ARCHIVED Physical Occupational and Speech Therapies 2023-04-09 to 2024-04-13

Archive Date: 04/14/2024

This document has been archived because it has outdated information. It is for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the Carelon Medical Benefits Management website at http://guidelines.carelonmedicalbenefitsmanagement.com

Status: Revised Effective Date: 04/09/2023

Doc ID: REH01-0423.1 Last Review Date: 09/21/2022

Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details.

Clinical Appropriateness Guidelines

Outpatient Rehabilitative and Habilitative Services

Appropriate Use Criteria: Physical Therapy, Occupational Therapy, and Speech Therapy

Proprietary

Description and Application of the Guidelines

General Clinical Guideline

Clinical Appropriateness Framework

Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions

Repeat Diagnostic Intervention

Repeat Therapeutic Intervention

Rehabilitation and Habilitative Therapies

Speech-Language Pathology

Adjunctive & Alternative Treatments

Physical Therapy and Occupational Therapy Adjunctive Treatments

Speech Therapy Alternative Treatments

Description and Application of the Guidelines

The Carelon Clinical Appropriateness Guidelines (hereinafter “the Carelon Clinical Appropriateness Guidelines” or the “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific clinical condition for an individual. As used by Carelon, the Guidelines establish objective and evidence-based criteria for medical necessity determinations where possible. In the process, multiple functions are accomplished:

To establish criteria for when services are medically necessary (i.e., in general, shown to be effective in improving health outcomes and considered the most appropriate level of service)
To assist the practitioner as an educational tool
To encourage standardization of medical practice patterns
To curtail the performance of inappropriate and/or duplicate services
To advocate for patient safety concerns
To enhance the quality of health care
To promote the most efficient and cost-effective use of services

The Carelon guideline development process complies with applicable accreditation standards, including the requirement that the Guidelines be developed with involvement from appropriate providers with current clinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinical principles and best practices. Relevant citations are included in the References section attached to each Guideline. Carelon reviews all of its Guidelines at least annually.

Carelon makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Copies of the Carelon Clinical Appropriateness Guidelines are also available upon oral or written request. Although the Guidelines are publicly-available, Carelon considers the Guidelines to be important, proprietary information of Carelon, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of Carelon.

Carelon applies objective and evidence-based criteria, and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. The Carelon Guidelines are just guidelines for the provision of specialty health services. These criteria are designed to guide both providers and reviewers to the most appropriate services based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.

The Guidelines do not address coverage, benefit or other plan specific issues. Applicable federal and state coverage mandates take precedence over these clinical guidelines. If requested by a health plan, Carelon will review requests based on health plan medical policy/guidelines in lieu of the Carelon Guidelines. Pharmaceuticals, radiotracers, or medical devices used in any of the diagnostic or therapeutic interventions listed in the Guidelines must be FDA approved or conditionally approved for the intended use. However, use of an FDA approved or conditionally approved product does not constitute medical necessity or guarantee reimbursement by the respective health plan.

The Guidelines may also be used by the health plan or by Carelon for purposes of provider education, or to review the medical necessity of services by any provider who has been notified of the need for medical necessity review, due to billing practices or claims that are not consistent with other providers in terms of frequency or some other manner.

General Clinical Guideline

Clinical Appropriateness Framework

Critical to any finding of clinical appropriateness under the guidelines for a specific diagnostic or therapeutic intervention are the following elements:

Prior to any intervention, it is essential that the clinician confirm the diagnosis or establish its pretest likelihood based on a complete evaluation of the patient. This includes a history and physical examination and, where applicable, a review of relevant laboratory studies, diagnostic testing, and response to prior therapeutic intervention.
The anticipated benefit of the recommended intervention should outweigh any potential harms that may result (net benefit).
Current literature and/or standards of medical practice should support that the recommended intervention offers the greatest net benefit among competing alternatives.
Based on the clinical evaluation, current literature, and standards of medical practice, there exists a reasonable likelihood that the intervention will change management and/or lead to an improved outcome for the patient.

Providers may be required to submit clinical documentation in support of a request for services. Such documentation must a) be current enough to accurately reflect the clinical situation at the time of the requested service, and b) contain the elements necessary to determine compliance with guideline criteria without Carelon physician reviewers having to make assumptions or interpretations about an ordering provider’s clinical intent.

If these elements are not established with respect to a given request, the determination of appropriateness will most likely require a peer-to-peer conversation to understand the individual and unique facts that would supersede the requirements set forth above. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account.

Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions

Requests for multiple diagnostic or therapeutic interventions at the same time will often require a peer-to-peer conversation to understand the individual circumstances that support the medical necessity of performing all interventions simultaneously. This is based on the fact that appropriateness of additional intervention is often dependent on the outcome of the initial intervention.

Additionally, either of the following may apply:

Current literature and/or standards of medical practice support that one of the requested diagnostic or therapeutic interventions is more appropriate in the clinical situation presented; or
One of the diagnostic or therapeutic interventions requested is more likely to improve patient outcomes based on current literature and/or standards of medical practice.

Repeat Diagnostic Intervention

In general, repeated testing of the same anatomic location for the same indication should be limited to evaluation following an intervention, or when there is a change in clinical status such that additional testing is required to determine next steps in management. At times, it may be necessary to repeat a test using different techniques or protocols to clarify a finding or result of the original study.

Repeated testing for the same indication using the same or similar technology may be subject to additional review or require peer-to-peer conversation in the following scenarios:

Repeated diagnostic testing at the same facility due to technical issues
Repeated diagnostic testing requested at a different facility due to provider preference or quality concerns
Repeated diagnostic testing of the same anatomic area based on persistent symptoms with no clinical change, treatment, or intervention since the previous study
Repeated diagnostic testing of the same anatomic area by different providers for the same member over a short period of time

Repeat Therapeutic Intervention

In general, repeated therapeutic intervention in the same anatomic area is considered appropriate when the prior intervention proved effective or beneficial and the expected duration of relief has lapsed. A repeat intervention requested prior to the expected duration of relief is not appropriate unless it can be confirmed that the prior intervention was never administered. For situations wherein ongoing services might be appropriate, requests for subsequent services may be denied until completion of the previously authorized services so that patient response to the previously authorized services can be considered.

Rehabilitation and Habilitative Therapies

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
20560	Needle insertion(s) without injection(s), 1 or 2 muscle(s)
20561	Needle insertion(s) without injection(s), 3 or more muscle(s)
90901	Biofeedback training by any modality (when done for medically necessary indications)
90912	Biofeedback training for bowel or bladder control, initial 15 minutes
90913	Biofeedback training for bowel or bladder control, additional 15 minutes
94667	Demonstration and/or evaluation of manual maneuvers to chest wall to assist movement of lung secretions
94668	Manual maneuvers to chest wall to assist movement of lung secretions
96001	Three-dimensional, video-taped, computer-based gait analysis during walking
97010	Application of hot or cold packs to 1 or more areas
97012	Application of mechanical traction to 1 or more areas
97014	Application of electrical stimulation to 1 or more areas, unattended by therapist
97016	Application of blood vessel compression or decompression device to 1 or more areas
97018	Application of hot wax bath to 1 or more areas
97022	Application of whirlpool therapy to 1 or more areas
97024	Application of heat wave therapy to 1 or more areas
97026	Application of low energy heat (infrared) to 1 or more areas
97028	Application of ultraviolet light to 1 or more areas
97032	Application of electrical stimulation to 1 or more areas
97033	Application of medication through skin using electrical current, each 15 minutes
97034	Therapeutic hot and cold baths to 1 or more areas, each 15 minutes
97035	Application of ultrasound to 1 or more areas, each 15 minutes
97036	Physical therapy treatment to 1 or more areas, Hubbard tank, each 15 minutes
97039	Unlisted modality (specify type and time if constant attendance)
97110	Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
97112	Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes
97113	Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes
97116	Walking training to 1 or more areas, each 15 minutes
97124	Therapeutic massage to 1 or more areas, each 15 minutes
97139	Unlisted therapeutic procedure (specify)
97140	Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
97150	Therapeutic procedures in a group setting
97161	Evaluation of physical therapy, typically 20 minutes
97162	Evaluation of physical therapy, typically 30 minutes
97163	Evaluation of physical therapy, typically 45 minutes
97164	Re-evaluation of physical therapy, typically 20 minutes
97530	Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes
97533	Sensory technique to enhance processing and adaptation to environmental demands, each 15 minutes
97535	Self-care or home management training, each 15 minutes
97537	Community or work reintegration training, each 15 minutes
97542	Wheelchair management, each 15 minutes
97545	Work hardening or conditioning, first 2 hours
97546	Work hardening or conditioning
97750	Physical performance test or measurement with report, each 15 minutes
97755	Assistive technology assessment to enhance functional performance, each 15 minutes
97760	Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15 minutes
97761	Training in use of prosthesis for arms and/or legs, per 15 minutes
97763	Management and/or training in use of orthotics (supports, braces, or splints) for arms, legs, and/or trunk, per 15 minutes
G0281	Electrical stimulation, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous statsis ulcers
G0282	Electrical stimulation, to one or more areas, for wound care
G0283	Electrical Stimulation, to one or more areas, for other than wound care
G0295	Electromagnetic therapy, one or more areas, for wound care
G0329	Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers
S8940	Therapeutic horseback riding, per session
S8948	Treatment with low level laser (phototherapy) each 15 minutes
S8950	Complex lymphedema therapy, each 15 minutes
S8990	Physical or manipulative therapy for maintenance
S9090	Vertebral axial decompression (lumbar traction), per session

Modifiers

96	Habilitative Services
97	Needle insertion(s) without injection(s), 1 or 2 muscle(s)

ICD-10 Diagnosis

Refer to the ICD-10 CM Manual

Physical Therapy

General Information

Abbreviations

Ankle foot orthosis (AFO)
Congestive heart failure (CHF)
Heart rate (HR)
Long-term goals (LTG)
Lower Extremity Functional Scale (LEFS)
Range of motion (ROM)

Background

Physical therapy, also known as physiotherapy, is a skilled, nonsurgical treatment involving education, active exercise as well as passive measures in order to maximize physical mobility and function, and quality of life. Physical therapy is a goal-directed and collaborative approach, most commonly employed when abilities have been impaired due to a medical condition, disease, or injury.

Details and Scope

The purpose of this guideline is to establish conceptual principles and documentation requirements for the appropriate initial and subsequent use of outpatient physical therapy services for habilitation and rehabilitation, and maintenance programs. This guideline does not provide specific clinical requirements or direction for a given episode of physical therapy. Specific types of physical therapy interventions, for instance hippotherapy or wobble board, may be subject to additional guidelines (please refer to the Adjunctive and Alternative Treatments section of this document). Requirements defined by benefit design (maximum number of physical therapy visits), state and federal regulations supersede this guideline.

For requests that meet the specific criteria set forth in the clinical guidelines, determination of the appropriate number of visits will depend on some or all of the following case details as applicable to the individual clinical circumstances:

Functional outcome tool and/or severity of impairment
History of pertinent surgery
Comorbidities expected to impact treatment
Progress toward functional goals (or mitigating factors if lack of progress)
Existence of additional, achievable, functional goals
Potential for progress
Revisions to the plan of care

Requesting providers will need to provide information on such factors in order to support their request for more than an evaluation visit. A peer-to-peer conversation may be required to determine appropriateness in certain cases.

Unless specifically stated in the document, these guidelines do not express any opinion about the appropriate scope of practice for the practitioners who deliver these services and should not be put forth as having such an opinion.

Definitions

Acceptable mitigating factors refers to issues which could realistically contribute to or fully account for the lack of progress/improvement that would otherwise be expected during a course of treatment. These include but are not limited to an intervening fall, injury, illness, surgery, or hospitalization, transportation difficulties, or poor response to the initial treatment plan.
Caregiver refers to someone who regularly looks after or helps with the care of the child or adult (patient) with the disability.
Duplicative therapy refers to treatments by more than one provider (same or different discipline) which are 1) rendered during an overlapping time period, 2) intended to treat the same or similar body parts (e.g., arm and shoulder), conditions or diagnoses, and 3) have substantively similar goals (e.g., improved functional shoulder range of motion).
Functional progress refers to progress that directly reflects improvement in specific functional tasks such as mobility and self-care activities.
Habilitation refers to services performed to help patients develop skills and functions for daily living that have not yet been acquired at an age appropriate level ^1,² or keep those skills and functions which are at risk of being permanently lost (not merely fluctuating) due to illness or disease without the habilitative service.
Maintenance program is defined as a program provided to the patient expressly to maintain the patient’s current condition or to prevent or slow further deterioration due to a disease or illness. The creation, design and instruction of the program must require the skilled knowledge or judgement of a qualified therapist. A prescribed maintenance program can generally be performed by the patient individually or with the assistance of a caregiver. The provision of such a program would be considered a skilled intervention.
Qualified physical therapy provider refers to a physical therapist or physical therapy assistant or other provider type who is duly licensed or certified, respectively, by his/her state to deliver physical therapy services and who provides such services in accordance with his/her state’s PT practice act. State regulations regarding appropriate providers may supersede this guideline.
Rehabilitation focuses on the maximal restoration of physical and psychological function in persons with injuries, pain syndromes, and/or other physical or cognitive impairments.³
Self-limited refers to impairments caused by a disease process or surgical intervention that are expected to resolve in the near term solely with resumption of normal activity and/or a nonsupervised home exercise program.
Skilled services are those services which require a qualified provider to administer the treatment plan. A service is not considered skilled simply because a qualified provider is performing it.

Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes, but is not limited to, autism spectrum disorder and developmental delay.

Clinical Indications

Initiation of physical therapy for rehabilitative or habilitative services is considered medically necessary when criteria for both A and B are met:

A. Initial Physical Therapy Evaluation

Initial physical therapy evaluation is performed by a qualified physical therapy provider documenting ALL of the following:

The reason for referral, specifically a condition that causes or contributes to one or more impairments in physical function that is not self-limited
A need for physical therapy to:
- restore function (rehabilitation), or
- keep, learn, or improve function that has not yet been acquired at any age appropriate level, or if clinically indicated, prevent loss of function that is at risk of being lost (habilitation)
A relevant case history including comorbidities expected to impact treatment, a relevant physical examination, and a review of supporting, available documentation
Functional impairment on at least 1 relevant, validated, therapist-rated and/or patient-reported outcome measure
Potential for clinically meaningful progress, the assessment of which must be supported by clinical details documented within the evaluation

Note: Potential for clinically meaningful progress will not apply for habilitation cases in which the appropriate purpose of therapy is to prevent loss of function that is at risk of being lost (habilitation).

B. Individualized Physical Therapy Plan of Care

Individualized physical therapy plan requires the skill and training of a qualified physical therapy provider employing interventions and delivery methods that adhere to the Clinical Appropriateness Framework (outlined in the General Clinical Guideline above). There must be a reasonable expectation that the condition being treated is amenable to such intervention and that clinically meaningful, sustained improvement will be achieved.

Note: The expectation of clinically meaningful, sustained improvement will not apply for habilitation cases in which the appropriate purpose of therapy is to prevent loss of function that is at risk of being lost (habilitation).

This plan must include ALL of the following components:

One or more goals which are:
- Specific
- Measurable
- Likely to be attained in a reasonable amount of time
- Based on clinically significant improvement in the functional impairment(s) identified on initial evaluation
- Formulated in collaboration with the patient and/or primary caregiver

Note: There may be additional goals which do not meet the above criteria, but at least one goal must meet these criteria in order for medical necessity to be met.

Examples of appropriate goals:

Increase knee ROM to 100 degs to allow safe, independent toilet transfers (to be achieved in 4 weeks)
Patient to do 8 steps with minimum assist and one handrail (8 weeks)
Patient will ambulate on level surface without AFO for 50 ft without loss of balance (estimated time 12 weeks)
Patient will be able to lift 20# with neutral C-spine and 0/10 pain to improve ability to lift feed bags at her ranch (LTG 6 weeks)

Examples of inappropriate goals:

-Increase knee ROM to 100 degrees (acceptable as an additional goal but not as the required functional, time-limited goal)

-Patient to go up/down stairs (to be achieved in 8 weeks)

-Normalize gait

– Patient to lift heavy load without discomfort

-LEFS score of 60

Recommended frequency and estimated duration of treatment needed to achieve documented goals
Patient and/or caregiver education particularly related to the patient’s individual goals
A recommendation for evaluation/examination by a physician or otherwise appropriate provider if there is reasonable suspicion that an undiagnosed condition outside therapist’s scope of practice is present or limiting current progression towards goals

Proceeding with physical therapy services is considered medically necessary when ALL of the following criteria (A-F) are met:

A. Require the skills and training of a qualified physical therapy provider:

The skilled intervention(s) must be clearly denoted in the documentation

Examples of skilled intervention documentation:

Skilled passive ROM to shoulder needed to maintain post-op restrictions and due to high risk of dislocation
Advancing strengthening exercises, requires skilled monitoring of patient’s HR response and activity tolerance due to CHF risk

B. ANY of the following:

Therapy has produced clinically meaningful improvement on reassessment of one or more of the therapist-rated or patient centered outcome measures documented on initial evaluation

Example of clinically meaningful improvement on outcome measure:

Statistically significant improvement in outcome tool score with improvement in at least one of the functional parameters of the outcome measure (e.g., walking parameter in the Oswestry Disability Index)

Examples of non-clinically meaningful improvement on outcome measure:

-Improvements only in non-specific, non-functional parameters of the functional tool (e.g., pain parameter in the Oswestry Disability Index)

-Statistically insignificant improvement in outcome tool score

There is attainment of functional goals established on initial evaluation or otherwise qualitative and sustained functional progress

Examples of functional progress:

Patient able to do three 4-inch steps with step-up pattern and no assistance before fatiguing
Patient able to get off toilet with minimal assistance using only one-hand push-off
Patient knee flexion ROM now 60 degrees (when documented as progress towards specific functional goal such as “Increase knee ROM to 100 degrees for safe toilet transfer.” Such progress might then also reasonably be documented as “ROM 60% met” if applied to this same functional goal)

Examples of non-functional progress:

-Stairs ongoing

-Toilet transfers partially met

-Goal 60% met (without clear indication of what parameter 60% reflects and what functional goal it applies to)

-Strength improved to 3/5

-Shoulder ROM increased 20 degrees

There is little to no demonstrable progress; however, there are acceptable mitigating factors and a treatment plan has been revised accordingly
There is confirmation of functional status being maintained in cases in which the appropriate purpose of therapy is to prevent loss of function that is at risk of being lost (habilitation)

C. There is ongoing patient and/or caregiver education and/or training

D. There is at least one unmet functional or caregiver training goal

E. There is an expectation that the remaining goal(s) will be met within a reasonable and defined period of time

F. Progress is commensurate with the duration of treatment rendered

A recommendation for evaluation/examination by a physician or otherwise appropriate provider must be made if there is poor progression toward goals due to new or persistent symptoms

Institution of a physical therapy maintenance program may be considered medically necessary in specific circumstances (refer to Definitions section)

Exclusions

The following are considered not medically necessary:

Maintenance therapies extending beyond the creation, design, and instruction of a therapy program
Therapies for which the primary purpose is anything other than rehabilitation or habilitation of a functional impairment due to medical illness, disease, condition, or injury. This includes therapies to improve recreational sports performance or general fitness, provide massage, or athletic taping.

Examples of rehabilitation purpose:

Treatment rendered in order to restore ability to do pain-free push off for jumping
Treatment rendered in order to restore ability to do running gait

Examples of recreational/sports purpose:

Treatment rendered in order to improve endurance to allow for running a longer distance
Treatment rendered in order to improve muscle endurance to allow playing full 60 minutes of basketball without muscle fatigue or pain
Treatment rendered to achieve (or restore) ability to jump high enough to dunk a basketball
Progress is not commensurate with the duration of treatment provided (e.g. range of motion improved but only a small amount relative to the length of time patient has been in treatment, and without any reasonable mitigating factor(s) accounting for it.)
Therapies deemed to be duplicative (see definition above)
Any and all non-skilled services

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National Institute for Health and Care Excellence (NICE). Spasticity in under 19s: management, cg145.: National Institute for Health and Care Excellence (NICE), ; 2016. p. 41.
National Institute for Health and Care Excellence (NICE). Stroke rehabilitation. Long-term rehabilitation after stroke, cg 162. London (UK): National Institute for Health and Care Excellence (NICE); 2013. p. 45.
National Institute for Health and Care Excellence (NICE). The management of hip fracture in adults, cg124. London (UK): National Institute for Health and Care Excellence (NICE), ; 2017. p. 664.
National Institute for Health and Care Excellence (NICE). Urinary incontinence and pelvic organ prolapse in women: management ng123. London (UK): National Institute for Health and Care Excellence (NICE), ; 2019. p. 76.
North American Spine Society (NASS). Diagnosis and Treatment of Low Back Pain. Burr Ridge (IL): North American Spine Society; 2020. p. 217.
Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic pain. SIGN 136. Revised edition 2019. Edinburgh (UK): Scottish Intercollegiate Guidelines Network; 2019. p. 77.
Scottish Intercollegiate Guidelines Network. Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning ncg118. Edinburgh (UK): Scottish Intercollegiate Guidelines Network,; 2010. p. 108.
South Australian Government. Guidelines for treatment, care and support for amputees within the LSS living in the community. Adelaide (South Australia)2016. p. 34.
Spanish NHS -Working Group of the Clinical Practice Guideline for the Management of Patients with Parkinson’s Disease. Clinical practice guideline for the management of patients with Parkinson’s disease. Madrid (Spain): Spanish NHS, Ministry of Health, Social Services and Equality; Institute of Health Sciences of Aragon; 2014. p. 159.
Strenk M, Gevedon A, Monfreda J. Cincinnati Children’s Hospital Medical Center: Best Evidence Statement Physical therapy during the hemopoietic stem cell transplant process to improve quality of life. Cincinnati OH: Cincinnati Children’s Hospital Medical Center; 2014. p. 9.
Tawil R, Kissel JT, Heatwole C, et al. Evidence-based guideline summary: Evaluation, diagnosis, and management of facioscapulohumeral muscular dystrophy: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the Practice Issues Review Panel of the American Association of Neuromuscular & Electrodiagnostic Medicine. Neurology. 2015;85(4):357-64.
U.S. Centers for Medicare & Medicaid Services. Glossary – Habilitative/Habilitation Services. Baltimore (MD): U.S. Centers for Medicare & Medicaid Services; 2018.
U.S. Centers for Medicare & Medicaid Services. Habilitative/Habilitation Services. Baltimore (MD): U.S. Centers for Medicare & Medicaid Services; 2018.
U.S. Department of Health and Human Services NIoH. Physical Medicine and Rehabilitation. Bethesda (MD): U.S. National Library of Medicine; 2004.
VA/DoD Management of Concussion-mild Traumatic Brain Injury Working Group. VA/DoD clinical practice guideline for the management of concussion-mild traumatic brain injury. Washington (DC): Department of Veterans Affairs, Department of Defense; 2021. p. 128.
VA/DoD Non-Surgical Management of Hip and Knee Osteoarthritis Working Group. VA/DoD clinical practice guideline for the non-surgical management of hip and knee osteoarthritis. Washington (DC): Department of Veterans Affairs, Department of Defense; 2020. p. 127.
VA-DoD The Rehabilitation of Individuals with Lower Limb Amputation Work Group. VA/DoD Clinical practice guideline for the rehabilitation of individuals with lower limb amputation Washington (DC): Department of Veterans Affairs, Department of Defense; 2017. p. 123.
Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis & rheumatology (Hoboken, NJ). 2019;71(10):1599-613. Epub 2019/08/23.
Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and cartilage. 2008;16(2):137-62.

Occupational Therapy

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
20560	Needle insertion(s) without injection(s), 1 or 2 muscle(s)
20561	Needle insertion(s) without injection(s), 3 or more muscle(s)
90901	Biofeedback training by any modality (when done for medically necessary indications)
92526	Treatment of swallowing and/or oral feeding function
92605	Evaluation and prescription of non-speech-generating and alternative communication device first hour
92606	Therapeutic services for use of non-speech-generating device with programming
92607	Evaluation of patient with prescription of speech-generating and alternative communication device
92608	Evaluation and prescription of speech-generating and alternative communication device
92609	Therapeutic services for use of speech-generating device with programming
92610	Evaluation of swallowing function
92611	Fluoroscopic and video recorded motion evaluation of swallowing function
92618	Evaluation and prescription of non-speech-generating and alternative communication device
94667	Demonstration and/or evaluation of manual maneuvers to chest wall to assist movement of lung secretions
94668	Manual maneuvers to chest wall to assist movement of lung secretions
97010	Application of hot or cold packs to 1 or more areas
97012	Application of mechanical traction to 1 or more areas
97014	Application of electrical stimulation to 1 or more areas, unattended by therapist
97016	Application of blood vessel compression or decompression device to 1 or more areas
97018	Application of hot wax bath to 1 or more areas
97022	Application of whirlpool therapy to 1 or more areas
97024	Application of heat wave therapy to 1 or more areas
97026	Application of low energy heat (infrared) to 1 or more areas
97028	Application of ultraviolet light to 1 or more areas
97032	Application of electrical stimulation to 1 or more areas
97033	Application of medication through skin using electrical current, each 15 minutes
97034	Therapeutic hot and cold baths to 1 or more areas, each 15 minutes
97035	Application of ultrasound to 1 or more areas, each 15 minutes
97036	Physical therapy treatment to 1 or more areas, Hubbard tank, each 15 minutes
97039	Unlisted modality (specify type and time if constant attendance)
97110	Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
97112	Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes
97113	Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes
97116	Walking training to 1 or more areas, each 15 minutes
97124	Therapeutic massage to 1 or more areas, each 15 minutes
97129	One-on-one therapeutic interventions focused on thought processing and strategies to manage activities
97130	Each additional 15 minutes (list separately in addition to code for primary procedure)
97139	Unlisted therapeutic procedure (specify)
97140	Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
97150	Therapeutic procedures in a group setting
97165	Evaluation of occupational therapy, typically 30 minutes
97166	Evaluation of occupational therapy, typically 45 minutes
97167	Evaluation of occupational therapy established plan of care, typically 60 minutes
97168	Re-evaluation of occupational therapy established plan of care, typically 30 minutes
97530	Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes
97533	Sensory technique to enhance processing and adaptation to environmental demands, each 15 minutes
97535	Self-care or home management training, each 15 minutes
97537	Community or work reintegration training, each 15 minutes
97542	Wheelchair management, each 15 minutes
97545	Work hardening or conditioning, first 2 hours
97546	Work hardening or conditioning
97750	Physical performance test or measurement with report, each 15 minutes
97755	Assistive technology assessment to enhance functional performance, each 15 minutes
97760	Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15 minutes
97761	Training in use of prosthesis for arms and/or legs, per 15 minutes
97763	Management and/or training in use of orthotics (supports, braces, or splints) for arms, legs, and/or trunk, per 15 minutes
G0281	Electrical stimulation, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers
G0282	Electrical stimulation, to one or more areas, for wound care
G0283	Electrical Stimulation, to one or more areas, for other than wound care
G0295	Electromagnetic therapy, one or more areas, for wound care
G0329	Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers
S8948	Treatment with low level laser (phototherapy) each 15 minutes
S8950	Complex lymphedema therapy, each 15 minutes
S8990	Physical or manipulative therapy for maintenance

Modifiers

96	Habilitative Services
97	Needle insertion(s) without injection(s), 1 or 2 muscle(s)

ICD-10 Diagnosis

Refer to the ICD-10 CM Manual

General Information

Abbreviations

Activities of daily living (ADLs)
Congestive heart failure (CHF)
Heart rate (HR)
Long-term goals (LTG)
Range of motion (ROM)
Right upper extremity (RUE)

Background

Occupational therapy is a skilled, nonsurgical treatment involving the therapeutic use of occupations (see definition below) and goal-oriented physical exercises as well as adaptive equipment, environmental modifications, and education in order to maximize productive function and quality of life. Occupational therapy is goal-directed and collaborative.

Details and Scope

The purpose of this guideline is to establish conceptual principles and documentation requirements for the appropriate initial and subsequent use of outpatient occupational therapy services for habilitation and rehabilitation, and maintenance programs. This guideline does not provide specific clinical requirements or direction for a given episode of occupational therapy. Specific types of occupational therapy interventions may be subject to additional guidelines (please refer to the Adjunctive and Alternative Treatments section of this document). Requirements defined by benefit design (maximum number of occupational therapy visits), state and federal regulations supersede this guideline.

Functional outcome tool and/or severity of impairment
History of pertinent surgery
Comorbidities expected to impact treatment
Progress toward functional goals (or mitigating factors if lack of progress)
Existence of additional, achievable, functional goals
Potential for progress
Revisions to the plan of care

Definitions

Acceptable mitigating factors refers to issues which could realistically contribute to or fully account for the lack of progress/improvement that would otherwise be expected during a course of treatment. These include but are not limited to an intervening fall, injury, illness, surgery, or hospitalization, transportation difficulties, or poor response to the initial treatment plan.
Activities of daily living (ADLs) are tasks that a person generally needs or wants to perform on a daily or routine basis to complete self-care and occupational duties and participate in other daily environments (e.g., school, daycare).
Caregiver refers to someone who regularly looks after or helps with the care of the child or adult (patient) with the disability.
Duplicative therapy refers to treatments by more than one provider (same or different discipline) which are 1) rendered during an overlapping time period, 2) intended to treat the same or similar body parts (e.g., arm and shoulder), and 3) have substantively similar goals (e.g., improved functional shoulder range of motion).
Functional progress refers to progress that directly reflects improvement in specific functional tasks such as mobility and self-care activities.
Habilitation refers to services performed to help patients develop skills and functions for daily living that have not yet been acquired at an age appropriate level ^1,² or keep those skills and functions which are at risk of being permanently lost (not merely fluctuating) due to illness or disease without the habilitative service.
Maintenance program is defined as a program provided to the patient expressly to maintain the patient’s current condition or to prevent or slow further deterioration due to a disease or illness. The creation, design and instruction of the program must require the skilled knowledge or judgement of a qualified therapist. A prescribed maintenance program can generally be performed by the patient individually or with the assistance of a caregiver. The provision of such a program would be considered a skilled intervention.
Occupations refers to the purposeful activities a person does throughout the lifespan, including but not limited to work, basic self-care activities, instrumental daily activities, exercise and recreational activities.
Qualified occupational therapy provider refers to an occupational therapist or occupational therapy assistant who is duly licensed or certified, respectively, by his/her state to deliver occupational therapy services and who provides such services in accordance with his/her state’s occupational therapy practice act. State regulations regarding appropriate providers may supersede this guideline.
Rehabilitation focuses on the maximal restoration of physical and psychological function in persons with injuries, pain syndromes, and/or other physical or cognitive impairments.³
Self limited refers to impairments caused by a disease process or surgical intervention that are expected to resolve in the near term solely with resumption of normal activity and/or an unsupervised home exercise program.
Skilled services are those services which require a qualified provider to administer the treatment plan. A service is not considered skilled simply because a qualified provider is performing it.

Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes, but is not limited to, autism spectrum disorder and developmental delay.

Clinical Indications

Initiation of occupational therapy for rehabilitative or habilitative services is considered medically necessary when criteria for both A and B are met:

A. Initial Occupational Therapy Evaluation

Initial occupational therapy evaluation is performed by a qualified occupational therapy provider documenting ALL of the following:

The reason for referral, specifically a condition that causes or contributes to one or more impairments in function as related to activities of daily living that is not self-limited
A need for occupational therapy to:
- restore function (rehabilitation), or
- keep, learn, or improve function that has not yet been acquired at any age appropriate level, or if clinically indicated, prevent loss of function that is at risk of being lost (habilitation)
A relevant case history including comorbidities expected to impact treatment, a relevant physical examination, and a review of supporting, available documentation
Functional impairment on at least 1 relevant, validated, therapist-rated, and/or patient reported outcome measure
Potential for clinically meaningful progress, the assessment of which must be supported by clinical details documented within the evaluation

Note: The expectation of clinically meaningful progress will not apply for habilitation cases in which the appropriate purpose of therapy is to prevent loss of function that is at risk of being lost (habilitation).

B. Individualized Occupational Therapy Plan of Care

Individualized occupational therapy plan requires the skill and training of a qualified occupational therapy provider employing interventions and delivery methods that adhere to the Clinical Appropriateness Framework (outlined in the General Clinical Guideline above). There must be a reasonable expectation that the condition being treated is amenable to such intervention and that clinically meaningful, sustained improvement will be achieved.

This plan must include ALL of the following components:

One or more goals which are:
- Specific
- Measurable
- Likely to be attained in a reasonable amount of time
- Based on clinically significant improvement in the functional impairment(s) identified on initial evaluation
- Formulated in collaboration with the patient and/or primary caregiver

Note: There may be additional goals which do not meet the above criteria, but at least one goal must meet these criteria in order for medical necessity to be met.

Examples of appropriate goals:

Patient to don button-down shirt with min assist using right hand and adaptive equipment (to be achieved in 4 weeks)
Decrease pain 2/10 to allow full left upper extremity weight-bearing and push-off for independent sit-stand transfer (8 weeks)
Patient to be independent 100% of time with toileting (estimated time 12 weeks)
Increase elbow extension ROM to 100 degrees to safely operate overhead machinery at work (LTG 6 weeks)

Examples of inappropriate goals:

Improve ADLS
Patient will improve RUE ROM 20 degrees to increase participation in upper body ADLs
Resume baseline work function (12 weeks)
Increase elbow ROM to 100 degrees (acceptable as an additional goal but not as the required functional, time-limited goal)
QuickDASH score less than 10%
Recommended frequency and estimated duration of treatment needed to achieve documented goals
Patient and/or caregiver education, particularly related to the patient’s individual goals
A recommendation for evaluation/examination by a physician or otherwise appropriate provider if there is reasonable suspicion that an undiagnosed condition outside therapist’s scope of practice is present or limiting current progression towards goals.

Proceeding with occupational therapy services is considered medically necessary when ALL of the following criteria (A-F) are met:

A. Require the skills and training of a qualified occupational therapy provider:

The skilled intervention(s) must be clearly denoted in the documentation

Examples of skilled intervention documentation:

Skilled passive ROM to shoulder needed to maintain post-op restrictions and due to high risk of dislocation
Advancing strengthening exercises, requires skilled monitoring of patient’s HR response and activity tolerance due to CHF risk

B. ANY of the following:

Therapy has produced clinically meaningful improvement on reassessment of one or more of the therapist-rated or patient centered outcome measures documented on initial evaluation

Example of clinically meaningful improvement on outcome measure:

Statistically significant improvement in outcome tool score with improvement in at least one of the functional parameters of the outcome measure (e.g., reading parameter in the Neck Disability Index)

Examples of non-clinically meaningful improvement on outcome measure:

Improvements only in non-specific, non-functional parameters of the functional tool (e.g., pain parameter in the Neck Disability Index)
Statistically insignificant improvement in outcome tool score

Examples of functional progress:

Dexterity improved, now requiring only moderate assistance to manipulate buttons and don shirt with use of adaptive equipment
Shoulder pain decreased to 5/10 allowing patient to partial weight-bear on left upper extremity.
Able to toilet self with only stand-by assistance for donning pants 80% of the time
Patient elbow flexion ROM now 60 degrees (when documented as progress towards specific functional goal of “Increase elbow ROM to 100 degrees to safely operate machinery at work.” Such progress might then also reasonably be documented as “ROM 60% met” if applied to this same functional goal)

Examples of non-functional progress:

Upper body dressing ongoing
Toileting partially met
Goal 60% met (without clear indication of what parameter 60% reflects and what functional goal it applies to)
Strength improved to 3/5
Shoulder ROM increased 20 degrees

C. There is ongoing patient and/or caregiver education and/or training

D. There is at least one unmet functional or caregiver training goal

E. There is an expectation that the remaining goal(s) will be met with additional therapy within a reasonable and defined period of time

F. Progress is commensurate with the duration of treatment rendered

A recommendation for evaluation/examination by a physician or otherwise appropriate provider must be made if there is poor progression toward goals due to new or persistent symptoms

Institution of an occupational therapy maintenance program may be considered medically necessary in specific circumstances (refer to Definitions section)

Exclusions

The following are considered not medically necessary:

Maintenance therapies extending beyond the creation, design, and instruction of a therapy program
Therapies for which the primary purpose is anything other than rehabilitation or habilitation of a functional impairment due to medical illness, disease, condition, or injury. This includes therapies to improve recreational sports performance or general fitness, provide massage, or athletic taping.

Example of rehabilitation purpose:

Treatment rendered in order to restore ability to throw overhead pain-free

Examples of recreational/sports purpose:

Treatment rendered in order to improve endurance to allow pain-free overhead throwing for a 90 pitch-count game
Treatment rendered in order to achieve (or restore) ability to garden with arms unsupported for 30 minutes without fatigue-related pain
Progress is not commensurate with the duration of treatment provided (e.g. range of motion improved but only a small amount relative to the length of time patient has been in treatment, and without any reasonable mitigating factor(s) accounting for it.)
Therapies deemed to be duplicative (see definition above)
Any and all non-skilled services

References

American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical practice guideline on management of hip fractures in the elderly. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2014. p. 521.
American Occupational Therapy Association (AOTA). Occupational therapy practice guidelines for adults with serious mental illness. Bethesda (MD): AOTA Press; 2019. p. 113.
American Occupational Therapy Association (AOTA). Standards of Practice for Occupational Therapy. 2020/04/30 ed: American Occupational Therapy Association; 2020. p. 1-3.
Braveman B, Hunter EG, American Occupational Therapy Association. Occupational therapy practice guidelines for cancer rehabilitation with adults. Bethesda (MD): AOTA Press; 2017. 37 p.
Colorado Division of Workers’ Compensation. Lower extremity injury medical treatment guidelines. Denver (CO): Colorado Division of Workers’ Compensation; 2016. p. 211.
Combe B, Landewe R, Daien CI, et al. 2016 update of the EULAR recommendations for the management of early arthritis. 2017;76(6):948-59.
Kaldenberg J, Smallfield S, American Occupational Therapy Association (AOTA). Occupational therapy practice guidelines for older adults with low vision. American Journal of Occupational Therapy. 2020;74:119.
Kang PB, Morrison L, Iannaccone ST, et al. Evidence-based guideline summary: evaluation, diagnosis, and management of congenital muscular dystrophy: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Issues Review Panel of the American Association of Neuromuscular & Electrodiagnostic Medicine. Neurology. 2015;84(13):1369-78.
Kelly DA, Bucuvalas JC, Alonso EM, et al. Long-term medical management of the pediatric patient after liver transplantation: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2013;19(8):798-825.
Koenig KP, American Occupational Therapy Association. Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda (MD): AOTA Press; 2016. 47 p.
Leland N, Elliott SJ, Johnson KJ, et al. Occupational therapy practice guidelines for productive aging for community-dwelling older adults. Bethesda (MD): AOTA Press; 2012. 167 p.
Miller RG, Jackson CE, Kasarskis EJ, et al. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2009;73(15):1227-33.
Narayanaswami P, Weiss M, Selcen D, et al. Evidence-based guideline summary: diagnosis and treatment of limb-girdle and distal dystrophies: report of the guideline development subcommittee of the American Academy of Neurology and the practice issues review panel of the American Association of Neuromuscular & Electrodiagnostic Medicine. Neurology. 2014;83(16):1453-63.
National Institute for Health and Care Excellence (NICE). Cerebral palsy in children and young people. London (UK): National Institute for Health and Care Excellence (NICE); 2017.
National Institute for Health and Care Excellence (NICE). Cerebral palsy in under 25s: assessment and management, NG62. London (UK): National Institute for Health and Care Excellence (NICE), ; 2017. p. 21.
National Institute for Health and Care Excellence (NICE). Chronic obstructive pulmonary disease in over 16s: diagnosis and management, ng115. London (UK): National Institute for Health and Care Excellence (NICE), ; 2019. p. 69.
National Institute for Health and Care Excellence (NICE). Nerve transfer to partially restore upper limb function in tetraplegia, ipg610. London (UK): National Institute for Health and Care Excellence (NICE), ; 2018. p. 4.
National Institute for Health and Care Excellence (NICE). Parkinson’s disease in adults cg71. London (UK): National Institute for Health and Care Excellence (NICE); 2017. p. 30.
National Institute for Health and Care Excellence (NICE). Rheumatoid arthritis in adults: management, ng100. London (UK): National Institute for Health and Care Excellence (NICE), ; 2020. p. 32.
National Institute for Health and Care Excellence (NICE). Spasticity in under 19s: management, cg145.: National Institute for Health and Care Excellence (NICE), ; 2016. p. 41.
National Institute for Health and Care Excellence (NICE). Stroke rehabilitation. Long-term rehabilitation after stroke, cg 162. London (UK): National Institute for Health and Care Excellence (NICE); 2013. p. 45.
National Institute for Health and Care Excellence (NICE). The management of hip fracture in adults, cg124. London (UK): National Institute for Health and Care Excellence (NICE), ; 2017. p. 664.
Poole J, Siegel P, Tencza M. Occupational therapy practice guidelines for adults with arthritis and other rheumatic conditions. Bethesda (MD): AOTA Press; 2017. 46 p.
Preissner K, American Occupational Therapy Association. Occupational therapy practice guidelines for adults with neurodegenerative diseases. Bethesda (MD): AOTA Press; 2014. 187 p.
Royal College of Occupational Therapists Ltd. Occupational therapy in the prevention and management of falls in adults, (2020) Practice guideline. London (UK): Royal College of Occupational Therapists Ltd; 2020. p. 173.
Royal College of Occupational Therapists. Occupational therapy for adults undergoing total hip replacement: Practice guideline. London (UK): Royal College of Occupational Therapists,; 2017. p. 180.
Scottish Intercollegiate Guidelines Network. Brain injury rehabilitation in adults ncg130. Edinburgh (UK): Scottish Intercollegiate Guidelines Network; 2013. p. 75.
Scottish Intercollegiate Guidelines Network. Management of early rheumatoid arthritis ncg123,. Edinburgh (UK): Scottish Intercollegiate Guidelines Network; 2011. p. 35.
Scottish Intercollegiate Guidelines Network. Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning ncg118. Edinburgh (UK): Scottish Intercollegiate Guidelines Network,; 2010. p. 108.
Siebert C, Smallfield S, Stark S, et al. Occupational therapy practice guidelines for home modifications. Bethesda (MD): AOTA Press; 2014. 109 p.
Snodgrass J, Amini D. Occupational therapy practice guidelines for adults with musculoskeletal conditions. Bethesda (MD): AOTA Press; 2017. 77 p.
South Australian Government. Guidelines for treatment, care and support for amputees within the LSS living in the community. Adelaide (South Australia)2016. p. 34.
Spanish NHS -Working Group of the Clinical Practice Guideline for the Management of Patients with Parkinson’s Disease. Clinical practice guideline for the management of patients with Parkinson’s disease. Madrid (Spain): Spanish NHS, Ministry of Health, Social Services and Equality; Institute of Health Sciences of Aragon; 2014. p. 159.
U.S. Centers for Medicare & Medicaid Services. Glossary – Habilitative/Habilitation Services. Baltimore (MD): U.S. Centers for Medicare & Medicaid Services; 2018.
U.S. Centers for Medicare & Medicaid Services. Habilitative/Habilitation Services. Baltimore (MD): U.S. Centers for Medicare & Medicaid Services; 2018.
U.S. Department of Health and Human Services NIoH. Physical Medicine and Rehabilitation. Bethesda (MD): U.S. National Library of Medicine; 2004.
U.S. Department of Health and Human Services. Occupational Therapy – Clinical Services Bethesda, MD: U.S. Department of Health and Human Services; 2017 [updated 09/15/2017]. Available from: https://clinicalcenter.nih.gov/rmd/ot/otclinaservice.html.
VA/DoD Management of Concussion-mild Traumatic Brain Injury Working Group. VA/DoD clinical practice guideline for the management of concussion-mild traumatic brain injury. Washington (DC): Department of Veterans Affairs, Department of Defense; 2021. p. 128.
VA-DoD The Rehabilitation of Individuals with Lower Limb Amputation Work Group. VA/DoD Clinical practice guideline for the rehabilitation of individuals with lower limb amputation Washington (DC): Department of Veterans Affairs, Department of Defense; 2017. p. 123.
Verrier Piersol C, Jensen L. Occupational therapy practice guidelines for adults with alzheimer’s disease and related neurocognitive disorders. Bethesda (MD): AOTA Press; 2017. 45 p.
Wolf TJ, Nilsen DM, American Occupational Therapy Association. Occupational therapy practice guidelines for adults with stroke. Bethesda (MD): AOTA Press; 2015. 256 p.

Speech-Language Pathology

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

92507	Treatment of speech, language, voice, communication, and/or hearing processing disorder
92508	Group treatment of speech, language, voice, communication, and/or hearing processing disorder
92521	Evaluation of speech fluency
92522	Evaluation of speech sound production
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance
92526	Treatment of swallowing and/or oral feeding function
92605	Evaluation and prescription of non-speech-generating and alternative communication device first hour
92606	Therapeutic services for use of non-speech-generating device with programming
92607	Evaluation of patient with prescription of speech-generating and alternative communication device
92608	Evaluation and prescription of speech-generating and alternative communication device
92609	Therapeutic services for use of speech-generating device with programming
92610	Evaluation of swallowing function
92611	Fluoroscopic and video recorded motion evaluation of swallowing function
92618	Evaluation and prescription of non-speech-generating and alternative communication device
92626	Evaluation of hearing rehabilitation first hour
92627	Evaluation of hearing rehabilitation
92630	Hearing training and therapy for hearing loss prior to learning to speak
92633	Hearing training and therapy for hearing loss after speech
97039	Unlisted modality (specify type and time if constant attendance)
97129	One-on-one therapeutic interventions focused on thought processing and strategies to manage activities
97130	Each additional 15 minutes (list separately in addition to code for primary procedure)
S9152	Speech therapy re-evaluation
V5362	Speech screening
V5363	Language screening
V5364	Dysphagia screening

Modifiers

96	Habilitative Services
97	Needle insertion(s) without injection(s), 1 or 2 muscle(s)

ICD-10 Diagnosis

Refer to the ICD-10 CM Manual

General Information

Background

Speech-language pathology is a skilled, nonsurgical treatment primarily concerned with the diagnosis and treatment of disorders of communication, cognition, and swallowing. The scope of practice includes, but is not limited to, disorders of speech fluency, production, resonance, voice, language, feeding, hearing, and swallowing for patients of all ages.¹ Speech-language pathology is a goal-directed, collaborative approach focused on improving function and quality of life.

Speech-language pathologists are the primary providers of speech therapy services in the U.S. They are autonomous professionals who may hold the American-Speech-Language-Hearing Association (ASHA) Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) and who demonstrate continued professional development.¹ In some clinical settings and under some state practice acts, occupational therapists might also be considered qualified to provide certain speech therapy services delineated in this guideline.

Details and Scope

The purpose of this guideline is to establish conceptual principles and documentation requirements for the appropriate initial and subsequent use of outpatient speech-language pathology services for habilitation and rehabilitation, and maintenance programs. This guideline does not provide specific clinical requirements or direction for a given episode of speech therapy. Specific types of speech therapy interventions, such as electrical stimulation for swallowing dysfunction, may be subject to additional guidelines (please refer to the Adjunctive and Alternative Treatments section of this document). Requirements defined by benefit design (maximum number of speech therapy visits), state and federal regulations supersede this guideline.

Severity of impairment and/or level of independence
History of pertinent surgery
Comorbidities expected to impact treatment
Progress toward functional goals (or mitigating factors if lack of progress)
Existence of additional, achievable, functional goals as applicable
Potential for progress
Revisions to the plan of care

Requesting providers will need to provide information on these factors in order to support their request for more than an evaluation visit. A peer-to-peer conversation may be required to determine appropriateness in certain cases.

Definitions

Acceptable mitigating factors refers to issues which could realistically contribute to or fully account for the lack of progress/improvement that would otherwise be expected during a course of treatment. These include but are not limited to an intervening injury, illness, surgery, or hospitalization, transportation difficulties, or poor response to the initial treatment plan.
Caregiver refers to someone who regularly looks after or helps with the care of the child or adult (patient) with the disability.
Duplicative therapy refers to treatments by more than one provider (same or different discipline) which are 1) rendered during an overlapping time period, 2) intended to treat the same or similar body parts, conditions, or diagnoses, and 3) have substantively similar goals
Functional progress refers to progress that directly reflects improvement in specific functional tasks such as swallowing, speech and cognitive activities.
Habilitation refers to services performed to help patients develop skills and functions for daily living that have not yet been acquired at an age appropriate level ^1,² or keep those skills and functions which are at risk of being permanently lost (not merely fluctuating) due to illness or disease without the habilitative service.
Individualized clinical assessments refer to pre-assessment (e.g., baseline before laryngectomy, neurosurgery) to determine prognosis and post-procedure plan, post-assessment (e.g., after laryngectomy, neurosurgery) to determine therapy needs, or comprehensive initial assessment.
Maintenance program is defined as a program provided to the patient expressly to maintain the patient’s current condition or to prevent or slow further deterioration due to a disease or illness. The creation, design and instruction of the program must require the skilled knowledge or judgement of a qualified therapist. A prescribed maintenance program can generally be performed by the patient individually or with the assistance of a caregiver, The provision of such would be considered a skilled intervention.
Qualified speech-language pathology provider refers to a speech language pathologist, also known as a speech therapist, who may hold the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) designation from the American-Speech-Language-Hearing Association (ASHA). Speech-language pathology support personnel such as assistants, aides, and associates are individuals who may work under the supervision and direction of a CCC-SLP therapist within the scope of their individual licensures and credentialing and as allowed by applicable state regulations. In some clinical settings and under some state practice acts, occupational therapists might also be considered qualified to provide certain speech therapy services delineated in this guideline
Rehabilitation focuses on the maximal restoration of physical and psychological function in persons with injuries, pain syndromes, and/or other physical or cognitive impairments.²
Self-limited refers to impairments caused by a disease process or surgical intervention that are expected to resolve within a reasonable period of time solely with resumption of normal activity and/or a non-supervised home exercise program.
Skilled services are those services which require a qualified provider to administer the treatment plan. A service is not considered skilled simply because a qualified provider is performing it.

Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes, but is not limited to, autism spectrum disorder and developmental delay.

Clinical Indications

Initiation of speech-language pathology for rehabilitative or habilitative services is considered medically necessary when criteria for both A and B are met.

A. Initial Speech-Language Pathology Evaluation

Initial speech-language pathology evaluation performed by a qualified speech-language pathology provider documenting ALL of the following:

Referral for speech-language pathology from a physician, nurse practitioner or physician assistant, specifically for a condition that causes one or more impairments in swallowing, cognition and/or communication function that is/are not self-limiting

Individualized evaluation(s) of any of the following (as indicated) utilizing linguistically and culturally appropriate standardized and/or formal (non-standardized) measures:
Structure and function of anatomy for speech and swallowing, expressive communication, receptive communication
Voice
Cognitive-communicative skills
Functional status of communication, cognition, and/or swallowing

B. Individualized Speech-Language Pathology Plan of Care

Individualized speech-language pathology plan requiring the skill and training of a qualified speech-language pathology provider employing interventions and delivery methods that adhere to the Clinical Appropriateness Framework (outlined in the General Clinical Guideline above). There must be a reasonable expectation that the condition being treated is amenable to such intervention and that clinically meaningful, sustained improvement will be achieved.

This plan must include ALL of the following components:

One or more goals which are:
Specific
Measurable
Likely to be attained in a reasonable amount of time
Based on clinically significant improvement in the functional impairment(s) identified on initial evaluation
Formulated in collaboration with the patient and/or primary caregiver

Note: There may be additional goals which do not meet the above criteria, but at least one goal must meet these criteria in order for medical necessity to be met.

Examples of appropriate goals:

Patient will tolerate safest yet least restrictive po diet without signs or symptoms of aspiration at 95% with use of compensatory strategies and minimal cues provided. (to be achieved in 12 weeks)
Patient will use fifteen 2-3 word phrases to express wants and needs independently within a play activity. (8 weeks)
Patient will independently use trained compensatory speech strategies to improve functional communication at conversational speech level with > 90% accuracy. (expected in 4 weeks)

Examples of inappropriate goals:

Improved swallow function
Will increase expressive output to communicate needs (8 weeks)
Will increase utterance level to 2-3 words
Patient will improve speech intelligibility
Recommended frequency and estimated duration of treatment needed to achieve documented goals
Patient and/or caregiver education, particularly related to the patient’s individual goals
A recommendation for evaluation/examination by a physician or otherwise appropriate provider if there is concern for an undiagnosed condition outside therapist’s scope of practice that is likely to impede progress toward goals

Proceeding with speech-language pathology services is considered medically necessary when ALL of the following criteria (A-F) are met:

A. Require the skills and training of a qualified speech language pathology provider:

The skilled intervention(s) must be clearly denoted in the documentation

B. ANY of the following:

Therapy has produced clinically meaningful improvement on reassessment of one or more of the therapist-rated or patient-centered outcome measures documented on initial evaluation
There is attainment of the functional goal(s) established on initial evaluation or otherwise qualitative and sustained functional progress

Examples of functional progress:

Patient has improved recalled info from 2 to 4 items within a 3-5 sentence paragraph information
Patient has improved overall intelligibility from 75% to 95% from conversational speech level with use of strategies
Patient demonstrating problem solving with functional solutions evidenced by requiring moderate cueing from initial max cueing
Patient has maintained 10-15 mins attention to conversation or task or structured activity vs prior 5-10 mins

Examples of non-functional progress:

Patient has improved problem solving
Patient using external memory aide more consistently
Patient has improved conversational attention
There is limited or no demonstrable progress; however, there are acceptable mitigating factors and a treatment plan has been revised accordingly
There is confirmation of functional status being maintained in cases in which the appropriate purpose of therapy is to prevent loss of function that is at risk of being lost (habilitation)

C. There is ongoing patient and/or caregiver education and/or training

D. There is at least one unmet functional or caregiver training goal

E. There is an expectation that the remaining goal(s) will be met with additional therapy within a reasonable and defined period of time

F. Progress is commensurate with the duration of treatment rendered

A recommendation for evaluation/examination by a physician or otherwise appropriate provider must be made if there is poor progression toward goals due to new or persistent symptoms

Institution of a speech-language pathology maintenance program may be considered medically necessary in specific circumstances (refer to Definitions section)

Exclusions

The following are considered not medically necessary:

Maintenance therapies extending beyond the creation, design, instruction of a therapy program
Therapies for which the primary purpose is anything other than rehabilitation or habilitation of a functional impairment due to medical illness, disease, condition or injury. This includes therapies to improve recreational activities such as singing or general vocal performance.
Progress is not commensurate with the duration of treatment provided (e.g. speech intelligibility improved but only a small amount relative to the length of time patient has been in treatment, and without any reasonable mitigating factor(s) accounting for it.)
Therapies deemed to be duplicative (see definition above)
Any and all non-skilled services.

References

American Speech-Language Hearing Association (ASHA). Scope of practice in speech-language pathology [Internet] 2016. Available from: https://www.asha.org/policy/SP2016-00343/.
American Speech-Language-Hearing Association (ASHA). Preferred practice patterns for the profession of speech-language pathology [Internet] 2004 [cited 2021 May 7]. Available from: https://www.asha.org/policy/PP2004-00191/.
Bassez G, Fossati B, Gamez J, et al. Consensus-based care recommendations for adults with myotonic dystrophy type 2. (2019) Oakland, CA: Myotonic Dystrophy Foundation. [28 p.]. Available from: https://www.myotonic.org/toolkits-publications.
Bengtsson L, Berggren K, van den Engel-Hoek L, et al. Care guidelines for speech and language pathologists treating adults and children with myotonic dystrophy. (2020) Oakland, CA: Myotonic Dystrophy Foundation. [43 p.]. Available from: https://www.myotonic.org/toolkits-publications.
Chandrasekhar SS, Randolph GW, Seidman MD, et al. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg. 2013;148(6 Suppl):S1-37.
Cohen EE, LaMonte SJ, Erb NL, et al. American Cancer Society head and neck cancer survivorship care guideline. CA Cancer J Clin. 2016;66(3):203-39.
Corben LA, Lynch D, Pandolfo M, et al. Consensus clinical management guidelines for Friedreich ataxia. Orphanet journal of rare diseases. 2014;9(Article no. 184):[11 p.].
Department of Defense (US), Department of Veterans Affairs, Management of Concussion-mild Traumatic Brain Injury Working Group. VA/DoD clinical practice guideline for the management of concussion-mild traumatic brain injury, version 2.0. (2016). [133 p.]. Available from: https://www.healthquality.va.gov/guidelines/rehab/mtbi/index.asp.
Department of Defense (US), Department of Veterans Affairs, Management of Stroke Rehabilitation Work Group. VA/DoD clinical practice guideline for the management of stroke rehabilitation, version 4.0. (2019). [170 p.]. Available from: https://www.healthquality.va.gov/guidelines/Rehab/stroke/.
Guideline Development Group (GRG). Stroke in childhood: clinical guideline for diagnosis, management, and rehabilitation (2017) Royal College of Paediatrics and Child Health and the Stroke Association. [197 p.]. Available from: https://www.rcpch.ac.uk/resources/stroke-in-childhood-clinical-guideline.
Habilitation/habilitative services [Internet] Healthcare.gov: U.S. Centers for Medicare & Medicaid Services; [cited 2021 April 8]. Available from: https://www.healthcare.gov/glossary/habilitative-habilitation-services/.
Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1-133.
Irish J, Kim J, Waldron J, et al. Organizational guidance for the care of patients with head and neck cancer in Ontario. Guideline 5-3ORG version 2. (2019) Toronto, ON: Cancer Care Ontarion; Program in Evidence-Based Care (PEBC). Available from: https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/58936.
Kang PB, Morrison L, Iannaccone ST, et al. Evidence-based guideline summary: evaluation, diagnosis, and management of congenital muscular dystrophy. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Issues Review Panel of the American Association of Neuromuscular & Electrodiagnostic Medicine. (2015 [Reaffirmed July 21, 2018]) Minneapolis, MN: American Academy of Neurology. [12 p.]. Available from: https://www.aan.com/Guidelines/home/GuidelineDetail/683.
Marshall S, Bayley M, S. M, et al. Guideline for concussion/mild traumatic brain injury and prolonged symptoms: 3rd edtion for adults over 18 years of age [Internet] Toronto, ON: Ontario Neurotrauma Foundation; 2018 [cited 2021 May 7]. Available from: https://onf.org/knowledge-mobilization/acquired-brain-injury/guidelines-for-concussion-and-moderate-to-severe-traumatic-brain-injury/.
Miller RG, Jackson CE, Kasarskis EJ, et al. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. (2009 [Reaffirmed on April 30, 2014, April 25, 2017, and January 11, 2020]) Minneapolis, MN American Academy of Neurology. [8 p.]. Available from: https://www.aan.com/Guidelines/home/GuidelineDetail/371.
National Institute for Health and Care Excellence (NICE). Cerebral palsy in under 25s: assessment and management (NG62). (2017). [48 p.]. Available from: https://www.nice.org.uk/guidance/ng62.
National Institute for Health and Care Excellence (NICE). Developmental follow-up of children and young people born preterm (NG72). (2017). [30 p.]. Available from: https://www.nice.org.uk/guidance/ng72.
National Institute for Health and Care Excellence (NICE). Suspected neurological conditions: recognition and referral (NG127). (2019 [Updated July 4 2019]). [77 p.]. Available from: https://www.nice.org.uk/guidance/ng127.
National Institutes of Health. U.S. National Library of Medicine. MedlinePlus. Rehabilitation [Internet] [Updated Dec 9 2020] [cited 2021 May 5 ]. Available from: https://medlineplus.gov/rehabilitation.html#summary.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-e418.
Reed N, Zemek R, Dawson J, et al. Living guideline for diagnosing and managing pediatric concussion [Internet] Toronto, ON: Ontario Neurotrauma Foundation; 2019 [cited 2021 May 7]. Available from: https://onf.org/knowledge-mobilization/acquired-brain-injury/guidelines-for-concussion-and-moderate-to-severe-traumatic-brain-injury/.
Rinaldi B, Vaisfeld A, Amarri S, et al. Guideline recommendations for diagnosis and clinical management of Ring14 syndrome-first report of an ad hoc task force. Orphanet journal of rare diseases. 2017;12(1):[11 p.].
Royal College of Physicians. National clinical guideline for stroke. 5th edition. (2016) London, United Kingdom: Royal College of Physicians [178 p.]. Available from: https://www.strokeaudit.org/Guideline/Full-Guideline.aspx.
Scottish Intercollegiate Guidelines Network (SIGN). Assessment, diagnosis and interventions for autism spectrum disorders: a national clincal guideline [Publication no. 145]. (2016) Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; NHS Quality Improvement Scotland. [83 p.]. Available from: https://www.sign.ac.uk/our-guidelines/assessment-diagnosis-and-interventions-for-autism-spectrum-disorders/.
Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guidelines hoarseness (dysphonia) (update). Otolaryngol Head Neck Surg. 2018;158(1 Suppl):S1-S42.
Stroke Foundation. Clinical guidelines for stroke management [Internet] Melbourne, Australia©2021 [cited 2021 May 12]. Available from: https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management.
Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(6):e98-e169.
Working Group. Consensus-based care recommendations for adults with myotonic dystrophy type 1. (2018) Oakland, CA: Myotonic Dystrophy Foundation. [56 p.]. Available from: https://www.myotonic.org/toolkits-publications.
Zapata Aldana E, Nathalie Angeard N, Ashizawa A, et al. Consensus-based care recommendations for children with myotonic dystrophy type 1. (2019) Oakland, CA: Myotonic Dystrophy Foundation. [56 p.]. Available from: https://www.myotonic.org/toolkits-publications.

Adjunctive & Alternative Treatments Physical Therapy and Occupational Therapy Adjunctive Treatments

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
20560	Needle insertion(s) without injection(s), 1 or 2 muscle(s)
20561	Needle insertion(s) without injection(s), 3 or more muscle(s)
90901	Biofeedback training by any modality (when done for medically necessary indications)
90912	Biofeedback training for bowel or bladder control, initial 15 minutes
90913	Biofeedback training for bowel or bladder control, additional 15 minutes
92526	Treatment of swallowing and/or oral feeding function
92605	Evaluation and prescription of non-speech-generating and alternative communication device first hour
92606	Therapeutic services for use of non-speech-generating device with programming
92607	Evaluation of patient with prescription of speech-generating and alternative communication device
92608	Evaluation and prescription of speech-generating and alternative communication device
92609	Therapeutic services for use of speech-generating device with programming
92610	Evaluation of swallowing function
92611	Fluoroscopic and video recorded motion evaluation of swallowing function
92618	Evaluation and prescription of non-speech-generating and alternative communication device
94667	Demonstration and/or evaluation of manual maneuvers to chest wall to assist movement of lung secretions
94668	Manual maneuvers to chest wall to assist movement of lung secretions
96001	Three-dimensional, video-taped, computer-based gait analysis during walking
97010	Application of hot or cold packs to 1 or more areas
97012	Application of mechanical traction to 1 or more areas
97014	Application of electrical stimulation to 1 or more areas, unattended by therapist
97016	Application of blood vessel compression or decompression device to 1 or more areas
97018	Application of hot wax bath to 1 or more areas
97022	Application of whirlpool therapy to 1 or more areas
97024	Application of heat wave therapy to 1 or more areas
97026	Application of low energy heat (infrared) to 1 or more areas
97028	Application of ultraviolet light to 1 or more areas
97032	Application of electrical stimulation to 1 or more areas
97033	Application of medication through skin using electrical current, each 15 minutes
97034	Therapeutic hot and cold baths to 1 or more areas, each 15 minutes
97035	Application of ultrasound to 1 or more areas, each 15 minutes
97036	Physical therapy treatment to 1 or more areas, Hubbard tank, each 15 minutes
97039	Unlisted modality (specify type and time if constant attendance)
97110	Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes
97112	Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes
97113	Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes
97116	Walking training to 1 or more areas, each 15 minutes
97124	Therapeutic massage to 1 or more areas, each 15 minutes
97129	One-on-one therapeutic interventions focused on thought processing and strategies to manage activities
97130	each additional 15 minutes (list separately in addition to code for primary procedure)
97139	Unlisted therapeutic procedure (specify)
97140	Manual (physical) therapy techniques to 1 or more regions, each 15 minutes
97150	Therapeutic procedures in a group setting
97161	Evaluation of physical therapy, typically 20 minutes
97162	Evaluation of physical therapy, typically 30 minutes
97163	Evaluation of physical therapy, typically 45 minutes
97164	Re-evaluation of physical therapy, typically 20 minutes
97165	Evaluation of occupational therapy, typically 30 minutes
97166	Evaluation of occupational therapy, typically 45 minutes
97167	Evaluation of occupational therapy established plan of care, typically 60 minutes
97168	Re-evaluation of occupational therapy established plan of care, typically 30 minutes
97530	Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes
97533	Sensory technique to enhance processing and adaptation to environmental demands, each 15 minutes
97535	Self-care or home management training, each 15 minutes
97537	Community or work reintegration training, each 15 minutes
97542	Wheelchair management, each 15 minutes
97545	Work hardening or conditioning, first 2 hours
97546	Work hardening or conditioning
97750	Physical performance test or measurement with report, each 15 minutes
97755	Assistive technology assessment to enhance functional performance, each 15 minutes
97760	Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15 minutes
97761	Training in use of prosthesis for arms and/or legs, per 15 minutes
97763	Management and/or training in use of orthotics (supports, braces, or splints) for arms, legs, and/or trunk, per 15 minutes
G0281	Electrical stimulation, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers
G0282	Electrical stimulation, to one or more areas, for wound care
G0283	Electrical Stimulation, to one or more areas, for other than wound care
G0295	Electromagnetic therapy, one or more areas, for wound care
G0329	Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers
S8940	Therapeutic horseback riding, per session
S8948	Treatment with low level laser (phototherapy) each 15 minutes
S8950	Complex lymphedema therapy, each 15 minutes
S8990	Physical or manipulative therapy for maintenance
S9090	Vertebral axial decompression (lumbar traction), per session

Modifiers

96	Habilitative Services
97	Needle insertion(s) without injection(s), 1 or 2 muscle(s)

ICD-10 Diagnosis

Refer to the ICD-10 CM Manual

General Information

Background

Physical therapy and occupational therapy adjunctive treatments are distinct, therapeutic interventions or methods used by therapists to aid in their treatment of patients. Adjunctive treatments are primarily but not exclusively passive measures which are mechanical, electrical, magnetic or thermal in nature. They must be used as a complement to a more comprehensive and active therapy program and may be performed by both qualified providers of occupational and physical therapy depending on the indication. Examples include diathermy, dry needling, and hippotherapy. Performance of all services is subject to state regulations including therapy practice acts and should be rendered in accordance with those.

Scope

The purpose of this guideline is to establish appropriate use criteria for specific physical therapy and occupational therapy adjunctive treatments that complement the conceptual principles and documentation requirements established by the parent physical or occupational therapy guidelines.

Clinical indications for the appropriate use of services in these guidelines are intended to be limited to those that would be within the treatment scope of practice for qualified allied health services providers specifically physical and occupational therapists. Medical indications for the appropriate use of physical and occupational therapy adjunctive treatments are out of scope of these guidelines.

Indications and criteria for the appropriate acquisition of durable medical equipment (DME) used in provision of adjunctive therapies is also out of scope.

Therapies deemed to be duplicative (see definition in the parent physical or occupational therapy guidelines) will be considered not medically necessary.

Definitions

Active Therapeutic Movement® – device-based treatment that aims to train patients to move in ways that are pain free and to activate and strengthen core stabilization muscles, facilitating the coordination of body movement by developing spatial and kinesthetic awareness of body-segment relationships
Diathermy – an electromagnetic modality used to apply superficial heat to injured tissues in order to increase blood flow and reduce swelling. It is typically used to treat muscle spasms, joint stiffness, muscle and joint pain.
Dry needling – a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation (source: APTA).
Elastic taping – the application of specialized adhesive tape to specific body parts to lift the skin (microscopically), commonly with the intent of increasing proprioceptive awareness/feedback, reducing swelling and inflammation, improving blood flow, or facilitating lymphatic drainage.
Electrical stimulation, unattended – treatment modality whereby an electrical current is delivered to the body with the use of a stimulator device and electrodes. Unattended refers to the situation in which the provider may be present for and involved in the set-up but whose presence is not required during the administration of the treatment.
Gait analysis, instrumented – use of dynamic electromyography (EMG), biofeedback, computers, gait labs or other devices to evaluate patients’ walking patterns
Hippotherapy – a form of therapy that involves horseback riding under supervised and controlled circumstances, typically for children with neuromotor and/or psychologic disabilities. It is often intended to improve gross motor function, balance, muscle spasticity, and/or cognitive function.
Hot/Cold packs – application of warm/hot or cold packs to a body part for the purposes of conductive treatment of superficial tissues. Heat is commonly used to increase blood flow or mobility. Cold is often used to reduce pain, inflammation and swelling.
Interactive metronome® – assessment and training tool that measures & improves Neurotiming, or the synchronization of neural impulses within key brain networks for cognitive, communicative, sensory & motor performance (source: www.interactivemetronome.com)
Iontophoresis – the use of an electrical gradient to deliver medicine, typically anti-inflammatory agents, into the body via the skin.
Lee Silverman Voice Treatment BIG® – proprietary program of intensive physical and occupational therapy of at least one month duration involving large, full-body exercises to improve functional movement and self-care tasks of people with Parkinson’s disease and other neurological conditions. It requires company-certification of providers.
Low level laser therapy – the use of a laser or light to enhance tissue repair and/or reduce inflammation and pain.
Mechanical traction for spinal disorders – instrumented-assisted treatment used to distract the spine and relieve axial pressure from a particular spinal region (primarily cervical and lumbar) in patients with painful spinal-related disorders (e.g., herniated discs, radiculopathy)
MEDEK (Dynamic Method of Kinetic Stimulation)® – also known as Cuevas MEDEK Exercises (CME)®, “is a psychomotor therapy based on dynamic challenging exercises [sic], manually applied for children affected on their developmental motor functions.”
Motion analysis, instrumented – use of dynamic electromyography (EMG), biofeedback, computers, motion labs or other devices to evaluate patients’ movement patterns
Phonophoresis – the use of ultrasound to deliver medicine, typically anti-inflammatory agents, into the body via the skin.
Sensory integration – technique used to enhance sensory processing and promote adaptive responses to environmental demands (per APTA/Optum coding guide), such as use of weighted vests.
Therapeutic magnetic resonance – the use of pulsed electromagnetic fields (PEMF) at low frequency and low intensity to reduce inflammation and arthritic pain.
Ultraviolet phototherapy – application of ultraviolet light to a patient’s skin, primarily for the treatment of skin disorders and wound healing
Vasopneumatic compression devices – devices applied to a joint as a means of delivering cryotherapy to reduce swelling and inflammation after surgery or injury, or applied to a limb for the treatment of lymphedema
Whirlpool – a warm water pool in which the water is continuously moving and into which the patient or a specific body part is submerged.
Whole body advanced exercise – Total body-focused structured exercise intended to optimize a patient’s preoperative general physical state in order to maximize their post-operative recovery.
Whole body vibration – use of a vibrating platform on which the patient sits or stands while doing prescribed exercises.

Clinical Indications

Physical therapy and occupational therapy adjunctive treatments are considered to be MEDICALLY NECESSARY when a clinically significant net benefit above and beyond conventional therapies has been determined from currently available evidence. The provision of such adjunctive treatments must also meet the Carelon clinical criteria for the rendering of physical or occupational therapy and is limited to the clinical indications noted below, documentation of which must be in the medical record.

Sensory Integration Therapy

Sensory integration therapy is considered medically necessary for patients diagnosed with Autism Spectrum Disorders (ASD).

Note: Sensory integration therapy is considered not medically necessary for all other clinical scenarios (see Exclusions).

Additional services

Other services covered by CPT codes listed in the coding section which are not better accounted for by a more specific service or indication listed in this guideline may be considered medically necessary when ALL of the following criteria are met:

The anticipated benefit of the recommended intervention outweighs any potential harms that may result such that there is a clinically significant, net benefit.
Current literature and/or standards of rehabilitative or habilitative practice support that the recommended intervention offers the greatest net benefit among competing alternatives.

Note: for the purposes of this criterion, “current literature” typically requires a minimum of one well-designed randomized controlled trial that demonstrates clinically significant net benefit relative to or as a supplement to the current standard of care.

Based on the clinical evaluation, current literature, and standards of rehabilitative or habilitative practice, there exists a reasonable likelihood that the intervention will directly or indirectly lead to an improved outcome for the patient.

Exclusions

The following physical therapy and occupational therapy adjunctive treatments are considered to be not medically necessary because a clinically significant net benefit above and beyond conventional therapies could not be determined based on currently available evidence, evidence expressly demonstrated there was not a net benefit, and/or it is a nonskilled service.

Active Therapeutic Movements® is considered not medically necessary in all clinical scenarios.
Diathermy is considered not medically necessary in all clinical scenarios.
Dry needling is considered not medically necessary in all clinical scenarios.
Elastic taping is considered not medically necessary in all clinical scenarios.
Electrical stimulation, unattended is considered not medically necessary in all clinical scenarios.
Gait analysis, instrumented is considered not medically necessary in all clinical scenarios.
Hippotherapy is considered not medically necessary in all clinical scenarios.
Hot and/or cold pack is considered not medically necessary in all clinical scenarios .
Interactive metronome® is considered not medically necessary in all clinical indications.
Iontophoresis is considered not medically necessary in all clinical scenarios.
Lee Silverman Voice Treatment BIG® is considered not medically necessary in all clinical scenarios.
Low level laser is considered not medically necessary in all clinical scenarios.
Mechanical traction for spinal disorders is considered not medically necessary in all clinical scenarios.
MEDEK® (Dynamic Method of Kinetic Stimulation), Cuevas MEDEK Exercises (CME)® is considered not medically necessary in all clinical scenarios.
Motion analysis, instrumented is considered not medically necessary in all clinical scenarios.
Phonophoresis is considered not medically necessary in all clinical scenarios.
Sensory integration therapy is considered not medically necessary in all other clinical scenarios. (see Indications)
Therapeutic magnetic resonance is considered not medically necessary in all clinical scenarios.
Ultraviolet phototherapy is considered not medically necessary in all clinical scenarios.
Vasopneumatic compression device is considered not medically necessary in all clinical scenarios .
Whirlpool is considered not medically necessary in all clinical scenarios.
Whole body advanced exercise is considered not medically necessary in all clinical scenarios.
Whole body vibration is considered not medically necessary in all clinical scenarios.

References

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Al-Boloushi Z, Lopez-Royo MP, Arian M, et al. Minimally invasive non-surgical management of plantar fasciitis: A systematic review. J Bodywork Mov Ther. 2019;23(1):122-37.
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Speech Therapy Alternative Treatments

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

92507	Treatment of speech, language, voice, communication, and/or hearing processing disorder
92508	Group treatment of speech, language, voice, communication, and/or hearing processing disorder
92521	Evaluation of speech fluency
92522	Evaluation of speech sound production
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance
92526	Treatment of swallowing and/or oral feeding function
92605	Evaluation and prescription of non-speech-generating and alternative communication device first hour
92606	Therapeutic services for use of non-speech-generating device with programming
92607	Evaluation of patient with prescription of speech-generating and alternative communication device
92608	Evaluation and prescription of speech-generating and alternative communication device
92609	Therapeutic services for use of speech-generating device with programming
92610	Evaluation of swallowing function
92611	Fluoroscopic and video recorded motion evaluation of swallowing function
92618	Evaluation and prescription of non-speech-generating and alternative communication device
92626	Evaluation of hearing rehabilitation first hour
92627	Evaluation of hearing rehabilitation
92630	Hearing training and therapy for hearing loss prior to learning to speak
92633	Hearing training and therapy for hearing loss after speech
97039	Unlisted modality (specify type and time if constant attendance)
97129	One-on-one therapeutic interventions focused on thought processing and strategies to manage activities
97130	Each additional 15 minutes (list separately in addition to code for primary procedure)
S9152	Speech therapy re-evaluation
V5362	Speech screening
V5363	Language screening
V5364	Dysphagia screening

Modifiers

96	Habilitative Services
97	Needle insertion(s) without injection(s), 1 or 2 muscle(s)

ICD-10 Diagnosis

Refer to the ICD-10 CM Manual

General Information

Background

Speech therapists use several alternative methods, techniques and devices to aid in their traditional treatment of patients with a range of speech, language, swallowing and cognitive conditions. They must be used as a component of a more comprehensive speech therapy program and may be performed by a qualified provider of speech therapy services. Examples include thermal tactile stimulation and expiratory muscle strengthening using a device. Performance of all services is subject to state regulations including therapy practice acts and should be rendered in accordance with those.

Scope

The purpose of this guideline is to establish appropriate use criteria for specific speech therapy treatments that complements the conceptual principles and documentation requirements for speech therapy established by the parent speech-language pathology guidelines.

Clinical indications for the appropriate use of services in these guidelines are intended to be limited to those that would be within the treatment scope of practice for qualified allied health services providers specifically speech therapists or occupational therapists. Medical indications for the appropriate use of speech therapy alternative treatments are out of scope of these guidelines.

Indications and criteria for the appropriate acquisition of durable medical equipment (DME) used in provision of alternative therapies are also out of scope for these guidelines.

Therapies deemed to be duplicative (see definition in the parent speech-language pathology guidelines) will be considered not medically necessary.

Definitions

Blue dye test – Clinical test that involves putting colored dye, historically FD&C Blue Number 1 food coloring, in a patient’s food or tube feedings to aid in the clinical assessment of aspiration.
Electrical stimulation – application of electrical current to the skin (transcutaneous electrical stimulation) in the region of the larynx in order to stimulate muscles involved in swallowing.
Expiratory muscle strengthening therapy (with device) – exercise performed with the aid of an external device (e.g., threshold device) aimed at improving the strength and endurance of expiratory muscles of breathing for the purpose of treating speech, voice, and/or swallowing dysfunction.
Integrative yoga therapy – method of holistic therapy that incorporates yoga into traditional speech therapy for the purpose of improving posture, balance, speech motor system, attention and focus to improve swallowing function, used most commonly in pediatric populations.
Lee Silverman Voice Treatment – proprietary speech therapy program that involves an intensive program of voice exercises to improve voice quality and communication of people with Parkinson’s disease and other neurological conditions. It requires company-certification of providers.
Myofascial release therapy for dysphagia – form of manual therapy that attempts to relieve soft tissue, particularly fascial, restriction affecting swallowing for the purpose of improving swallow dysfunction.
Neurodevelopmental technique for dysphagia – a treatment approach focused on the neurological basis of movement which involves guided or facilitated movements to improve function in patients with neuromotor conditions.
Oral motor exercises for dysphagia – exercises aimed at improving the strength, coordination, range of motion, and responsiveness of the affected oro-motor muscles for the purpose of treating oral pharyngeal dysphagia.
Parkinson Voice Project – proprietary speech therapy program, involving individual and group therapy techniques, for people with Parkinson’s and Parkinson’s-plus syndromes. Provider training is company sponsored. Parkinson Voice Project is the company that offers the training. The program is called SPEAK OUT!® & The LOUD Crowd®.⁴
Thermal tactile stimulation for dysphagia – method of speech therapy that uses the application of a cold stimulant to the faucial pillars to facilitate the activation of the swallow mechanism and improve swallowing function.

Clinical Indications

None.

Additional Services

The anticipated benefit of the recommended intervention outweighs any potential harms that may result such that there is a clinically significant, net benefit.
Current literature and/or standards of rehabilitative or habilitative practice support that the recommended intervention offers the greatest net benefit among competing alternatives.

Note: for the purposes of this criterion, “current literature” requires a minimum of one well-designed randomized controlled trial that demonstrates clinically significant, net benefit relative to or as a supplement to the current standard of care.

Based on the clinical evaluation, current literature, and standards of rehabilitative or habilitative practice, there exists a reasonable likelihood that the intervention will directly or indirectly lead to an improved outcome for the patient.

Exclusions

The following complementary and/or emerging speech therapy treatments are considered to be not medically necessary, because a clinically significant net benefit above and beyond conventional therapies could not be determined based on currently available evidence, or current evidence expressly demonstrates there is not a net benefit.

Blue dye test is considered not medically necessary for all clinical scenarios.
Electrical stimulation/Biofeedback is considered not medically necessary in all clinical scenarios.
Expiratory muscle strengthening with a device is considered not medically necessary in all clinical scenarios.
Integrative yoga therapy is considered not medically necessary in all clinical scenarios.
Lee Silverman Voice Treatment is considered not medically necessary in all clinical scenarios.
Myofascial release therapy for dysphagia is considered not medically necessary in all clinical scenarios of dysphagia.
Neurodevelopmental technique for dysphagia is considered not medically necessary in all clinical scenarios of dysphagia.
Oral motor exercises for dysphagia are considered not medically necessary in all clinical scenarios of dysphagia.
Parkinson Voice Project is considered not medically necessary in all clinical scenarios.
Thermal tactile stimulation for dysphagia is considered not medically necessary in all clinical scenarios of dysphagia.

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History

Status	Review Date	Effective Date	Action
Archived	–	04/14/2024	Not to be used for dates of service on or after 04/14/2024.
Revised	08/29/2022; 09/21/2022	04/09/2023	Independent Multispecialty Physician Panel (IMPP) review. Updates to Background and Definitions. Definition and exclusion added for Lee Silverman Voice Treatment BIG®.
Revised	08/31/2021	06/12/2022	Independent Multispecialty Physician Panel (IMPP) review. Updates to Definitions. Examples added for clarification. Revised indications: Dry Needling.
Revised	–	05/01/2021	Removed CPT codes 97597, 97598, 97602.
Created	05/11/2020	12/01/2020	IMPP review. Original effective date.

ARCHIVED Physical Occupational and Speech Therapies 2023-04-09 to 2024-04-13

Clinical Appropriateness Guidelines

Table of Contents

Description and Application of the Guidelines

General Clinical Guideline

Clinical Appropriateness Framework

Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions

Repeat Diagnostic Intervention

Repeat Therapeutic Intervention

Codes

CPT/HCPCS

Modifiers

ICD-10 Diagnosis

Physical Therapy

General Information

Abbreviations

Background

Details and Scope

Definitions

Clinical Indications

Initiation of physical therapy for rehabilitative or habilitative services is considered medically necessary when criteria for both A and B are met:

A. Initial Physical Therapy Evaluation

B. Individualized Physical Therapy Plan of Care

Proceeding with physical therapy services is considered medically necessary when ALL of the following criteria (A-F) are met:

A. Require the skills and training of a qualified physical therapy provider:

B. ANY of the following:

C. There is ongoing patient and/or caregiver education and/or training

D. There is at least one unmet functional or caregiver training goal

E. There is an expectation that the remaining goal(s) will be met within a reasonable and defined period of time

F. Progress is commensurate with the duration of treatment rendered

A recommendation for evaluation/examination by a physician or otherwise appropriate provider must be made if there is poor progression toward goals due to new or persistent symptoms

Institution of a physical therapy maintenance program may be considered medically necessary in specific circumstances (refer to Definitions section)

Exclusions

References

Occupational Therapy

Codes

CPT/HCPCS

Modifiers

ICD-10 Diagnosis

General Information

Abbreviations

Background

Details and Scope

Definitions

Clinical Indications

Initiation of occupational therapy for rehabilitative or habilitative services is considered medically necessary when criteria for both A and B are met:

A. Initial Occupational Therapy Evaluation

B. Individualized Occupational Therapy Plan of Care

Proceeding with occupational therapy services is considered medically necessary when ALL of the following criteria (A-F) are met:

A. Require the skills and training of a qualified occupational therapy provider:

B. ANY of the following:

C. There is ongoing patient and/or caregiver education and/or training

D. There is at least one unmet functional or caregiver training goal

E. There is an expectation that the remaining goal(s) will be met with additional therapy within a reasonable and defined period of time

F. Progress is commensurate with the duration of treatment rendered

A recommendation for evaluation/examination by a physician or otherwise appropriate provider must be made if there is poor progression toward goals due to new or persistent symptoms

Institution of an occupational therapy maintenance program may be considered medically necessary in specific circumstances (refer to Definitions section)

Exclusions

References

Speech-Language Pathology

Codes

CPT/HCPCS

Modifiers

ICD-10 Diagnosis

General Information

Background

Details and Scope

Definitions

Clinical Indications

Initiation of speech-language pathology for rehabilitative or habilitative services is considered medically necessary when criteria for both A and B are met.

A. Initial Speech-Language Pathology Evaluation

B. Individualized Speech-Language Pathology Plan of Care

Proceeding with speech-language pathology services is considered medically necessary when ALL of the following criteria (A-F) are met:

A. Require the skills and training of a qualified speech language pathology provider:

B. ANY of the following:

C. There is ongoing patient and/or caregiver education and/or training

D. There is at least one unmet functional or caregiver training goal

E. There is an expectation that the remaining goal(s) will be met with additional therapy within a reasonable and defined period of time

F. Progress is commensurate with the duration of treatment rendered

A recommendation for evaluation/examination by a physician or otherwise appropriate provider must be made if there is poor progression toward goals due to new or persistent symptoms