Physical Therapy (CPG 135)
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Cigna Medical Coverage Policy- Therapy Services
Physical Therapy
Effective Date: 4/15/2024
Next Review Date: 12/15/2024
INSTRUCTIONS FOR USE
Cigna / ASH Medical Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by
Cigna Companies. Please note, the terms of a customer’s particular benefit plan document may differ significantly from the standard
benefit plans upon which these Cigna / ASH Medical Coverage Policies are based. In the event of a conflict, a customer’s benefit plan
document always supersedes the information in the Cigna / ASH Medical Coverage Policy. In the absence of a controlling federal or
state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Determinations in each
specific instance may require consideration of:
1) the terms of the applicable benefit plan document in effect on the date of service
2) any applicable laws/regulations
3) any relevant collateral source materials including Cigna-ASH Medical Coverage Policies and
4) the specific facts of the particular situation
Where coverage for care or services does not depend on specific circumstances, reimbursement will only be provided if a requested
service(s) is submitted in accordance with the relevant guidelines and criteria outlined in this policy, including covered diagnosis and/or
procedure code(s) outlined in the Coding Information section of this policy. Reimbursement is not allowed for services when billed for
conditions or diagnoses that are not covered under this policy. When billing, providers must use the most appropriate codes as of the
effective date of the submission. Claims submitted for services that are not accompanied by covered code(s) under this policy will be
denied as not covered.
Cigna / ASH Medical Coverage Policies relate exclusively to the administration of health benefit plans.
Cigna / ASH Medical Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.
Some information in these Coverage Policies may not apply to all benefit plans administered by Cigna. Certain Cigna Companies
and/or lines of business only provide utilization review services to clients and do not make benefit determinations. References to standard
benefit plan language and benefit determinations do not apply to those clients.
Under many benefit plans, coverage for outpatient physical therapy programs and physical therapy
provided in the home is subject to the terms, conditions and limitations of the applicable benefit plan’s
Short-Term Rehabilitative Therapy benefit and schedule of copayments. Under many plans, coverage of
inpatient physical therapy is subject to the terms, conditions and limitations of the Other Participating
Health Care Facility/Other Health Care Facility benefit as described in the applicable plan’s schedule of
copayments.
Outpatient physical therapy is the most medically appropriate setting for these services unless the
individual independently meets coverage criteria for a different level of care. An outpatient physical
therapy treatment visit is limited to a maximum of 4 timed codes (equivalent to one hour) for each date
of service.
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If covered, massage therapy is generally subject to the terms, conditions and limitations of the Short-
Term Rehabilitation Therapy or Chiropractic Care Services benefits as described in the applicable plan’s
schedule of copayments. Many benefit plans include a maximum allowable benefit for duration of
treatment or number of visits. Please refer to the applicable benefit plan document to determine benefit
availability and the terms and conditions of coverage.
Coverage for physical therapy varies across plans. Refer to the customer’s benefit plan document for
coverage details.
If coverage is available for physical therapy, the following conditions of coverage apply.
GUIDELINES
Rehabilitative Physical Therapy Services
Medically Necessary
I. A physical therapy evaluation is considered medically necessary for the assessment of a
physical impairment.
II. Physical therapy services are considered medically necessary to improve, adapt or restore
functions which have been impaired or permanently lost and/or to reduce pain as a result of
illness, injury, loss of a body part, or congenital abnormality when ALL the following criteria are
met:
• The individual’s condition has the potential to improve or is improving in response to therapy,
maximum improvement is yet to be attained; and there is an expectation that the anticipated
improvement is attainable in a reasonable and generally predictable period of time.
• The program is individualized, and there is documentation outlining quantifiable, attainable
treatment goals.
• Improvement is evidenced by successive objective measurements.
• The services are delivered by a qualified provider of physical therapy services (i.e.,
appropriately trained and licensed by the state to perform physical therapy services).
• Physical therapy occurs when the judgment, knowledge, and skills of a qualified provider of
physical therapy services (as defined by the scope of practice for therapists in each state) are
necessary to safely and effectively furnish a recognized therapy service due to the complexity
and sophistication of the plan of care and the medical condition of the individual, with the goal of
improvement of an impairment or functional limitation.
Not Medically Necessary
I. PT services are considered not medically necessary if any of the following is determined:
• The individual’s condition does not have the potential to improve or is not improving in response
to therapy; or would be insignificant relative to the extent and duration of therapy required; and
there is an expectation that further improvement is NOT attainable.
• The individual’s condition is strictly of a behavioral nature without any associated motor
involvement that impacts functional activities (e.g., ADHD, anxiety).
• Improvement or restoration of function could reasonably be expected as the individual gradually
resumes normal activities without the provision of skilled therapy services. For example:
An individual suffers a transient and easily reversible loss or reduction in function which
could reasonably be expected to improve spontaneously as the patient gradually
resumes normal activities;
A fully functional individual who develops temporary weakness from a brief period of
bed rest following abdominal surgery.
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• Therapy services that do not require the skills of a qualified provider of PT services. Examples
include but not limited to:
Activities for the general good and welfare of patients
General exercises (basic aerobic, strength, flexibility or aquatic programs) to
promote overall fitness/conditioning
Services/programs for the primary purpose of enhancing or returning to athletic
or recreational sports.
Massages and whirlpools for relaxation
General public education/instruction sessions
Repetitive gait or other activities and services that an individual can practice
independently and can be self-administered safely and effectively.
Activities that require only routine supervision and NOT the skilled services of a
physical therapy provider
When a home exercise program is sufficient and can be utilized to continue
therapy (examples of exceptions include but would not be limited to the
following: if patient has poor exercise technique that requires cueing and
feedback, lack of support at home if necessary for exercise program
completion, and/or cognitive impairment that doesn’t allow the patient to
complete the exercise program)
• Documentation fails to objectively verify subjective, objective and functional progress over a
reasonable and predictable period of time.
• The physical modalities are not preparatory to other skilled treatment procedures.
• Modalities that have been deemed to provide minimal to no clinical value independently or
within a comprehensive treatment for any condition and/or not considered the current standard
of care within a treatment program
Infrared light therapy
Vasopneumatic device
• Treatments are not supported in peer-reviewed literature.
II. The following treatments are considered not medically necessary because they are
nonmedical, educational or training in nature or related to academic or work performance. In
addition, these treatments/programs are specifically excluded under many benefit plans:
• back school
• vocational rehabilitation programs and any program with the primary goal of returning an
individual to work
• work hardening programs
• education and achievement testing, including Intelligence Quotient (IQ) testing
• educational interventions (e.g., classroom environmental manipulation, academic skills training
and parental training)
• services provided within the school setting and duplicated in the rehabilitation setting
III. Physical therapy services for executive functioning is considered not medically necessary
as it does not address an underlying medical condition affecting motor deficits.
• Executive functioning involves learning and cognitive skills which can be addressed with
instruction and practice in a life skills or educational program
examples of executive functioning includes deficits in the following areas, but not
limited to: sustaining and shifting attention, focusing, planning, organizing, sequencing,
managing frustration, modulating emotions that are affecting life skills and daily
activities
IV. Duplicative or redundant services expected to achieve the same therapeutic goal are
considered not medically necessary. For example:
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• Multiple modalities procedures that have similar or overlapping physiologic effects (e.g., multiple
forms of superficial or deep heating modalities)
• Same or similar rehabilitative services provided as part of an authorized therapy program
through another therapy discipline.
When individuals receive physical, occupational, or speech therapy, the therapists
should provide different treatments that reflect each therapy discipline's unique
perspective on the individual's impairments and functional deficits and not duplicate the
same treatment. They must also have separate evaluations, treatment plans, and goals.
When individuals receive manual therapy services from a physical therapist and
chiropractic or osteopathic manipulation, the services must be documented as separate
and distinct, performed on different body parts, and must be justified and non-
duplicative.
Not Covered or Reimbursable
I. The following physical therapy service is not covered or reimbursable:
• The treatment visit extends beyond 4 timed unit services per date of service per provider
(equivalent to one hour).
Habilitative Physical Therapy Services
Habilitative services may or may not be covered services. When the benefit is available for
habilitative services, the following applies:
Medically Necessary
I. Habilitative PT services are considered medically necessary when ALL the following
criteria are met:
• The therapy is intended to keep, learn, or improve skills and functioning for daily living
which have not (but normally would have) developed or which are at risk of being lost as a
result of illness (including developmental delay), injury, loss of a body part, or congenital
abnormality. Examples include therapy for a child who isn't walking or talking at the
expected age.
• The physical therapy services are evidence-based and require the judgment, knowledge,
and skills of a qualified provider of physical therapy services due to the complexity and
sophistication of the plan of care and the medical condition of the individual.
• There is an expectation that the therapy will improve function, assist development of
function, or keep an acceptable level of functioning.
• An individual would either not be expected to develop the function or would be expected to
permanently lose the function (not merely experience fluctuation in the function) without the
habilitative service. If the undeveloped or impaired function is not the result of a loss of body
part or injury, a physician experienced in the evaluation and management of the
undeveloped or impaired has confirmed that the function would not either be expected to
develop or would be permanently lost without the habilitative service. This information also
concurs with the written treatment plan, which is likely to result in meaningful development
of function or prevention of the loss of function.
• There is a written treatment plan documenting the short and long-term goals (including
estimated time when goals will be met) of treatment, frequency and duration of treatment,
and what quantitative outcome measures will be used to assess function objectively.
• Documentation objectively verifies that, at a minimum, functional status is kept or
developed.
• The services are delivered by a qualified provider of physical therapy services.
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Not Medically Necessary
I. Habilitative PT services are considered not medically necessary if any of the criteria above
are not met or the individual’s condition is strictly of a behavioral nature without any
associated motor involvement that impacts functional activities (e.g., ADHD, anxiety).
II. Physical therapy for the treatment of ANY of the following conditions is considered not
medically necessary:
• sexual dysfunction unrelated to a musculoskeletal or orthopedic condition
• scoliosis curvature correction (e.g., Schroth Method)
Experimental, Investigational, Unproven
I. Use of the following treatments is considered experimental, investigational, and/or
unproven:
• Dry hydrotherapy/aquamassage/hydromassage
• Dry needling
• Elastic therapeutic tape/taping (e.g., Kinesio
™
tape, KT TAPE/KT TAPE PRO
™
, Spidertech
™
tape)
• Equestrian therapy (e.g., hippotherapy)
• H-WAVE
®
• Intensive Model of constraint-induced movement therapy(CIMT)
• Intensive Model of Therapy (IMOT) programs
• MEDEK Therapy
• Microcurrent Electrical Nerve Stimulation (MENS)
• Non-invasive Interactive Neurostimulation (e.g., InterX
®
)
• Spinal manipulation for the treatment of non-musculoskeletal conditions and related disorders
• The Interactive Metronome Program
• Vertebral axial decompression therapy and devices (e.g., VAX-D, DRX, DRX2000, DRX3000,
DRX5000, DRX9000, DRS, Dynapro
™
DX2, Accu-SPINA™ System, IDD Therapy
®
[Intervertebral Differential Dynamics Therapy], Tru Tac 401, Lordex Power Traction device,
Spinerx LDM)
Not Covered or Reimbursable
I. The following physical therapy service is not covered or reimbursable:
• The treatment visit extends beyond 4 timed unit services per date of service per provider
(equivalent to one hour).
Massage Therapy
Massage therapy is considered not medically necessary when provided in the absence of covered
physical therapy, occupational therapy or chiropractic modalities.
Note: Massage therapy may be provided by several types of providers. To qualify for coverage, the
provider must meet the definition of provider contained in the benefit plan. Please refer to the
applicable plan language to determine benefit coverage for the rendering provider.
Hand Orthotic
A custom fitted (L3807, L3915, L3917, L3923, L3929, L3931) or custom fabricated (L3763-L3766, L3806,
L3808, L3891, L3900, L3901, L3905, L3906, L3913, L3919, L3921, L3933, L3935, L3956, L4205) hand
orthotic is medically necessary for a patient requiring stabilization or support to the hand and/or wrist
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and who is expected to have improved function with the use of the device and when the patient’s
clinical findings are severe and dysfunctional such that an off-the-shelf orthotic is insufficient for the
patient’s needs when ALL of the following criteria are met:
• The orthosis is prescribed to support, align, prevent or correct a deformity
• Evidence of a physical examination within the prior six months, for a condition that supports the use of
the item prescribed, is documented in the individual’s medical record.
• One or more of the following criteria are met:
to substitute for weak muscles (e.g., following cervical spine injury, brachial plexus injury, peripheral
nerve injury [e.g., median, ulnar or radial nerves], sprain, strain)
to support or immobilize a structure (e.g., rheumatoid arthritis, osteoarthritis, overuse syndromes
[e.g., lateral epicondylitis, cubital tunnel syndrome, carpal tunnel syndrome, de Quervain
tenosynovitis, trigger finger], trauma, following surgical repairs, fractures [e.g., acromioclavicular
dislocation, clavicle fracture])
prevent contracture or deformity from neurological injury (e.g., brain injury, stroke [i.e., spasticity],
spinal cord injury, brachial plexus injury, peripheral nerve injury)
correct joint contractures resulting from disease or immobilization (e.g., post fracture, burns)
when necessary to carry out ADLs (e.g., spinal cord injured individuals)
• One of more of the following additional criteria are met:
post-surgical intervention
orthotic requires unique components (e.g., pulleys, rubber bands)
neurologic co-morbidities (e.g., sensory deficit, spasticity)
swelling/lymphedema comorbidity
multiple-joint involvement
plan of care for serial splinting
orthotic will need frequent modification
skin impairment co-morbidity
• The clinical documentation supports the medical necessity of a custom fitted or custom fabricated
orthotic beyond what is necessary for an off-the-self orthotic.
DESCRIPTION
Physical therapy (PT) services are skilled services which may be delivered by a physical therapist or other
health care professional acting within the scope of a professional license. A service is not considered a skilled
therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct
or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and
effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a
therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes
the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding
the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the
service. Services that do not require the professional skills of a therapist to perform or supervise are not
medically necessary, even if they are performed or supervised by a therapist, physician or NPP. Therefore, if a
patient’s therapy can proceed safely and effectively through a home exercise program, self-management
program, restorative nursing program or caregiver assisted program, physical therapy services are not indicated
or medically necessary.
Rehabilitative PT services are intended to improve, adapt or restore functions which have been impaired or
permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an
individual can reach in a reasonable period of time. If no improvement is documented after two weeks of
treatment, an alternative treatment plan should be attempted. If no significant improvement is documented after
a total of four weeks, re-evaluation by the referring provider may be indicated. Treatment is no longer medically
necessary when the individual stops progressing toward established goals.
The Guide to Physical Therapist Practice, published by the APTA (2014), supports this guideline in all areas of
physical therapy practice.
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Habilitative services are defined by the National Association of Insurance Commissioners as “health care services
that help a person keep, learn or improve skills and functioning for daily living.” Habilitative services are intended
to keep, develop or improve skills needed to perform activities of daily living (ADLs) or instrumental activities of
daily living (IADLs) which have not (but normally would have) developed or which are at risk of being lost as a
result of illness, injury, loss of a body part, or congenital abnormality. Examples include therapy for a child who
is not walking at the expected age.
GENERAL BACKGROUND
Physical therapists provide services to patients who have impairments, functional limitations, disabilities, or
changes in physical function and health status resulting from injury, disease, or other causes. Medically
necessary physical therapy services must relate to a written treatment plan of care and be of a level of
complexity that requires the judgment, knowledge and skills of a physical therapist to perform and/or supervise
the services. The plan of care for medically necessary physical therapy services is established by a licensed
physical therapist. The amount, frequency and duration of the physical therapy services must be reasonable
(within regional norms and commonly accepted practice patterns); the services must be considered appropriate
and needed for the treatment of the condition and must not be palliative in nature. Thus, once therapeutic
benefit has been achieved, or a home exercise program could be used for further gains without the need for
skilled physical therapy, continuing supervised physical therapy is not considered medically necessary. If
measurable improvement is made, then the progress towards identified goals should be clearly documented and
the treatment plan updated accordingly.
Physical therapists should document in clinical records the objective
findings and subjective complaints that support the necessity for treatment. A treatment plan should be
developed with planned procedures/modalities (frequency and duration), measurable and attainable short- and
long-term goals, and anticipated duration of care. At a minimum, documentation is required for every treatment
day and for each intervention performed. Each daily record should include: the date of service, the total
treatment time for each date of service, and the identity of the person(s) providing the services;, and specific
interventions used; the name of each modality and/or procedure performed, the parameters for each modality
(e.g., amperage/voltage, location of pads/electrodes), area of treatment, and total treatment time spent for each
intervention (mandatory for timed services). Failure to properly identify and sufficiently document the parameters
for each intervention on a daily progress note may result in an adverse determination (partial approval or
denial).There should be a reasonable expectation that the identified goals will be met.
Duplicated / Insufficient Information
(1) Entries in the medical record should be contemporaneous, individualized, appropriately comprehensive, and
made in a chronological, systematic, and organized manner. Duplicated/nearly duplicated medical records
(a.k.a. cloned records) are not acceptable. It is not clinically reasonable or physiologically feasible that a
patient’s condition will be identical on multiple encounters. (Should the findings be identical for multiple
encounters, it would be expected that treatment would end because the patient is not making progress toward
current goals.)
This includes, but not limited to:
• duplication of information from one treatment session to another (for the same or different patient[s]);
• duplication of information from one evaluation to another (for the same or different patient[s]).
Duplicated medical records do not meet professional standards of medical record keeping and may result in an
adverse determination (partial approval or denial) of those services.
(2) The use of a system of record keeping that does not provide sufficient information (e.g., checking boxes,
circling items from lists, arrows, travel cards with only dates of visit and listings) should not be submitted. These
types of medical record keeping may result in an adverse determination (partial approval or denial) of those
services.
Effective and appropriate documentation that meets professional standards of medical record keeping that
adequately detail a proper assessment of the patient’s status, the nature and severity of patient complaint(s) or
condition(s), and/or other relevant clinical information (e.g., history, parameters of each therapy performed,
objective findings, progress towards treatment goals, response to care, prognosis.) is expected.
Physical Therapy Treatment Sessions
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A physical therapy intervention is the purposeful interaction of the physical therapist with the patient and, when
appropriate, with other individuals involved in patient care, using various physical therapy procedures and
techniques to produce changes in the condition that are consistent with the diagnosis and prognosis. Physical
therapy interventions consist of coordination, communication, and documentation; patient-related and
family/caregiver instruction; and procedural interventions. Physical therapists aim to alleviate impairment and
functional limitation by designing, implementing, and modifying therapeutic interventions. A physical therapy
treatment session in the outpatient setting lasts up to one-hour on any given day and must be supported in the
plan of care and based on a patient's medical condition. Consistent with Centers for Medicare & Medicaid
Services (CMS) Local Coverage Determinations (LCDs), up to a maximum of 4 timed codes (equivalent to one
hour) will be allowed. PT services in excess of 60 minutes per day are generally not demonstrated to have
additional medical benefit in an outpatient setting. Physical therapy can also be performed in a group setting.
Patients with total joint replacement, low back pain, and urinary incontinence present with favorable outcomes in
a group setting.
A physical therapy session may include:
• Evaluation or reevaluation;
• Therapeutic exercise, including neuromuscular reeducation, strengthening, coordination, and
balance;
• Functional training in self-care and home management including activities of daily living (ADL) and
instrumental activities of daily living (IADL);
• Functional training in and modification of environments (home, work, school, or community),
including body mechanics and ergonomics;
• Manual therapy techniques, including soft tissue mobilization, joint mobilization, and manual
lymphatic drainage;
• Assessment, design, fabrication, application, fitting, and training in assistive technology, adaptive
devices, and orthotic devices;
• Training in the use of prosthetic devices;
• Integumentary and wound care and protection techniques;
• Electrotherapeutic modalities;
• Physical agents and mechanical modalities;
• Community functional reintegration;
• Training of the patient, caregivers, and family/parents in home exercise and activity programs;
• Skilled reassessment of the individual's problems, plan, and goals as part of the treatment session
Modalities And Procedures
The American Medical Association (AMA) Current Procedural Terminology (CPT) manual defines a modality as
"any physical agent applied to produce therapeutic changes to biologic tissue; includes but is not limited to
thermal, acoustic, light, mechanical, or electric energy” (AMA, 2018). Modalities may be supervised, which
means that the application of the modality doesn’t require direct one-on-one patient contact by the practitioner.
This means that set-up and application of the modality needs to be supervised by a physical therapist, but they
do not need to perform the modality. Modalities may also involve constant attendance, which indicates that the
modality requires direct one-on-one patient contact by the practitioner.
Examples of supervised modalities include application of:
• Hot or cold packs
• Mechanical traction
• Unattended electrical stimulation (i.e., for pain relief)
• Vasopneumatic devices
• Whirlpool
• Paraffin bath
• Diathermy
Examples of modalities that require constant attendance include:
• Contrast baths
• Ultrasound
• Attended electrical stimulation (i.e., NMES)
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• Iontophoresis
Passive modalities are most effective during the acute phase of treatment, since they are typically directed at
reducing pain, inflammation, and swelling. They may also be utilized during the acute phase of the exacerbation
of a chronic condition. Passive modalities are rarely beneficial alone and are most effective when performed as
part of a comprehensive treatment approach. Some improvement with the use of passive modalities should be
seen within three visits. If passive therapy is not contributing to improvement, passive therapy should be
discontinued and other evidence supported interventions implemented.
The utilization of more than two passive
modalities per office visit is typically considered excessive and is not supported as medically necessary. Use of
more than two modalities on each visit date should be justified in the documentation. After one or two weeks,
the clinical effectiveness of passive modalities begins to decline significantly. In some situations, passive
modalities may be indicated for up to one or two months as part of comprehensive physical therapy program.
The need for passive modalities beyond two weeks should be objectively documented in the clinical record.
The AMA CPT manual defines therapeutic procedures as "A manner of effecting change through the application
of clinical skills and/or services that attempt to improve function" (AMA, 2018). Examples of therapeutic
procedures include therapeutic exercise to develop strength and endurance, range of motion and flexibility;
neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or
proprioception for sitting and/or standing activities; aquatic therapy with therapeutic exercises; gait training
(including stairs); and manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage,
manual traction); or therapeutic activities using dynamic activities to improve functional performance (direct one-
on-one patient contact by the practitioner).
Transition from passive physiotherapy modalities to active treatment procedures should be timely and
evidenced in the medical record, including instructions on self/home care. And in most cases, active treatment
should be initiated in addition to modality use at a level that is appropriate for the patient.
Active therapeutic procedures are typically started as swelling, pain, and inflammation are reduced. The need
for stabilization and support is replaced by the need for increased range of motion and restoration of function.
Active care elements include increasing range of motion, strengthening primary and secondary stabilizers of a
given region, and increasing the endurance capability of the muscles. Care focuses on active participation of the
patient in their exercise program. Gait training, muscle strengthening, and progressive resistive exercises are
considered active procedures. Many active procedures may be performed independently and safely by the
patient in a non-medically supervised setting. In general, patients should progress from active procedures to a
home exercise program that is progressed throughout treatment.
Below is a description and medical necessity criteria, as applicable, for different treatment interventions,
including specific modalities and therapeutic procedures associated with physical therapy. This material is for
informational purposes only and is not indicative of coverage, nor is it an exhaustive list of services provided.
Hydrotherapy/Whirlpool/Hubbard Tank
These modalities involve supervised use of agitated water in order to relieve muscle spasm, improve circulation,
or cleanse wounds e.g., ulcers, skin conditions. More specifically, Hubbard tank involves a full-body immersion
tank for treating severely burned, debilitated and/or neurologically impaired individuals. Hydrotherapy is
considered medically necessary for pain relief, muscle relaxation and improvement of movement for persons
with musculoskeletal conditions. It is also considered medically necessary for wound care (cleansing and
debridement). It is not appropriate to utilize more than one hydrotherapy modality on the same day.
Fluidotherapy®
This modality is used specifically for acute and subacute conditions of the extremities. Fluidotherapy® is a dry
superficial thermal modality that transfers heat to soft tissues by agitation of heated air and Cellux particles. The
indications for this modality are similar to paraffin baths and whirlpool and it is an acceptable alternative to other
heat modalities for reducing pain, edema, and muscle spasm from acute or subacute traumatic or non-traumatic
musculoskeletal disorders of the extremities, including complex regional pain syndrome (CRPS). A benefit of
Fluidotherapy® is that patients can perform active range of motion (AROM) while undergoing treatment.
Vasopneumatic Devices
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These special devices apply pressure for swelling/edema reduction, either after an acute injury, following a
surgical procedure, due to lymphedema, or due to pathology such as venous insufficiency. Units that provide
cold therapy with compression are not examples of vasopneumatic devices. Vasopneumatic devices are
considered not medically necessary for any condition given the state of evidence relative to lymphedema.
Standard of care for lymphedema is complex lymphedema therapy, which includes skin and nail care, manual
drainage techniques, compression bandaging, and therapeutic exercise.
Hot/Cold Packs
Hot packs increase blood flow, relieve pain and increase movement; cold packs decrease blood flow to an area
for pain and swelling reduction and are typically used in the acute phase of injury or in the acute phase of an
exacerbation. They are considered medically necessary for painful musculoskeletal conditions and acute injury.
Paraffin Bath
This modality uses hot wax for application of heat. It is indicated for use to relieve pain and increase range of
motion of extremities (typically wrists and hands) due to chronic joint problems or post-surgical scenarios.
Mechanical Traction
This device provides a mechanical pull on the spine (cervical or lumbar) to relieve pain, spasm, and nerve root
compression.
Infrared Light Therapy
Infrared light therapy is a form of superficial heat therapy used to increase circulation to relieve muscle spasm.
Other heating modalities are considered superior to infrared lamps and evidence is lacking in peer-reviewed
literature to support effectiveness. Utilization of the Infrared light therapy CPT code is not appropriate for low
level laser treatment. This also does not refer to Anodyne® Therapy System.
Electrical Stimulation
Electrical stimulation is used in different variations to relieve pain, reduce swelling, heal wounds, and improve
muscle function. Functional electric stimulation is considered medically necessary for muscle re-education (to
improve muscle contraction) in the earlier phases of rehabilitation.
Iontophoresis
Electric current used to transfer certain chemicals (medications) into body tissues. Use to treat inflammatory
conditions, such as plantar fasciitis and lateral epicondylitis.
Contrast Baths
This modality is the application of alternative hot and cold baths and is typically used to treat extremities with
subacute swelling or CRPS. Contrast baths assist with hypersensitivity reduction and swelling reduction.
Ultrasound
This modality provides deep heating through high frequency sound wave application. Non-thermal applications
are also possible using the pulsed option. Ultrasound is commonly used to treat many soft tissue conditions that
require deep heating or micromassage to a localized area to relieve pain and improve healing.
Diathermy (i.e., shortwave)
This modality utilizes high frequency magnetic and electrical current to provide deep heating to larger joints and
soft tissue structures for pain relief, increased healing, and muscle spasm reduction. Microwave diathermy
presents a negative benefit: risk ratio and is not recommended.
Therapeutic Exercises
This procedure includes instruction, feedback, and supervision of a person in an exercise program for their
condition. The purpose is to increase/maintain flexibility and muscle strength. Therapeutic exercise is performed
with a patient either actively, active-assisted, or passively. It is considered medically necessary for loss or
restriction of joint motion, strength, functional capacity or mobility which has resulted from disease or injury.
Note: Exercising done subsequently by the member without a physician or therapist present and supervising
would not be covered.
Neuromuscular Reeducation
Physical Therapy (CPG 135)
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This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and
proprioception to a person who has reduced balance, strength, functional capacity or mobility which has resulted
from disease, injury, or surgery. The goal is to develop conscious control of individual muscles and awareness
of position of extremities. The procedure may be considered medically necessary for impairments which affect
the body's neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine
motor coordination) that may result from musculoskeletal or neuromuscular disease or injury such as severe
trauma to nervous system, post orthopedic surgery, cerebral vascular accident and systemic neurological
disease.
Aquatic Therapy
Pool therapy (aquatic therapy) is provided individually, in a pool, to debilitated or neurologically impaired
individuals. (The term is not intended to refer to relatively normal functioning individuals who exercise, swim laps
or relax in a hot tub or Jacuzzi.) The goal is to develop and/or maintain muscle strength and range of motion by
reducing forces of gravity through total or partial body immersion (except for head).
Gait Training
This procedure involves teaching individuals with neurological or musculoskeletal disorders how to ambulate
given their disability or to ambulate with an assistive device. Assessment of muscle function and joint position
during ambulation is considered a necessary component of this procedure, including direct visual observation
and may include video, various measurements, and progressive training in ambulation and stairs. Gait training is
considered medically necessary for training individuals whose walking abilities have been impaired by
neurological, integumentary, muscular or skeletal abnormalities, surgery, or trauma. This also includes
crutch/cane ambulation training and re-education.
Massage Therapy
Massage involves manual techniques that include applying fixed or movable pressure, holding and/or causing
movement of or to the body, using primarily the hands. These techniques affect the musculoskeletal, circulatory-
lymphatic, nervous, and other systems of the body with the intent of improving a person's well-being or health.
The most widely used forms of basic massage therapy include Swedish massage, deep-tissue massage, sports
massage, neuromuscular massage, and manual lymph drainage. Massage therapy may be considered
medically necessary when designed to restore muscle function, reduce edema, improve joint motion, or for relief
of muscle spasm, and determined not duplicative to other modalities/procedures.
Soft Tissue Mobilization
Soft tissue mobilization techniques are more specific in nature and include, but are not limited to, myofascial
release techniques, friction massage, and trigger point techniques. Specifically, myofascial release is a soft
tissue manual technique that involves manipulation of the muscle, fascia, and skin. Skilled manual techniques
(active and/or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural
or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous
muscles, or stretching of shortened connective tissue. This procedure is considered medically necessary for
treatment of restricted motion of soft tissues in involved extremities, neck, and trunk.
Joint Mobilization/Manipulation
Joint mobilization and manipulation is utilized to reduce pain and increase joint mobility. Most often mobilizations
are indicated for extremity and spine conditions, while manipulation may be more generally indicated for spinal
conditions.
Therapeutic Activities
This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, pushing, pulling,
stooping, catching and overhead activities) to improve functional performance in a progressive manner. The
activities are usually directed at a loss or restriction of mobility, strength, balance or coordination. They require
the professional skills of a practitioner and are designed to address a specific functional need of the member.
This intervention may be appropriate after a patient has completed exercises focused on strengthening and
range of motion but need to be progressed to more function-based activities. These dynamic activities must be
part of an active treatment plan and directed at a specific outcome.
Activities of Daily Living (ADL) Training
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Training of impaired individuals in essential activities of daily living and self- care activities including: bathing;
feeding; preparing meals; toileting; dressing; walking; making a bed; and transferring from bed to chair,
wheelchair or walker. This procedure is considered medically necessary to enable the member to perform
essential activities of daily living related to the patient's health and hygiene, within or outside the home, and with
minimal or no assistance from others. Services provided concurrently by physical therapists and occupational
therapists may be considered medically necessary if there are separate and distinct functional goals.
Cognitive Skills Development
This procedure is considered medically necessary for persons with acquired cognitive defects resulting from
head trauma, or acute neurologic events including cerebrovascular accident or pediatric developmental
condition. It is not appropriate for persons without potential for improvement. Occupational/speech therapists
with specific training typically provide this care, however physical therapists can also provide this care through a
team approach. This procedure should be aimed at improving or restoring specific functions which were
impaired by an identified illness or injury.
Orthotic Training
Training and re-education with braces and/or splints (orthotics).
Hand Orthotic Fabrication
Orthotic devices are defined as orthopedic appliances used to support, align, prevent or correct deformities.
Orthotics may also redirect, eliminate or restrict motion of an impaired body part. In this context, they are not used
for participation in sports, to improve athletic performance, and/or to prevent injury in an otherwise uninjured body
part. Static orthoses are rigid and are used to support weakened or paralyzed body parts in a particular position.
Dynamic orthoses are used to facilitate body motion to allow optimal function. Medical necessity for any orthotic
device must be documented in the individual’s medical record. Supportive documentation includes a prescription
for the specific device, recent physical examination for the condition being treated, (i.e., < six months) with
assessment of functional capabilities/limitations and any other comorbidities. Orthoses may be prefabricated or
custom fabricated. A prefabricated orthosis is any orthoses that is manufactured in quantity without a specific
patient in mind. A prefabricated orthosis can be modified (e.g., trimmed, bent or molded) for use by a specific
patient and is then considered a custom-fitted orthosis. An orthosis that is made from prefabricated components
is considered a prefabricated orthosis. Any orthosis that does not meet the standard definition of custom-fabricated
is considered to be a prefabricated device. A custom-fabricated orthosis is one that is specifically made for an
individual patient starting with the most basic materials that may include plastic, metals, leather or various cloths.
The construction of these devices requires substantial labor such as cutting, bending, molding and sewing, and
may even involve the use of some prefabricated components. A molded-to-patient model orthosis is a type of
custom-fabricated device for which an impression of the specific body part is made (e.g., by means of a plaster
cast, or computer-aided design/computer-aided manufacturing [CAD-CAM] technology). The impression is then
used to make a specific patient model. The actual orthosis is molded from the patient-specific model. CAD-Cam
and other technologies, such as those that determine alignment of the device, are considered integral to the fitting
and manufacturing of the base device. An unmodified, prefabricated orthosis is generally used in treating a
condition prior to a custom-fitted orthosis (prefabricated orthosis that is modified by bending or molding for a
specific patient). A custom-fitted orthosis is generally attempted prior to the use of a custom-fabricated orthosis
(individually constructed from materials). Custom fabricated devices are considered medically necessary only
when the established medical necessity criteria is met for the device and the individual cannot be fitted with a
prefabricated (off-the-shelf) device or one is not available. Examples of conditions precluding the use of a
prefabricated device typically include abnormal limb contour (e.g., disproportionate size/shape) or deformity (e.g.,
valgus, varus deformity) or when there is minimal muscle mass upon which to suspend the orthosis.
Prosthetic Checkout
These assessments are considered medically necessary when a device is newly issued or there is a
modification or re-issue of the device. These assessments are considered medically necessary when a member
experiences loss of function directly related to the orthotic or prosthetic device (e.g., pain, skin breakdown, or
falls). This is usually completed in 1-2 sessions.
Prosthetic Training
Training and re-education with prosthetics devices. Considered medically necessary for persons with a
medically necessary prosthetic. Periodic return visits beyond the third month may be necessary.
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Wheelchair Management Training
This procedure is considered medically necessary only when it is part of an active treatment plan directed at a
specific goal. The member must have the capacity to learn from instructions. Typically, three (3) sessions are
adequate.
Certain physical medicine modalities and therapeutic procedures are considered duplicative in nature and it
would be inappropriate to perform or bill for these services during the same session, such as:
• Functional activities and ADLs
• More than one deep heating modality
• Massage therapy and myofascial release
• Orthotics training and prosthetic training
• Whirlpool and Hubbard tank
The medical necessity of neuromuscular reeducation, therapeutic exercises, and/or therapeutic activities,
performed on the same day, must be documented in the medical record.
Only one heat modality would be considered medically necessary during the same treatment session, with the
exception of use of one form of superficial heat and one form of deep heat (i.e. ultrasound or diathermy and hot
packs). Use of two forms of deep or superficial heat would not be acceptable.
Active Wound Care Management
The AMA CPT manual defines active wound care procedures as those procedures "performed to remove
devitalized tissue and/or necrotic tissue and promote healing" (AMA, 2014). The practitioner is required to have
direct one-on-one contact with the patient. Examples of active wound care management include debridement of
an open wound, including topical application; use of whirlpool or other modalities; and negative pressure wound
therapy.
Electromyography (EMG) and Nerve Conduction Velocity (NCV) Tests
According to the AMA CPT manual “Needle electromyographic procedures include the interpretation of electrical
waveforms measured by equipment that produces both visible and audible components of electrical signals
recorded from the muscle(s) studied by the needle electrode" (AMA, 2014). For nerve conduction testing, “motor
nerve conduction study recordings must be made from electrodes placed directly over the motor point of the
specific muscle to be tested. Sensory nerve conduction study recordings must be made from electrodes placed
directly over the specific nerve to be tested.” Waveforms must be reviewed on site in real-time. Reports must be
prepared on site by the examiner and consist of the work product of the interpretation of numerous test results.
EMG and NCV testing is only covered if provided by a qualified health care professional or physician. Physical
therapists who are board certified by the APTA are considered qualified health professionals. State licensure
rules and regulations apply.
Pulmonary Rehabilitation
Pulmonary rehabilitation (PR) is a widely accepted therapeutic tool used to improve the quality of life and
functional capacity of individuals with chronic lung disease. It is a multidisciplinary, comprehensive program of
care that is individually tailored and designed to optimize autonomy and physical performance in patients with
chronic respiratory impairment. The goal of PR is to help the individual achieve the highest level of independent
functioning by improving pulmonary function, increasing exercise endurance and exercise work capacity,
reducing dyspnea and normalizing blood gases. Manipulation of the chest wall, such as cupping, percussing,
and vibration to facilitate lung function may be an important component of a multi-modal treatment plan for
individuals with pulmonary conditions. Specific therapeutic procedures to increase strength or endurance of
respiratory muscles may also be an acceptable intervention as well.
DOCUMENTATION GUIDELINES
Initial Examination/Evaluation/Diagnosis/Prognosis
The physical therapist performs an initial examination and evaluation to establish a physical therapy diagnosis,
prognosis, and plan of care prior to intervention. An initial evaluation for a new condition by a Physical Therapist
is defined as the evaluation of a patient:
• For which this is their first encounter with the practitioner or practitioner group
• Who presents with:
A new injury or new condition; or
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The same or similar complaint after discharge from previous care.
• Choice of code is dependent upon the level of complexity.
Note: Appropriate range of motion (ROM) testing (CPT codes 95851- 95852), including digital wireless
inclinometers or other such electronic device that measures ROM using a handheld device are integral within
Evaluation/Reevaluation codes. Computerized isokinetic muscle strength and endurance testing using a
machine, such as a Biodex, would be considered a physical performance test or measurement using CPT code
97750 – “Physical performance test or measurement (e.g. musculoskeletal, functional capacity), with written
report, each 15 minutes.”
Four components are used to select the appropriate PT evaluation CPT code. These include:
• Patient history and comorbidities
• Examination and the use of standardized tests and measures
• Clinical presentation
• Clinical decision making
Relevant CPT Codes: CPT 97161, 97162, and 97163 – Physical Therapy evaluation
The physical therapist examination:
• Is documented, dated, and appropriately authenticated by the physical therapist who performed it
• Identifies the physical therapy needs of the patient
• Incorporates appropriate tests and measures to facilitate outcome measurement
• Produces data that are sufficient to allow evaluation, diagnosis, prognosis, and the establishment of a
plan of care
• The program is expected to result in significant therapeutic improvement over a clearly defined period of
time.
The physical therapist’s plan of care should be sufficient to determine the medical necessity of treatment,
including:
• The diagnosis along with the date of onset or exacerbation of the disorder/diagnosis
• A reasonable estimate of when the goals will be reached
• Long-term and short-term goals that are specific, quantitative and objective
• Physical therapy evaluation
• The frequency and duration of treatment
• Rehabilitation or habilitation prognosis
• The specific treatment techniques and/or exercises to be used in treatment
• Signature of the patient's physical therapist.
Treatment Sessions
Documentation of treatment sessions must include:
• Date of treatment
• Specific treatment(s) provided that match the procedure codes billed
• Total treatment time
• Response to treatment
• Skilled ongoing reassessment of the individual's progress toward the goals; including objective data that
can be compared across time
• Any challenges or changes to the plan of care
• Name and credentials of the treating clinician
Progress Reports
In order to reflect that continued PT services are medically necessary, intermittent progress reports must
demonstrate that the individual is making functional progress. Progress reports should include at a minimum:
• Start date of therapy
• Time period covered by the report
• All diagnoses
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• Statement of the patient's functional level at the beginning of the progress report period and current
status relative to baseline data at evaluation or previous progress report; objective measures related to
goals should be included
• Changes in prognosis, plan of care, and goals; and why
• Consultations with or referrals to other professionals or coordination of services, if applicable
• Signature and title of qualified professional responsible for the therapy services
Reexamination/Reevaluation
Re-evaluations are distinct from therapy assessments. There are several routine reassessments that are not
considered re-evaluations. These include ongoing reassessments that are part of each skilled treatment session,
progress reports, and discharge summaries. Re-evaluation provides additional objective information not included
in documentation of ongoing assessments, treatment or progress notes. Assessments are considered a routine
aspect of intervention and are not billed separately from the intervention. Continuous assessment of the patient’s
progress is a component of the ongoing therapy services and is not payable as a re-evaluation.
Re-evaluation services are considered medically necessary when all of the following conditions are met:
• Re-evaluation is not a recurring routine assessment of patient status
• The documentation of the re-evaluation includes all of the following elements:
• An evaluation of progress toward current goals;
• Making a professional judgment about continued care;
• Making a professional judgment about revising goals and/or treatment or terminating
services.
AND the following indication is documented:
• An exacerbation or significant change in patient/client status or condition.
A re-evaluation is indicated when there is an exacerbation or significant change in the status or condition of the
patient. Re-evaluation is a more comprehensive assessment that includes all of the components of the initial
evaluation, such as:
• Data collection with objective measurements taken based on appropriate and relevant
assessment tests and tools using comparable and consistent methods;
• Making a judgment as to whether skilled care is still warranted;
• Organizing the composite of current problem areas and deciding a priority/focus of treatment;
• Identifying the appropriate intervention(s) for new or ongoing goal achievement;
• Modification of intervention(s);
• Revision in plan of care if needed;
• Correlation to meaningful change in function; and
• Deciphering effectiveness of intervention(s).
Discharge/Discontinuation of Intervention
The physical therapist discharges the patient from physical therapy services when the anticipated goals or
expected outcomes for the patient have been achieved. The physical therapist discontinues intervention when
the patient is unable to continue to progress toward goals or when the physical therapist determines that the
patient will no longer benefit from physical therapy.
The physical therapy discharge documentation:
• Includes the status of the patient at discharge and the goals and outcomes attained;
• Is dated and appropriately authenticated by the physical therapist who performed the discharge
• Includes, when a patient is discharged prior to attainment of goals and outcomes, the status of the
patient and the rationale for discontinuation
• Includes initial, subsequent, and final FOM scores
• Includes proposed self-care recommendations, if applicable
• Includes referrals to other health care practitioners/referring physicians, as appropriate
Standardized Tests and Measures/Functional Outcome Measures (FOMs)
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Measuring outcomes is an important component of physical therapists’ practice. Outcome measures are
important in direct management of individual patient care and for the opportunity they provide the profession in
collectively comparing care and determining effectiveness.
The use of standardized tests and measures early in an episode of care establishes the baseline status of the
patient, providing a means to quantify change in the patient's functioning. Outcome measures, along with other
standardized tests and measures used throughout the episode of care, as part of periodic
reexamination/reevaluation, provide information about whether predicted outcomes are being realized. As the
patient reaches the termination of physical therapy services and the end of the episode of care, the physical
therapist measures the outcomes of the physical therapy services. Standardized outcome measures provide a
common language with which to evaluate the success of physical therapy interventions, thereby providing a
basis for comparing outcomes related to different intervention approaches. Measuring outcomes of care within
the relevant components of function (including body functions and structures), activity, and participation, among
patients with the same diagnosis, is the foundation for determining which intervention approaches comprise best
clinical practice.
LITERATURE REVIEW
There are several guidelines, systematic reviews, meta-analyses, and randomized controlled trials (RCTs)
published that examine physical therapy (a variety of interventions) for various conditions and note effectiveness
of physical rehabilitation, exercise, education, manual therapies (e.g. mobilization, manipulation, soft tissue
mobilization), and other various modalities (Taylor et al., 2007; Chou et al., 2016; Qaseem et al., 2017; Byström
et al., 2013; Macedo et al., 2016; Oliveira et al., 2012; Saragiotto et al., 2016; Steffens et al., 2016; van
Middelkoop et al., 2010; Logerstedt et al., 2010; Cibulka et al., 2009; Cibulka et al., 2017; Blanpied et al., 2017;
Gay et al., 2016; Fransen et al., 2014; Babatunde et al., 2017; BiDonde et al., 2017; Pollock et al., 2014; French
et al., 2005; Yousefi-Nooraie et al., 2008;
Chou et al., 2020; Skelly et al., 2018; Skelly et al., 2020; Jacobi et al.,
2021; Mertens et al., 2022; Núñez-Cabaleiro et al., 2022; Schenk et al., 2022; Huang et al., 2022, Neal et al.,
2022; Shu et al,. 2022; Demont et al., 2023; Liaghat et al., 2023) Passive modalities, such as ultrasound,
electric stimulation, traction, laser, and hot and cold packs, are often used in combination with manual therapies
and exercise despite insufficient and/or inconclusive evidence for many conditions. Often methodologic flaws
and heterogeneity of studies result in an inability to draw confirmatory conclusions.
Massage Therapy: Few clinical trials have been undertaken to assess the effect of this modality alone in the
treatment of specific medical conditions. Rehabilitation programs frequently combine massage therapy with one
or more other treatment interventions. While there is scant literature regarding the efficacy of this treatment
when used as the sole modality, massage therapy has been a part of physical therapy or chiropractic treatment
plans for the management of musculoskeletal pain. As an example, for mechanical low back pain, the greatest
effects of massage therapy are seen in short term relief of pain. The effects on function were less clear. These
therapeutic effects tend to diminish in the longer term (Chou et al., 2016).
Massage therapy was also noted as
an effective treatment of acute post-operative pain (Chou et al., 2020) and chronic low back pain in the
intermediate term (Skelly et al., 2018). Slight functional improvements were noted in the intermediate term for
fibromyalgia using myofascial release massage (Skelly et al., 2018; Kundakci et al., 2022).
Physical Therapy For Conditions Considered Experimental, Investigational Or Unproven
Sexual Dysfunction (unrelated to musculoskeletal or orthopedic condition)
Female sexual dysfunction conditions can be classified as sexual desire disorders, sexual arousal disorder,
orgasmic disorder, or sexual pain disorders. Hypoactive sexual desire disorder and sexual aversion disorder
comprise the sexual desire disorders.
ACOG (2019) published a clinical management guideline on female sexual dysfunction. Conditions included in
this guideline include: sexual desire disorders (e.g., hypoactive sexual desire disorder and sexual aversion
disorder), female sexual arousal disorder, female orgasmic disorder, and sexual pain disorders with no muscular
involvement (e.g., dyspareunia, vaginismus). Physical therapy is not included in the recommendations in this
guideline.
The European Urological Association published guidelines on male sexual dysfunction, including erectile
dysfunction and premature ejaculation. Physical therapy is not included in the guidelines as a treatment for
these conditions (Hatzimouratidis, et al., 2014; Salonia et al., 2021).
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Scoliosis
Scoliosis, lateral curvature of the spine, is a structural alteration that occurs in a variety of conditions.
Progression of the curvature during periods of rapid growth can result in significant deformity, which may be
accompanied by cardiopulmonary compromise (Schreiber et al., 2019; Scherl, 2016). Options for treatment of
scoliosis include observation, bracing, and surgery. Evidence is insufficient to demonstrate effectiveness of
physical therapy (scoliosis-specific exercises, including the Schroth Method), chiropractic treatment, electrical
stimulation, or biofeedback to correct, improve or prevent further curvature (Ceballos-Laita et al., 2023;
Seleviciene et al., 2022; Santos et al., 2022; Fan et al., 2020; Schreiber et al., 2019; Scherl, 2016; National
Institutes of Health [NIH]/National Institute of Arthritis and Musculoskeletal and Skin Disease [NIAMS], 2015;
American Academy of Orthopedic Surgeons [AAOS], 2015; Mehlman, 2015; Romana, et al., 2012).
.
Physical Therapy Treatments Considered Experimental, Investigational Or Unproven
Constraint-Induced Movement Therapy (CIMT)
Constraint-induced movement therapy (CIMT) is a multi-faceted intervention that has been proposed for
neurological conditions that involve hemiparesis. CIMT is also referred to as constraint-induced therapy or
forced use therapy and is primarily provided by physical therapists and occupational therapists. Several
variations exist based on method and length of restraint, and type and duration of therapy (e.g. environment and
provider). The therapy involves constraining the unaffected arm or hand with a sling, glove or mitt. CIMT
typically involves intensive individualized therapy with up to six–eight hours of therapy provided per day.
However, other forms of modified CIMT have been developed with less therapy provided, but longer periods of
restraint (Wolf, 2007). Veterans Affairs/Dept of Defense (VA/DoD) published guidelines that have also been
endorsed by American Heart Association/American Stroke Association (AHA/ASA)—Clinical Practice Guideline
for the Management of Adult Stroke Rehabilitation Care (Bates, et al., 2005). The guidelines note that, “Use of
constraint-induced therapy should be considered for a select group of patients—that is, patients with 20 degrees
of wrist extension and 10 degrees of finger extension, who have no sensory and cognitive deficits.” indicating a
recommendation that the intervention may be considered). The Royal College of Physicians/Intercollegiate
Stroke Working Party (United Kingdom) and the Ottawa Panel (2006) agree with these recommendations.
CIMT has demonstrated inconsistent effectiveness for treatment of patients post-stroke (Pulman et al., 2013;
McIntyre et al., 2012; Corbetta et al., 2010; Sirtori et al., 2009;
Abdullahi et al., 2021a; Abdullahi et al., 2021b;
Alaca and Ocal, 2022; Zhang et al., 2023). Future randomized controlled trials need to have accurate
characteristics in terms of methodological quality, larger samples, longer follow up, reliable and relevant
measure and report of adverse events. Some evidence demonstrates that modified CIMT could reduce the level
of disability, improve the ability to use the paretic upper extremity, and enhance spontaneity during movement
time, but evidence is still limited about the effectiveness of modified CIMT in kinematic analysis (Pollack et al.,
2014; Shi et al., 2011). Research suggests that modified CIMT and intensive CIMT produce similar results
(Peurala et al., 2012).
CIMT has also been used for the treatment of children with cerebral palsy (CP). Research is not conclusive with
regards to the effectiveness of CIMT for this population; however there appears to be modest evidence to
support its use in a modified format (Taub et al., 2004; Sakzewski et al., 2009; Eliasson et al., 2005; Hoare et
al., 2007
Chen et al., 2014; Chiu and Ada, 2016; Eliasson et al., 2014, Hoare et al., 2019; Martínez-Costa
Montero et al., 2020; Ramey et al., 2021; Walker et al., 2022; Dionisio and Terrill, 2022; Jackman et al., 2022;
Baker et al., 2022;
Regalado et al., 2023). Further research using adequately powered RCTs [randomized
controlled trials], rigorous methodology and valid, reliable outcome measures is essential to provide higher level
support of the effectiveness of CIMT for children with hemiplegic cerebral palsy.
Intensive Model of Therapy (IMOT) programs
IMOT was developed in Poland for treating children and adults with cerebral palsy and other neurologic
disorders. This therapy involves performing exercises over an extended period of time — typically 5 days a
week for 4 hours a day. The time in the program may be a 3 week period or longer. There is insufficient
evidence to conclude that IMOT demonstrates improved long term and short term outcomes over less
intensive/frequent care (Sakzewski et al., 2014; Anderson et al., 2013; Christiansen and Lange 2008;
Sakzewski, Ziviani et al., 2014;
Almeida et al., 2017). Therapeutic suits such as the Adeli and NeuroSuit are
also used and proposed to assist in re-training the central nervous system by allowing the child to overcome
increasingly complex pathological movement and to execute and repeat previously unknown movement
patterns. More studies are needed to provide evidence to support use of these suits to improve outcomes.
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Dry hydrotherapy
Dry hydrotherapy, also referred to as aquamassage, water massage, or hydromassage, is a treatment that
incorporates water with the intent of providing therapeutic massage. The treatment is generally provided in
chiropractor or physical therapy offices. There are several dry hydrotherapy devices available that provide this
treatment, including the following:
•
Aqua Massage® (AMI Inc., Mystic, CT)
•
AquaMED® (JTL Enterprises, Inc., Clearwater, FL)
•
H2OMassage System™ (H2OMassage Systems, Winnipeg, MB, Canada)
•
Hydrotherapy Tables (Sidmar Manufacturing, Inc., Princeton, MN)
Proponents of dry hydrotherapy maintain that it can be used in lieu of certain conventional physical medicine
therapeutic modalities and procedures, such as heat packs, wet hydrotherapy, massage, and soft tissue
manipulation. The assertions that have been made by manufacturers of this device at their websites have not
yet been proven. No published studies or information regarding dry hydrotherapy devices or dry hydrotherapy
treatment were identified in the peer-reviewed scientific literature. In the absence of peer- reviewed literature
demonstrating the effectiveness of dry hydrotherapy and in the absence of comparison to currently accepted
treatment modalities, no definitive conclusions can be drawn regarding the clinical benefits of this treatment.
Non-invasive Interactive Neurostimulation (e.g., InterX®)
Non-invasive, Interactive Neurostimulation (NIN) (e.g. InterX®) is used for the treatment of acute and chronic
pain using high amplitude, high density stimulation to the cutaneous nerves, activating the natural pain relieving
mechanisms of the body (segmental and descending inhibition). There is a lack of evidence to support this form
of modality.
Microcurrent Electrical Nerve Stimulation (MENS)
There is insufficient evidence in the published peer-reviewed scientific literature to support the safety and
effectiveness of MENS (Rajpurohit et al., 2010; Zuim et al., 2006; Nair et al., 2018; Iijima and Takahashi, 2021).
H-WAVE®
H-wave stimulation is a form of electrical stimulation that differs from other forms of electrical stimulation, such
as transcutaneous electrical nerve stimulation (TENS), in terms of its wave form. There is insufficient evidence
in the published peer reviewed scientific literature to support the safety and effectiveness of the H-WAVE®
electrical stimulators (Blum et al., 2008; Williamson et al. 2021).
Spinal Manipulation for the Treatment of Non-Musculoskeletal Conditions and Related Disorders
Spinal manipulation is considered experimental, investigational, or unproven for the treatment of non-
musculoskeletal conditions and related disorders including, but not limited to:
•
Asthma
•
ADHD
•
Autism spectrum disorders
•
Dysmenorrhea
•
Hypertension
•
Infantile colic
•
Nocturnal enuresis
•
Otitis media
The set of conditions above represents those non-musculoskeletal conditions which have been found in the
literature relative to spinal manipulation either through RCTs, systematic reviews, or both. Evidence is
insufficient to support use of spinal manipulation for treatment of these conditions (Alcantara et al., 2011;
Hondras et al., 2011; Kaminskyj et al., 2014; Gleberzon et al., 2012; Clar et al., 2014; Karpouzis et al., 2010;
Ferrance and Miller, 2010; Proctor, et al., 2006; Bakris, 2007; Mangum et al., 2012; Dobson et al., 2012; Huang
et al., 2011; Pohlman, Holton-Brown, 2012; Driehuis et al., 2019; Côté et al., 2021; Goertz et al., 2021; Milne et
al., 2022).
Equestrian therapy (e.g. hippotherapy)
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Equestrian therapy, also known as hippotherapy, is proposed to offer a person with a disability a means of
physical activity that aids in improving balance, posture, coordination, the development of a positive attitude and
a sense of accomplishment. It is proposed for treatment of several conditions including autism spectrum
disorders and cerebral palsy. There is insufficient published evidence regarding the effects of this therapy on
individuals with impaired physical function resulting from illness, injury, congenital defect or surgery (Bronson et
al., 2010; Lee et al., 2014; O'Haire et al., 2014;
De Guindos-Sanchez et al., 2020; De Miguel et al., 2018; Kraft
et al., 2019; Marquez et al., 2020; White et al., 2020; Santos de Assis et al., 2022; Pantera et al., 2022; Pérez-
Gómez et al., 2022; Heussen and Häusler, 2022; Prieto et al., 2022; Peia et al., 2023). The authors note that
most studies were limited by methodological weaknesses. This review demonstrates that there is a need for
further, more rigorous research.
MEDEK Therapy
MEDEK, a form of physiotherapy, refers to Metodo Dinamico de Estimulacion Kinesica or Dynamic Method for
Kinetic Stimulation. MEDEK is used for developing gross motor skills in young children with physical disabilities
and movement disorders (e.g., cerebral palsy, Down’s syndrome, hypotonia, muscular dystrophy, and
developmental motor delay). At this time, no evidence exists of its effectiveness in the peer reviewed literature.
Well-designed clinical studies are needed to determine the effectiveness of MEDEK and whether a clinically
significant improvement is achieved through the use of MEDEK Therapy, as there appears to be no peer-
reviewed, published literature available as noted with a thorough literature search at this time.
The Interactive Metronome Program
Interactive Metronome® (IM) is purported to be an assessment and training tool that measures and improves
Neurotiming, or the synchronization of neural impulses within key brain networks for cognitive, communicative,
sensory and motor performance. It is designed to improve processing speed, focus, and coordination. Patients
wear headphones and match a beat using a hand or foot sensor along with visual and auditory feedback. The
IM program has been promoted as a treatment for children with attention-deficit hyperactivity disorder (ADHD)
and for other special needs children to increase concentration, focus, and coordination. It has also been
promoted to improve athletic performance, to assess and improve academic performance of normal children,
and to improve children's performance in the arts (e.g., dance, music, theater, creative arts). Additionally, it has
been implemented as part of a therapy program for patients with balance disorders, cerebrovascular accident,
limb amputation, multiple sclerosis, Parkinson's disease, and traumatic brain injury. However, based on peer-
reviewed literature, evidence is insufficient to support effectiveness of the IM program. Well-designed clinical
studies are needed to determine the effectiveness of the IM program and whether a clinically significant
improvement is achieved.
Taping/Elastic therapeutic tape (e.g., Kinesio™ tape, Spidertech™ tape)
Elastic therapeutic tape, also known as kinesiology tape, differs from traditional white athletic tape in the sense
that it is elastic and can be stretched to 140% of its original length before being applied to the skin.
Elastic tape is available in various lengths or pre-cut. There are several types of elastic therapeutic tape
available including:
•
Kinesio™ tape (Kinesio Taping, LLC. Albuquerque, NM)
•
SpiderTech™ tape (SpiderTech Inc., Toronto, Ontario)
•
KT TAPE/KT TAPE PRO™ (LUMOS INC., Lindon, UT)
The clinical value of elastic therapeutic taping (i.e., Kinesio taping) or rigid therapeutic taping (i.e., McConnell)
for back pain, radicular pain syndromes, and other back-related conditions has not been established as there is
insufficient evidence in the peer-reviewed literature (Chou et al., 2016).
The effectiveness of elastic therapeutic taping (i.e. Kinesio taping) or rigid therapeutic taping (i.e., McConnell)
for all conditions such as lower extremity spasticity, meralgia paresthetica, post-operative subacromial
decompression, wrist injury, performance enhancement and prevention of ankle sprains has not been
established as the evidence is insufficient in the peer-reviewed literature (Added et al., 2016; Al-Shareef et al.,
2016; Csapo et al., 2014; Kalron et al., 2013; Lim et al., 2015; Mostafavifa et al., 2012; Nelson 2016; Parreira et
al., 2014; Williams et al., 2012; Luz Júnior et al., 2019; Lin et al., 2020; Li et al., 2020; Martonick et al., 2020;
Cupler et al., 2020; Lim and Tay 2015; Montalvo et al. 2014;
Hedden et al., 2020; Nunes et al., 2021; Pinheiro et
al., 2021; Luo and Li, 2021; Jassi et al., 2021; de Oliveira et al., 2021; Araya-Quintanilla et al., 2021; de Sire et
al., 2021; Deng et al., 2021; Wang et al, 2022).
Physical Therapy (CPG 135)
Page 20 of 40
The following uses of therapeutic taping are professionally recognized and safe; however, additional studies are
needed before the clinical effectiveness can be established. Use of elastic or rigid taping techniques as part of
comprehensive treatment program may be clinically appropriate for the following:
•
Elastic therapeutic tape (e.g., Kinesio tape, Spidertech tape) in the treatment or management of
lymphedema
•
Rigid therapeutic taping for pain reduction in patellofemoral pain syndrome
•
Rigid therapeutic taping of the shoulder in patients with hemiplegia
The use of rigid taping or elastic taping for rehabilitation of orthopedic or neurologic conditions is not intended as
a sole treatment or as a separately billable procedure, but rather is part of a broad treatment program that
includes exercise, manual therapy and/or neuromuscular re-education (NMR) and is inclusive in these
procedures. Strapping codes are not allowed for application of therapeutic taping.
Dry Needling
Research suggests that dry needling may improve pain control, reduce muscle tension, normalize biochemical
and electrical dysfunction of motor endplates, and may facilitate an accelerated return to active rehabilitation
[American Association of Orthopaedic Manual Physical Therapists (AAOMPT) position statement, 2010; APTA
Resource Paper, 2012]. However further high quality research is needed to confirm findings for specific
conditions and to relate improvements in pain and muscle quality to objective functional measures (Boyles et al.,
2015; Cerezo-Téllez et al., 2016; Cotchett et al., 2010; Dommerholt et al., 2016; Dıraçoğlu et al., 2012; Gerber
et al., 2016; Kalichman et al., 2010; Kietrys et al., 2013; Liu et al., 2015; Rodríguez-Mansilla et al., 2016; Tekin
et al., 2014; Tough et al., 2009; Gattie et al., 2017; Espí-López et al., 2017; Liu et al., 2017; Sánchez Romero et
al., 2020; Navarro-Santana et al., 2020; Pourahmadi et al., 2021; Navarro-Santana et al., 2021; Gattie et al.,
2021; Bier et al., 2018; Sánchez-Infante et al., 2021; Jayaseelan et al., 2021; Llurda-Almuzara et al., 2021; Al-
Moraissi et al., 2020; Valencia-Chulián et al., 2020; Sousa Filho et al., 2021; Wang et al., 2022; Mousavi-Khatir
et al., 2022; Khan et al., 2021; Kamonseki et al., 2022; Giorgi et al.,2022; Nuhmani et al., 2023).
Vertebral Axial Decompression Therapy and Devices
Vertebral axial decompression therapy, also referred to as mechanized spinal distraction therapy, has been
proposed as a nonsurgical treatment for back pain. Vertebral axial decompression devices are typically used in
a clinic or rehabilitation setting and include the VAX-D (VAX-D Medical Technologies LLC, Oldsmar, FL), DRS
system (Professional Distribution Systems, Inc., Boca Raton, FL), DRX2000 (Axiom Worldwide, Inc., Tampa,
FL) and other FDA-approved devices.
The published scientific data is insufficient to validate improved clinical outcomes (e.g., reduction of back pain,
improved functioning) associated with vertebral axial decompression therapy. While several technology
assessments have been published, effectiveness of the various devices have not been proven when compared
to standard equipment or testing (Macario and Pergolizzi 2006, 2008; Daniel 2007; Beattie et al., 2008;
Schimmel et al.,2009; Apfel et al., 2010; Kang et al., 2016; Demirel et al., 2017).
Providers of Physical Therapy Services
Physical therapists are licensed health care professionals. Qualification for licensure includes passing the
National Physical Therapy Exam (NPTE), administered by the Federation of State Boards of Physical Therapy.
Another important qualification for licensure is graduation from a physical therapy education program accredited
by the Commission on Accreditation in Physical Therapy Education (CAPTE) or a program that is deemed
substantially equivalent to a CAPTE accredited program. Physical therapist assistants working under the
supervision and direction of a PT are also considered qualified providers of PT services.
Coding Information
Note: 1) This list of codes may not be all-inclusive.
2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible
for reimbursement.
Physical Therapy (CPG 135)
Page 21 of 40
Considered Medically Necessary when criteria in the applicable policy statements listed
above are met:
CPT
®
*
Codes
Description
94667
Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function;
initial demonstration and/or evaluation
94668
Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function;
subsequent
97010
Application of a modality to 1 or more areas; hot or cold packs
97012
Application of a modality to 1 or more areas; traction, mechanical
97014
Application of a modality to 1 or more areas; electrical stimulation (unattended)
97018
Application of a modality to 1 or more areas; paraffin bath
97022
Application of a modality to 1 or more areas; whirlpool
97024
Application of a modality to 1 or more areas; diathermy (eg, microwave)
97028
Application of a modality to 1 or more areas; ultraviolet
97032
Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
97033
Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
97034
Application of a modality to 1 or more areas; contrast baths, each 15 minutes
97035
Application of a modality to 1 or more areas; ultrasound, each 15 minutes
97036
Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes
97110
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop
strength and endurance, range of motion and flexibility
97112
Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of
movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting
and/or standing activities
97113
Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic
exercises
97116
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
97124
Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage,
petrissage and/or tapotement (stroking, compression, percussion)
97140
Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual
traction), 1 or more regions, each 15 minutes
97150
Therapeutic procedure(s), group (2 or more individuals)
97161
Physical therapy evaluation: low complexity, requiring these components: A history with no
personal factors and/or comorbidities that impact the plan of care; An examination of body
system(s) using standardized tests and measures addressing 1-2 elements from any of the
following: body structures and functions, activity limitations, and/or participation restrictions; A
clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision
making of low complexity using standardized patient assessment instrument and/or measurable
assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient
and/or family.
97162
Physical therapy evaluation: moderate complexity, requiring these components: A history of
present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An
examination of body systems using standardized tests and measures in addressing a total of 3
or more elements from any of the following: body structures and functions, activity limitations,
and/or participation restrictions; An evolving clinical presentation with changing characteristics;
and Clinical decision making of moderate complexity using standardized patient assessment
instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are
spent face-to-face with the patient and/or family.
97163
Physical therapy evaluation: high complexity, requiring these components: A history of present
problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An
examination of body systems using standardized tests and measures addressing a total of 4 or
more elements from any of the following: body structures and functions, activity limitations,
and/or participation restrictions; A clinical presentation with unstable and unpredictable
characteristics; and Clinical decision making of high complexity using standardized patient
Physical Therapy (CPG 135)
Page 22 of 40
assessment instrument and/or measurable assessment of functional outcome. Typically, 45
minutes are spent face-to-face with the patient and/or family.
97164
Re-evaluation of physical therapy established plan of care, requiring these components: An
examination including a review of history and use of standardized tests and measures is
required; and Revised plan of care using a standardized patient assessment instrument and/or
measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with
the patient and/or family.
97530
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve
functional performance), each 15 minutes
97535
Self-care/home management training (eg, activities of daily living (ADL) and compensatory
training, meal preparation, safety procedures, and instructions in use of assistive technology
devices/adaptive equipment) direct one-on-one contact, each 15 minutes
97542
Wheelchair management (eg, assessment, fitting, training), each 15 minutes
97760
Orthotic(s) management and training (including assessment and fitting when not otherwise
reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter
each 15 minutes
97761
Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15
minutes
97763
Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies),
and/or truck, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
HCPCS
Codes
Description
G0151
Services performed by a qualified physical therapist in the home health or hospice setting, each
15 minutes
G0237
Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face,
one-on-one, each 15 minutes (includes monitoring)
G0238
Therapeutic procedures to improve respiratory function, other than described by G0237, one-
on-one, face to face, per 15 minutes (includes monitoring)
G0239
Therapeutic procedures to improve respiratory function or increase strength or endurance of
respiratory muscles, two or more individuals (includes monitoring)
S9131
Physical therapy; in the home, per diem
Considered Not Medically Necessary:
CPT
®
*
Codes
Description
97016
Application of a modality to 1 or more areas; vasopneumatic devices
97026
Application of a modality to 1 or more areas; infrared
Considered Educational or Training in Nature/Not Medically Necessary:
CPT
®
*
Codes
Description
97169
Athletic training evaluation, low complexity, requiring these components: A history and physical
activity profile with no comorbidities that affect physical activity; An examination of affected body
area and other symptomatic or related systems addressing 1-2 elements from any of the
following: body structures, physical activity, and/or participation deficiencies; and Clinical
decision making of low complexity using standardized patient assessment instrument and/or
measurable assessment of functional outcome. Typically, 15 minutes are spent face-to-face
with the patient and/or family
97170
Athletic training evaluation, moderate complexity, requiring these components: A medical history
and physical activity profile with 1-2 comorbidities that affect physical activity. An examination
of affected body area and other symptomatic or related systems addressing a total of 3 or more
elements from any of the following: body structures, physical activity, and/or participation
deficiencies; and Clinical decision making of moderate complexity using standardized patient
Physical Therapy (CPG 135)
Page 23 of 40
assessment instrument and/or measurable assessment of functional outcome. Typically, 30
minutes are spent face-to-face with the patient and/or family.
97171
Athletic training evaluation, high complexity, requiring these components: A medical history and
physical activity profile, with 3 or more comorbidities that affect physical activity; A
comprehensive examination of body systems using standardized tests and measures
addressing a total of 4 or more elements from any of the following: body structures, physical
activity, and/or participation deficiencies; Clinical presentation with unstable and unpredictable
characteristics; and Clinical decision making of high complexity using standardized patient
assessment instrument and/or measurable assessment of functional outcome. Typically, 45
minutes are spent face-to-face with the patient and/or family.
97172
Re-evaluation of athletic training established plan of care requiring these components: An
assessment of patient’s current functional status when there is a documented change, and A
revised plan of care using a standardized patient assessment instrument and/or measurable
assessment of functional outcome with an update in management options, goals, and
interventions. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97537
Community/work reintegration training (eg, shopping, transportation, money management,
avocational activities and/or work environment/modification analysis, work task analysis, use of
assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes
97545
Work hardening/conditioning; initial 2 hours
97546
Work hardening/conditioning; each additional hour (List separately in addition to code for
primary procedure)
HCPCS
Codes
Description
S8990
Physical or manipulative therapy performed for maintenance rather than restoration
S9117
Back school, per visit
Considered Not Medically Necessary:
CPT
®
*
Codes
Description
20560
Needle insertion(s) without injection(s); 1 or 2 muscle(s)
20561
Needle insertion(s) without injection(s); 3 or more muscles
HCPCS
Codes
Description
S8940
Equestrian/hippotherapy, per session
S9090
Vertebral axial decompression, per session
Considered not medically necessary when used to report any other treatment listed as not covered or
reimbursable in the policy statement that does not have an assigned code:
CPT
®
*
Codes
Description
97039
Unlisted modality (specify type and time if constant attendance)
97799
Unlisted physical medicine/rehabilitation service or procedure
Hand Orthotic
Considered Medically Necessary when criteria in the applicable policy statements listed
above are met:
CPT
®
*
Codes
Description
L3763
Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
Physical Therapy (CPG 135)
Page 24 of 40
L3764
Elbow wrist hand orthosis, includes one or more non-torsion joints, elastic bands, turnbuckles,
may include soft interface, straps, custom fabricated, includes fitting and adjustment
L3765
Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
L3766
Elbow wrist hand finger orthosis, includes one or more non-torsion joint(s), elastic bands,
turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and
adjustment
L3806
Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/
springs, may include soft interface material, straps, custom fabricated, includes fitting and
adjustment
L3807
Wrist hand finger orthosis without joint(s), prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient by an individual with
expertise
L3808
Wrist hand finger orthosis rigid without joints, may include soft interface material, straps, custom
fabricated, includes fitting and adjustment
L3891
Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism
for custom fabricated orthotics only, each
L3900
Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/flexion, finger
flexion/extension, wrist or finger driven, custom fabricated
L3901
Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/flexion, finger
flexion/extension, cable driven, custom fabricated
L3905
Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated, includes fitting and adjustment
L3906
Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3913
Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3915
Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may
include soft interface, straps, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an individual with expertise
L3917
Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient by an individual with
expertise
L3919
Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes
fitting and adjustment
L3921
Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated, includes fitting and adjustment
L3923
Hand-finger orthosis, without joints, may include soft interface, straps, prefabricated item that
has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by
an individual with expertise
L3929
Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic
bands/springs, may include soft interface material, straps, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an
individual with expertise
L3931
Wrist-hand-finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic
bands/springs, may include soft interface material, straps, prefabricated, includes fitting and
adjustment
L3933
Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and
adjustment
L3935
Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting
and adjustment
L3956
Addition of joint to upper extremity orthosis, any material; per joint
L4205
Repair of orthotic device, labor component, per 15 minutes
*Current Procedural Terminology (CPT
®
)
©
2023 American Medical Association: Chicago, IL.
Physical Therapy (CPG 135)
Page 25 of 40
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