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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Tricare Physical Therapy

Description of Services

The treatment by physical means, hydrotherapy, heat, or similar modalities, physical agents, bio-mechanical and neuro-physiological principles, and devices to relieve pain, restore maximum function, and prevent disability following disease, injury or loss of a body part.

Physical therapy services consist of the physical evaluation of a patient by muscle testing and other means and the prescribed therapeutic treatment and services of a definite functional nature.

Physical therapy to improve, restore, or maintain function, or to minimize or prevent deterioration of function of a patient when prescribed by a physician is covered in accordance with the rehabilitative therapy provisions.

Policy

Benefits are payable for inpatient or outpatient physical therapy services that are determined to be medically necessary for the treatment of a covered condition, and that are directly and specifically related to an active written regimen.

Physical therapy services must be prescribed by a physician, certified Physician Assistant (PA working under the supervision of a physician), or certified Nurse Practitioner (NP) and professionally administered to aid in the recovery from disease or injury to help the patient in attaining greater self-sufficiency, mobility, and productivity through exercises and other modalities intended to improve muscle strength, joint motion, coordination, and endurance.

If physical therapy is performed by other than a physician, a physician (or other authorized individual professional provider acting within the scope of his/her license) should refer the patient for treatment and supervise the physical therapy.

Reimbursement for covered physical therapy services is based on the appropriate CPT1 procedure codes for the services billed on the claim.

Physical therapists are not authorized to bill using Evaluation and Management (E&M) codes listed in the Physician’s Current Procedural Terminology (CPT).

Maintenance Therapy Programs

The specialized knowledge of a skilled provider may be required to establish a maintenance program intended to prevent or minimize deterioration caused by a medical condition. Establishing such a program is a skilled service. The initial evaluation of the patient’s needs, the designing by a skilled provider of a maintenance program which is appropriate to the capacity and tolerance of the patient, the instruction of the patient or family members in carrying out the program and infrequent evaluations may be required.

Rehabilitative Therapy Programs

While a patient is under a restorative rehabilitative therapy program, the skilled provider should reevaluate his/her condition when necessary and adjust any exercise program that the patient is expected to carry out himself/herself or with the aid of family members to maintain the function being restored. Consequently, by the time it is determined that no further restoration is possible, i.e., by the end of the last restorative session, the provider will have already designed the maintenance program required and instructed the patient or family member in the carrying out of the program. Therefore, where a maintenance program is not established until after the restorative rehabilitative therapy has been completed, it would not be considered medically necessary and appropriate medical care and would be excluded from coverage.

Once a patient has reached the point where no further significant practical improvement can be expected, the skills of an authorized provider will not be required in the carrying out of an activity/exercise program required to maintain function at the level to which it has been restored. The services of a skilled provider in designing a maintenance program will be covered, carrying out the program is not considered skilled care, medically necessary or appropriate medical care consequently such services are not covered.

Services Not Covered

The following services are not covered:

    • Diathermy, ultrasound, and heat treatments for pulmonary conditions.
    • General exercise programs, even if recommended by a physician (or other authorized individual professional provider acting within the scope of their license).
    • Electrical nerve stimulation used in the treatment of upper motor neuron disorders such as multiple sclerosis.
    • Separate charges for instruction of the patient and family in therapy procedures.
    • Repetitive exercise to improve gait, maintain strength and endurance, and assistative walking such as that provided in support of feeble or unstable patients.
    • Range of motion and passive exercises which are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities.
    • Maintenance therapy that does not require a skilled level after a therapy program has been designed.
    • Services of chiropractors and naturopaths whether or not such services would be eligible for benefits if rendered by an authorized provider.
    • Acupuncture with or without electrical stimulation.
    • Athletic training evaluation (CPT2 procedure codes 97005 and 97006).
    • Sensory integration therapy (CPT2 procedure code 97533) which may be considered a component of cognitive rehabilitation is unproven.
Note: This policy does not exclude multidisciplinary services, such as physical therapy, occupational therapy, or speech therapy after traumatic brain injury, stroke and children with an autistic disorder.
    • Nonsurgical spinal decompression therapy (including Internal or Intervertebral Disc Decompression (IDD), Decompression Reduction Stabilization (DRS), or Vertebral Axial Decompression (VAX-D) therapy) provided by mechanical or motorized traction for the treatment of low back and/or neck pain is unproven. The use of powered traction devices (including, but not limited to, the Accu-SPINA™, VAX-D, and DRX9000) are likewise unproven.
    • For beneficiaries under the age of three, services and items provided in accordance with the beneficiary’s Individualized Family Service Plan (IFSP) as required by Part C of the Individuals with Disabilities Education Act (IDEA), and which are otherwise allowable under the TRICARE Basic program or the Extended Care Health Option (ECHO) but determined not to be medically or psychologically necessary, are excluded.
    • For beneficiaries aged three to 21, who are receiving special education services from a public education agency, cost-sharing of outpatient physical therapy services that are required by the IDEA and which are indicated in the beneficiary’s Individualized Education Program (IEP), may not be cost-shared except when the intensity or timeliness of physical therapy services as proposed by the educational agency are not sufficient to meet the medical needs of the beneficiary.
    • Low Level Laser Therapy (LLLT) (also known as low level light therapy or cold laser therapy) for treatment of soft tissue injuries, pain or inflammation is unproven.
    • Spinalator therapy and use of a Spinalator Table for the treatment of neck and low back pain. Spinalator therapy is defined as a type of traction that uses the patient’s weight to create the traction force in the absence of any external pulling force. The Spinalator Table is defined as a table with rollers that applies consistent pressure and movement under the patient in the absence of any external pulling devices.

CPT Codes

93668, 96000 - 96004, 97001 - 97002, 97012 - 97530, 97533, 97542 - 97750, 97799

Citation

Tricare Policy Manual Ch. 7 Sec. 18.1 and 18.2

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