Local Coverage Determination (LCD): Outpatient Occupational Therapy (L31591)

Transcription

1 Local Coverage Determination (LCD): Outpatient Occupational Therapy (L31591) Contractor Information Contractor Name Palmetto GBA LCD Information Document Information LCD ID L31591 LCD Title Outpatient Occupational Therapy AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Original Effective Date For services performed on or after 09/07/2012 Revision Effective Date For services performed on or after 01/01/2015 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 12/09/2010 Notice Period End Date N/A

2 UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See 1869(f)(1)(A)(i) of the Social Security Act. Title XVIII of the Social Security Act, 1862 (a)(1)(a) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, 1862(a)(7) excludes routine physical examinations. Title XVIII of the Social Security Act, 1833(e), states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Title 42, Code of Federal Regulations, and CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 6, CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 8, , , and 30.6 CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 12, 10, 20, 20.1, 20.2, 30, 30.1, 40.3 and 40.7 CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 15, 80.3, , 220.3, 230, and CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 10.2, 30.1 and

3 CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 150.5, 150.8, 160.2, 160.7, , , and CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 3, CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 240.3, 270.1, and CMS Internet-Only Manual, Pub , Medicare Claims Processing Manual, Chapter 5, 20B and Program Memorandum: AB ; dated May 29, 2002; Change Request 2083 CMS Manual System, Pub , One-Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338 CMS Manual System, Pub , Medicare Benefit Policy Manual, Transmittal 163, dated November 30, 2012, Change Request 8005 CMS Manual System, Pub , Medicare Claims Processing Manual, Transmittal 2622, dated December 21, 2012, Change Request 8005 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Although rehabilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational therapy. Occupational therapy (OT) is an integral component of rehabilitative services in the areas of physical, cognitive and psychosocial impairment. Occupational therapy is based on purposeful, goal directed activity (occupation). The goal of occupational therapy is to prevent, improve or restore physical and/or cognitive impairment following disease or injury. Occupational therapists utilize clinical history, observation, interview, standardized testing and assessment of activities of daily living skills, work skills, and leisure skills to characterize individuals with impairments, functional limitations and disabilities. The results of these assessments are used to identify structural impairments and functional limitations and to design an individualized plan of treatment to assist in improving or restoring function. All occupational therapy services must be performed by or under the supervision of a qualified occupational therapist. For the purposes of this Local Coverage Determination (LCD), the following descriptions/definitions of terms are used: Direct Supervision: This requires that the physician or nonphysician practitioner (NPP) or

4 therapist be immediately available to furnish assistance and direction throughout the performance of the procedure. General Supervision: This requires the service to be furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Qualified Occupational Therapist: An individual who is licensed as an occupational therapist and meets the practice requirements in the state where they are practicing. For outpatient settings, references to physicians throughout this policy include nonphysician practitioners (NPP), such as nurse practitioners, clinical nurse specialists and physician assistants. Such nonphysician practitioners may certify, order and establish the plan of care for services by occupational therapists as authorized by state law. A qualified occupational therapist, for program coverage purposes, is defined as an individual who is licensed as an occupational therapist and meets the practice requirements in the state where they are practicing. Physiatrists, physicians or NPPs, and qualified occupational therapists have the knowledge, training, and experience required to evaluate and, as necessary, re-evaluate a patient s level of function, and determine whether an occupational therapy program could reasonably be expected to improve, restore or compensate for lost function. Where appropriate, the occupational therapist can recommend to the physician or NPP a plan of care. While the skills of a qualified occupational therapist are required to evaluate the patient s level of function and develop a plan of care, implementation of the plan may also be carried out by a qualified occupational therapy assistant functioning under the general supervision of the qualified occupational therapist. General supervision means the procedure or service is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. NOTE: Occupational therapy assistants (OTAs) may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service. They act at the direction and under the supervision of the treating occupational therapist and in accordance with state laws. This statement does not apply to maintenance services in the Skilled Nursing Facility (SNF) setting rendered by an OTA. Restorative/Rehabilitative therapy: In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary s potential for improvement from the services. CMS notes that such a consideration must always be made in the IRF setting where skilled therapy must be reasonably expected to improve the patient s functional capacity or adaptation to impairments in order to be covered. Maintenance therapy:

5 Even if no improvement is expected, under the SNF, HH, and OPT coverage standards, skilled therapy services are covered when an individualized assessment of the patient s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient s current condition or prevent or slow further deterioration. Skilled maintenance therapy may be covered when the particular patient s special medical complications or the complexity of the therapy procedures require skilled care. The treatment approach includes: a) evaluation b) basic activities of daily living (BADLs) training c) instrumental activities of daily living (IADLs) training d) muscle reeducation/strengthening/coordination e) cognitive training f) perceptual motor training g) orthotics (splinting) h) adaptive equipment fabrication and training i) environment modification recommendations/training j) patient/caregiver education/training k) transfer training l) functional modality training m) manual therapy n) physical agent modality 1. Occupational therapy services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed occupational therapist or under his/her supervision. Services normally considered a routine part of nursing care are not covered as occupational therapy (i.e., provide ADLs for patient with no rehabilitation potential). 2. In order for the plan of treatment to be covered, it must address a condition for which occupational therapy is an accepted method of treatment as defined by standards of medical

6 practice. Also, the plan of treatment must be for a condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness or injury it is determined that the treatment is not rehabilitative, or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer considered reasonable and necessary and are excluded from coverage. 3. Covered occupational therapy services must be furnished while the individual is or was under the care of a physician. Services must relate directly and specifically to a written plan of treatment. The plan of treatment should address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or non-physician practitioner should periodically review the plan of treatment. 4. The physician, non-physician practitioner and/or therapist must document the patient's functional limitations in terms that are objective and measurable. Documentation serves as the means by which a provider would be able to establish and a contractor would be able to confirm that skilled care is, in fact, needed and received in a given case. 5. Rehabilitation services for vision impairment: The coverage criteria and definition of rehabilitation services for beneficiaries with vision impairment are found in Program Memorandum, Transmittal AB , dated May 29, 2002, Change Request SPECIFIC PROCEDURE AND MODALITY GUIDELINES Computerized Dynamic Posturography (CPT code 92548) Computerized dynamic posturography is a "quantitative method for assessing balance functioning under various simulated tasks. Protocols are designed to test the sensory, motor and biomechanical components of balance individually and in concert." Computerized dynamic posturography "may assist with lesion localization, identifying adaptive strategies and functional capabilities." *Note: Results of computerized dynamic posturography must be used in determining the patient centered plan of care. Fabrication/Application of Casts, Splints and Strapping (CPT codes- see below) Fabrication and application of casts, splints, and strapping will be considered reasonable and necessary if used to support weak, post surgical or ineffective joints/muscles, facilitating increased motor response, to assist in compensation in a permanent loss of motor function, reduce/correct joint limitations/deformities and/or protect body parts from injury, thus enhancing the performance of tasks or movements. The casts, splints and strapping are often used in conjunction with therapeutic exercise, functional training, other interventions, and should be selected in the context of patient's needs, social/culture environments, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL).

7 Note: When identifying orthotics fitting and training see CPT code BODY AND UPPER EXTREMITY CASTS Application of long arm (CPT code 29065) May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue. Application of short arm (CPT code 29075) May be indicated for the forearm, wrist, and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue. Application of hand and lower forearm (CPT code 29085) May be indicated for the forearm, wrist, and/or hand in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue. Application of finger cast (eg, contracture) (CPT code 29086) May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue. SPLINTS Application of long arm splint (CPT code 29105) May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue. Application of short arm splint (CPT code and 29126) May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprain/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue. Application of finger splint (CPT code and 29131) May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities

8 involving soft tissue. STRAPPING-ANY AGE Strapping of thorax (CPT code 29200) Indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures, or other deformities involving soft tissue. Strapping of low back (CPT code 29799) May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of shoulder (e.g. Velpeau) (CPT code 29240) May be indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of elbow or wrist (CPT code 29260) May be indicated for the elbow or wrist when there is involvement of the humerus, forearm, wrist, or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, edema, scar management, contractures or other deformities involving soft tissue. Strapping of hand or finger (CPT code 29280) May be indicated where there is involvement of the hand or fingers in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, edema, scar management, contractures or other deformities involving soft tissue. LOWER EXTREMITY CASTS Application of long leg cast (CPT code and 29365) May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue. Application of short leg cast (CPT code 29405) May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of

9 contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue. SPLINTS Application of long leg splint(cpt code 29505) May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue. Application of short leg splint (CPT code 29515) May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, contractures or other deformities involving soft tissue. STRAPPING ANY AGE Strapping of hip (CPT code 29520) May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op contusions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of knee (CPT code 29530) May be indicated when there is involvement of the lower leg, ankle and /or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op contusions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of ankle and/or foot(cpt code 29540) Indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of toes (CPT code 29550) May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Biofeedback Training by any method and biofeedback training perineal muscles, anorectal or urethral sphincter CPT code and 90911) The coverage criteria and definition of biofeedback therapy are found in the CMS Internet-Only

10 Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 30.1 and "Biofeedback is a tool utilized by occupational therapists to assist with muscle training. This includes facilitation of muscles that are demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can be visual or auditory." Evaluation of oral and pharyngeal swallowing function(cpt code 92610) The evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory, oral/voluntary and pharyngeal in reference to oral and motility problems in the oral cavity and pharynx. The clinical examination may include: a) history of patient's disorder and awareness of swallowing disorder, and indications of localization and nature of disorder b) medical status including nutritional and respiratory status c) oral anatomy/physiology (labial control, lingual control, palatal function) d) pharyngeal function e) laryngeal function f) ability to follow directions; alertness g) efforts and interventions used to facilitate normal swallow; (compensatory strategies such as chin tuck, dietary changes, etc.) h) identifying symptoms during attempts to swallow The clinical examination can be divided into two phases: 1. The preparatory examination with no swallow, and 2. The initial swallow examination with actual swallow while physiology is observed. Note: Based on the findings, an instrumental exam may be recommended. Treatment of swallowing dysfunction and/or oral function for feeding (CPT code 92526) This involves the treatment for impairments/functional limitations of mastication, the preparatory phase, oral phase, pharyngeal stage, and esophageal phase of swallowing. Make appropriate recommendations regarding diet and compensatory techniques and instruct in direct/indirect therapies to facilitate oral motor control for feeding.

11 Muscle testing, manual (CPT codes ) The series of codes are intended to report manual test of muscles or muscle groups for strength based on grading scales. Muscle testing, manual (separate procedure); extremity (excluding hand) or trunk, with report (CPT code 95831) To use this code for extremity manual muscle testing, every muscle of at least one extremity would need to be tested, with documentation of why such a thorough assessment was warranted. Muscle testing, manual (separate procedure) with report; Hand, with or without comparison with normal side (CPT code 95832) Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands (CPT code and 95834) The measurement of muscle performance using manual muscle testing only. Range of Motion Measurements (CPT code and 95852) This is the determination of range of motion using a tape measure, ruler, electronic device or goniometer. To use CPT code for extremity range of motion testing, every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted. Developmental Testing; extended (CPT code 96111) CPT code is an assessment/ test code used to report the services provided during testing of the cognitive function of the central nervous system. Extended testing includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, with interpretation and report. Standardized Thought Processing Testing, Interpretation, and Report per hour (CPT 96125) Neuropsychological Testing (eg. Ross Information Processing Assessment, LOTCA- Loewenstein Occupational Therapy Cognitive Assessment, MVPT - Motor-Free Visual Perception Test, ACL - Allen Cognitive Test), per hour of the Occupational Therapist's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. This is usually done outside the OTs initial evaluation/re-evaluation. Occupational Therapy Evaluation (CPT code 97003) and Occupational Therapy Reevaluation (CPT code 97004)

12 Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions. The time spent in evaluation does not count as treatment time. 1. The initial examination has the following components: a. The patient history to include prior level of function b. Relevant systems review c. Tests and measures d. Current functional status (abilities and deficits) e. Evaluation of patient's, physician's, non-physician practitioner's and as appropriate the caregiver's goals 2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, and the patient's overall physical and cognitive health status. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Occupational therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, disability, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment. 3. Initial evaluations or reevaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized. 4. Reevaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient's condition or functional status that was not anticipated in the plan of care. Some regulations and state practice acts require reevaluation at specific intervals. A reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services. Occupational therapist assistants may assist the occupational therapist in a reevaluation within their scope of practice by gathering objective data, tests, measurements, etc; however, the occupational therapist must actively and personally participate in the reevaluation and is responsible for the assessment and the plan of care.

13 5. A reevaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued. MAINTENANCE PROGRAMS MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness. Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function. Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following circumstances: Establishment or design of maintenance programs. If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patient s current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered. If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered. If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered. Delivery of maintenance programs. Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiary s need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patient s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program. Such skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the therapy procedures required to maintain the patient s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patient s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures. Unlike coverage for rehabilitation therapy, coverage of therapy services to carry out a maintenance program does not depend on the presence or absence of the patient s potential for improvement from the therapy.

14 The deciding factors are always whether the services are considered reasonable, effective treatments for the patient s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel or caregivers. Where services that are required to maintain the patient s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered physical therapy services. Further, where the particular patient s special medical complications require the skills of a qualified therapist to perform a therapy service safely and effectively that would otherwise be considered unskilled, such services would be covered physical therapy services. Hot or Cold Packs Therapy (CPT code 97010) 1. Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm and reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs are used for subacute or chronic painful conditions. 2. The payment for hot or cold packs is bundled into the payment for other covered services and is not reimbursable. 3. Ice massage should be reported using this code. Mechanical Traction Therapy (CPT code 97012) 1. Traction is generally limited to the cervical or lumbar spine with the hope of relieving pain in or originating from those areas. 2. Specific indications for the use of mechanical traction include: a. Cervical and/or lumbar radiculopathy b. Back disorders such as disc herniation, lumbago, and sciatica Vasopneumatic Device Therapy (CPT code 97016) 1. The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema. 2. Specific indications for the use of vasopneumatic devices include: a. Reduction of edema after acute injury b. Lymphedema c. Education and training on the use of vasopneumatic devices for home use

15 Note: Further treatment on the use of vasopneumatic devices by occupational therapists, after the education and training visits, is usually not reasonable and necessary. Generally, education and training can be completed in three visits. Paraffin Bath (CPT code 97018) Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems or the wrist, hands, and feet. Heat treatments of this type do not ordinarily require the skills of a qualified occupational therapist. However, in a particular case, the skills, knowledge and judgment of a qualified occupational therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled occupational therapy procedure, the treatments would be considered part of the occupational therapy service. Whirlpool and Dry Whirlpool (CPT code 97022)/Hubbard Tank (CPT code 97036) 1. Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified occupational therapist. However, in a particular case, the skills, knowledge and judgment of a qualified occupational therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled occupational therapy procedure, the treatment would be considered part of the skilled occupational therapy service. 2. Whirlpool bath and Hubbard Tanks are the most common forms of hydrotherapy. The use of whirlpool is considered reasonable and necessary when used as part of a plan directed at facilitating the healing of an open wound (e.g., burns). 3. Specific indications for the use of whirlpools include the following: a. The patient having a documented open wound which is draining, has a foul odor, or evidence of necrotic tissue. b. The patient having a documented need for wound debridement/bandage removal. c. Exfoliative skin impairments. Fluidized Therapy Dry Heat For Certain Musculoskeletal Disorders (Dry Whirlpool) The coverage criteria and definition of fluidized therapy dry heat (dry whirlpool) are found in the CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 150.8

16 Diathermy Treatment (CPT code 97024) Diathermy coverage criteria and definition are found in the CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 2, and Part 4, Infrared Therapy Devices (CPT code 97026) Noncoverage of Infrared Therapy Devices is described in CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Electrical Stimulation (CPT codes and 97032, HCPCS codes G0281 and G0283) CPT code requires "visual, verbal and/or manual contact" (i.e. constant attendance). A separate CPT code is available for "initial application of a TENS unit in which electrodes are placed on the skin for patients that will be operating the TENS unit at home." Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity. Electromagnetic Therapy (HCPCS G0329) Electromagnetic therapy criteria and definition are found in the CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Iontophoresis Application (CPT code 97033) 1. Iontophoresis is a process in which electrically charged molecules or atoms (i. e., ions) are driven into tissue with an electrical field. Voltage provides the driving force. Parameters such as drug polarity and electrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites below the skin. 2. The application of iontophoresis is considered reasonable and necessary for the topical delivery of medications into a specific area of the body. 3. Specific indications for the use of iontophoresis application may include but are not limited to patients having: a. tendonitis or calcific tendonitis b. bursitis

17 c. adhesive capsulitis d. hyperhidrosis e. thick adhesive scar(s) Contrast Baths (CPT code 97034) 1. Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications are possible, contrast baths often are used in treatment to decrease edema and inflammation. 2. The use of contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold. 3. Specific indications for the use of contrast baths include: a. The patient having rheumatoid arthritis or other inflammatory arthritis b. The patient having reflex sympathetic dystrophy c. The patient having a sprain or strain resulting from an acute injury 4. Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified occupational therapist. However, in a particular case, the skills, knowledge and judgment of a qualified occupational therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. If such treatments were given prior to but as an integral part of a skilled occupational therapy procedure, the treatment would be considered part of the skilled occupational therapy service Ultrasound (CPT code 97035) 1. Therapeutic ultrasound is a deep heating modality that produces a sound wave of 0.8 to 3.0 MHz. In the human body, ultrasound has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of ultrasound, as much as 30% more. Because of the increased extensibility ultrasound produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted range of motion. 2. The application of ultrasound is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.

18 3. Specific indications for the use of ultrasound application include: a. The patient having tightened structures limiting joint motion that require an increase in extensibility b. The patient having symptomatic soft tissue calcification c. The patient having neuromas Note: Ultrasound is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition. GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES: 1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services. 2. Use of these procedures requires that these services be rendered under the supervision of an occupational therapist. 3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented in the written plan of treatment, affected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of more than one of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal. 4. Services provided concurrently by an occupational therapist, physical therapist and speech therapist may be covered, if separate and distinct goals are documented in the written plan of treatment. 5. Requires (one on one) direct patient contact, unless otherwise stated (i.e., group therapy). Therapeutic Exercise (CPT code 97110) 1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., isokinetic exercise, stretching, strengthening and gross and fine motor movement). 2. An occupational therapist may use this code when addressing impairments of exercise tolerance due to cardiopulmonary impairments. Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.

19 3. Therapeutic exercise is considered reasonable and necessary if at least one of the following conditions is present and documented: a. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint range of motion, functional mobility deficits, balance and/or coordination deficits, abnormal posture, muscle imbalance b. The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or reeducation 4. Documentation for therapeutic exercise typically includes objective loss of joint motion, strength, and /or mobility (e.g., degrees of motion, strength grades, levels of assistance). Neuromuscular Reeducation (CPT code 97112) 1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, motor planning, body awareness, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkreis, Bobath). 2. Neuromuscular reeducation may be considered reasonable and 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, desensitization, proprioception, hypo/hypersensitivity, hypo/hypertonicity, and neglect). Aquatic Therapy with Therapeutic Exercise (CPT code 97113) "Aquatic therapy describes therapeutic exercises performed in a water-based environment. The properties and temperature of the water facilitate movement, particularly for muscles that are compromised due to injury, surgery, or disease (e.g., polio, rheumatoid arthritis, multiple sclerosis, joint arthroplasty)." It is important for the occupational therapist to document the need for exercises performed in a water-environment vs land-based exercises. There should be a plan for transitioning from water-based exercises to land-based exercises. 1. This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and necessary for a loss or restriction of joint motion, strength, or mobility (e. g., degrees or motion, strength grades, levels of assistance). 2. Aquatic therapy with therapeutic exercise may be considered reasonable and necessary in the treatment of the following conditions which may include but are not limited to the patient having: a. The patient having pain, joint stiffness or muscle spasms resulting from rheumatoid arthritis b. The patient having had a cast removed or recent surgery and requiring mobilization of limbs

20 c. The patient having paraparesis or hemiparesis d. The patient having a recent amputation e. The patient recovery from a paralytic condition f. The patient requiring limb mobilization after a head trauma g. The patient having the inability to tolerate exercise for rehabilitation under gravity based weight bearing h. The patient having fibromyalgia Note: Aquatic therapy with therapeutic exercise (CPT code 97113) should not be billed in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers). Massage Therapy (CPT code 97124) 1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment as well as a treatment tool. 2. Massage therapy, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least one of the following conditions is present and documented: a. The patient having paralyzed musculature contributing to impaired circulation b. The patient having sensitivity of tissues to pressure c. The patient having tight muscles resulting in shortening and/or spasticity of affective muscles d. The patient having abnormal adherence of tissue to surrounding tissue e. The patient having patient requiring relaxation in preparation for neuromuscular reeducation or therapeutic exercise f. The patient having contractures and decreased range of motion Manual Therapy Techniques (CPT code 97140) 1. Joint Mobilization (Peripheral or Spinal) This procedure may be considered reasonable and necessary if restricted joint motion is present

21 and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure. 2. Soft Tissue Mobilization This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order 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 muscular or connective tissue. Myofascial release/soft tissue mobilization can be considered reasonable and necessary if at least one of the following conditions is present and documented: a. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk b. treatment being a necessary adjunct to other occupational therapy interventions such as 97110, or Manipulation This procedure may be considered reasonable and necessary for treatment of painful spasm, the loss of articular motion, or restricted motion of soft tissues or joints. It may also be used as an adjunct to other therapeutic procedures such as 97110, or Manual Lymphatic Drainage/Complex Decongestive Physiotherapy The goal of this type of therapy is to reduce lymphedema by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain the reduction after therapy is complete. This therapy involves intensive treatment to reduce the size by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program. a. It is expected that during these sessions, education is being provided to the patient and/or caregiver on the correct application of the compression bandage b. It is also expected that after the completion of the therapy, the patient and/or caregiver can perform these activities without supervision Group Therapeutic Procedure(s)(CPT code 97150) A group for the purpose of performing group therapy will be defined as: a. Two or more patients per therapist receiving active therapy but not one on one treatment and b. the patients may be performing the same exercise or a different exercise but the occupational therapist is instructing all the patients in the group

22 Note: Regardless of the procedure or modality being performed, if the patient is not receiving direct one on one contact but is being supervised by the therapist, the group therapy code should be used. Orthotics Training (CPT code 97760) For entities subject to this policy, assessment of the patient regarding the orthotic, measurement and/or fitting, supplies to fabricate or modify the orthotic, and time associated with making the orthotic should not be reported with CPT code 97760, unless the entities are certain that duplicate payments will not be made to DMEPOS suppliers using the "L" code. 1. This procedure may be considered reasonable and necessary, if there is an indication for education for the application of orthotics, and the functional use of the orthotic is present and documented. 2. Generally, orthotic training can be completed in three visits; however, for modification of the orthotic due to healing of tissues, change in edema, or impairment in skin integrity, additional visits may be required. 3. The medical record should document the distinct treatments rendered when orthotic training for upper and lower extremity is done. 4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to apply the device. Prosthetic Training (CPT code 97761) 1. This procedure and training may be considered reasonable and necessary, if there is an indication for education in the application of the prosthesis, and the functional use of the prosthesis is present and documented. 2. The medical record should document the distinct goals and service rendered when prosthetic training for upper and lower extremity is done. 3. Periodic revisits beyond the third month would require documentation to support medical necessity. Orthotic/Prosthetic Checkout (CPT Code 97762) 1. These assessments are reasonable and necessary when there is a modification or reissue of a recently issued device or a reassessment of a newly issued device. 2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls).

23 3. These assessments may be reasonable and necessary for determining "the patients response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, underwrap, or socks and determining the patient's tolerance to any dynamic forces being applied." Therapeutic Activities (CPT code 97530) 1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques. Activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities to improve performance in a progressive manner. The activities are usually directed at a loss or impairment of mobility, strength, balance, coordination or cognition. They require the skills of occupational therapists and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active written plan of treatment and be directed at a specific outcome. 2. In order for therapeutic activities to be covered, the following requirements must be met: a. The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning b. The patient's condition being such that he/she is unable to perform therapeutic activities except under the supervision of an occupational therapist c. There being a clear correlation between the type of exercise performed and the patient's underlying medical condition for which the therapeutic activities were prescribed Cognitive Skills Development (CPT code 97532) 1. This procedure is reasonable and necessary for patients who have a disease or injury in which impairment of cognitive functioning is documented. Impaired functions may include but are not limited to ability to follow simple commands, attention to tasks, problem solving skills, memory, ability to follow numerous steps in a process, perform in a logical sequence and ability to compute. 2. This procedure is reasonable and necessary only when it requires the skills of an occupational therapist and is designed to address specific needs of the patient and is part of the written plan of care. 3. Treatment techniques utilized include but are not limited to recall of information, tabletop graded activities focusing on attentional skills (e.g. cancellation tasks, mazes), and graded processes in steps, which the patient must follow to complete the task, and computer programs that focus on the above. 4. Development of cognitive skills must be reasonable and necessary to restore and improve functioning of the patient. Documentation must relate the training to expected functional goals

24 that are attainable by the patient. 5. Services provided concurrently by physicians, non-physician practitioners, occupational therapists and speech therapists may be covered, if separate and distinct goals are documented in the written plan of treatment. Sensory Integration (CPT code 97533) The use of sensory integrative techniques is considered reasonable and necessary when patients must develop adaptive skills for sensory processing. When there has been a disruption of the auditory, vestibular, proprioceptive, tactile and/or visual system; interventions are required to assist the patient in remaining functional in their environment. The loss of sensory systems often compromises the safety of the patient; therefore therapy should provide adaptations that allow the patient to interact with their environment that promotes well-being. Self-Care/Home Management Training (CPT code 97535) The coverage criteria and definition of self-care/home management training is found in the CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 3, "Self-care/home management training (97535) describes a group of interventions that focuses on activities of daily living skills and compensatory activities needed to achieve independence" or adapt to an evolving deterioration in health and function. "These include activities such as dressing, bathing, food preparation, and cooking. The patient/client may require adaptive equipment and/or assistive technology in the home environment. This code includes training the patient/client and/or caregiver in the use of the equipment." This code should not be used globally for all home instructions. When instructing the patient in a self management program, use the code that best describes the focus of the self management activity. Community/Work Reintegration Training (CPT codes 97537) Services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1) of the Social Security Act. Services that are covered include complex IADLLs a person must do to maintain independence in the community. These tasks involve interaction with the physical and social environment. Examples of these activities may include telephone skills, written communication, handling mail, use of money, shopping, emergency procedure use/skills and use of assistive technology device/adaptive equipment. This service is only covered when the skilled intervention of occupational therapy is required to achieve established goals. Work Hardening/Conditioning (CPT codes and 97546)

25 "Work hardening and work conditioning (97545 and 97546) are different interventions. Work hardening is an interdisciplinary program that is focused on tasks required for a specific job and uses real or simulated work activities to restore physical, behavioral, and vocational functions. Work hardening addresses productivity, safety, physical tolerances, and worker behavior. In contrast, work conditioning describes a work-related, intensive treatment program designed to restore strength/flexibility, and function so that the patient/client can return to work." These interventions are not covered. Wheelchair Management Training (CPT code 97542) Wheelchair management "includes assessing if the patient/client needs a wheelchair, determining what kind of wheelchair is appropriate, including its size and components, measuring the patient/client to ensure proper fit, and fitting the patient/client into the chair once it is received. This code is also used for reporting the time associated with training the patient/client and/or caregiver in transfers in and out of the chair as well as propulsion on all surfaces. It is important for the therapist to provide instructions for safety so as not to risk skin breakdown or a fall." 1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who use wheelchairs for mobility may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications. 2. This procedure is reasonable and necessary only when it requires the skills of an occupational therapist and is designed to address specific needs of the patient, and must be part of an active written plan of treatment directed at a specific goal. 3. The patient and/or caregiver must have the capacity to learn from instructions. 4. Typically, three to four sessions should be sufficient to teach the patient and/or caregiver these skills. 5. When billing for wheelchair propulsion training, documentation should relate the training to expected functional goals that are attainable by the patient. Wound Care Selective Debridement (CPT codes and 97598) a) Debridement Debridement is indicated whenever necrotic tissue is present on a documented open wound. Debridement may also be indicated in cases of abnormal wound repair. Debridement techniques usually progress from non-selective to selective but can be combined. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. b) Conservative Sharp Debridement

26 Conservative sharp debridement is a minor procedure that requires no anesthesia and is performed on an outpatient basis. Scalpel, scissors, forceps and high-pressure waterjet may be used and only clearly identified devitalized tissue is removed. Generally, there is no bleeding associated with this procedure. Wound Care Non-Selective Debridement (CPT codes 97602, and 97606) a) Enzymatic Debridement Debridement with topical enzymes is used when necrotic substances to be removed from a wound are protein, fibrin and collagen. The manufacturer's product insert contains indications, contra-indications, precautions, dosage, and administration. It would be the clinician's responsibility to comply with the product insert/guidelines. b) Autolytic Debridement This type of debridement is indicated where manageable amounts of necrotic tissue are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found in wound fluids are sequestered under synthetic dressings. Autolytic debridement is contraindicated for wounds that contain infection. c) Mechanical Debridement Wet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing. Hydrotherapy and wound irrigation are also forms of mechanical debridement used to remove necrotic tissue. They also should be used cautiously, as maceration of surrounding tissue may hinder healing. d) Negative Pressure Wound Therapy Negative Pressure Wound Therapy is a non-invasive treatment by which controlled localized negative pressure is delivered to a wide variety of acute, sub-acute, and chronic wounds. Negative Pressure Wound Therapy should be used cautiously as maceration of surrounding tissue may hinder healing. Physical Performance Test or Measurement (CPT code 97750) This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific written plan of treatment, or to determine a patient's functional capacity. Assistive Technology Assessment (CPT code 97755)

27 This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the patient's status since the last visit and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or reevaluation is indicated. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 018x Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 034x Home Health - Other (for medical and surgical services not under a plan of treatment) 071x Clinic - Rural Health 074x Clinic - Outpatient Rehabilitation Facility (ORF) 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 077x Clinic - Federally Qualified Health Center (FQHC) 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes Occupational Therapy - General Classification

28 0431 Occupational Therapy - Visit 0432 Occupational Therapy - Hourly 0433 Occupational Therapy - Group 0434 Occupational Therapy - Evaluation or Reevaluation 0439 Occupational Therapy - Other Occupational Therapy CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: Application of long arm cast Application of forearm cast Apply hand/wrist cast Apply finger cast Apply long arm splint Apply forearm splint Apply forearm splint Application of finger splint Application of finger splint Strapping of chest Strapping of shoulder Strapping of elbow or wrist Strapping of hand or finger Application of long leg cast Application of long leg cast Apply short leg cast Application long leg splint Application lower leg splint Strapping of hip Strapping of knee Strapping of ankle and/or ft Strapping of toes Casting/strapping procedure Apply neurostimulator Biofeedback train any meth Biofeedback peri/uro/rectal Oral function therapy Posturography Evaluate swallowing function Limb muscle testing manual

29 95832 Hand muscle testing manual Body muscle testing manual Body muscle testing manual Range of motion measurements Range of motion measurements Developmental test extend Cognitive test by hc pro Ot evaluation Ot re-evaluation Hot or cold packs therapy Mechanical traction therapy Vasopneumatic device therapy Paraffin bath therapy Whirlpool therapy Diathermy eg microwave Infrared therapy Electrical stimulation Electric current therapy Contrast bath therapy Ultrasound therapy Hydrotherapy Therapeutic exercises Neuromuscular reeducation Aquatic therapy/exercises Massage therapy Manual therapy 1/> regions Group therapeutic procedures Therapeutic activities Cognitive skills development Sensory integration Self care mngment training Community/work reintegration Wheelchair mngment training Work hardening Work hardening add-on Rmvl devital tis 20 cm/< Rmvl devital tis addl 20cm/< Wound(s) care non-selective Neg press wound tx </=50 cm Neg press wound tx >50 cm Physical performance test Assistive technology assess

30 97760 Orthotic mgmt and training Prosthetic training C/o for orthotic/prosth use Physical medicine procedure G0281 Elec stim unattend for press G0283 Elec stim other than wound G0329 Electromagntic tx for ulcers ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: N/A Group 1 Codes: 138 LATE EFFECTS OF ACUTE POLIOMYELITIS DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE EATING DISORDER UNSPECIFIED OTHER DISORDERS OF EATING PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE PSEUDOBULBAR AFFECT OTHER SPECIFIED NONPSYCHOTIC MENTAL DISORDERS FOLLOWING ORGANIC BRAIN DAMAGE MATHEMATICS DISORDER CORTICOBASAL DEGENERATION ATHETOID CEREBRAL PALSY - OTHER ACQUIRED TORSION DYSTONIA SPASMODIC TORTICOLLIS ORGANIC WRITERS' CRAMP SUBACUTE DYSKINESIA DUE TO DRUGS STIFF-MAN SYNDROME FRIEDREICH'S ATAXIA - UNSPECIFIED DISEASE OF SPINAL CORD REFLEX SYMPATHETIC DYSTROPHY OF THE UPPER LIMB - REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE

31 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE CONGENITAL DIPLEGIA - INFANTILE HEMIPLEGIA OTHER SPECIFIED INFANTILE CEREBRAL PALSY - INFANTILE CEREBRAL PALSY UNSPECIFIED QUADRIPLEGIA UNSPECIFIED QUADRIPLEGIA C1-C4 COMPLETE QUADRIPLEGIA C1-C4 INCOMPLETE QUADRIPLEGIA C5-C7 COMPLETE QUADRIPLEGIA C5-C7 INCOMPLETE OTHER QUADRIPLEGIA PARAPLEGIA DIPLEGIA OF UPPER LIMBS MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE UNSPECIFIED MONOPLEGIA CAUDA EQUINA SYNDROME WITHOUT NEUROGENIC BLADDER - CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER LOCKED-IN STATE - OTHER SPECIFIED PARALYTIC SYNDROME PARALYSIS UNSPECIFIED MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS - MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS

32 MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS

33 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS BELL'S PALSY BRACHIAL PLEXUS LESIONS - OTHER NERVE ROOT AND PLEXUS DISORDERS UNSPECIFIED NERVE ROOT AND PLEXUS DISORDER CARPAL TUNNEL SYNDROME - OTHER MONONEURITIS OF UPPER LIMB MONONEURITIS OF UPPER LIMB UNSPECIFIED MERALGIA PARESTHETICA

34 CAUSALGIA OF LOWER LIMB MONONEURITIS OF UNSPECIFIED SITE HEREDITARY PERIPHERAL NEUROPATHY - OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY ACUTE INFECTIVE POLYNEURITIS POLYNEUROPATHY IN DIABETES LAMBERT-EATON SYNDROME, UNSPECIFIED LAMBERT-EATON SYNDROME IN NEOPLASTIC DISEASE LAMBERT-EATON SYNDROME IN OTHER DISEASES CLASSIFIED ELSEWHERE CONGENITAL HEREDITARY MUSCULAR DYSTROPHY HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY MYOTONIC MUSCULAR DYSTROPHY MYOTONIA CONGENITAL MYOTONIC CHONDRODYSTROPHY DRUG INDUCED MYOTONIA OTHER SPECIFIED MYOTONIC DISORDER INCLUSION BODY MYOSITIS OTHER INFLAMMATORY AND IMMUNE MYOPATHIES, NEC SCOTOMA INVOLVING CENTRAL AREA GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION HOMONYMOUS BILATERAL FIELD DEFECTS HETERONYMOUS BILATERAL FIELD DEFECTS BETTER EYE: TOTAL VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT BETTER EYE: NEAR-TOTAL VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT BETTER EYE: NEAR-TOTAL VISION IMPAIRMENT; LESSER EYE: NEAR- TOTAL VISION IMPAIRMENT BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: NEAR- TOTAL VISION IMPAIRMENT BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: NEAR-TOTAL VISION IMPAIRMENT BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT

35 BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: NEAR- TOTAL VISION IMPAIRMENT BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: SEVERE VISION IMPAIRMENT BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: SEVERE VISION IMPAIRMENT BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: MODERATE VISION IMPAIRMENT BENIGN PAROXYSMAL POSITIONAL VERTIGO COGNITIVE DEFICITS HEMIPLEGIA AFFECTING UNSPECIFIED SIDE HEMIPLEGIA AFFECTING DOMINANT SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE - OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE OTHER PARALYTIC SYNDROME BILATERAL ALTERATIONS OF SENSATIONS APRAXIA CEREBROVASCULAR DISEASE DYSPHAGIA CEREBROVASCULAR DISEASE FACIAL WEAKNESS ATAXIA VERTIGO OTHER LATE EFFECTS OF CEREBROVASCULAR DISEASE UNSPECIFIED LATE EFFECTS OF CEREBROVASCULAR DISEASE ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE RAYNAUD'S SYNDROME POSTMASTECTOMY LYMPHEDEMA SYNDROME OTHER LYMPHEDEMA POSTPHLEBETIC SYNDROME WITH ULCER

36 POSTPHLEBETIC SYNDROME WITH ULCER AND INFLAMMATION CHRONIC VENOUS HYPERTENSION WITH ULCER CHRONIC VENOUS HYPERTENSION WITH ULCER AND INFLAMMATION 490 BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC SIMPLE CHRONIC BRONCHITIS MUCOPURULENT CHRONIC BRONCHITIS OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION OBSTRUCTIVE CHRONIC BRONCHITIS WITH ACUTE BRONCHITIS OTHER CHRONIC BRONCHITIS UNSPECIFIED CHRONIC BRONCHITIS EMPHYSEMATOUS BLEB OTHER EMPHYSEMA EXTRINSIC ASTHMA UNSPECIFIED - EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION INTRINSIC ASTHMA UNSPECIFIED - INTRINSIC ASTHMA WITH (ACUTE) EXACERBATION CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED - CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION EXERCISE-INDUCED BRONCHOSPASM COUGH VARIANT ASTHMA ASTHMA UNSPECIFIED - ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION BRONCHIECTASIS WITHOUT ACUTE EXACERBATION - BRONCHIECTASIS WITH ACUTE EXACERBATION 496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER - ONYCHIA AND PARONYCHIA OF FINGER CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB 683 ACUTE LYMPHADENITIS CIRCUMSCRIBED SCLERODERMA KELOID SCAR PRESSURE ULCER, UNSPECIFIED SITE PRESSURE ULCER, ELBOW PRESSURE ULCER, UPPER BACK PRESSURE ULCER, LOWER BACK PRESSURE ULCER, HIP PRESSURE ULCER, BUTTOCK PRESSURE ULCER, ANKLE PRESSURE ULCER, HEEL PRESSURE ULCER, OTHER SITE

37 UNSPECIFIED ULCER OF LOWER LIMB ULCER OF THIGH ULCER OF CALF ULCER OF ANKLE ULCER OF HEEL AND MIDFOOT ULCER OF OTHER PART OF FOOT ULCER OF OTHER PART OF LOWER LIMB PRESSURE ULCER, UNSPECIFIED STAGE PRESSURE ULCER, STAGE I PRESSURE ULCER, STAGE II PRESSURE ULCER, STAGE III PRESSURE ULCER, STAGE IV CHRONIC ULCER OF OTHER SPECIFIED SITES CHRONIC ULCER OF UNSPECIFIED SITE SCAR CONDITIONS AND FIBROSIS OF SKIN PYOGENIC ARTHRITIS SITE UNSPECIFIED - ARTHROPATHY INVOLVING MULTIPLE SITES ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS RHEUMATOID ARTHRITIS - UNSPECIFIED INFLAMMATORY POLYARTHROPATHY OSTEOARTHROSIS GENERALIZED INVOLVING UNSPECIFIED SITE OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT SPECIFIED AS GENERALIZED OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING OTHER SPECIFIED SITES KASCHIN-BECK DISEASE SITE UNSPECIFIED - UNSPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES ARTICULAR CARTILAGE DISORDER SITE UNSPECIFIED ARTICULAR CARTILAGE DISORDER INVOLVING SHOULDER REGION ARTICULAR CARTILAGE DISORDER INVOLVING HAND ARTICULAR CARTILAGE DISORDER INVOLVING PELVIC REGION AND THIGH ARTICULAR CARTILAGE DISORDER INVOLVING ANKLE AND FOOT ARTICULAR CARTILAGE DISORDER INVOLVING MULTIPLE SITES LOOSE BODY IN JOINT SITE UNSPECIFIED LOOSE BODY IN JOINT OF SHOULDER REGION - LOOSE BODY IN HAND JOINT LOOSE BODY IN JOINT OF PELVIC REGION AND THIGH LOOSE BODY IN ANKLE AND FOOT JOINT - LOOSE BODY IN JOINT OF MULTIPLE SITES PATHOLOGICAL DISLOCATION OF JOINT SITE UNSPECIFIED

38 PATHOLOGICAL DISLOCATION OF JOINT OF SHOULDER REGION PATHOLOGICAL DISLOCATION OF HAND JOINT PATHOLOGICAL DISLOCATION OF JOINT OF PELVIC REGION AND THIGH PATHOLOGICAL DISLOCATION OF JOINT OF LOWER LEG PATHOLOGICAL DISLOCATION OF JOINT OF MULTIPLE SITES RECURRENT DISLOCATION OF JOINT SITE UNSPECIFIED RECURRENT DISLOCATION OF JOINT OF SHOULDER REGION RECURRENT DISLOCATION OF HAND JOINT RECURRENT DISLOCATION OF JOINT OF PELVIC REGION AND THIGH RECURRENT DISLOCATION OF LOWER LEG JOINT - RECURRENT DISLOCATION OF JOINT OF MULTIPLE SITES CONTRACTURE OF JOINT SITE UNSPECIFIED CONTRACTURE OF JOINT OF SHOULDER REGION - CONTRACTURE OF HAND JOINT CONTRACTURE OF JOINT OF PELVIC REGION AND THIGH CONTRACTURE OF LOWER LEG JOINT - CONTRACTURE OF JOINT OF MULTIPLE SITES ANKYLOSIS OF JOINT SITE UNSPECIFIED ANKYLOSIS OF JOINT OF SHOULDER REGION - ANKYLOSIS OF HAND JOINT ANKYLOSIS OF JOINT OF PELVIC REGION AND THIGH ANKYLOSIS OF LOWER LEG JOINT - ANKYLOSIS OF JOINT OF MULTIPLE SITES UNSPECIFIED INTRAPELVIC PROTRUSION OF ACETABULUM PELVIC REGION AND THIGH DEVELOPMENTAL DISLOCATION OF JOINT SITE UNSPECIFIED DEVELOPMENTAL DISLOCATION OF JOINT SHOULDER REGION DEVELOPMENTAL DISLOCATION OF JOINT HAND DEVELOPMENTAL DISLOCATION OF JOINT PELVIC REGION AND THIGH DEVELOPMENTAL DISLOCATION OF JOINT LOWER LEG DEVELOPMENTAL DISLOCATION OF JOINT MULTIPLE SITES OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING UNSPECIFIED SITE OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING SHOULDER REGION - OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING HAND OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING PELVIC REGION AND THIGH OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING LOWER LEG - OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING MULTIPLE SITES UNSPECIFIED DERANGEMENT OF JOINT SITE UNSPECIFIED UNSPECIFIED DERANGEMENT OF JOINT OF SHOULDER REGION - UNSPECIFIED DERANGEMENT OF HAND JOINT

39 UNSPECIFIED DERANGEMENT OF JOINT OF PELVIC REGION AND THIGH UNSPECIFIED DERANGEMENT OF ANKLE AND FOOT JOINT - UNSPECIFIED DERANGEMENT OF JOINT OF MULTIPLE SITES EFFUSION OF JOINT OF SHOULDER REGION - EFFUSION OF HAND JOINT EFFUSION OF JOINT OF OTHER SPECIFIED SITES HEMARTHROSIS SITE UNSPECIFIED - PAIN IN JOINT SITE UNSPECIFIED PAIN IN JOINT INVOLVING SHOULDER REGION - PAIN IN JOINT INVOLVING MULTIPLE SITES STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING UNSPECIFIED SITE STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING SHOULDER REGION - STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING MULTIPLE SITES OTHER SYMPTOMS REFERABLE TO JOINT SITE UNSPECIFIED OTHER SYMPTOMS REFERABLE TO JOINT OF SHOULDER REGION - OTHER SYMPTOMS REFERABLE TO JOINT OF MULTIPLE SITES DIFFICULTY IN WALKING OTHER SPECIFIED DISORDERS OF JOINT SITE UNSPECIFIED OTHER SPECIFIED DISORDERS OF JOINT OF SHOULDER REGION - OTHER SPECIFIED DISORDERS OF JOINT OF MULTIPLE SITES UNSPECIFIED DISORDER OF JOINT OF SHOULDER REGION - UNSPECIFIED DISORDER OF HAND JOINT UNSPECIFIED JOINT DISORDER OF OTHER SPECIFIED SITES ANKYLOSING SPONDYLITIS SPINAL ENTHESOPATHY SACROILIITIS NOT ELSEWHERE CLASSIFIED - TORTICOLLIS UNSPECIFIED UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK PAIN IN THORACIC SPINE LUMBAGO BACKACHE UNSPECIFIED OTHER SYMPTOMS REFERABLE TO BACK 725 POLYMYALGIA RHEUMATICA ADHESIVE CAPSULITIS OF SHOULDER DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION UNSPECIFIED CALCIFYING TENDINITIS OF SHOULDER BICIPITAL TENOSYNOVITIS PARTIAL TEAR OF ROTATOR CUFF

40 OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION OTHER AFFECTIONS OF SHOULDER REGION NOT ELSEWHERE CLASSIFIED ENTHESOPATHY OF ELBOW UNSPECIFIED MEDIAL EPICONDYLITIS LATERAL EPICONDYLITIS OLECRANON BURSITIS OTHER ENTHESOPATHY OF ELBOW REGION ENTHESOPATHY OF WRIST AND CARPUS OTHER PERIPHERAL ENTHESOPATHIES SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED SYNOVITIS AND TENOSYNOVITIS IN DISEASES CLASSIFIED ELSEWHERE GIANT CELL TUMOR OF TENDON SHEATH TRIGGER FINGER (ACQUIRED) RADIAL STYLOID TENOSYNOVITIS OTHER TENOSYNOVITIS OF HAND AND WRIST SPECIFIC BURSITIDES OFTEN OF OCCUPATIONAL ORIGIN OTHER BURSITIS DISORDERS SYNOVIAL CYST UNSPECIFIED GANGLION OF JOINT GANGLION OF TENDON SHEATH GANGLION UNSPECIFIED OTHER GANGLION AND CYST OF SYNOVIUM TENDON AND BURSA RUPTURE OF SYNOVIUM UNSPECIFIED - OTHER RUPTURE OF SYNOVIUM NONTRAUMATIC RUPTURE OF UNSPECIFIED TENDON - NONTRAUMATIC RUPTURE OF FLEXOR TENDONS OF HAND AND WRIST NONTRAUMATIC RUPTURE OF OTHER TENDON CONTRACTURE OF TENDON (SHEATH) CALCIUM DEPOSITS IN TENDON AND BURSA - UNSPECIFIED DISORDER OF SYNOVIUM TENDON AND BURSA CALCIFICATION AND OSSIFICATION UNSPECIFIED PROGRESSIVE MYOSITIS OSSIFICANS TRAUMATIC MYOSITIS OSSIFICANS POSTOPERATIVE HETEROTOPIC CALCIFICATION OTHER MUSCULAR CALCIFICATION AND OSSIFICATION MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED OTHER SPECIFIC MUSCLE DISORDERS LAXITY OF LIGAMENT HYPERMOBILITY SYNDROME

41 728.6 CONTRACTURE OF PALMAR FASCIA INTERSTITIAL MYOSITIS FOREIGN BODY GRANULOMA OF MUSCLE RUPTURE OF MUSCLE NONTRAUMATIC SPASM OF MUSCLE MUSCLE WEAKNESS (GENERALIZED) OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA RHEUMATISM UNSPECIFIED AND FIBROSITIS MYALGIA AND MYOSITIS UNSPECIFIED - NEURALGIA NEURITIS AND RADICULITIS UNSPECIFIED FASCIITIS UNSPECIFIED PAIN IN LIMB NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY SWELLING OF LIMB CRAMP OF LIMB OTHER MUSCULOSKELETAL SYMPTOMS REFERABLE TO LIMBS DISORDERS OF SOFT TISSUE, UNSPECIFIED POST-TRAUMATIC SEROMA NONTRAUMATIC HEMATOMA OF SOFT TISSUE OTHER DISORDERS OF SOFT TISSUE OSTEITIS DEFORMANS WITHOUT BONE TUMOR MAJOR OSSEOUS DEFECTS JUVENILE OSTEOCHONDROSIS OF UPPER EXTREMITY OTHER SPECIFIED FORMS OF OSTEOCHONDROPATHY PATHOLOGICAL FRACTURE UNSPECIFIED SITE PATHOLOGICAL FRACTURE OF HUMERUS PATHOLOGICAL FRACTURE OF DISTAL RADIUS AND ULNA PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE ASEPTIC NECROSIS OF BONE SITE UNSPECIFIED ASEPTIC NECROSIS OF HEAD OF HUMERUS MALUNION OF FRACTURE NONUNION OF FRACTURE DISORDER OF BONE AND CARTILAGE UNSPECIFIED - OTHER DISORDERS OF BONE AND CARTILAGE HALLUX VALGUS (ACQUIRED) UNSPECIFIED DEFORMITY OF FOREARM EXCLUDING FINGERS - VARUS DEFORMITY OF WRIST (ACQUIRED) WRIST DROP (ACQUIRED) CLAW HAND (ACQUIRED) CLUB HAND ACQUIRED OTHER ACQUIRED DEFORMITIES OF FOREARM EXCLUDING FINGERS

42 736.1 MALLET FINGER UNSPECIFIED DEFORMITY OF FINGER BOUTONNIERE DEFORMITY SWAN-NECK DEFORMITY OTHER ACQUIRED DEFORMITIES OF FINGER UNSPECIFIED ACQUIRED DEFORMITY OF HIP - OTHER ACQUIRED DEFORMITIES OF HIP GENU VALGUM (ACQUIRED) - GENU VARUM (ACQUIRED) GENU RECURVATUM (ACQUIRED) OTHER ACQUIRED DEFORMITIES OF KNEE UNSPECIFIED DEFORMITY OF ANKLE AND FOOT ACQUIRED ACQUIRED EQUINOVARUS DEFORMITY EQUINUS DEFORMITY OF FOOT ACQUIRED - OTHER ACQUIRED CALCANEUS DEFORMITY OTHER ACQUIRED DEFORMITIES OF ANKLE AND FOOT UNEQUAL LEG LENGTH (ACQUIRED) OTHER ACQUIRED DEFORMITY OF OTHER PARTS OF LIMB ADOLESCENT POSTURAL KYPHOSIS KYPHOSIS (ACQUIRED) (POSTURAL) KYPHOSIS DUE TO RADIATION KYPHOSIS POSTLAMINECTOMY OTHER KYPHOSIS ACQUIRED LORDOSIS (ACQUIRED) (POSTURAL) LORDOSIS POSTLAMINECTOMY OTHER POSTSURGICAL LORDOSIS OTHER LORDOSIS ACQUIRED SCOLIOSIS (AND KYPHOSCOLIOSIS) IDIOPATHIC RESOLVING INFANTILE IDIOPATHIC SCOLIOSIS PROGRESSIVE INFANTILE IDIOPATHIC SCOLIOSIS SCOLIOSIS DUE TO RADIATION THORACOGENIC SCOLIOSIS OTHER KYPHOSCOLIOSIS AND SCOLIOSIS UNSPECIFIED CURVATURE OF SPINE ASSOCIATED WITH OTHER CONDITIONS KYPHOSIS ASSOCIATED WITH OTHER CONDITIONS LORDOSIS ASSOCIATED WITH OTHER CONDITIONS SCOLIOSIS ASSOCIATED WITH OTHER CONDITIONS OTHER CURVATURES OF SPINE ASSOCIATED WITH OTHER CONDITIONS UNSPECIFIED CURVATURE OF SPINE ASSOCIATED WITH OTHER CONDITIONS

43 ACQUIRED MUSCULOSKELETAL DEFORMITY OF OTHER SPECIFIED SITE - ACQUIRED MUSCULOSKELETAL DEFORMITY OF UNSPECIFIED SITE CONGENITAL MUSCULOSKELETAL DEFORMITIES OF STERNOCLEIDOMASTOID MUSCLE UNSPECIFIED REDUCTION DEFORMITY OF UPPER LIMB CONGENITAL TRANSVERSE DEFICIENCY OF UPPER LIMB LONGITUDINAL DEFICIENCY OF UPPER LIMB NOT ELSEWHERE CLASSIFIED LONGITUDINAL DEFICIENCY COMBINED INVOLVING HUMERUS RADIUS AND ULNA (COMPLETE OR INCOMPLETE) LONGITUDINAL DEFICIENCY HUMERAL COMPLETE OR PARTIAL (WITH OR WITHOUT DISTAL DEFICIENCIES INCOMPLETE) LONGITUDINAL DEFICIENCY RADIOULNAR COMPLETE OR PARTIAL (WITH OR WITHOUT DISTAL DEFICIENCIES INCOMPLETE) LONGITUDINAL DEFICIENCY RADIAL COMPLETE OR PARTIAL (WITH OR WITHOUT DISTAL DEFICIENCIES INCOMPLETE) LONGITUDINAL DEFICIENCY ULNAR COMPLETE OR PARTIAL (WITH OR WITHOUT DISTAL DEFICIENCIES INCOMPLETE) LONGITUDINAL DEFICIENCY CARPALS OR METACARPALS COMPLETE OR PARTIAL (WITH OR WITHOUT INCOMPLETE PHALANGEAL DEFICIENCY) LONGITUDINAL DEFICIENCY PHALANGES COMPLETE OR PARTIAL UNSPECIFIED ANOMALY OF UPPER LIMB CONGENITAL - RADIOULNAR SYNOSTOSIS MADELUNG'S DEFORMITY ACROCEPHALOSYNDACTYLY - OTHER CONGENITAL ANOMALIES OF UPPER LIMB INCLUDING SHOULDER GIRDLE CONGENITAL ANOMALY OF SPINE UNSPECIFIED CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION SPONDYLOLISTHESIS CONGENITAL ABSENCE OF VERTEBRA CONGENITAL HEMIVERTEBRA FUSION OF SPINE (VERTEBRA) CONGENITAL KLIPPEL-FEIL SYNDROME SPINA BIFIDA OCCULTA OTHER CONGENITAL ANOMALIES OF SPINE HEREDITARY EDEMA OF LEGS DIZZINESS AND GIDDINESS ABNORMAL INVOLUNTARY MOVEMENTS ABNORMALITY OF GAIT LACK OF COORDINATION TRANSIENT PARALYSIS OF LIMB NEUROLOGIC NEGLECT SYNDROME ABNORMAL POSTURE

44 OCULAR TORTICOLLIS FACIAL WEAKNESS OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS DISTURBANCE OF SKIN SENSATION LOCALIZED SUPERFICIAL SWELLING MASS OR LUMP EDEMA CHANGES IN SKIN TEXTURE FEEDING DIFFICULTIES AND MISMANAGEMENT ADULT FAILURE TO THRIVE HEADACHE SYMBOLIC DYSFUNCTION UNSPECIFIED ALEXIA AND DYSLEXIA OTHER SYMBOLIC DYSFUNCTION GANGRENE DYSPHAGIA, UNSPECIFIED DYSPHAGIA, ORAL PHASE DYSPHAGIA, OROPHARYNGEAL PHASE DYSPHAGIA, PHARYNGEAL PHASE DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE OTHER DYSPHAGIA FULL INCONTINENCE OF FECES URGE INCONTINENCE STRESS INCONTINENCE MALE MIXED INCONTINENCE (MALE) (FEMALE) INCONTINENCE WITHOUT SENSORY AWARENESS OTHER SYMPTOMS INVOLVING URINARY SYSTEM NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM ATTENTION OR CONCENTRATION DEFICIT COGNITIVE COMMUNICATION DEFICIT VISUOSPATIAL DEFICIT PSYCHOMOTOR DEFICIT FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT MULTIPLE CLOSED PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE MULTIPLE OPEN PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE CLOSED FRACTURE OF CLAVICLE UNSPECIFIED PART CLOSED FRACTURE OF STERNAL END OF CLAVICLE - CLOSED FRACTURE OF ACROMIAL END OF CLAVICLE

45 OPEN FRACTURE OF CLAVICLE UNSPECIFIED PART - OPEN FRACTURE OF ACROMIAL END OF CLAVICLE CLOSED FRACTURE OF SCAPULA UNSPECIFIED PART CLOSED FRACTURE OF ACROMIAL PROCESS OF SCAPULA - CLOSED FRACTURE OF OTHER PART OF SCAPULA FRACTURE OF UNSPECIFIED PART OF UPPER END OF HUMERUS CLOSED FRACTURE OF SURGICAL NECK OF HUMERUS CLOSED - OTHER CLOSED FRACTURES OF UPPER END OF HUMERUS FRACTURE OF UNSPECIFIED PART OF UPPER END OF HUMERUS OPEN OTHER OPEN FRACTURE OF UPPER END OF HUMERUS FRACTURE OF UNSPECIFIED PART OF HUMERUS CLOSED - FRACTURE OF SHAFT OF HUMERUS CLOSED FRACTURE OF UNSPECIFIED PART OF HUMERUS OPEN - FRACTURE OF SHAFT OF HUMERUS OPEN FRACTURE OF UNSPECIFIED PART OF LOWER END OF HUMERUS CLOSED OTHER CLOSED FRACTURES OF LOWER END OF HUMERUS FRACTURE OF UNSPECIFIED PART OF LOWER END OF HUMERUS OPEN OTHER FRACTURE OF LOWER END OF HUMERUS OPEN CLOSED FRACTURE OF UPPER END OF FOREARM UNSPECIFIED FRACTURE OF OLECRANON PROCESS OF ULNA CLOSED FRACTURE OF CORONOID PROCESS OF ULNA CLOSED - FRACTURE OF RADIUS WITH ULNA UPPER END (ANY PART) CLOSED OPEN FRACTURE OF UPPER END OF FOREARM UNSPECIFIED - FRACTURE OF RADIUS WITH ULNA UPPER END (ANY PART) OPEN FRACTURE OF SHAFT OF RADIUS OR ULNA UNSPECIFIED CLOSED FRACTURE OF SHAFT OF RADIUS WITH ULNA CLOSED FRACTURE OF SHAFT OF RADIUS OR ULNA UNSPECIFIED OPEN FRACTURE OF SHAFT OF RADIUS WITH ULNA OPEN CLOSED FRACTURE OF LOWER END OF FOREARM UNSPECIFIED FRACTURE OF LOWER END OF RADIUS WITH ULNA CLOSED TORUS FRACTURE OF RADIUS (ALONE) TORUS FRACTURE OF ULNA (ALONE) TORUS FRACTURE OF RADIUS AND ULNA OPEN FRACTURE OF LOWER END OF FOREARM UNSPECIFIED - FRACTURE OF LOWER END OF RADIUS WITH ULNA OPEN CLOSED FRACTURE OF UNSPECIFIED PART OF FOREARM - FRACTURE OF UNSPECIFIED PART OF RADIUS WITH ULNA CLOSED FRACTURE OF UNSPECIFIED PART OF FOREARM OPEN - FRACTURE OF UNSPECIFIED PART OF RADIUS WITH ULNA OPEN CLOSED FRACTURE OF CARPAL BONE UNSPECIFIED - OPEN FRACTURE OF OTHER BONE OF WRIST CLOSED FRACTURE OF METACARPAL BONE(S) SITE UNSPECIFIED - OPEN FRACTURE OF MULTIPLE SITES OF METACARPUS

46 CLOSED FRACTURE OF PHALANX OR PHALANGES OF HAND UNSPECIFIED - OPEN FRACTURE OF MULTIPLE SITES OF PHALANX OR PHALANGES OF HAND MULTIPLE CLOSED FRACTURES OF HAND BONES - MULTIPLE OPEN FRACTURES OF HAND BONES ILL-DEFINED CLOSED FRACTURES OF UPPER LIMB - ILL-DEFINED OPEN FRACTURES OF UPPER LIMB MULTIPLE CLOSED FRACTURES INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM - MULTIPLE OPEN FRACTURES INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - OTHER TRANSCERVICAL FRACTURE OF FEMUR CLOSED FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR OPEN - OTHER TRANSCERVICAL FRACTURE OF FEMUR OPEN FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR CLOSED - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR CLOSED FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR OPEN FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR OPEN FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR CLOSED FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN FRACTURE OF UNSPECIFIED PART OF FEMUR CLOSED - OTHER FRACTURE OF LOWER END OF FEMUR OPEN CLOSED DISLOCATION OF SHOULDER UNSPECIFIED SITE CLOSED ANTERIOR DISLOCATION OF HUMERUS - CLOSED DISLOCATION OF OTHER SITE OF SHOULDER OPEN DISLOCATION OF SHOULDER UNSPECIFIED - OPEN DISLOCATION OF OTHER SITE OF SHOULDER CLOSED DISLOCATION OF ELBOW UNSPECIFIED SITE CLOSED ANTERIOR DISLOCATION OF ELBOW - CLOSED DISLOCATION OF OTHER SITE OF ELBOW OPEN DISLOCATION OF ELBOW UNSPECIFIED SITE - OPEN DISLOCATION OF OTHER SITE OF ELBOW NURSEMAID'S ELBOW CLOSED DISLOCATION OF WRIST UNSPECIFIED PART CLOSED DISLOCATION OF RADIOULNAR (JOINT) DISTAL - CLOSED DISLOCATION OF OTHER PART OF WRIST OPEN DISLOCATION OF WRIST UNSPECIFIED PART - OPEN DISLOCATION OF OTHER PART OF WRIST CLOSED DISLOCATION OF FINGER UNSPECIFIED PART CLOSED DISLOCATION OF METACARPOPHALANGEAL (JOINT) - CLOSED DISLOCATION OF INTERPHALANGEAL (JOINT) HAND

47 OPEN DISLOCATION OF FINGER UNSPECIFIED PART - OPEN DISLOCATION INTERPHALANGEAL (JOINT) HAND TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT DISLOCATION OF PATELLA CLOSED ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN - SPRAIN OF OTHER SPECIFIED SITES OF SHOULDER AND UPPER ARM SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM RADIAL COLLATERAL LIGAMENT SPRAIN - SPRAIN OF UNSPECIFIED SITE OF ELBOW AND FOREARM SPRAIN OF UNSPECIFIED SITE OF WRIST SPRAIN OF CARPAL (JOINT) OF WRIST - OTHER WRIST SPRAIN SPRAIN OF UNSPECIFIED SITE OF HAND SPRAIN OF CARPOMETACARPAL (JOINT) OF HAND - OTHER HAND SPRAIN CONCUSSION WITH PROLONGED LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL OPEN WOUND OF SHOULDER REGION WITHOUT COMPLICATION - OPEN WOUND OF MULTIPLE SITES OF SHOULDER AND UPPER ARM WITH TENDON INVOLVEMENT OPEN WOUND OF FOREARM WITHOUT COMPLICATION - OPEN WOUND OF WRIST WITH TENDON INVOLVEMENT OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITHOUT COMPLICATION - OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITH TENDON INVOLVEMENT OPEN WOUND OF FINGERS WITHOUT COMPLICATION - OPEN WOUND OF FINGERS WITH TENDON INVOLVEMENT MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITHOUT COMPLICATION - MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITH TENDON INVOLVEMENT TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) COMPLICATED TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) COMPLICATED TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) UNILATERAL BELOW ELBOW WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL BELOW KNEE WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

48 LATE EFFECT OF FRACTURE OF SPINE AND TRUNK WITHOUT SPINAL CORD LESION - LATE EFFECT OF TRAUMATIC AMPUTATION LATE EFFECT OF OPEN WOUND OF HEAD NECK AND TRUNK - LATE EFFECT OF BURN OF UNSPECIFIED SITE LATE EFFECT OF INTRACRANIAL INJURY WITHOUT SKULL FRACTURE - LATE EFFECT OF INJURY TO OTHER AND UNSPECIFIED NERVE LATE EFFECT OF CERTAIN COMPLICATIONS OF TRAUMA LATE EFFECT OF RADIATION LATE EFFECT OF COMPLICATIONS OF SURGICAL AND MEDICAL CARE CRUSHING INJURY OF FACE AND SCALP CRUSHING INJURY OF NECK CRUSHING INJURY OF SHOULDER REGION - CRUSHING INJURY OF MULTIPLE SITES OF UPPER LIMB CRUSHING INJURY OF UNSPECIFIED SITE OF UPPER LIMB CRUSHING INJURY OF MULTIPLE SITES NOT ELSEWHERE CLASSIFIED CRUSHING INJURY OF UNSPECIFIED SITE BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FACE AND HEAD UNSPECIFIED SITE BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF EAR (ANY PART) - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF FACE AND HEAD FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF EAR (ANY PART) - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF FACE AND HEAD WITHOUT LOSS OF BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES (EXCEPT EYE) OF FACE HEAD AND NECK WITH LOSS OF A BODY PART BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF TRUNK BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF BREAST - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF BACK (ANY PART) BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF GENITALIA - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF TRUNK

49 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF BREAST - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF BACK (ANY PART) FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF GENITALIA - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF OTHER AND MULTIPLE SITES OF TRUNK DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TRUNK UNSPECIFIED SITE WITHOUT LOSS OF BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK WITH LOSS OF A BODY PART BURN OF UNSPECIFIED DEGREE OF UNSPECIFIED SITE OF UPPER LIMB - ERYTHEMA DUE TO BURN (FIRST DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF UPPER LIMB BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FOREARM - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF UPPER LIMB FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOREARM - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF UPPER LIMB WITHOUT LOSS OF A BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND WITH LOSS OF UPPER LIMB BURN OF UNSPECIFIED DEGREE OF UNSPECIFIED SITE OF HAND - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF HAND BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF HAND FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF HAND WITHOUT LOSS OF HAND - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD

50 DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) WITH LOSS OF A BODY PART BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FOOT - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S) FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOOT - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF LOWER LIMB(S) BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SPECIFIED SITES - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SPECIFIED SITES DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITHOUT LOSS OF A BODY PART DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITH LOSS OF A BODY PART FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) UNSPECIFIED SITE - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART INJURY TO BRACHIAL PLEXUS INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS INJURY TO AXILLARY NERVE - INJURY TO MULTIPLE NERVES OF SHOULDER GIRDLE AND UPPER LIMB INJURY TO UNSPECIFIED NERVE OF SHOULDER GIRDLE AND UPPER LIMB INJURY TO SCIATIC NERVE VOLKMANN'S ISCHEMIC CONTRACTURE TRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY UNSPECIFIED MECHANICAL COMPLICATION OF INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT MECHANICAL LOOSENING OF PROSTHETIC JOINT DISLOCATION OF PROSTHETIC JOINT BROKEN PROSTHETIC JOINT IMPLANT PERI-PROSTHETIC FRACTURE AROUND PROSTHETIC JOINT PERI-PROSTHETIC OSTEOLYSIS ARTICULAR BEARING SURFACE WEAR OF PROSTHETIC JOINT OTHER MECHANICAL COMPLICATION OF PROSTHETIC JOINT IMPLANT OTHER MECHANICAL COMPLICATION OF OTHER INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL ORTHOPEDIC DEVICE IMPLANT AND GRAFT

51 OTHER COMPLICATIONS DUE TO INTERNAL JOINT PROSTHESIS - OTHER COMPLICATIONS DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT COMPLICATIONS OF REATTACHED FOREARM - COMPLICATIONS OF REATTACHED UPPER EXTREMITY OTHER AND UNSPECIFIED UNSPECIFIED LATE COMPLICATION OF AMPUTATION STUMP NEUROMA OF AMPUTATION STUMP - INFECTION (CHRONIC) OF AMPUTATION STUMP OTHER LATE AMPUTATION STUMP COMPLICATION OTHER SPECIFIED COMPLICATIONS OF PROCEDURES NOT ELSEWHERE CLASSIFIED V15.88 HISTORY OF FALL V43.60 UNSPECIFIED JOINT REPLACEMENT V SHOULDER JOINT REPLACEMENT - KNEE JOINT REPLACEMENT V43.65 V43.66 ANKLE JOINT REPLACEMENT V43.69 OTHER JOINT REPLACEMENT V43.7 LIMB REPLACED BY OTHER MEANS V46.3 WHEELCHAIR DEPENDENCE V UNSPECIFIED LEVEL UPPER LIMB AMPUTATION STATUS - SHOULDER V49.67 AMPUTATION STATUS V BELOW KNEE AMPUTATION STATUS - ABOVE KNEE AMPUTATION V49.76 STATUS V52.0 FITTING AND ADJUSTMENT OF ARTIFICIAL ARM (COMPLETE) (PARTIAL) V52.1 FITTING AND ADJUSTMENT OF ARTIFICIAL LEG (COMPLETE) (PARTIAL) V52.4 FITTING AND ADJUSTMENT OF BREAST PROSTHESIS AND IMPLANT V52.8 FITTING AND ADJUSTMENT OF OTHER SPECIFIED PROSTHETIC DEVICE V53.7 FITTING AND ADJUSTMENT OF ORTHOPEDIC DEVICES V53.8 FITTING AND ADJUSTMENT OF WHEELCHAIR V53.90 FITTING AND ADJUSTMENT OF UNSPECIFIED DEVICE V ENCOUNTER FOR REMOVAL OF INTERNAL FIXATION DEVICE - V54.02 ENCOUNTER FOR LENGTHENING/ADJUSTMENT OF GROWTH ROD V54.09 OTHER AFTERCARE INVOLVING INTERNAL FIXATION DEVICE V54.10 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF ARM UNSPECIFIED V54.11 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF UPPER ARM V54.12 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF LOWER ARM V54.17 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF VERTEBRAE V54.19 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF OTHER BONE AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF ARM V54.20 UNSPECIFIED V54.21 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF UPPER ARM V54.22 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF LOWER ARM V54.27 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF VERTEBRAE

52 V54.29 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF OTHER BONE V54.81 AFTERCARE FOLLOWING JOINT REPLACEMENT V54.89 OTHER ORTHOPEDIC AFTERCARE V54.9 UNSPECIFIED ORTHOPEDIC AFTERCARE V57.81 CARE INVOLVING ORTHOTIC TRAINING ENCOUNTER FOR CHANGE OR REMOVAL OF NONSURGICAL WOUND V58.30 DRESSING ENCOUNTER FOR CHANGE OR REMOVAL OF SURGICAL WOUND V58.31 DRESSING V58.49 OTHER SPECIFIED AFTERCARE FOLLOWING SURGERY V88.21 ACQUIRED ABSENCE OF HIP JOINT V88.22 ACQUIRED ABSENCE OF KNEE JOINT V88.29 ACQUIRED ABSENCE OF OTHER JOINT ICD-9 Codes that DO NOT Support Medical Necessity Paragraph: N/A N/A General Information Associated Information Documentation Requirements Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 15, Documentation supporting the medical necessity should be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request. 2. The documentation in the medical records should have sufficient information to determine that a service was performed on specific dates, and the medical necessity of the service(s) rendered. 3. If the signed order includes a plan of care, no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the

53 plan. 4. Required documentation: - Evaluation/and Plan of care including any other pertinent characteristics of the beneficiary; - Certifications and recertifications; - The history and physical exam pertinent to the patient s care, (including the response or changes in behavior to previously administered skilled services); - The skilled services provided; - A detailed rationale that explains the need for the skilled service in light of the patient s overall medical condition and experiences; - The complexity of the service to be performed; - Progress reports written by the clinician-services related to progress reports are to be furnished on or before every 10th treatment day; - Treatment notes for each visit detailing the patient s response to the skilled services provided (may also serve as progress notes); - When appropriate, a justification statement for services that are more extensive than is typical for the condition treated; - Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. It is not required that the same physician/npp who participated initially in recommending or planning the patient's care certify and/or recertify the plans. Occupational therapy services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient's response to treatment. Such visits would be considered covered therapy services when the skills of a therapist are required to perform the services. The patient s needs, course of therapy and response to therapy must be documented. Functional reporting uses nonpayable G-codes and related modifiers to convey information about the patient s functional status at specified points during treatment. This functional data reporting is effective for therapy services with dates of service on and after January 1, The functional reporting requirements apply to the therapy services furnished by the following providers: CAHs, SNFs, CORFs, rehabilitation agencies, and HHAs (where a beneficiary is not under a home health plan of care. In the medical record, functional documentation must be included: at the beginning of a therapy episode of care in the therapy plan of care as functional limitations and expressed as part of the patient s long term goals as the patient s current status, projected goal, and discharge status (for each date of service) in the progress report at the end of each progress reporting period, i.e. at least once every tenth treatment day

54 at the time of discharge, on the discharge note or summary when an evaluation or re-evaluation is furnished and billed for reporting that a particular functional limitation is ended, but further therapy is required when reporting is begun for a new or different functional limitation during the same therapy episode Documentation of functional reporting in the medical record of therapy services must be completed by the clinician furnishing the therapy services: The qualified therapist furnishing the therapy services The physician/npp personally furnishing the therapy services The qualified therapist furnishing services incident to the physician/npp The physician/npp for incident to services furnished by qualified personnel, who are not qualified therapists. The qualified therapist furnishing the PT, OT, or SLP services in a CORF 5. Documentation should justify: - the individual is under the care of a physician or non-physician practitioner - services require the skills of a therapist - services are of the appropriate type, frequency, intensity and duration for the individual needs of the patient. 6. For restorative/rehabilitative therapy documentation should establish: - variables that influence the patient's condition - services provided at the time of treatment - objective measurements that the patient is making progress toward goals. If it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services. - clinical rationale for continued treatment and/or reasons for lack of progress - recommended changes to the plan of care - ongoing reassessment of the patient's response to treatment. 7. For maintenance therapy: It is expected that the documentation in the patient s medical record will reflect the need for the skilled services provided. In situations where the maintenance program is performed to maintain the patient s current condition, such documentation would serve to demonstrate the program s effectiveness in achieving this goal. When the maintenance program is intended to slow further

55 deterioration of the patient s condition, the efficacy of the services could be established by documenting that the natural progression of the patient s medical or functional decline has been interrupted. Assessments of all goals must be performed in a frequent and regular manner so that the resulting documentation provides a sufficient basis for determining the appropriateness of coverage. The maintenance program provisions do not apply to the OT services furnished in a comprehensive outpatient rehabilitation facility (CORF) because the statute specifies that CORF services are rehabilitative. 8. CORF social and/or psychological services do not include services for mental health diagnoses. Social and/or psychological services are covered only if the patient's physician or the CORF physician establishes that the services directly relate to the patient's rehabilitation plan of treatment and are needed to achieve the goals in the rehabilitation plan of treatment. Social and/or psychological services are those services that address the patients response and adjustment to the rehabilitation treatment plan: rate of improvement and progress towards the rehabilitation goals, or other services as they directly relate to the occupational therapy plan of treatment being provided to the patient. Sources of Information and Basis for Decision Applegate WB, Blass JP, Williams TF. Instruments for the functional assessment of older patients. New Engl J Med. 1990;322: The Institute of Medicine's Committee on a National Agenda for Prevention of Disabilities. Executive Summary in Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press;1991. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9: Occupational Therapy Practice Guidelines for Adults With Neurodegenerative Diseases. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Adults With Rheumatoid Arthritis. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Adults With Spinal Cord Injury. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Adults With Stroke. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Chronic Pain. The AOTA Practice Guidelines Series. AOTA;1999.

56 Occupational Therapy Practice Guidelines for Tendon Injuries. The AOTA Practice Guidelines Series. AOTA;1999. Fife TD, Iverson DJ, Lempert JM, et al. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Am Acad Neur. 2008; Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 01/01/2015 R6 03/29/2014 R5 03/27/2014 R4 Revision History Number Revision History Explanation Under CPT/HCPCS Codes revisions were made to the description for and Under CMS National Coverage Policy added statutory requirement Title XVIII of the Social Security Act, 1833(e), states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Under CMS National Coverage Policy added CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 8, , , and The following manual reference was deleted: CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 3, (B). Under Coverage Indications, Limitations and/or Medical Necessity deleted the second paragraph referencing the psychiatric therapy LCDs as these LCDs were retired. Throughout this section of the LCD CMS Manual System was revised to now read CMS Internet-Only Manual. Verbiage was added related to restorative/rehabilitative therapy, and maintenance therapy. A note Reason(s) for Change Revisions Due To CPT/HCPCS Code Changes Provider Education/Guidance Other (Added statutory requirement.) Provider Education/Guidance Typographical Error Other (Change Request 8458, Transmittal 179, dated January 14, 2014)

57 01/16/2014 R3 04/12/2013 R2 was added related to occupational therapy assistants furnishing skilled maintenance program services in the outpatient setting and the skilled nursing facility (SNF) settings. Verbiage was also added to statement #5. Under Maintenance Programs the entire section of narrative was revised. Under Aquatic Therapy with Therapeutic Exercise-h. and Massage Therapy 2. typographical spelling errors were corrected. Under Self-Care/Home Management Training (CPT code 97535) added additional verbiage to the second paragraph. Under Documentation Requirements verbiage was added to statements #1, #4, #6, and #7. This LCD was revised due to the implementation of Change Request 8458, Transmittal 179 effective January 7, This LCD revision becomes effective 03/27/2014. Under Coverage Indications, Limitations, and/or Medical Necessity-Standard Cognitive Performance Testing (CPT 96125) the CPT/HCPCS code long description for was revised and the title of the LCD section was changed to now read, Standardized Thought Processing Testing, Interpretation and Report per hour. Under Coverage Indications, Limitations, and/or Medical Necessity-Ultrasound (CPT code 97035) deleted and 0183T ) from the title and deleted sentence #4 related to 0183T as literature was inconclusive to support the services are reasonable and necessary for wound assessment and care. Under CPT/HCPCS Codes deleted 0183T. These revisions were due to the 2014 CPT/HCPCS Annual Update. These CPT/HCPCS updates became effective 01/01/2014. This LCD revision becomes effective 01/16/2014. Under CMS National Coverage Policy added change request Documentation Requirements and Utilization Guidelines have been moved Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes Provider Education/Guidance

58 under Associated Information. Under Associated Information added verbiage regarding the functional reporting uses nonpayable G-codes for dates of service on or after January 1, Revision #7, 01/01/2013 Under CMS National Coverage Policy added change request Under CPT/HCPCS Codes the following codes had description changes: 97140, 97530, 97532, 97533, 79535, 97537, 97598, 97605, and Under Documentation Requirements #4 added verbiage regarding the progress notes to be furnished on or before every 10th visit. This revision becomes effective on 01/01/ /01/2013 R1 Revision #6, 10/04/2012 Under CMS National Coverage Policy section added the following manual citation: CMS Manual System, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Under Indications and Limitations of Coverage and/or Medical N/A Necessity-Electrical Stimulation Therapy (CPT codes and 97032, HCPCS codes G0281 and G0283) added verbiage regarding TENS used for treatment of chronic low back pain. This revision becomes effective 10/04/2012. Revision #5, 03/29/2012 Under CMS National Coverage Policy added the following manual citation: CMS Manual System, Pub , Chapter 6, Under Indications and Limitations of Coverage and/or Medical Necessity added the 4th-6th paragraphs regarding the descriptions/definitions of direct and general supervision used in the LCD and the definition of a qualified occupational therapist to reflect Change Request 7672, Transmittal 152. The verbiage in the Change Request was

59 manualized. Correction of revision #2, under CPT/HCPCS Codes added 97799, but inadvertently omitted it from the revision history. Under ICD-9 Codes That Support Medical Necessity it states that ICD-9 code was added when it should have read was added. Also ICD-9 code was added to the LCD but was inadvertently omitted from the revision history. This revision becomes effective on 03/29/2012 Revision #4, 01/01/2012 Under Indications and Limitations of Coverage and/or Medical Necessity deleted CPT code and the accompanying verbiage as the code description for this service was revised to now indicate a screening. The service described by CPT code is no longer a covered benefit and is therefore not covered by Medicare. The examples cited in the verbiage of this type of testing were deleted. Under CPT/HCPCS Codes added the NOTE to indicate that the service described by CPT code is no longer a covered benefit and is therefore not covered by Medicare and deleted CPT code from the list. The code description was revised for CPT code This revision to the LCD was due to the 2012 CPT/HCPCS Annual Update. This revision becomes effective 01/01/2012. Revision #3, 10/01/2011 Under ICD-9 Codes That Support Medical Necessity the following ICD-9 codes have been added: , 331.6, , , , , , , , , V88.21, V88.22 and V ICD-9 codes , , , , , , , , and had verbiage revisions. ICD-9 code was deleted and not replaced. This revision becomes

60 effective 10/01/2011. Revision #2, 08/11/2011 Under CMS National Coverage Policy the following citations have been deleted: CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 12, 40, 40.1 and 40.3 CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 13, CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 13, CMS Manual System, Pub , Medicare Claims Processing, Transmittal 1625, dated October 31, 2008, Change Request 6254 CMS Manual System, Pub , Medicare Benefit Policy, Transmittal 111, dated September 25, 2009, Change Request 6005 The following citations have been added; CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 12, 30.1 and 40.7 CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, 80.3 CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 5, 20B and Under Indications and Limitations of Coverage and/or Medical Necessity added 2nd paragraph, "For specific coverage of...". Under CPT code added #3. Added a "note" under CPT code 97016, Under the following CPT codes: , 95851, 95852, 97010, 97016, 97018, & 97036, & & G0281 & G0283, 97033, 97034, & 0183T, 97110, 97113, and verbiage was added or changed. Under CPT code 97140, deleted myofascial release from the subtitle. CPT

61 codes 92548, and have been added. Under CPT/HCPCS Codes added 92548, and Under ICD-9 Codes That Support Medical Necessity the following codes have been added: , , , 310.1, 315.1, , 351.0, 357.2, , , , 490, 491.0, 491.1, , , , 491.8, 491.9, 492.0, 492.8, , , , , , , 496, , , , , , , , , , , , , , , , 728.9, 729.4, , , 737.0, , , , , , , , , , , , , , , , , , , 737.8, 737.9, , , , , , , , , , 780.0, , , , , 794.2, , , and Under Documentation Requirements #4 added last statement. This revision becomes effective 08/11/2011. Revision #1, 05/16/2011 Per scheduled J11 implementation, contractor numbers (Virginia) and (West Virginia) were added to this LCD. This revision becomes effective on 05/16/ /24/ In accordance with Section 911 of the Medicare Modernization Act of 2003, in compliance with the J11 AB MAC Statement of Work (SOW), C Consolidation of Local Coverage Determinations, this LCD has been selected for implementation within the Palmetto GBA J11 AB MAC territory. Effective date of this implementation is January 24, 2011.

62 Associated Documents Attachments N/A Related Local Coverage Documents Article(s) A CPT Code Assistive Technology Assessment A Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) A Outpatient Occupational Therapy Supplemental Instructions Article Related National Coverage Documents N/A Public Version(s) Updated on 12/12/2014 with effective dates 01/01/ N/A Updated on 03/07/2014 with effective dates 03/29/ /31/2014 Updated on 02/20/2014 with effective dates 03/27/ /28/2014 Updated on 01/11/2014 with effective dates 01/16/ /26/2014 Updated on 04/04/2013 with effective dates 04/12/ /15/2014 Local Coverage Article: CPT Code Assistive Technology Assessment (A50466) Contractor Information Contractor Name Palmetto GBA Contractor Information Table Article Information General Information Article ID A50466 General Article Information Table Original Effective Date 01/24/2011

63 Article Title CPT Code Assistive Technology Assessment AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Revision Effective Date 09/18/2014 Revision Ending Date N/A Retirement Date N/A Article Guidance Article Text:

64 CPT code 97755, assistive technology assessment (for example, to restore, augment or compensate for an existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider with written report, each 15 minutes, has been added to the following local coverage determinations (LCD): Outpatient Physical Therapy Outpatient Occupational Therapy Occupational Therapy for Home Health Physical Therapy for Home Health This is an assessment code, per each 15 minutes, and must be accompanied by a written report explaining the nature and complexity of the assistive technology needed by the patient. This can include: testing multiple components/systems to determine optimal interface between client and technology applications and determining the appropriateness of commercial (off the shelf) components/systems. If the service provided by a physical or occupational therapist is more clearly defined by another CPT code (for example, 97535), it should be used instead. It would be inappropriate to use the CPT code for services other than for those who have lost the use of their limbs and who can benefit from new technology advancements. CPT should only be billed by occupational and physical therapists that have the additional knowledge and expertise of the assistive technology that is required for these individuals. For rationale, clinical example and description of CPT 97755, please refer to CPT Changes 2004: An Insider's View, American Medical Association. (2003 ). Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. N/A Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

65 N/A CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: CPT/HCPCS Codes Information Table 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 ASSISTIVE TECHNOLOGY ASSESSMENT (EG, TO RESTORE, AUGMENT OR COMPENSATE FOR EXISTING FUNCTION, OPTIMIZE FUNCTIONAL TASKS AND/OR MAXIMIZE ENVIRONMENTAL ACCESSIBILITY), DIRECT ONE-ON-ONE CONTACT, WITH WRITTEN REPORT, EACH 15 MINUTES Covered ICD-9 Codes N/A Non-Covered ICD-9 Codes N/A Revision History Information Please note: The Revision History information included in this Article prior to 06/20/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 06/20/2013 will display as a row in the Revision History section of the Article and numbering will begin with "R2". Revision History Date 09/18/2014 R4 Revision History Number Revision History Explanation Added CPT codes from Text to the CPT/HCPCS Coding Section. Added Keywords.

66 Under Article Text deleted "is" from the last sentence of the second 02/27/2014 R3 paragraph. This article revision becomes effective 02/27/ /20/2012 R2 Annual Review, no changes made. Revision #2, 12/20/2012 Annual review completed 12/20/2012 R1 Revision #1, 05/16/2011 Per scheduled J11 implementation, contractor numbers (Virginia) and (West Virginia) were added to this LCD. This revision becomes effective on 05/16/ /24/ In accordance with Section 911 of the Medicare Modernization Act of 2003, in compliance with the J11 AB MAC Statement of Work (SOW), C Consolidation of Local Coverage Determinations and articles, this article has been selected for implementation within the Palmetto GBA J11 AB MAC territory. Effective date of this implementation is January 24, Associated Documents Related Local Coverage Document(s) LCD(s) L Outpatient Occupational Therapy L Outpatient Physical Therapy Related National Coverage Document(s) N/A Statutory Requirements URL(s) N/A Rules and Regulations URL(s) N/A CMS Manual Explanations URL(s) N/A Other URL(s) N/A Public Version(s) Updated on 09/11/2014 with effective dates 09/18/ N/A Updated on 02/19/2014 with effective dates 02/27/ N/A Updated on 01/09/2014 with effective dates 12/20/ N/A Updated on 12/12/2012 with effective dates 12/20/ N/A

67 Local Coverage Article: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A53759) Contractor Information Contractor Name Palmetto GBA Contractor Information Table Article Information General Information Article ID A53759 General Article Information Table Article Title Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Original Effective Date 10/03/2014 Revision Effective Date 10/03/2014 Revision Ending Date N/A Retirement Date N/A

68 Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Article Guidance Article Text: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) describes a system employed in wound care that uses continuous low frequency ultrasonic energy to atomize a liquid and deliver continuous low frequency ultrasound to the wound bed. MIST therapy or other similar products are included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597, 97598,97602,97605,97606) or wound debridement CPT codes (e.g., CPT codes , 97597, 97598). Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. N/A Revenue Codes:

69 Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. N/A CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: CPT/HCPCS Codes Information Table DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS,

70 BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON- SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO- MOIST DRESSINGS, ENZYMATIC, ABRASION), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS LOW FREQUENCY, NON-CONTACT, NON-THERMAL ULTRASOUND, INCLUDING TOPICAL APPLICATION(S), WHEN PERFORMED, WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER DAY Covered ICD-9 Codes N/A Non-Covered ICD-9 Codes N/A

71 Revision History Information Please note: The Revision History information included in this Article prior to 06/20/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 06/20/2013 will display as a row in the Revision History section of the Article and numbering will begin with "R2". Revision History Date 10/03/2014 R1 Revision History Number Revision History Explanation Under Article Text, deleted the following, "Effective October 3, 2014, MIST Therapy or other similar treatments would be separately billable if other active wound management and/or wound debridement is NOT performed" as this is a bundled service that would not be provided alone. Associated Documents Related Local Coverage Document(s) LCD(s) L Outpatient Occupational Therapy L Outpatient Physical Therapy Related National Coverage Document(s) N/A Statutory Requirements URL(s) N/A Rules and Regulations URL(s) N/A CMS Manual Explanations URL(s) N/A Other URL(s) N/A Public Version(s) Updated on 12/06/2014 with effective dates 10/03/ N/A Updated on 09/10/2014 with effective dates 10/03/ N/A Updated on 09/08/2014 with effective dates 10/03/ N/A Local Coverage Article: Outpatient Occupational Therapy Supplemental Instructions Article (A51957)

72 Contractor Information Contractor Name Palmetto GBA Contractor Information Table Article Information General Information Article ID A51957 General Article Information Table Article Title Outpatient Occupational Therapy Supplemental Instructions Article AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA Original Effective Date 11/03/2011 Revision Effective Date 09/18/2014 Revision Ending Date N/A Retirement Date N/A

73 SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Article Guidance Article Text: Language quoted from the Centers for Medicare and Medicaid Services (CMS)Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual is italicized throughout the article. Electrical Stimulation (CPT codes and 97032, HCPCS codes G0281 and G0283), and Electromagnetic Therapy (HCPCS code G0329) CPT code Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Attended Electrical stimulation requires direct (one-on-one) contact with the patient by the qualified professional/qualified personnel in providing electrical stimulation manually through the use of probes or other devices. Types of electrical stimulation that may require constant attendance and direct one-on-one contact by the qualified professional/qualified personnel include but are not limited to: Direct motor point stimulation Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES). If performed with therapeutic exercise, neuromuscular reeducation or functional activities, may be billed for the time the qualified professional/qualified personnel spends applying/instructing and adjusting the FES application, but 97110, 97112, or should not be billed during the same time period Ultrasound with electrical stimulation provided concurrently should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period Determining trigger points associated with application of a TENS unit using a hand held probe, would be reported by

74 The actual application of a TENS unit including the instruction in use and appropriate settings would be described by reporting 64550(Application of surface (transcutaneous) neurostimulator). Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity. Non-Implantable Pelvic Floor Electrical Stimulation (CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 4, ) Nonimplantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Stimulation is generally delivered by vaginal or anal probes connected to an external pulse generator and may be billed as Stimulation delivered via electrodes should be billed as G0283. The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (ma), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis. Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing four weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength. The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training. Utilization of electrical stimulation may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement. Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring). Documentation must clearly support the medical necessity of electrical stimulation for more than 12 visits as adjunctive therapy or for muscle retraining. Typically patients can be trained in the use of a home muscle stimulator for retraining weak muscles. Up to two visits should be

75 necessary to complete the training. Once training is successfully completed, this procedure should not be billed as a treatment modality in the clinic, as the patient would be independent in application and use of the modality. Non-covered Indications Electrical Stimulation (CPT code 97032) used in the treatment of facial nerve paralysis, commonly known as Bell s palsy (CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Electrical Stimulation (CPT code 97032) used to treat motor function disorders such as multiple sclerosis (CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 160.2) Electrical Stimulation (CPT code 97032) for the treatment of strokes when it is determined there is no potential for restoration of function Electrical Stimulation when it is an isolated intervention utilized purely for strengthening of a muscle with at least fair graded strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activities. Supportive Documentation Recommendations for Type of electrical stimulation used (in addition to the description specifying manual and attended ) Area(s) being treated If used for muscle weakness, objective rating of strength and functional deficits If used for pain include pain rating, location of pain, effect of pain on function HCPCS G Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care. See for instructions in manual electrical stimulation Most non-wound care electrical stimulation treatment provided as part of a therapy plan of care should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/assistive personnel) without constant, direct contact required throughout the treatment. Code G0283 is classified as a supervised modality. A supervised modality does not require direct (one-on-one) patient contact by the provider. Typically electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples of unattended electrical stimulation modalities include, but are not limited to, Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation). Utilization of electrical stimulation may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement.

76 Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring) Documentation must clearly support the medical necessity of unattended electrical stimulation used for control of pain and swelling, with objective and/or subjective changes noted in swelling and/or pain within 12 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality. Typically patients can be trained in the use of a TENS unit for self-management of their pain. Up to two visits should be necessary to complete the training. Once training is successfully completed, this procedure should not be billed as a treatment modality in the clinic, as the patient would be independent in application and use of the modality. The cost of electrodes used with unattended electrical stimulation is included in the practice expense portion of G0283. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality. CPT code is an invalid code on the Medicare fee schedule and should not be reported in the claim form. Supportive Documentation Recommendations for G0283 Type of electrical stimulation used (e.g., TENS, IFC) Area(s) being treated Objective/subjective measures of how treatment is impacting pain (intensity, location, impact on function) and/or swelling HCPCS G Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care HCPCS Code G0281 Electrical stimulation, (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care Supportive Documentation Recommendations for G0281 and G0329 Etiology and duration of wound Type of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatment Stage of wound Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate Evidence of infection, undermining, or tunneling Nutritional status Co-morbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use

77 Patient s functional level Skilled plan of treatment, including specific frequency of the modality Changing plan of treatment based on clinical judgment of the patient s response or lack of response to treatment Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session) Self-Care Home Management Training (CPT code 97535) When instructing the patient in a self management program, use the code that best describes the focus of the self management activity. For example, if the instruction given is for exercises to be done at home to improve ROM or strength, use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if teaching the patient aquatic exercises to use as an independent program in the community pool, use Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. N/A Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. N/A CPT/HCPCS Codes Group 1 Paragraph: CPT Group 1 Codes:

78 CPT/HCPCS Codes Information Table APPLICATION OF SURFACE (TRANSCUTANEOUS) NEUROSTIMULATOR APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; AQUATIC THERAPY WITH THERAPEUTIC EXERCISES 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 Group 2 Paragraph: HCPCS Group 2 Codes: CPT/HCPCS Codes Information Table G0281 G0283 G0329 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR CHRONIC STAGE III AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS, AND VENOUS STATSIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL CARE, AS PART OF A THERAPY PLAN OF CARE ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE ELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS FOR CHRONIC STAGE III AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS AND VENOUS STASIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL CARE AS PART OF A THERAPY PLAN OF CARE

79 Group 3 Paragraph: CPT: If Billing 97032,cannot bill 97110, or on the same claim. Group 3 Codes: CPT/HCPCS Codes Information Table THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 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 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES Covered ICD-9 Codes N/A Non-Covered ICD-9 Codes N/A Revision History Information Please note: The Revision History information included in this Article prior to 06/20/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 06/20/2013 will display as a row in the Revision History section of the Article and numbering will begin with "R2". Revision History Date 09/18/2014 R1 Revision History Number Revision History Explanation Added CPT/HCPCS from Text to the CPT/HCPCS Coding Section. Added Keywords. Associated Documents

80 Related Local Coverage Document(s) LCD(s) L Outpatient Occupational Therapy Related National Coverage Document(s) N/A Statutory Requirements URL(s) N/A Rules and Regulations URL(s) N/A CMS Manual Explanations URL(s) N/A Other URL(s) N/A Public Version(s) Updated on 09/11/2014 with effective dates 09/18/ N/A Updated on 08/27/2014 with effective dates 11/03/ N/A