitioners, clinical nurse specialists and physician assistants. Such NPPs may certify, order and establish the POC for services by physical therapists as authorized by state law.

A qualified physical therapist, for program coverage purposes, is defined as an individual who is licensed as a physical therapist and meets the practice requirements in the state where they are practicing. Physiatrists, physicians or NPPs, and qualified physical therapists have the knowledge, training, and experience required to evaluate and, as necessary, re-evaluate a patient’s level of function, and determine whether a PT program could reasonably be expected to improve, restore or compensate for lost function. Where appropriate, the physical therapist can recommend to the physician or NPP a POC. While the skills of a qualified physical therapist are required to evaluate the patient’s level of function and develop a POC, implementation of the plan may also be carried out by a qualified physical therapy assistant (PTA) functioning under the general supervision of the qualified physical therapist.

Some services must be provided by a licensed therapist and may not be performed by a PTA such services include:

• Making clinical judgements or decisions

• Developing, managing or furnishing skilled maintenance programs

• Supervising other clinicians or taking responsibility for the service rendered

• Acting outside of the directions and supervision of a treating therapist in accordance with state laws

Restorative/Rehabilitative therapy:

In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services.

Maintenance therapy:

A maintenance program is a program designed to maintain or to slow deterioration as described in the CMS Internet-Only Manual Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220 and §220.2 and must meet these criteria to be considered reasonable and necessary.

GENERAL PT GUIDELINES

1. PT services are covered services provided the 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 physical therapist or under his/her supervision. Services normally considered a routine part of nursing care are not covered as PT (i.e., turning patients to prevent pressure injuries, walking a patient in the hallway postoperatively or ambulation without gait training).

2. Covered PT must be furnished while the individual is or was under the care of a physician. Services must relate directly and specifically to a written plan of treatment regimen established by the physician or NPP after any necessary consultation with the qualified physical therapist, or by the physical therapist providing the services and must be reasonable and necessary to the treatment of the individual's illness or injury.

3. In order for the plan of treatment to be covered, it must address a condition for which PT is an accepted method of treatment as defined by standards of medical practice. Also, the plan of treatment must be for a condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer be considered reasonable and necessary and are excluded from coverage.

4. PT is only covered when it is rendered under a written plan of treatment established by the physician, NPP or the qualified physical therapist, to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or NPP should periodically review the plan of treatment.

5. The physician or NPP and/or therapist must document the patient's functional limitations in terms that are objective and measurable.

SPECIFIC PROCEDURE AND MODALITY GUIDELINES

Computerized Dynamic Posturography

Computerized dynamic posturography is a "quantitative method for assessing balance functioning under various simulated tasks. Protocols are designed to test the sensory, motor and biomechanical components of balance individually and in concert." Computerized dynamic posturography "may assist with lesion localization, identifying adaptive strategies and functional capabilities."

*Note: Results of computerized dynamic posturography must be used in determining the patient centered POC.

Wound Care Selective

a) Debridement:

Debridement is indicated whenever necrotic tissue is present on a documented open wound. Debridement may also be indicated in cases of abnormal wound repair.

b) Conservative Sharp Debridement:

Conservative sharp debridement is a minor procedure that requires no anesthesia and is performed on an outpatient basis. Scalpel, scissors, and forceps may be used and only clearly identified devitalized tissue is removed. Generally, there is no specific bleeding associated with this procedure.

Wound(s) Care Non-Selective Debridement and Negative Pressure Wound Therapy

a) Enzymatic Debridement:

Debridement with topical enzymes is used when necrotic substances to be removed from a wound are protein, fibrin and collagen. The manufacturer's product insert contains indications, contraindications, precautions, dosage, and administration. It would be the clinician's responsibility to comply with the product insert/guidelines.

b) Autolytic Debridement:

This type of debridement is indicated where manageable amounts of necrotic tissue are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found in wound fluids are sequestered under synthetic dressings. Autolytic debridement is contraindicated for wounds that contain infection.

c) Mechanical Debridement:

Wet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing.

Hydrotherapy and wound irrigation are also forms of mechanical debridement used to remove necrotic tissue. They also should be used cautiously, as maceration of surrounding tissue may hinder healing.

d) Negative Pressure Wound Therapy:

Negative Pressure Wound Therapy is a non-invasive treatment by which controlled localized negative pressure is delivered to a wide variety of acute, sub-acute, and chronic wounds. Negative Pressure Wound Therapy should be used cautiously as maceration of surrounding tissue may hinder healing.

Fabrication/Application of Casts, Splints and Strapping

Fabrication and application of casts, splints, and strapping (e.g., the use of elastic wraps, heavy cloth, adhesive tape) will be considered reasonable and necessary if used to support weak or ineffective joints/muscles, reduce/correct joint limitations/deformities and/or protect body parts from injury, thus enhancing the performance of tasks or movements. The casts, splints and strapping are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of patient needs and social/culture environments.

BODY AND UPPER EXTREMITY CASTS

Application of long arm cast

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures and/or other deformities involving soft tissue.

Application of short arm cast

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Application of hand and lower forearm cast

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

SPLINTS

Application of long arm splint

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Application of short arm splint

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Application of finger splint

May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

STRAPPING-ANY AGE

Strapping of thorax

May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of low back

May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of shoulder (e.g., Velpeau)

May be indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of elbow or wrist

May be indicated for the elbow or wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

Strapping of hand or finger

May be indicated when there is involvement of the hand or finger(s) in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

LOWER EXTREMITY CASTS

Application of long leg cast

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg cast

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of rigid leg cast

May be indicated for recent amputees or patients with lower extremity ulcers.

SPLINTS

Application of long leg splint

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg splint

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

STRAPPING-ANY AGE

Strapping of hip

May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of knee

May be indicated when there is involvement of the thigh, knee, or lower leg in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of ankle and/or foot

May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of toes

May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Application of unna boot

N/A