LCD L34564: Home Health 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 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.

Rehabilitation Services for Vision Impairment - Partial or complete vision loss may make therapy to improve activities of daily living reasonable and necessary.

Maintenance Therapy

Coverage of skilled rehabilitation services is contingent upon beneficiary’s need for skilled care whether the goals of therapy include maintenance or improvement.

Restorative/Rehabilitative Therapy

Restorative/rehabilitative therapy has the purpose of improving function or reversing loss of function.

General Physical Therapy Guidelines

A beneficiary must require the services of a skilled physical therapist for the service to be covered. The pressing need for a service, or the lack of availability of unskilled personnel to render the service with the necessary frequency does not itself make a service skilled. However, some services that would not normally be considered skilled therapy, may require the skilled services of a therapy professional because of a special complicating medical factor. This must be clearly evident in the medical record.

SPECIFIC PROCEDURE AND MODALITY GUIDELINES:

FABRICATION/APPLICATION OF SPLINTS AND STRAPPING

1. Fabrication and application (as appropriate) of splints and strapping (e.g., the use of elastic wraps, heavy cloth and adhesive tape) are used to enhance performance of tasks or movements, support weak or ineffective joints or muscles, reduce/correct joint limitations/deformities, and/or protect body parts from injury. Splints and strapping are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of a patient’s needs and social/cultural environments.

2. The physical therapist targets the problems in performance of movements or tasks. The physical therapist may select (or fabricate) the most appropriate device or equipment, fit it and train the patient and/or caregiver(s) in its use and application. The goal is for the patient to function at a higher level by decreasing functional limitations.

3. The simple application of a commercial splint or brace will not be considered in this section.

Application 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 of thorax

May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, 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 and wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, 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, sprains/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissues.

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 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

A dressing for ulcers resulting from venous insufficiency, consisting of a paste made from gelatin zinc oxide and glycerin which is applied to the leg then covered with a spiral bandage, this in turn being given a coat of the paste. The process is repeated until satisfactory rigidity is attained.

Biofeedback training any method and biofeedback training perineal muscles, anorectal or urethral sphincter

The coverage criteria and definition of biofeedback therapy is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, §30.1 Biofeedback Therapy and §30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence.

Biofeedback is a tool utilized by physical therapists to assist with muscle training. This includes facilitation of muscles that are demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can be visual or auditory.

Muscle testing, manual

Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk

For extremity manual muscle testing, every muscle of at least 1 extremity would need to be tested, with documentation of why such a thorough assessment was warranted.

Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side

Manual testing of hands only.

Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands or including hand

The measurement of muscle performance using manual muscle testing only.

Range of Motion (ROM) Measurements

Determination of ROM using a tape measure, flexible ruler, electronic device or goniometer.

PT Evaluation and PT Re-evaluation

Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted at the start of therapy or when the beneficiary’s condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. The time spent in evaluation does not count as treatment time.

1. The initial examination has the following components:

a. The patient history to include prior level of function,

b. Relevant systems review,

c. Tests and measures,

d. Current functional status (abilities and deficits), and

e. Evaluation of patient's, physician's, and as appropriate the caregiver's goals.

2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, the patient's overall physical and cognitive health status, social/cultural supports, psychosocial factors and use of adaptive equipment. Thus, 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. Physical therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment.

3. Initial evaluations or re-evaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized.

4. Re-evaluation is considered reasonable and necessary when the beneficiary’s condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. Some regulations and state practice acts require re-evaluation at specific intervals.

5. Re-evaluations are appropriate periodically to assess progress toward goals established in the plan of treatment, or to identify and establish interventions for newly developed impairments at least once every 30 days, for each therapy discipline.

Maintenance Programs

A maintenance program is a program designed to help a beneficiary maintain an existing level of function or minimize a loss of function. Coverage of skilled rehabilitation services is contingent upon beneficiary’s need for skilled care whether the goals of therapy include maintenance or improvement.

Hot or Cold Packs Therapy

1. 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.

2. Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not reasonable and necessary and therefore, are not covered.

Mechanical Traction Therapy

1. Traction is generally limited to the cervical or lumbar spine with the hope of relieving pain in or originating from those areas.

2. Specific indications for the use of mechanical traction include:

a. Cervical and/or lumbar radiculopathy

b. Back disorders such as disc herniation, lumbago, and sciatica

Vasopneumatic Device Therapy

1. The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema.

2. Specific indications for the use of vasopneumatic devices include:

a. Reduction of edema after acute injury

b. Lymphedema of an extremity

c. Education on the use of a lymphedema pump for home use

Note: Further treatment of lymphedema by a physical therapist after the educational visits are generally not reasonable and necessary. Generally, education can be completed in 3 visits.

Paraffin Bath

1. Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands, and feet.

2. Heat treatments alone do not typically make the skills of a therapist reasonable and necessary. However, heat treatments in the presence of a complicating medical factor may make the skills of a therapist reasonable and necessary.

Whirlpool

1. Whirlpool baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths (e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications). Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.

N/A