Local Coverage Determination (LCD) for Physical Medicine and Rehabilitation Policy (L28290)

Transcription

1 Search Home Medicare Medicaid CHIP About CMS Regulations & Guidance Research, Statistics, Data & Systems Outreach & Education People with Medicare & Medicaid Questions Careers Newsroom Contact CMS Acronyms Help Print Back to Local Coverage Determinations (LCDs) for Palmetto GBA (01192, MAC - Part B) Local Coverage Determination (LCD) for Physical Medicine and Rehabilitation Policy (L28290) Select the Print Record, Add to Basket or Record buttons to print the record, to add it to your basket or to the record. Section Navigation Select Section Go Contractor Information Contractor Name Palmetto GBA Contractor Number Contractor Type MAC - Part B Back to Top LCD Information Document Information LCD ID Number L28290 LCD Title Physical Medicine and Rehabilitation Policy Contractor's Determination Number J1B L AMA CPT/ADA CDT 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 Primary Geographic Jurisdiction California - Southern Oversight Region Region X Original Determination Effective Date For services performed on or after 09/02/2008 Original Determination Ending Date Revision Effective Date For services performed on or after 06/28/2012

2 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. Revision Ending Date CMS National Coverage Policy Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be medically reasonable and necessary. Title XVIII of the Social Security Act, 1862(a)(7), excludes routine examinations. Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim, which lacks the necessary information to process the claim. Title XVIII of the Social Security Act, 1879 placed a limitation of liability on the beneficiary where Medicare claims are disallowed when both the beneficiary and provider of services did not know and could not reasonably have known the services would not be paid. Title XVIII of the Social Security Act, 1861(p)(4) defines services for outpatient physical therapy services and conditions of operation. Title XVIII of the Social Security Act, 1835(2)(D), lists requirements for certification and recertification of speech pathology services. 42CFR states personnel qualifications for audiologists, occupational therapists and physical therapists. 42CFR states conditions of participation for clinics, rehabilitation agencies as providers of outpatient physical therapy and speech-language pathology services. 42CFR (c)(i) gives outpatient physical therapy service conditions. 42CFR , plan of treatment requirements for outpatient rehabilitation including services furnished by a qualified physical or occupational therapist in private practice. 42CFR , regarding outpatient LSP services: Conditions and exclusions 42 CFR , certification and plan of treatment requirements. 42 CFR , Conditions of participation: Specialized Providers for clinics, rehabilitation agencies, public health agencies as providers of outpatient physical therapy and speech-language pathology services. 42 CFR , Condition of participation: Speech pathology services 42CFR states that supervision levels for outpatient rehabilitation therapy services are the same as those for diagnostic tests. 42CFR states the conditions of participation with program evaluation. CMS Transmittal AB , CR 2083, Provider Education Article: Medicare Coverage of Rehabilitation Services for Beneficiaries With Vision Impairment, dated May 29, 2002

3 CMS Transmittal AB , Change Request 1793, Medical Review of Services for Patients with Dementia, dated September 25, 2001 CMS Transmittal AB , Change Request 2073, Payment for Services Furnished by Audiologists, dated June 7, CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, , therapy personnel qualifications and the timing of recertification of plans of care. CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 6, , Diagnostic Services Defined. CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 6, , Coverage of outpatient theraputic services incident to a physicians service. CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, CMS Manual System, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 10.2, 10.3, 10.4, 30.3, , , 50.2, 50.3 and 50.4; Part 2, 150.1, 150.2, 150.5, 150.8, 160.2, 160.7, , , , , , , and ; Part 3, 170.1, and 170.3; Part 4, 240.3, 240.7, 240.8, 250.1, 270.2, 270.6, 280.6, and CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 5, 20, 20.1, 20.2, 20.3, 20.4, 20.5 CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 12, 30.3 CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 23, 10 CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 3, , , signature requirements and diagnosis code requirement CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 13, , reasonable and necessary provisions in LCD Indications and Limitations of Coverage and/or Medical Necessity This policy defines the coverage and limitations under Medicare for physical medicine and rehabilitation (PM&R) modalities and procedures provided by physicians or independent physical therapists, occupational therapists, and speech-language pathologists in home and office settings. Assessment: Assessment is included in services or procedures and is not separately payable (as distinguished from Current Procedural Terminology (CPT) codes that specify assessment, e.g., 97755, Assistive Technology Assessment which may be payable). 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/treatment day and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgments about progress toward goals and/or determine that a more complete evaluation or reevaluation (see definitions below) is indicated.

4 Certification: Certification is the physician s/nonphysician Practitioner s (NPP) approval of the plan of care. Evaluation: Evaluation is a separately payable 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 also count as treatment time. Reevaluation: Reevaluation is separately payable and is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline, or change in the patient s condition or functional status. Some state regulations and state practice acts require reevaluation at specific times. Reevaluation may also be appropriate at a planned discharge. 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. Reevaluation requires the same professional skills as evaluation. Current Procedural Terminology does not define a reevaluation code for speech-language pathology; use the evaluation code. Interval: Interval of certified treatment (certification interval) consists of 90 calendar days or less based on an individual's needs. Nonphysician Practitioners (NPP): Nonphysician Practitioners (NPP) means physician assistants, clinical nurse specialists, and nurse practitioners who may, if state and local laws permit it, and when appropriate rules are followed, provide, certify or supervise therapy services. Physician: Physician with respect to outpatient rehabilitation therapy services means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine (as authorized by applicable state law), or optometry (for low vision rehabilitation only). Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care. Qualified Professional: Qualified professional means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies. Qualified professionals may also include physical therapy assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law. Assistants may not supervise others. Qualified Physical Therapist Defined: A qualified physical therapist for program coverage purposes is a person who is licensed, if applicable, as a PT by the state in which he or she is practicing unless licensure does not apply, has graduated from an accredited PT education program and passed a national examination approved by the state in which PT services are provided. Qualified Occupational Therapist Defined: A qualified occupational therapist for program coverage purposes is an individual who is licensed, if licensure applies, or otherwise regulated, if applicable, as an OT by the state in which practicing, and graduated from an accredited education program for OT's, and is eligible to take or has passed the examination for OT's administered by the National Board of Certification in Occupational Therapy, Inc. (NBCOT).

5 Qualified Personnel: Qualified personnel means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of licensure. Qualified personnel have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP. Qualifications of Auxiliary Personnel: Therapy services appropriately billed incident to a physician s/npp s service shall be subject to the same requirements as therapy services that would be furnished by a physical therapist, occupational therapist or speech-language pathologist in any other outpatient setting with one exception. When therapy services are performed incident to a physician s/npp s service, the qualified personnel who perform the service do not need to have a license to practice therapy, unless it is required by state law. The qualified personnel must meet all the other requirements except licensure. The person who furnishes the service to the patient must, at least, be a graduate of a program of training for one of the therapy services as described above. Regardless of any state licensing that allows other health professionals to provide therapy services, Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology. That means that the services of athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as therapy services. Signature: Signature means a legible identifier of any type acceptable signatures.(e.g., hand written or electronic)(stamped signatures are not acceptable). Supervision Levels: Supervision levels for outpatient rehabilitation therapy services are the same as those for diagnostic tests. Depending on the setting, the levels include personal supervision (in the room), direct supervision (in the office suite), and general supervision (physician/npp is available but not necessarily on the premises). Suppliers: Suppliers of therapy services include individual practitioners such as physicians, NPPs, physical therapists, occupational therapists and speech language pathologists who have Medicare provider numbers. Therapist: Therapist refers only to qualified physical therapists, occupational therapists and speech-language pathologists. Other Definitions: Provider: PM&R services may be billed under one of four different practitioner benefits: (1) by physicians as their own professional services or as services of their employees furnished incident to their professional services (2) by physical therapists in private practice, (3) by occupational therapists in private practice or (4) by speech language pathologist in private practice. The term provider in this policy includes any of these four. Not covered: This term means that a requirement in Medicare s definition of the benefit category is not met and coverage is denied. No Medicare payment is made. Not medically reasonable and necessary: Medicare payment is denied and the provider may not seek reimbursement from the beneficiary unless he/she has signed a waiver (Advanced Beneficiary Notice of Noncoverage)(ABN) for the specific service. Incident to: This term means services that are: 1. furnished as an integral, although incidental, part of a physician s personal professional services; 2. performed under the physician s direct supervision;

6 3. performed by qualified therapists or other qualified auxiliary personnel who are employees of the physician (as defined above); and 4. furnished during a course of treatment where the physician performs an initial direct, personal, professional service and performs subsequent services at a frequency that reflects his/her continuing active participation in and management of the course of treatment. 5. The services of a PTA or OTA shall not be billed as services incident to a physician/npp s service, because they do not meet the qualifications of a therapist. Direct Supervision in the Office: This term means that the provider must be physically present in the same office suite and immediately available to provide assistance and direction throughout the time the employee is performing services. Activities of physical therapy assistants (PTA) and/or occupational therapy assistant (OTA) require general supervision in all settings except private practice which requires direct supervision by the physical therapist or occupational therapist. Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered under Medicare. A. General PM&R Guidelines: For evaluations/re-evaluations, physical therapists should use codes and 97002, and occupational therapists should use codes and Intervention with PM&R modalities and procedures is indicated when an assessment and diagnosis by the physician and/or therapist supports utilization of the intervention; there is documentation of objective physical and functional limitations. PM&R services in providers offices and patients homes are covered when reasonable and medically necessary for the treatment of the patient s condition (signs and symptoms). The type, frequency and duration of services must be medically necessary for the patient s condition under accepted medical, physical therapy, and occupational therapy practice standards, and relate directly to a written treatment plan. There must be an expectation that the condition or the level of function will improve significantly within a reasonable and generally predictable period of time. 2. For all PM&R modalities and therapeutic procedures on a given day, it is usually not medically necessary to have more than one treatment session per discipline. Depending on the severity of the patient s condition, the usual treatment session provided in the home or office setting is from 30 to 60 minutes. The medical necessity of services for a longer length of time must be documented in the treatment note. Therapy directed at maintenance of current function is not a Medicare benefit. 3. For incident to claims submitted by a physician: Services performed by individuals who are not employees, not contracted, or not under a physician/nonphysician practitioner s (based upon the individual State s scope of practice) direct supervision, are not covered. Services not relating to a written treatment plan that was established by the therapist or by the physician before treatment began are not covered. Services that do not require the professional skills of a physician/nonphysician practitioner to perform or supervise are not medically necessary. 4. For claims submitted by a physical or occupational therapist in private practice:

7 Claims submitted by anyone other than a certified therapist are not covered. Licensed therapists include qualified therapists and qualified therapy assistants, but do not include aides. Services provided by aides or physical therapy students, regardless of the level of supervision, are not paid for by Medicare Part B. Services not performed by or under the direct supervision of the therapist are not covered. Services performed by persons who are not direct employees or contracted employees of the therapist are not reasonable and necessary. Services not relating to a written treatment plan that was established by the therapist or by the physician before treatment began are not reasonable and necessary. Physical or occupational therapy services that do not require the professional skills of a qualified physical or occupational therapist to perform or supervise will be denied as reasonable and necessary. 5. Services provided concurrently by a physician and/or physical therapist and/or occupational therapist may be covered if separate and distinct goals are documented in the treatment plans. 6. Because dementia is a diagnostic term with broad clinical implications, it may not support the medical necessity of a Medicare covered benefit when used alone...when a beneficiary with dementia experiences an illness or injury unrelated to the dementia, the provider should submit a claim with the primary diagnosis that most accurately reflects the need for the provided service. For example, following a hip replacement in a patient with Alzheimer's Disease, a physical therapy provider should submit a clean claim using ICD-9 Code 781.2(Abnormality of gait) as the primary diagnosis, not ICD-9 code (Alzheimer's Disease). If the patient s dementia is so severe that they would not benefit from the therapy, it would be inappropriate to bill for these services. 7. Certifications are required for each interval of treatment based on the patient's needs not to exceed 90 days from the initial therapy treatment. Certifications are timely when the initial certification (of certification of a significantly modified plan of care) is dated within 30 calendar days of the initial treatment under that plan. Recertification is timely when dated during the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whichever is less. Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/npp makes a certification accompanied by a reason for the delay. Certifications are acceptable without justification for 30 days after they are due. Delayed certification should include one or more certifications or recertifications on a single signed and dated document. B. Therapy for patients with symptoms from chronic disease Note: Use the ICD-9-CM code for the sign/symptom/complication diagnosis. The underlying condition may also be coded, but is not required. 1. Periodic evaluations of the patient s condition and response to treatment may be covered when medically necessary if the judgment and skills of a professional provider are required. Examples include: Design of a home therapy regimen required to delay or minimize muscular and functional deterioration in patients suffering from chronic disease; Instructing the patient or/and family members in carrying out the therapy program; and, Infrequent re-evaluations required to assess the patient s condition and adjust the program. These services should be billed with the appropriate E/M code (e.g., for physicians or NPPs; for PT and OT only). It is expected that these services will be infrequently required.

8 2. It is not medically reasonable and necessary for a provider to perform or supervise therapy programs that do not require the professional skills of a provider. These situations include: Services related to activities for the general good and welfare of patients (i.e., general exercises to promote overall fitness and flexibility in an otherwise healthy patient); Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients; Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities; and Continued therapies after the patient has achieved therapeutic goals or for patients who show no further meaningful progress. Maintenance therapy is not covered. C. Speech/Language/Hearing/Oral Guidelines Speech-Language Pathology (SLP) services are those services necessary for the diagnosis and treatment of speech, language and cognitive communication disorders which result in communication disabilities. Speech-Language Pathology also includes evaluation and treatment of swallowing. Laryngoscopy, flexible or rigid, with stroboscopy (e.g., 31579) Flexible fiberoptic nasoendoscopy or rigid fiberoptic oral endoscopy is performed using a strobe light correlated to voice fold vibration, which permits vocal tract structures to be visualized in an apparent slow motion format in order to assess the effect of pathology on the process of voicing and to determine appropriate therapy strategies. The Speech Language Pathologist (SLP) performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The equipment that is used in the examination may be fixed, mobile or portable. Professional guidelines recommend that the service be provided in a team setting with a physician/npp who provides supervision of the radiological examination and interpretation of medical conditions revealed in it. Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function, conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions and developing a treatment plan employing appropriate compensations and therapy techniques. Speech/Language/Hearing Evaluation (e.g., 92506) 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 provider setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions. The time spent in the evaluation does not also count as treatment time. 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

9 functional status. 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. Reevaluation requires the same professional skills as an evaluation. Note: Current Procedural Terminology does not define a reevaluation code for SLP: use the evaluation code. The evaluation is the identification, assessment, and diagnosis of the following disorders: a. Speech, articulation, fluency, and voice (including respiration, phonation, and resonance) b. Language skills (involving the parameters of phonology, morphology, syntax, semantics, and pragmatics, and including disorders of receptive and expressive communication in oral, written, graphic, and manual modalities) c. Cognitive aspects of communication (including communication disability and other functional disabilities associated with cognitive impairment) d. Aural rehabilitation Note: The condition for which the Speech Language Pathologist is seeing the patient must be expected to improve. Evaluation of patient for prescription voice prosthetic (e.g., 92506) The patient is evaluated for a voice prosthetic. The patient s ability to perform the mechanics necessary to provide voice, care and cleaning of the unit are evaluated, as well as the patient s preference for the unit (examples of voice prosthetics are tracheoesophageal valves, electrolarynges, speaking valves, and voice amplifiers). Speech/Language Hearing/Therapy (e.g., 92507) Speech/language/hearing therapy is the treatment/intervention, (e.g., prevention, restoration, amelioration, and compensation) and follow-up service for disorders of speech, articulation, fluency and voice, and language skills as well as for impairments of cognition, language and pragmatics found in cognitive communication disorders: a. Providing consultation, counseling, and making referrals when appropriate; b. Providing education, training and support to family members/caregivers and other communication partners of individuals with speech, voice, language, cognitive communication disorders, fluency, hearing and swallowing disabilities; c. Developing and establishing effective augmentative and alternative communication techniques and strategies, including selecting, prescribing and dispensing of aids and devices as identified by State Practice Acts and training individuals, their family members/caregivers, and other communication partners in their use. Regarding speechgenerating devices, use CPT code for selection and prescription; use CPT code for adaptation and training; d. Selecting, fitting, and establishing effective use of appropriate prosthetic/adaptive devices for speaking; e. Providing audiologic rehabilitation that is a facilitative process that provides intervention to address the impairments, activity limitations, participation restrictions, and possible

10 environmental and personal factors that may affect the communication, functional health, and well-being of persons with hearing impairment or by others who participate with them in those activities, including related counseling services to individuals with hearing loss and to their family members/caregivers; and /or f. Providing interventions for individuals with central auditory processing disorders. Treatment may include individualized communication partner/education and training appropriate to the individual s cultural and language community. Modifications in voice prosthetic to supplement oral speech would be appropriate and should be carried out by a SLP. (Modification of the voice prosthetic would involve programming or reprogramming the device to meet the patient s needs.) The patient is seen for sizing, fitting, placement or replacement and training of the voice prosthetic. Treatment of speech, language, voice, communication and or auditory processing disorders; group (e.g., 92508) A group for the purpose of performing group therapy will be defined as: a. Two or more patients per therapy receiving active therapy but not one on one treatment and b. the patients may be performing the same therapy or a different therapy but the Speech Language Pathologist is instructing all the patients in the group. Note: Regardless of the therapy 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. Nasopharynogoscopy endoscope (e.g., code 92511) Nasopharyngoscopy with endoscope is the visualization of the nasopharynx and vocal tract during speech production with an endoscope to assess and treat patients with resonance and/or aeromechanical disorders. The Speech Language Pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The equipment that is used in the examination may be fixed, mobile or portable. Professional guidelines recommend that the service be provided in a team setting with a physician/npp who provides supervision of the radiological examination and interpretation of medical conditions revealed in it. Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function, conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions and developing a treatment plan employing appropriate compensations and therapy techniques. Nasal Function Studies (e.g., 92512) Nasometry assessment is an instrumental assessment of resonance. This assessment provides numbers that represent a ratio between oral resonance and nasal resonance during production of specific syllables, phrases, and reading passages. Normative data is

11 available so that a patient s scores can be interpreted relative to normal. Nasometry helps quantify hypernasality and hyponasality. It also provides a baseline for measuring change following management-therapeutic or surgical. The speech-language pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The equipment that is used in the examination may be fixed, mobile, or portable. Professional guidelines recommended that the service be provided in a team setting with a physician/npp who provides supervision of the radiological examination and interpretation of medical conditions revealed in it. Laryngeal function studies (e.g ) Laryngeal function studies are the acoustic and aerodynamic measures used to evaluate vocal function. Oral Function Therapy (e.g., 92526) Oral function therapy involves the treatment for impairments and/or functional limitations of mastication (i.e. chewing), and/or swallowing (including preparatory, oral, pharyngeal, laryngeal, and esophageal phases). Oral function therapy may also involve indirect treatment to include recommendations regarding therapeutic diet, compensatory strategies/techniques and instructions to facilitate oral motor control for feeding. Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech (e.g., 92597) The patient is evaluated for a voice prosthetic. The patient s ability to perform the mechanics necessary to provide voice, care and cleaning of the unit are evaluated, as well as the patient s preference for the unit (examples of voice prosthetics are tracheoesophageal valves, electrolarynges, speaking valves, and voice amplifiers). These devices are not directly attached to the patient and are a supplement for a nonverbal patient. The voice prosthetic allows the patient to use his own vocal production to communicate to other people. Evaluation for prescription of non-speech-generating augumentative and alternative communication device, face-toface with patient first hour (e.g., 92605) Evaluation for prescription of non-speech-generating augumentative and alternative communication device, each additional 30 minutes (e.g ) Evaluation of patients who are non-verbal or who do not have the capacity for verbal communication, that may need augmented communication devices for communication purposes. Augmented communication devices may include the use of a computer device, book communication, pad/writing tools, etc. Therapeutic service(s) for the use of non-speech generating device, including programming and modification (e.g., 92606) Treatment of patients who are non-verbal or who do not have the capacity for verbal communication, that may need augmented communication devices for communication purposes. Augmented communication devices may include the use of a computer device, book communication, pad/writing tools, etc. Evaluation for prescription of speech-generating devices (e.g., 92607/92608)

12 Evaluation of a patient for prescription of speech-generating devices includes evaluation of language comprehension and production across modalities: written, spoken, and gestural. This may also include evaluation of motor skills and nonverbal communication strategies (e.g. words, pictures, and vocalizations). Evaluation includes the ability to operate and effectively use a speech-generating device or aid. When a reevaluation is required of the patient using speech-generating devices or aids to supplement oral speech, assess the need for continued use or identify the need for changes in objectives, the CPT codes 92607/92608 may be used. Patient adaptation and training for use of speech-generating devices (e.g., 92609) Patient adaptation and training for use of speech-generating devices includes the development of operational competence in using a speech-generating device or aids to include customizing the features of the device to meet the specific communication needs of each patient and providing opportunities for developing skill in all aspects of device use. Evaluation of swallowing function (e.g., 92610) Clinical evaluation of swallowing function is 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 bedside clinical examination may include: a. History of the patient s disorder and awareness of the swallowing disorder, and indications of localization and the nature of the disorder b. Medical status including the 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. 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: a. The pre-swallowing assessment/preparatory examination with no swallow, and b. the initial swallow examination with actual swallow while physiology is observed Note: Based on the findings of the clinical evaluation, an instrumental examination may or may not be recommended. Despite positive clinical findings there are times when an instrumental examination may not be indicated (e.g., the patient is too medically unstable to tolerate a procedure, the patient is unable to cooperate or participate in an instrumental exam, or when in the Speech-Language Pathologist s judgment the instrumental exam would not change the clinical management of the patient). In addition, because of the documented limitations of the clinical evaluation of swallowing, there may be scenarios where despite a negative clinical examination an instrumental examination may still be indicated. In these cases, information supporting the medical necessity of the instrumental examination should be documented in the medical records. When a reevaluation is reasonable and necessary bill Evaluation of swallowing involving swallowing of radio-opaque materials (e.g., 92611) Evaluation of swallowing involving swallowing of radio-opaque materials is the evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory,

13 oral/voluntary, pharyngeal, laryngeal, and esophageal in reference to oral and pharyngeal transit times during deglutition, motility problems in the oral cavity and pharynx, and the determination of the swallowing process. The Speech Language Pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The equipment that is used in the examination may be fixed, mobile or portable. Professional guidelines recommend that the service be provided in a team setting with a physician/npp who provides supervision of the radiological examination and interpretation of medical conditions revealed in it. The instrumental examination may include: a. History of the patient s disorder and awareness of the swallowing disorder, and indications of localization and the nature of the disorder b. Medical status including the 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. Interventions used to facilitate normal swallow (compensatory strategies such as chin tuck, dietary changes, etc.) h. Presence or absence of aspiration Note: Diagnostic radiographic studies are recommended when results of the bedside or clinical evaluation are inconclusive or suggest dysphagia and/or aspiration. Endoscopic study of swallowing function (FEES) (e.g., 92612) Evaluation of swallowing (FEES) involves placement of a flexible endoscope transnasally to the hypopharynx. The procedure permits direct visualization of anatomy as well as an assessment of amplitude, speed/briskness, and symmetry of movement of the velopharyngeal sphincter, base of tongue, pharynx, and larynx. Sensation is assessed by noting the reaction of the patient to the presence of the endoscope. Findings include briskness of swallow initiation, timing of bolus flow and swallow initiation, adequacy of bolus driving/clearing forces, adequacy of velar and laryngeal valving forces, penetration and/or aspiration before or after the swallow, and the presence of hypopharyngeal reflux. The Speech Language Pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The equipment that is used in the examination may be fixed, mobile or portable. Professional guidelines recommend that the service be provided in a team setting with a physician/npp who provides supervision of the radiological examination and interpretation of medical conditions revealed in it. Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to: identifying abnormal upper

14 aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques. Sensory testing during endoscopy study of swallowing (e.g., 92614) A fiberoptic endoscopic evaluation of swallowing with sensory testing is the performance of a FEES with the incorporation of sensory testing. The sensory evaluation is completed by delivering pulses of air at sequential pressures to elicit the laryngeal adductor reflex. A sensory threshold is thus established. Motor evaluation is completed by giving various food items with different consistencies while factors such as oral transit time, inhibition of swallowing, laryngeal elevation, spillage, residue, condition of swallow, laryngeal closure, reflux, aspiration, and ability to clear residue are monitored. The entire procedure may be done at bedside. The use of anesthesia may interfere with the sensory test and is usually not indicated. Note: Other instrumental assessments may be indicated to study swallowing. The appropriateness of the assessment procedure will be based on the nature of the disorder and standard of practice. Swallowing and laryngeal sensory testing (e.g., 92616) Swallowing and laryngeal sensory testing using a flexible fiberoptic endoscope is the evaluation of swallowing and laryngeal sensory testing by cine or video recording. The Speech Language Pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The equipment that is used in the examination may be fixed, mobile or portable. Professional guidelines recommend that the service be provided in a team setting with a physician/npp who provides supervision of the radiological examination and interpretation of medical conditions revealed in it. Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques. Speech/Aural rehabilitation, and Aural rehabilitation following cochlear ear implant (e.g., 92626, 92627, and 92633) Aural rehabilitation consists of treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal (e.g. visual, auditory-visual, and tactile) training, communication strategies, education and counseling. In determining the necessity for treatment, the patient s performance in both the clinical and natural environment should be considered. Aural rehabilitation following cochlear implant includes evaluation or aural rehabilitation status and hearing, and therapeutic services with or without speech processor programming. This may include:

15 a. Extensive auditory rehabilitation therapy for patients with cochlear implants focusing on audition, cognition, language and speech skills b. Family member or caregiver training for auditory verbal techniques c. Improve patients auditory skills pertaining to the suprasegmental aspects d. Improve patients ability to discriminate and exhibit improvements in the patient s speech (manner, place and voicing) Note: Speech processor programming is usually performed by an audiologist. Cholinesterase inhibitor challenge test for myasthenia gravis (e.g., 95857) The role of the Speech-Language Pathologist is to assess the patient s speech characteristics (e.g., dysarthria, intensity, voice quality, strength, resonance and endurance in isolated word production task, conversation, and speech) during cholinesterase inhibitor challenge testing. Assessment of aphasia (e.g., 96105) Evaluation, assessment, diagnosis, and identification of a communication disorder characterized by complete or partial impairment of language comprehension, formulation and use; excluding disorders associated with primary sensory, general mental deterioration or psychiatric disorders by standardized or informal measures Developmental testing, (e.g., This includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments; with interpretation and report. Neurobehavioral status exam (e.g., 96116) This is a clinical assessment of thinking, reasoning and judgment (e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning) with interpretation and report. Standard Cognitive Performance Testing (e.g., 96125) Testing to evaluate abilities of executive (cognitive) function including: assessment of learning abilities, memory and working memory, abstract thought, language, and attention. D. General Guidelines: ( ) Note: is bundled into the payment for other services and is not separately reimbursable. 1. CPT codes require supervision (but not one-on-one) patient contact by the provider; and require direct (one-on-one) patient contact by the provider. These services may be provided incident to a physician s services and, if so, must be directly supervised by the physician in his/her office. 2. CPT codes and 97018, are not separately payable when used alone and solely to promote healing, relieve muscle spasm, reduce inflammation and edema, or as analgesia. Generally, three visits are typically necessary to determine the effectiveness of treatment and for patient education. If effective, further treatment may be self-administered in the home and it is not medically necessary to continue treatment by the provider.

16 3. Generally, adjunctive use of services listed in #2 above is required only if the patient cannot tolerate the therapeutic procedures without them. Continued use of these services may be covered if the patient s record documents that continued use contributed significantly to the patient s progress. 4. Generally, one heating service is sufficient during a physical therapy and/or occupational therapy session. Documentation of the medical necessity of multiple heating services (97018, 97024, 97026, 97034, 97035) on the same day must be available for review. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired or when dealing with particularly severe hand deformities. 5. CPT codes (whirlpool) and (Hubbard tank) are subject to the guideline in #4 above when the sole purpose of these services are to relieve muscle spasm, inflammation or edema. When or are used to treat wounds or other skin conditions, other services could be necessary to treat other conditions on the same day. 6. Some of the services are considered components of other treatments and procedures and will not be separately reimbursed. Please refer to the National Correct Coding Initiative which can be found on the CMS Website ( Documentation must be available supporting the use of multiple services as contributing to the patient s progress and restoration of function. 7. Physical agents and services, in the absence of documentation justifying use, and in the absence of other skilled therapeutic or educational interventions, should not be considered physical therapy. E. Specific Guidelines: The following clinical guidelines pertain to the specific services listed below. Please refer to the ICD-9-CM Codes That Support Medical Necessity section in this policy for appropriate covered diagnoses to be used. Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver), per day (e.g., 95992) Epley maneuver is used for the treatment of benign paroxysmal positional vertigo (BPPV). Application to one or more areas; hot or cold packs and/or ice massage (e.g., 97010) 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. The payment for hot or cold packs is bundled into the payment for other covered services and is not reimbursable. Ice massage should be reported using this code Application to one or more areas; traction, mechanical (e.g., 97012) Supervised treatment would not be expected to exceed up to 4 sessions per week for longer than one month. Patients requiring continued treatment beyond this time are usually trained in the use of a home traction unit. Continued treatment by a provider may require documentation supportive of medical necessity. This modality is typically used in conjunction with therapeutic procedures, not as an

17 isolated treatment. Application to one or more areas; electrical stimulation (unattended) (e.g., 97014) For unattended electrical stimulation HCPCS G0281 for wound care of ulcers should be used and G0283 other than wound care, as part of a therapy plan of care. For attended electrical stimulation, please refer to CPT Application to one or more areas; vasopneumatic devices (e.g., 97016) It may be necessary to reduce edema after acute injury. Education for use of lymphedema pump in the home usually requires no more than 2 sessions. Further treatment of lymphedema with a vasopneumatic device after the educational visits is generally not medically necessary. Supportive documentation for additional visits must be available for review. Application to one or more areas; paraffin bath (e.g., 97018) Also known as hot wax treatment, this is primarily used for pain relief in chronic joint problems of the wrist, hands, or feet. No more than two visits are usually sufficient to educate the patient in home use and to evaluate effectiveness. Continued treatment by a provider may require supportive documentation of medical necessity. Application to one or more areas; whirlpool therapy and dry whirlpool (e.g., 97022) The coverage criteria and definition of fluidized therapy dry heat (dry whirlpool) is found in the CMS Manual System, Pub , Medicare National Coverage Determinations, Chapter 1, Part 2, 150. Application to one or more areas; diathermy (e.g., 97024) Diathermy coverage criteria and definition are found in the CMS Manual System, Pub , Medicare National Coverage Determinations (Internet-Only Manual). Application to one or more areas; infrared (e.g., 97026) NOTE: Monochromatic infrared photo energy (MIRE ), anodyne, anodyne therapy, or similar devices are NOT covered services. Therefore, it is not appropriate to bill using when utilizing monochromatic infrared photo energy (MIRE ), anodyne, anodyne therapy, or similar devices. Please refer to the procedure code for further instructions. Application to one or more areas; ultraviolet (e.g., ) Application to one or more areas; electrical stimulation (manual), each 15 minutes (e.g., This modality includes the following types of electrical stimulation (when provided under constant attendance): Transcutaneous electrical nerve stimulation (TENS) is used primarily for pain control. No more than a single office session will be allowed for the purpose of training for in-home use. Neuromuscular stimulation: Used for retraining weak muscles following surgery or injury.

18 Muscle stimulation: This type of stimulation is taken to the point of visible muscle contraction. High voltage pulsed current, also called electrogalvanic stimulation, may be useful for reducing swelling and for control of pain. Interferential current/medium current: These units use a frequency that allows the current to go deeper. IFC is used to control swelling and pain. These uses may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures (e.g., 97110) to effect continued improvement. Electrical stimulation is typically used in conjunction with therapeutic exercises. A limited number of visits without a therapeutic procedure may be medically necessary for treatment of muscle spasm and swelling. Treatment would not be expected to exceed 4 treatments per week, for no longer than one month when used as adjunctive therapy or for muscle retraining. When electrical stimulation is used for muscle strengthening or retraining, the nerve supply to the muscle must be intact. It is not medically necessary for motor nerve disorders such as Bell s Palsy. It is not medically necessary when there is limited potential for restoration of function. Application to one or more areas; iontophoresis, each 15 minutes (e.g., ) 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 include, but are not limited to: a. The patient having tendonitis or calcific tendonitis b. The patient having bursitis c. The patient having adhesive capsulitis d. The patient having hyperhidrosis e. Thick adhesive scar(s) Application to one or more areas; contrast baths, each 15 minutes (e.g., 97034) This modality may be useful to treat extremities affected by reflex sympathetic dystrophy, acute edema resulting from trauma, or synovitis/tenosynovitis. It is generally used as an adjunct to a therapeutic procedure. Treatment would not be expected to exceed 4 treatments per week for longer than one month. Application to one or more areas; ultrasound, each 15 minutes (e.g., 97035) This modality is used primarily to treat inflammation of periarticular structures, neuromas, pain, muscle spasms, contractures, and to soften adhesive scars. Treatment would not be expected to exceed 4 treatments per week for longer than one month.

19 Application to one or more areas; Hubbard tank, each 15 minutes (e.g., 97036) This service involves the use of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds e.g., ulcers, exfoliative skin conditions. Physician or therapist supervision of the whirlpool modality is already required but especially for the following indications: The patient s condition is complicated by circulatory deficiency or The patient s condition is complicated by areas of desensitization Treatment would not be expected to exceed 4 treatments per week for longer than one month. It is not medically necessary to have more than one form of hydrotherapy during a visit (CPT codes 97022, 97036, 97113), during the same visit. Unlisted modality (specify type and time if constant attendance) (e.g., 97039) For all claims submitted for unlisted services or procedures, the following documentation must be submitted: A description of the service or procedure; and, A treatment plan including information indicating the medical necessity of the service or procedure. Electrical Stimulation, (e.g., G0281 (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. Electrical stimulation, (e.g., G0283) (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care. Electromagnetic Therapy, (e.g., G0329) 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. Note: Medicare will not cover the electromagnetic energy treatment device (Code E0761) used for electromagnetic treatment of wounds, nor will Medicare cover unsupervised home use of electromagnetic therapy. F. General Guidelines for Therapeutic Procedures (e.g., ) The following clinical guidelines pertain to the specific therapeutic procedures listed below. Please refer to the ICD-9-CM Codes That Support Medical Necessity section in this policy for appropriate covered diagnoses to be used with these 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 the practitioner have direct (one-on-one) patient contact. In physicians offices, the incident to provisions apply. 3. These procedures describe several different types of therapeutic intervention. The expected goals documented in the treatment plan, effected by the use of each of these procedures, will help define whether these procedures are medically reasonable and

20 necessary. Therefore, since any one or a combination of more than one of these procedures may be used in a treatment plan, documentation must support the use of each code as it relates to a specific therapeutic goal. 4. For , treatment would not be expected to exceed 18 visits within an 8 week period. 5. Services provided concurrently by a physician, physical therapist and occupational therapist may be covered if separate and distinct goals are documented in the treatment plans. Therapeutic procedure, one or more areas, therapeutic exercises to develop strength and endurance, range of motion and flexibility, each 15 minutes (e.g ) Therapeutic exercise is performed with a patient either actively, active-assisted, or passively (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening). The exercise may be medically reasonable and necessary for a loss or restriction of joint motion, strength, functional capacity or mobility, which has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, levels of assistance with exercise). Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (e.g ) This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkreis, Bobath, BAP's boards and desensitization techniques). The procedure may be medically 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, hypo/hypertonicity) or which cause loss of proprioception. Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises (e.g ) This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be medically reasonable and necessary for a loss or restriction of joint motion, strength, mobility, or function that has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, levels of assistance). This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers). Other forms of exercise therapy may be medically necessary in addition to aquatic therapy when the patient cannot perform land-based exercises effectively to treat his/her condition without first undergoing the aquatic therapy, or when aquatic therapy facilitates progress to land-based exercise or increased function. Documentation must be available in the record to support medical necessity. It is not medically necessary to have more than one form of hydrotherapy (codes 97022, 97036, 97113) during the same visit. Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) (e.g ) This procedure may be medically necessary for training patients whose walking abilities have been impaired by neurological, muscular or skeletal abnormalities or trauma.

21 This procedure is not medically reasonable and necessary when the patient's walking ability is not expected to improve. Repetitive walk-strengthening exercises for feeble or unstable patients or to increase endurance do not require provider supervision and will be denied as not reasonable and necessary. The medical record should document the distinct treatments rendered when gait training for a lower extremity is done during the same visit as orthotic fitting and training (97760), prosthetic training (97761), or self care/home management training (97535). Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) (e.g ) This procedure may be medically necessary as adjunctive treatment to another therapeutic procedure on the same day, which is designed to restore muscle function, reduce edema, improve joint motion, or for relief of muscle spasm. Unlisted therapeutic procedure (specify) (e.g ) For all claims submitted for unlisted services or procedures, the following documentation must be submitted: A description of the service or procedure; and, A treatment plan including information indicating the medical necessity of the service or procedure. Manual therapy techniques (e.g ) 1. Joint Mobilization (Peripheral or Spinal) This procedure may be considered reasonable and necessary if restricted joint motion and/or pain is present 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. 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 physical 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 Therapy

22 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. Therapeutic procedure(s), group (2 or more individuals) (e.g ) Since many group procedures do not require the professional skills of a provider, the need for skilled intervention must be documented and submitted upon request. Documentation must be maintained in the medical record identifying the specific treatment technique(s) used in the group, how the treatment technique will restore function, the frequency and duration of the particular group setting, and the treatment goal in the individualized plan. The number of persons in the group must also be furnished. The medical record must be made available upon request. Group therapy is defined as physical therapy services, speech-language pathology services or occupational therapy services provided simultaneously to two or more individuals by a practitioner. The individuals can be, but need not be, performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required. Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (e.g ) This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance or coordination. They require the professional skills of a provider and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and directed at a specific outcome. Cognitive skills development, direct one-on-one patient contact, each 15 minutes (e.g ) This is the developing or restoring of cognitive status (alertness, orientation, attention, memory, problem solving, recall, affect, reasoning, judgment, organization, and retention) and (informal assessment/observation of cognitive abilities necessary for performing daily activities); with interpretation and report. Compensatory training is provided to make up for a deficiency or loss of cognitive skills resulting from brain injury or psychiatric disorders. Cognitive impairments addressed by this code include attentional impairments (loss of focused, sustained, alternating and divided attention), short term memory impairments, and problem solving impairments (inability to initiate a behavioral response, to organize parts or concepts or thoughts into a whole, and to sequence thoughts so as to modify behavior). This procedure is not medically reasonable and necessary when the patient's cognitive skills are not expected to improve. This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate

23 therapeutic procedures to effect continued improvement. Sensory integrative techniques, direct (one-on-one) patient contact by, each 15 minutes (e.g ) This service may be used for patients needing oral sensory stimulation. 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 to promote well -being. These treatments are performed when a deficit in processing input from one of the sensory systems decreases the patient s ability to make adaptive sensory, motor, and behavioral responses to environmental demands. These patients may demonstrate sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems. Sensory integrative interventions enhance sensory processing by persons with deficits in sensory systems (e. g., vestibular, proprioceptive, tactile) by increasing their ability to make adaptive sensory, motor, and behavioral responses to environmental demand. Sensory integrative treatments are almost exclusively provided to a pediatric population for responses to environmental demand and are almost exclusively provided for conditions such as autism, developmental disorders, attention deficit hyperactivity disorder, cerebral palsy, and motor apraxia. Similar techniques used in treatment for adults should be coded with This procedure is not medically reasonable and necessary when the patient's sensory processing and adaptive responses are not expected to improve. This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures to effect continued improvement. Self-care/Home Management Training (e.g ) Self-care/home management training includes but is not limited to compensatory training for life participation in communication situations in home and community environments, meal preparation, safety procedures, and instructions in use of assistive technology methods/devices/adaptive equipment. This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific outcome. The patient must have the capacity to learn from instructions. Medical treatment may generally require up to 12 visits in 4 weeks. Coverage beyond 12 visits in 4 weeks may require documentation supporting the medical necessity of continued treatment. Documentation must relate the training to expected functional goals that are attainable by the patient. The medical record should document the distinct goals and service rendered when selfcare/home management training is done during the same visit as gait training (97116), orthotics fitting and training (97760) or prosthetic training (97761). Community/work reintegration (e.g ) This training may be medically necessary when performed in conjunction with a patient s individual treatment plan aimed at improving or restoring specific functions which were impaired by an identified illness or injury and when expected outcomes that are attainable

24 by the patient are specified in the plan. This training is medically necessary only when it requires the professional skills of a provider. Generally speaking, the professional skills of a provider are not required to effect improvement or restoration of function where a patient suffers a temporary loss or reduction of function which could reasonably be expected to improve as the patient gradually resumes normal activities. General activity programs and all activities which are primarily social or diversional in nature will be denied because the professional skills of a provider are not required. Services which 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. The CPT code was expanded to complement the assessment code. The modification is intended to allow the post-assessment patient fitting and training for use of the advanced technology device/adaptive equipment. The patient must have the capacity to learn from instructions. Medical treatment may generally require up to 12 visits in 4 weeks. Documentation must relate the training to expected functional goals that are attainable by the patient. Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper and lower extremity(s), and/or trunk, each 15 minutes (e.g ) 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. The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training (97116), prosthetic training (97761), or self care/home management training (97535). It is unusual to require more than 30 minutes of static orthotic training. In some cases, dynamic training may require more additional time and when this occurs the medical record must document the medical necessity of additional time. Prosthetic training, upper and/or lower extremity(s), each15 minutes (e.g ) This procedure may be considered reasonable and necessary, if there is an indication for education in the application of the prosthetic and the functional use of the prosthetic is present and documented. The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training (97116), orthotics fitting and training (97760) or self care/home management training (97535). Periodic revisits beyond the third month may require supportive documentation of medical necessity if requested. In some cases, prosthetic training may require more than 30 minutes on a given date and when this occurs the medical record must document the medical necessity of the additional time. Orthotic/Prosthetic Checkout established patient, each 15 minutes (e.g ) These assessments may be medically necessary for established patients who have already received the orthotic or prosthetic device (permanent or temporary). These assessments may be medically necessary when patients experience loss of function directly related to the orthotic or prosthetic device (e.g., pain, skin breakdown, or

25 falls). 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 need for padding, underwrap, or socks and determining the patient s tolerance to any dynamic forces being applied. Requires direct one-on-one patient contact Note: The following items are included in the Durable Medical Equipment Medicare Administrative Contractors (DMAC) reimbursement for a prosthesis/orthosis within 90 days of delivery of the prosthesis/orthosis and, therefore, are not separately billable to Medicare: a. Evaluation of the residual limb and/or gait b. Fitting of the prosthesis/orthosis c. Cost of base component parts and labor contained in HCPCS base codes d. Repairs due to normal wear or tear e. Adjustments of the prosthesis/orthosis or the prosthetic component/orthotic component made when fitting the prosthesis/orthosis or component when the adjustments are not necessitated by changes in the residual limb or the patient s functional abilities. Rehabilitation for Vision Impairment A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient's level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical and should be performed by an occupational or physical therapist. (Physical Therapy and Occupational Therapy assistants cannot perform such evaluations.) Vision impairment ranging from low vision to total blindness may result from a primary eye diagnosis, such as macular degeneration, retinitis pigmentosa or glaucoma, or as a condition secondary to another primary diagnosis, such as diabetes mellitus or acquired immune deficiency syndrome (AIDS). In accordance with established conditions, all rehabilitation services to beneficiaries with a primary vision impairment diagnosis must be provided pursuant to a written treatment plan established by a Medicare physician (including Doctors of Optometry where allowed within their State scope of practice for low vision services only), and implemented by approved Medicare providers or incident to physician services. Some of the following rehabilitation programs/services for beneficiaries with vision impairment may include Medicare covered therapeutic services: Mobility; Activities of Daily Living; and Other rehabilitation goals that are medically necessary. The patient must have a potential for restoration or improvement of lost functions, and must be expected to improve significantly within a reasonable and generally predictable amount of time. Rehabilitation services are not covered if the patient is unable to cooperate in the treatment program or if clear goals are not definable. Most rehabilitation is short term and intensive. Maintenance therapy - services required to maintain a level of functioning - are not covered. Wheelchair management/propulsion training, each 15 minutes (e.g )

26 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 as not to risk skin breakdown or a fall. 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. This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific goal. The patient and/or caregiver must have the capacity to learn from instructions. Documentation of medical necessity must be available on request for an unusual frequency or duration of training sessions. Typically no more than 4 total sessions are sufficient. When billing for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient. Work hardening/conditioning; initial 2 hours (e.g ) and Work hardening/conditioning; each additional hour (e.g ) These services are related solely to specific work skills and will be denied as not a Medicare benefit Active Wound Care Management/Debridement total wounds first 20 sq. Cm or less (e.g ); each additional 20 square centimeters (e.g ) Consistent with reasonable and necessary guidelines, providers may bill CPT codes. However, the providers should not bill codes and the or together. Note that the codes may be billed only by physicians (MDs and DOs) and qualified nonphysician practitioners (PA, NP, CNS), as defined by CMS and as allowed by individual State scope of practice. Physicians may bill and for appropriate contact. Billing for and entails all of the elements of these codes; i.e., debridement, wound assessment, and instructions for ongoing care. The simple removal and replacement of a dressing of any kind is non-selective debridement and is always bundled into another service. Do not report in conjunction with If whirlpool is used for the same wound prior to selective debridement, it is bundled into the CPT codes (97597 or 97598). However, if whirlpool is used for a different body part or body area on the same date of service than the area being debrided the service may be billed. Removal of devitalized tissue from wound(s), non-selective debridement per session (e.g ). Negative pressure wound therapy (surface area less than or equal to 50 square centimeters (e.g ). Total wound(s) (e.g ). Note: These three codes (97602, 96705, 97606) are bundled services and not separately payable by Medicare or billable to the patient.

27 Physical Performance Test or Measurement (e.g., 97750) This testing may be medically necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific treatment plan, or to determine a patient's capacity. The patient's medical record must document the problem requiring tests, the specific tests performed, and measurement report. Documentation of the need for more than 30 minutes of time should be submitted upon request. Requires direct one-on-one patient contact. Assistive technology assessment (e.g., 97755) This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific outcome. The patient must have the capacity to learn from instructions. Documentation must relate to the assessment of the expected functional goals that are attainable by the patient. Requires direct one-on-one patient contact. Unlisted physical medicine/rehabilitation service or procedure (e.g., 97799) For all claims submitted for unlisted services or procedures, the following documentation must be submitted: A description of the service or procedure; and, A treatment plan including information indicating the medical necessity of the service or procedure Microamperage E-stimulation (MENS) has not been proven effective and will be denied as such. If MENS therapy is billed to Medicare for a denial, such as in cases of supplemental coverage, providers should bill using procedure code 97799, placing MENS therapy in Item 19 on the CMS 1500 form or equivalent electronic field. An Advance Beneficiary Notice of Noncoverage (ABN) should be obtained when MENS is utilized. Vertebral Axial Decompression (VAX-D ) Vertebral Axial Decompression (VAX-D ) is not covered by Medicare. Medicare notes that there is insufficient scientific data to support a finding of significant benefits of this technique. If billing for a denial for the provision of this service, you must use procedure code 97799, Unlisted physical medicine/rehabilitation service or procedure, and enter "VAX-D " in Item 19 on the CMS 1500 claim form, or electronic equivalent. An Advance Beneficiary Notice of Noncoverage (ABN) should be obtained when VAX-D is utilized. DO NOT bill using 64722, decompression, unspecified nerves, or 97012, application of service, traction, mechanical MedX or SPINEX or DRX9000 This A/B MAC, based on the advice of Physical Therapy consultants, considers MedX or SPINEX or DRX9000 treatments to also be non-covered, and such services will be denied as not proven effective. Use procedure code 97799, Unlisted physical medicine/rehabilitation service or procedure, and enter "MedX" or SPINEX or DRX90000 in Item 19 on the CMS 1500 claim form, or electronic equivalent. An Advance Beneficiary Notice of Noncoverage (ABN) should be obtained when MedX or SPINEX are utilized.

28 This A/B MAC will deny VAX-D, MedX, SPINEX and other similar devices as not proven effective. Providers may not bill the beneficiary unless the provider has previously informed the beneficiary that this service will be denied by Medicare and has obtained his/her signature on a valid Advance Beneficiary Notice of Noncoverage(ABN) before providing this service. Monochromatic infrared photo energy (MIRE ), anodyne, anodyne therapy, or similar devices are NOT covered services. Use procedure code 97799, Unlisted physical medicine/rehabilitation service or procedure, and enter "monochromatic infrared photo energy (MIRE ), anodyne, anodyne therapy, or similar devices" in Item 19 on the CMS 1500 claim form, or in the equivalent field on the electronic claims. This A/B MAC will deny this service as not proven effective. E-Stim (Vital Stim) for speech-language therapy for dysphagia or late effects CVA dysphasia has not been proven effective and will be denied as such. Currently there is limited literature supporting the use of E-Stim for dysphagia, therefore, it remains investigational and non-covered by Medicare. Please refer to the procedure code for further instructions. Acupuncture, without electrical stimulation, initial 15 minutes or personal one-onone contact with the patient (e.g., 97810) Acupuncture each additional 15 minutes, with re-insertion of needle(s)(e.g., 97811) Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes (e.g., 97813) Acupunctue each additional 15 minutes, with re-insertion of needle(s)(e.g., 97814) NOTE: These four codes (97810, 97811, 97813, 97814) are not covered services by Medicare. Back to Top 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. 999x Not Applicable 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.

29 99999 Not Applicable CPT/HCPCS Codes Please note that the following codes are non-covered for Medicare Part B: Noncovered by Medicare "I" Status not valid for Medicare "I" Status not valid for Medicare "B Status" Bundled Service, cannot be separately billed to Medicare Replaced with G0281 for wound care and for ulcers and G0283 for other than wound c of a therapy plan of care Restricted code not covered by Medicare Restricted code not covered by Medicare Noncovered Service Noncovered Service Noncovered Service Noncovered Service G0282 Noncovered Service The following CPT/HCPCS codes addressed in this policy are the CPT/HCPCS codes that are considered for reimbursement under the Medicare Part B program. Consult your current CPT book for complete descriptions Diagnostic laryngoscopy Speech/hearing evaluation Speech/hearing therapy Speech/hearing therapy Nasopharyngoscopy Nasal function studies Laryngeal function studies Oral function therapy Posturography Oral speech device eval Ex for nonspeech device rx Non-speech device service Ex for speech device rx 1hr Ex for speech device rx addl Use of speech device service

30 92610 Evaluate swallowing function Motion fluoroscopy/swallow Endoscopy swallow tst (fees) Laryngoscopic sensory test Fees w/laryngeal sense test Ex for nonspeech dev rx add Eval aud rehab status Eval aud status rehab add-on Aud rehab pre-ling hear loss Aud rehab postling hear loss Limb muscle testing manual Hand muscle testing manual Cholinesterase challenge Canalith repositioning proc Assessment of aphasia Developmental test extend Neurobehavioral status exam Cognitive test by hc pro Pt evaluation Pt re-evaluation Ot evaluation Ot re-evaluation Mechanical traction therapy Vasopneumatic device therapy Paraffin bath therapy Whirlpool therapy Diathermy eg microwave

31 97028 Ultraviolet therapy Electrical stimulation Electric current therapy Contrast bath therapy Ultrasound therapy Hydrotherapy Physical therapy treatment Therapeutic exercises Neuromuscular reeducation Aquatic therapy/exercises Gait training therapy Massage therapy Physical medicine procedure Manual therapy Group therapeutic procedures Therapeutic activities Cognitive skills development Sensory integration Self care mngment training Community/work reintegration Wheelchair mngment training Rmvl devital tis 20 cm/< Rmvl devital tis addl 20 cm< Wound(s) care non-selective Neg press wound tx < 50 cm Neg press wound tx > 50 cm Physical performance test

32 97755 Assistive technology assess Orthotic mgmt and training Prosthetic training C/o for orthotic/prosth use Physical medicine procedure G0281 G0283 G0329 Elec stim unattend for press Elec stim other than wound Electromagntic tx for ulcers ICD-9 Codes that Support Medical Necessity 138 LATE EFFECTS OF ACUTE POLIOMYELITIS DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE MUSCULOSKELETAL MALFUNCTION ARISING FROM MENTAL FACTORS ADULT ONSET FLUENCY DISORDER TOURETTE S DISORDER EATING DISORDER UNSPECIFIED OTHER DISORDERS OF EATING OTHER AND UNSPECIFIED SPECIAL SYMPTOMS OR SYNDROMES NOT ELSEWHERE CLASSIFIED PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE POSTCONCUSSION SYNDROME DEVELOPMENTAL READING DISORDER UNSPECIFIED - OTHER SPECIFIC DEVELOPMENTAL READING DISORDER MATHEMATICS DISORDER EXPRESSIVE LANGUAGE DISORDER

33 MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER SPEECH AND LANGUAGE DEVELOPMENTAL DELAY DUE TO HEARING LOSS CHILDHOOD ONSET FLUENCY DISORDER OTHER DEVELOPMENTAL SPEECH DISORDER DEVELOPMENTAL COORDINATION DISORDER MIXED DEVELOPMENT DISORDER OTHER SPECIFIED DELAYS IN DEVELOPMENT CORTICOBASAL DEGENERATION GENETIC TORSION DYSTONIA ATHETOID CEREBRAL PALSY ACUTE DYSTONIA DUE TO DRUGS OTHER ACQUIRED TORSION DYSTONIA OROFACIAL DYSKINESIA 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 THE LOWER LIMB REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE

34 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE 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 CONGENITAL HEMIPLEGIA CONGENITAL QUADRIPLEGIA CONGENITAL MONOPLEGIA 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

35 OTHER QUADRIPLEGIA PARAPLEGIA DIPLEGIA OF UPPER LIMBS MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT 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 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

36 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 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS

37 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 ANOXIC BRAIN DAMAGE

38 BELL'S PALSY - FACIAL NERVE DISORDER UNSPECIFIED GLOSSOPHARYNGEAL NEURALGIA - OTHER DISORDERS OF GLOSSOPHARYNGEAL (9TH) NERVE BRACHIAL PLEXUS LESIONS LUMBOSACRAL PLEXUS LESIONS CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED NEURALGIC AMYOTROPHY PHANTOM LIMB (SYNDROME) OTHER NERVE ROOT AND PLEXUS DISORDERS UNSPECIFIED NERVE ROOT AND PLEXUS DISORDER CARPAL TUNNEL SYNDROME OTHER LESION OF MEDIAN NERVE LESION OF ULNAR NERVE LESION OF RADIAL NERVE CAUSALGIA OF UPPER LIMB MONONEURITIS MULTIPLEX OTHER MONONEURITIS OF UPPER LIMB MONONEURITIS OF UPPER LIMB UNSPECIFIED LESION OF SCIATIC NERVE MERALGIA PARESTHETICA OTHER LESION OF FEMORAL NERVE LESION OF LATERAL POPLITEAL NERVE LESION OF MEDIAL POPLITEAL NERVE TARSAL TUNNEL SYNDROME LESION OF PLANTAR NERVE

39 CAUSALGIA OF LOWER LIMB OTHER MONONEURITIS OF LOWER LIMB MONONEURITIS OF UNSPECIFIED SITE HEREDITARY PERIPHERAL NEUROPATHY PERONEAL MUSCULAR ATROPHY HEREDITARY SENSORY NEUROPATHY REFSUM'S DISEASE IDIOPATHIC PROGRESSIVE POLYNEUROPATHY OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY ACUTE INFECTIVE POLYNEURITIS POLYNEUROPATHY IN DIABETES MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION MYASTHENIA GRAVIS WITH (ACUTE) EXACERBATION TOXIC MYONEURAL DISORDERS LAMBERT-EATON SYNDROME, UNSPECIFIED LAMBERT-EATON SYNDROME IN NEOPLASTIC DISEASE LAMBERT-EATON SYNDROME IN OTHER DISEASES CLASSIFIED ELSEWHERE OTHER SPECIFIED MYONEURAL DISORDERS MYONEURAL DISORDERS UNSPECIFIED CONGENITAL HEREDITARY MUSCULAR DYSTROPHY HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY MYOTONIC MUSCULAR DYSTROPHY MYOTONIA CONGENITAL MYOTONIC CHONDRODYSTROPHY DRUG INDUCED MYOTONIA

40 OTHER SPECIFIED MYOTONIC DISORDER PERIODIC PARALYSIS TOXIC MYOPATHY 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: NOT FURTHER SPECIFIED 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: NOT FURTHER SPECIFIED 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: BLIND NOT FURTHER SPECIFIED 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

41 BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: BLIND NOT FURTHER SPECIFIED 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; IMPAIRMENT NOT FURTHER SPECIFIED BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: SEVERE VISION IMPAIRMENT BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: IMPAIRMENT NOT FURTHER SPECIFIED BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: SEVERE VISION IMPAIRMENT BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: MODERATE VISION IMPAIRMENT UNQUALIFIED VISUAL LOSS BOTH EYES LEGAL BLINDNESS AS DEFINED IN U.S.A BLINDNESS ONE EYE NOT OTHERWISE SPECIFIED ONE EYE: TOTAL VISION IMPAIRMENT; OTHER EYE: NOT SPECIFIED ONE EYE: TOTAL VISION IMPAIRMENT; OTHER EYE: NEAR-NORMAL VISION ONE EYE: TOTAL VISION IMPAIRMENT; OTHER EYE: NORMAL VISION ONE EYE: NEAR-TOTAL VISION IMPAIRMENT; OTHER EYE: VISION NOT SPECIFIED ONE EYE: NEAR-TOTAL VISION IMPAIRMENT; OTHER EYE: NEAR- NORMAL VISION ONE EYE: NEAR-TOTAL VISION IMPAIRMENT; OTHER EYE: NORMAL VISION ONE EYE: PROFOUND VISION IMPAIRMENT; OTHER EYE: VISION NOT SPECIFIED

42 ONE EYE: PROFOUND VISION IMPAIRMENT; OTHER EYE: NEAR- NORMAL VISION ONE EYE: PROFOUND VISION IMPAIRMENT; OTHER EYE: NORMAL VISION LOW VISION ONE EYE NOT OTHERWISE SPECIFIED ONE EYE: SEVERE VISION IMPAIRMENT; OTHER EYE: VISION NOT SPECIFIED ONE EYE: SEVERE VISION IMPAIRMENT; OTHER EYE: NEAR- NORMAL VISION ONE EYE: SEVERE VISION IMPAIRMENT; OTHER EYE: NORMAL VISION ONE EYE: MODERATE VISION IMPAIRMENT; OTHER EYE: VISION NOT SPECIFIED ONE EYE: MODERATE VISION IMPAIRMENT; OTHER EYE: NEAR- NORMAL VISION ONE EYE: MODERATE VISION IMPAIRMENT; OTHER EYE: NORMAL VISION UNQUALIFIED VISUAL LOSS ONE EYE UNSPECIFIED VISUAL LOSS BENIGN PAROXYSMAL POSITIONAL VERTIGO ABNORMAL AUDITORY PERCEPTION UNSPECIFIED DIPLACUSIS IMPAIRMENT OF AUDITORY DISCRIMINATION ACQUIRED AUDITORY PROCESSING DISORDER CONDUCTIVE HEARING LOSS UNSPECIFIED - CONDUCTIVE HEARING LOSS INNER EAR CONDUCTIVE HEARING LOSS, UNILATERAL CONDUCTIVE HEARING LOSS, BILATERAL CONDUCTIVE HEARING LOSS OF COMBINED TYPES SENSORINEURAL HEARING LOSS UNSPECIFIED SENSORY HEARING LOSS, BILATERAL NEURAL HEARING LOSS, BILATERAL

43 NEURAL HEARING LOSS, UNILATERAL CENTRAL HEARING LOSS SENSORINEURAL HEARING LOSS, UNILATERAL SENSORINEURAL HEARING LOSS, ASYMMETRICAL SENSORY HEARING LOSS, UNILATERAL SENSORINEURAL HEARING LOSS, BILATERAL MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, BILATERAL DEAF, NONSPEAKING, NOT ELSEWHERE CLASSIFIABLE COGNITIVE DEFICITS SPEECH AND LANGUAGE DEFICIT UNSPECIFIED APHASIA DYSPHASIA LATE EFFECTS OF CEREBROVASCULAR DISEASE, DYSARTHRIA LATE EFFECTS OF CEREBROVASCULAR DISEASE, FLUENCY DISORDER OTHER SPEECH AND LANGUAGE 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

44 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 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER VARICOSE VEINS OF LOWER EXTREMITIES WITH INFLAMMATION VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION VARICOSE VEINS OF LOWER EXTREMITIES WITH OTHER COMPLICATIONS POSTMASTECTOMY LYMPHEDEMA SYNDROME OTHER LYMPHEDEMA POSTPHLEBETIC SYNDROME WITH ULCER POSTPHLEBETIC SYNDROME WITH ULCER AND INFLAMMATION CHRONIC VENOUS HYPERTENSION WITH ULCER CHRONIC VENOUS HYPERTENSION WITH ULCER AND INFLAMMATION CHRONIC LARYNGITIS - CHRONIC LARYNGOTRACHEITIS

45 UNSPECIFIED DISEASE OF PHARYNX - OTHER DISEASES OF PHARYNX OR NASOPHARYNX UNSPECIFIED PARALYSIS OF VOCAL CORDS - COMPLETE BILATERAL PARALYSIS OF VOCAL CORDS POLYP OF VOCAL CORD OR LARYNX OTHER DISEASES OF VOCAL CORDS EDEMA OF LARYNX UNSPECIFIED DISEASE OF LARYNX - OTHER DISEASES OF LARYNX BRONCHIECTASIS WITHOUT ACUTE EXACERBATION BRONCHIECTASIS WITH ACUTE EXACERBATION 496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED PNEUMONITIS DUE TO INHALATION OF FOOD OR VOMITUS 514 PULMONARY CONGESTION AND HYPOSTASIS UNSPECIFIED ANOMALY OF DENTAL ARCH RELATIONSHIP MALOCCLUSION, ANGLE S CLASS I - OTHER ANOMALIES OF DENTAL ARCH RELATIONSHIP DENTOFACIAL FUNCTIONAL ABNORMALITY, UNSPECIFIED TEMPOROMANDIBULAR JOINT DISORDERS UNSPECIFIED TEMPOROMANDIBULAR JOINT DISORDERS ADHESIONS AND ANKYLOSIS (BONY OR FIBROUS) TEMPOROMANDIBULAR JOINT DISORDERS ARTHRALGIA OF TEMPOROMANDIBULAR JOINT TEMPOROMANDIBULAR JOINT DISORDERS ARTICULAR DISC DISORDER (REDUCING OR NON-REDUCING) TEMPOROMANDIBULAR JOINT SOUNDS ON OPENING AND/OR CLOSING THE JAW TEMPOROMANDIBULAR JOINT DISORDERS OTHER SPECIFIED TEMPOROMANDIBULAR JOINT DISORDERS OTHER SPECIFIED CONDITIONS OF THE TONGUE ACHALASIA AND CARDIOSPASM STRICTURE AND STENOSIS OF ESOPHAGUS

46 530.6 DIVERTICULUM OF ESOPHAGUS ACQUIRED ESOPHAGEAL REFLUX INTRINSIC (URETHRAL) SPHINCTER DEFICIENCY [ISD] EDEMA OF PENIS OTHER SPECIFIED DISORDERS OF PENIS EDEMA OF MALE GENITAL ORGANS MASTODYNIA OTHER SPECIFIED NONINFLAMMATORY DISORDERS OF VULVA AND PERINEUM STRESS INCONTINENCE FEMALE DAMAGE TO PELVIC JOINTS AND LIGAMENTS WITH DELIVERY DAMAGE TO PELVIC JOINTS AND LIGAMENTS POSTPARTUM UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER - ONYCHIA AND PARONYCHIA OF TOE CELLULITIS AND ABSCESS OF FACE - CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES 683 ACUTE LYMPHADENITIS CONTACT DERMATITIS AND OTHER ECZEMA UNSPECIFIED CAUSE OTHER PSORIASIS AND SIMILAR DISORDERS 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

47 PRESSURE ULCER, HEEL PRESSURE ULCER, OTHER SITE UNSPECIFIED ULCER OF LOWER LIMB ULCER OF THIGH - 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 PYOGENIC ARTHRITIS INVOLVING SHOULDER REGION PYOGENIC ARTHRITIS INVOLVING UPPER ARM PYOGENIC ARTHRITIS INVOLVING FOREARM PYOGENIC ARTHRITIS INVOLVING HAND PYOGENIC ARTHRITIS INVOLVING PELVIC REGION AND THIGH PYOGENIC ARTHRITIS INVOLVING LOWER LEG PYOGENIC ARTHRITIS INVOLVING ANKLE AND FOOT PYOGENIC ARTHRITIS INVOLVING OTHER SPECIFIED SITES PYOGENIC ARTHRITIS INVOLVING MULTIPLE SITES ARTHROPATHY SITE UNSPECIFIED ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY INVOLVING UPPER ARM ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS

48 ARTHROPATHY INVOLVING FOREARM ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY INVOLVING HAND ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY INVOLVING PELVIC REGION AND THIGH ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY INVOLVING LOWER LEG ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY INVOLVING OTHER SPECIFIED SITES ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY INVOLVING MULTIPLE SITES ASSOCIATED WITH REITER'S DISEASE AND NONSPECIFIC URETHRITIS ARTHROPATHY IN BEHCET'S SYNDROME SITE UNSPECIFIED ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING SHOULDER REGION ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING UPPER ARM ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING FOREARM ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING HAND ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING PELVIC REGION AND THIGH ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING LOWER LEG ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING ANKLE AND FOOT ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING OTHER SPECIFIED SITES ARTHROPATHY IN BEHCET'S SYNDROME INVOLVING MULTIPLE SITES POSTDYSENTERIC ARTHROPATHY SITE UNSPECIFIED POSTDYSENTERIC ARTHROPATHY INVOLVING SHOULDER REGION POSTDYSENTERIC ARTHROPATHY INVOLVING UPPER ARM POSTDYSENTERIC ARTHROPATHY INVOLVING FOREARM

49 POSTDYSENTERIC ARTHROPATHY INVOLVING HAND POSTDYSENTERIC ARTHROPATHY INVOLVING PELVIC REGION AND THIGH POSTDYSENTERIC ARTHROPATHY INVOLVING LOWER LEG POSTDYSENTERIC ARTHROPATHY INVOLVING ANKLE AND FOOT POSTDYSENTERIC ARTHROPATHY INVOLVING OTHER SPECIFIED SITES POSTDYSENTERIC ARTHROPATHY INVOLVING MULTIPLE SITES ARTHROPATHY SITE UNSPECIFIED ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING UPPER ARM ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING FOREARM ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING HAND ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING PELVIC REGION AND THIGH ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING LOWER LEG ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH OTHER BACTERIAL DISEASE ARTHROPATHY INVOLVING OTHER SPECIFIED SITES ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY INVOLVING MULTIPLE SITES ASSOCIATED WITH OTHER BACTERIAL DISEASES ARTHROPATHY SITE UNSPECIFIED ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY INVOLVING UPPER ARM ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY INVOLVING FOREARM ASSOCIATED WITH OTHER VIRAL DISEASES

50 ARTHROPATHY INVOLVING HAND ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY INVOLVING PELVIC REGION AND THIGH ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY INVOLVING LOWER LEG ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY INVOLVING OTHER SPECIFIED SITES ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY INVOLVING MULTIPLE SITES ASSOCIATED WITH OTHER VIRAL DISEASES ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS RHEUMATOID ARTHRITIS - OTHER SPECIFIED INFLAMMATORY POLYARTHROPATHIES 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 OLD BUCKET HANDLE TEAR OF MEDIAL MENISCUS - OTHER INTERNAL DERANGEMENT OF KNEE UNSPECIFIED INTERNAL DERANGEMENT OF KNEE ARTICULAR CARTILAGE DISORDER SITE UNSPECIFIED ARTICULAR CARTILAGE DISORDER INVOLVING SHOULDER REGION ARTICULAR CARTILAGE DISORDER INVOLVING UPPER ARM ARTICULAR CARTILAGE DISORDER INVOLVING FOREARM ARTICULAR CARTILAGE DISORDER INVOLVING HAND ARTICULAR CARTILAGE DISORDER INVOLVING PELVIC REGION AND THIGH

51 ARTICULAR CARTILAGE DISORDER INVOLVING ANKLE AND FOOT ARTICULAR CARTILAGE DISORDER INVOLVING OTHER SPECIFIED SITES ARTICULAR CARTILAGE DISORDER INVOLVING MULTIPLE SITES LOOSE BODY IN JOINT SITE UNSPECIFIED LOOSE BODY IN JOINT OF SHOULDER REGION LOOSE BODY IN UPPER ARM JOINT LOOSE BODY IN FOREARM JOINT 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 OTHER SPECIFIED SITES LOOSE BODY IN JOINT OF MULTIPLE SITES PATHOLOGICAL DISLOCATION OF JOINT SITE UNSPECIFIED - PATHOLOGICAL DISLOCATION OF JOINT OF MULTIPLE SITES RECURRENT DISLOCATION OF JOINT SITE UNSPECIFIED - RECURRENT DISLOCATION OF JOINT OF MULTIPLE SITES CONTRACTURE OF JOINT SITE UNSPECIFIED CONTRACTURE OF JOINT OF SHOULDER REGION - CONTRACTURE OF JOINT OF MULTIPLE SITES ANKYLOSIS OF JOINT SITE UNSPECIFIED ANKYLOSIS OF JOINT OF SHOULDER REGION - 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 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 MULTIPLE SITES

52 UNSPECIFIED DERANGEMENT OF JOINT SITE UNSPECIFIED UNSPECIFIED DERANGEMENT OF JOINT OF SHOULDER REGION UNSPECIFIED DERANGEMENT OF UPPER ARM JOINT UNSPECIFIED DERANGEMENT OF FOREARM JOINT UNSPECIFIED DERANGEMENT OF HAND JOINT UNSPECIFIED DERANGEMENT OF JOINT OF PELVIC REGION AND THIGH UNSPECIFIED DERANGEMENT OF ANKLE AND FOOT JOINT UNSPECIFIED DERANGEMENT OF JOINT OF OTHER SPECIFIED SITES UNSPECIFIED DERANGEMENT OF JOINT OF MULTIPLE SITES EFFUSION OF JOINT SITE UNSPECIFIED - UNSPECIFIED JOINT DISORDER OF MULTIPLE SITES ANKYLOSING SPONDYLITIS SPINAL ENTHESOPATHY SACROILIITIS NOT ELSEWHERE CLASSIFIED INFLAMMATORY SPONDYLOPATHIES IN DISEASES CLASSIFIED ELSEWHERE OTHER INFLAMMATORY SPONDYLOPATHIES UNSPECIFIED INFLAMMATORY SPONDYLOPATHY CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY - SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY DISPLACEMENT OF THORACIC INTERVERTEBRAL DISC WITHOUT MYELOPATHY DISPLACEMENT OF INTERVERTEBRAL DISC SITE UNSPECIFIED WITHOUT MYELOPATHY - INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION POSTLAMINECTOMY SYNDROME OF UNSPECIFIED REGION

53 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION POSTLAMINECTOMY SYNDROME OF THORACIC REGION POSTLAMINECTOMY SYNDROME OF LUMBAR REGION OTHER AND UNSPECIFIED DISC DISORDER OF UNSPECIFIED REGION OTHER AND UNSPECIFIED DISC DISORDER OF CERVICAL REGION OTHER AND UNSPECIFIED DISC DISORDER OF THORACIC REGION OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION SPINAL STENOSIS IN CERVICAL REGION CERVICALGIA CERVICOCRANIAL SYNDROME CERVICOBRACHIAL SYNDROME (DIFFUSE) BRACHIAL NEURITIS OR RADICULITIS NOS TORTICOLLIS UNSPECIFIED OSSIFICATION OF POSTERIOR LONGITUDINAL LIGAMENT IN CERVICAL REGION OTHER SYNDROMES AFFECTING CERVICAL REGION UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION PAIN IN THORACIC SPINE LUMBAGO SCIATICA THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED BACKACHE UNSPECIFIED DISORDERS OF SACRUM UNSPECIFIED DISORDER OF COCCYX

54 HYPERMOBILITY OF COCCYX OTHER DISORDERS OF COCCYX OTHER SYMPTOMS REFERABLE TO BACK OTHER UNSPECIFIED BACK DISORDERS 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 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 ENTHESOPATHY OF ANKLE AND TARSUS OTHER PERIPHERAL ENTHESOPATHIES ENTHESOPATHY OF UNSPECIFIED SITE - EXOSTOSIS OF UNSPECIFIED SITE SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED SYNOVITIS AND TENOSYNOVITIS IN DISEASES CLASSIFIED ELSEWHERE GIANT CELL TUMOR OF TENDON SHEATH TRIGGER FINGER (ACQUIRED)

55 RADIAL STYLOID TENOSYNOVITIS OTHER TENOSYNOVITIS OF HAND AND WRIST TENOSYNOVITIS OF FOOT AND ANKLE OTHER SYNOVITIS AND TENOSYNOVITIS SPECIFIC BURSITIDES OFTEN OF OCCUPATIONAL ORIGIN OTHER BURSITIS DISORDERS SYNOVIAL CYST 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 OTHER TENDON CONTRACTURE OF TENDON (SHEATH) CALCIUM DEPOSITS IN TENDON AND BURSA PLICA SYNDROME OTHER DISORDERS OF SYNOVIUM TENDON AND BURSA UNSPECIFIED DISORDER OF SYNOVIUM TENDON AND BURSA CALCIFICATION AND OSSIFICATION UNSPECIFIED - OTHER MUSCULAR CALCIFICATION AND OSSIFICATION MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED OTHER SPECIFIC MUSCLE DISORDERS LAXITY OF LIGAMENT HYPERMOBILITY SYNDROME CONTRACTURE OF PALMAR FASCIA PLANTAR FASCIAL FIBROMATOSIS OTHER FIBROMATOSES OF MUSCLE LIGAMENT AND FASCIA INTERSTITIAL MYOSITIS - OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA RHEUMATISM UNSPECIFIED AND FIBROSITIS

56 729.1 MYALGIA AND MYOSITIS UNSPECIFIED NEURALGIA NEURITIS AND RADICULITIS UNSPECIFIED FASCIITIS UNSPECIFIED PAIN IN LIMB NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY NONTRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY SWELLING OF LIMB CRAMP OF LIMB OTHER MUSCULOSKELETAL SYMPTOMS REFERABLE TO LIMBS DISORDERS OF SOFT TISSUE, UNSPECIFIED - OTHER DISORDERS OF SOFT TISSUE OSTEITIS DEFORMANS WITHOUT BONE TUMOR MAJOR OSSEOUS DEFECTS JUVENILE OSTEOCHONDROSIS OF SPINE - UNSPECIFIED OSTEOCHONDROPATHY PATHOLOGICAL FRACTURE UNSPECIFIED SITE - PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE ASEPTIC NECROSIS OF BONE SITE UNSPECIFIED ASEPTIC NECROSIS OF HEAD OF HUMERUS - ASEPTIC NECROSIS OF OTHER BONE SITES OSTEITIS CONDENSANS MALUNION OF FRACTURE NONUNION OF FRACTURE DISORDER OF BONE AND CARTILAGE UNSPECIFIED ARREST OF BONE DEVELOPMENT OR GROWTH CHONDROMALACIA STRESS FRACTURE OF TIBIA OR FIBULA STRESS FRACTURE OF THE METATARSALS

57 STRESS FRACTURE OF OTHER BONE STRESS FRACTURE OF FEMORAL NECK STRESS FRACTURE OF SHAFT OF FEMUR STRESS FRACTURE OF PELVIS OTHER DISORDERS OF BONE AND CARTILAGE 734 FLAT FOOT HALLUX VALGUS (ACQUIRED) - UNSPECIFIED ACQUIRED DEFORMITY OF TOE UNSPECIFIED DEFORMITY OF FOREARM EXCLUDING FINGERS CUBITUS VALGUS (ACQUIRED) CUBITUS VARUS (ACQUIRED) VALGUS DEFORMITY OF WRIST (ACQUIRED) VARUS DEFORMITY OF WRIST (ACQUIRED) WRIST DROP (ACQUIRED) CLAW HAND (ACQUIRED) CLUB HAND ACQUIRED OTHER ACQUIRED DEFORMITIES OF FOREARM EXCLUDING FINGERS MALLET FINGER UNSPECIFIED DEFORMITY OF FINGER BOUTONNIERE DEFORMITY SWAN-NECK DEFORMITY OTHER ACQUIRED DEFORMITIES OF FINGER UNSPECIFIED ACQUIRED DEFORMITY OF HIP COXA VALGA (ACQUIRED) COXA VARA (ACQUIRED) OTHER ACQUIRED DEFORMITIES OF HIP GENU VALGUM (ACQUIRED)

58 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 CAVUS DEFORMITY OF FOOT ACQUIRED CLAW FOOT ACQUIRED CAVOVARUS 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) - OTHER KYPHOSIS ACQUIRED LORDOSIS (ACQUIRED) (POSTURAL) - UNSPECIFIED CURVATURE OF SPINE ASSOCIATED WITH OTHER CONDITIONS ACQUIRED MUSCULOSKELETAL DEFORMITY OF OTHER SPECIFIED SITE ACQUIRED MUSCULOSKELETAL DEFORMITY OF UNSPECIFIED SITE OTHER CONGENITAL ANOMALIES OF LARYNX TRACHEA AND BRONCHUS CLEFT PALATE UNSPECIFIED - CLEFT PALATE BILATERAL INCOMPLETE CLEFT LIP UNSPECIFIED - CLEFT LIP BILATERAL INCOMPLETE CLEFT PALATE WITH CLEFT LIP UNSPECIFIED - OTHER COMBINATIONS OF CLEFT PALATE WITH CLEFT LIP TONGUE TIE

59 CONGENITAL ANOMALY OF TONGUE UNSPECIFIED - OTHER CONGENITAL ANOMALIES OF TONGUE 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 REDUCTION DEFORMITY OF LOWER LIMB CONGENITAL - LONGITUDINAL DEFICIENCY PHALANGES COMPLETE OR PARTIAL UNSPECIFIED ANOMALY OF UPPER LIMB CONGENITAL CONGENITAL DEFORMITY OF CLAVICLE CONGENITAL ELEVATION OF SCAPULA RADIOULNAR SYNOSTOSIS MADELUNG'S DEFORMITY ACROCEPHALOSYNDACTYLY ACCESSORY CARPAL BONES MACRODACTYLIA (FINGERS)

60 CLEFT HAND CONGENITAL OTHER CONGENITAL ANOMALIES OF UPPER LIMB INCLUDING SHOULDER GIRDLE UNSPECIFIED CONGENITAL ANOMALY OF LOWER LIMB COXA VALGA CONGENITAL COXA VARA CONGENITAL OTHER CONGENITAL DEFORMITY OF HIP (JOINT) CONGENITAL DEFORMITY OF KNEE (JOINT) CONGENITAL ANOMALY OF SPINE UNSPECIFIED - OTHER CONGENITAL ANOMALIES OF SPINE HEREDITARY EDEMA OF LEGS DIZZINESS AND GIDDINESS OTHER GENERAL SYMPTOMS ABNORMAL INVOLUNTARY MOVEMENTS ABNORMALITY OF GAIT LACK OF COORDINATION TRANSIENT PARALYSIS OF LIMB NEUROLOGIC NEGLECT SYNDROME ABNORMAL POSTURE 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

61 DELAYED MILESTONES ADULT FAILURE TO THRIVE HEADACHE APHASIA VOICE AND RESONANCE DISORDER, UNSPECIFIED APHONIA DYSPHONIA OTHER VOICE AND RESONANCE DISORDERS DYSARTHRIA FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE OTHER SPEECH DISTURBANCE SYMBOLIC DYSFUNCTION UNSPECIFIED - OTHER SYMBOLIC DYSFUNCTION OTHER SYMPTOMS INVOLVING HEAD AND NECK GANGRENE STRIDOR COUGH 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)

62 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 CLOSED FRACTURE OF FIRST CERVICAL VERTEBRA - CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF ONE RIB - CLOSED FRACTURE OF EIGHT OR MORE RIBS CLOSED FRACTURE OF STERNUM CLOSED FRACTURE OF LARYNX AND TRACHEA - OPEN FRACTURE OF LARYNX AND TRACHEA CLOSED FRACTURE OF ACETABULUM CLOSED FRACTURE OF PUBIS CLOSED FRACTURE OF ILIUM CLOSED FRACTURE OF ISCHIUM MULTIPLE CLOSED PELVIC FRACTURES WITH DISRUPTION OF PELVIC CIRCLE MULTIPLE CLOSED PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE CLOSED FRACTURE OF OTHER SPECIFIED PART OF PELVIS

63 MULTIPLE OPEN PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE FRACTURE OF BONES OF TRUNK CLOSED FRACTURE OF BONES OF TRUNK OPEN CLOSED FRACTURE OF CLAVICLE UNSPECIFIED PART CLOSED FRACTURE OF STERNAL END OF CLAVICLE CLOSED FRACTURE OF SHAFT OF CLAVICLE CLOSED FRACTURE OF ACROMIAL END OF CLAVICLE OPEN FRACTURE OF CLAVICLE UNSPECIFIED PART OPEN FRACTURE OF STERNAL END OF CLAVICLE OPEN FRACTURE OF SHAFT OF CLAVICLE OPEN FRACTURE OF ACROMIAL END OF CLAVICLE CLOSED FRACTURE OF SCAPULA UNSPECIFIED PART CLOSED FRACTURE OF ACROMIAL PROCESS OF SCAPULA CLOSED FRACTURE OF CORACOID PROCESS OF SCAPULA CLOSED FRACTURE OF GLENOID CAVITY AND NECK 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 FRACTURE OF LOWER END OF HUMERUS OPEN CLOSED FRACTURE OF UPPER END OF FOREARM UNSPECIFIED FRACTURE OF OLECRANON PROCESS OF ULNA CLOSED - 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 CLOSED FRACTURE OF BASE OF THUMB (FIRST) METACARPAL CLOSED FRACTURE OF BASE OF OTHER METACARPAL BONE(S)

64 CLOSED FRACTURE OF SHAFT OF METACARPAL BONE(S) CLOSED FRACTURE OF NECK OF METACARPAL BONE(S) CLOSED FRACTURE OF MULTIPLE SITES OF METACARPUS OPEN FRACTURE OF METACARPAL BONE(S) SITE UNSPECIFIED OPEN FRACTURE OF BASE OF THUMB (FIRST) METACARPAL OPEN FRACTURE OF BASE OF OTHER METACARPAL BONE(S) OPEN FRACTURE OF SHAFT OF METACARPAL BONE(S) OPEN FRACTURE OF NECK OF METACARPAL BONE(S) OPEN FRACTURE OF MULTIPLE SITES OF METACARPUS 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 - 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 FRACTURE OF PATELLA OPEN FRACTURE OF PATELLA CLOSED FRACTURE OF UPPER END OF TIBIA - OPEN FRACTURE OF UNSPECIFIED PART OF FIBULA WITH TIBIA FRACTURE OF MEDIAL MALLEOLUS CLOSED FRACTURE OF MEDIAL MALLEOLUS OPEN

65 824.2 FRACTURE OF LATERAL MALLEOLUS CLOSED FRACTURE OF LATERAL MALLEOLUS OPEN BIMALLEOLAR FRACTURE CLOSED BIMALLEOLAR FRACTURE OPEN TRIMALLEOLAR FRACTURE CLOSED TRIMALLEOLAR FRACTURE OPEN UNSPECIFIED FRACTURE OF ANKLE CLOSED UNSPECIFIED FRACTURE OF ANKLE OPEN FRACTURE OF CALCANEUS CLOSED - OTHER FRACTURES OF TARSAL AND METATARSAL BONES OPEN CLOSED FRACTURE OF ONE OR MORE PHALANGES OF FOOT OPEN FRACTURE OF ONE OR MORE PHALANGES OF FOOT OTHER MULTIPLE AND ILL-DEFINED FRACTURES OF LOWER LIMB CLOSED OTHER MULTIPLE AND ILL-DEFINED FRACTURES OF LOWER LIMB OPEN CLOSED DISLOCATION OF SHOULDER UNSPECIFIED SITE CLOSED ANTERIOR DISLOCATION OF HUMERUS CLOSED POSTERIOR DISLOCATION OF HUMERUS CLOSED INFERIOR DISLOCATION OF HUMERUS CLOSED DISLOCATION OF ACROMIOCLAVICULAR (JOINT) CLOSED DISLOCATION OF OTHER SITE OF SHOULDER OPEN DISLOCATION OF SHOULDER UNSPECIFIED OPEN ANTERIOR DISLOCATION OF HUMERUS OPEN POSTERIOR DISLOCATION OF HUMERUS OPEN INFERIOR DISLOCATION OF HUMERUS OPEN DISLOCATION OF ACROMIOCLAVICULAR (JOINT) OPEN DISLOCATION OF OTHER SITE OF SHOULDER

66 CLOSED DISLOCATION OF ELBOW UNSPECIFIED SITE CLOSED ANTERIOR DISLOCATION OF ELBOW CLOSED POSTERIOR DISLOCATION OF ELBOW CLOSED MEDIAL DISLOCATION OF ELBOW CLOSED LATERAL DISLOCATION OF ELBOW CLOSED DISLOCATION OF OTHER SITE OF ELBOW OPEN DISLOCATION OF ELBOW UNSPECIFIED SITE OPEN ANTERIOR DISLOCATION OF ELBOW OPEN POSTERIOR DISLOCATION OF ELBOW OPEN MEDIAL DISLOCATION OF ELBOW OPEN LATERAL DISLOCATION OF ELBOW 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 RADIOCARPAL (JOINT) CLOSED DISLOCATION OF MIDCARPAL (JOINT) CLOSED DISLOCATION OF CARPOMETACARPAL (JOINT) CLOSED DISLOCATION OF METACARPAL (BONE) PROXIMAL END CLOSED DISLOCATION OF OTHER PART OF WRIST OPEN DISLOCATION OF WRIST UNSPECIFIED PART OPEN DISLOCATION OF RADIOULNAR (JOINT) DISTAL OPEN DISLOCATION OF RADIOCARPAL (JOINT) OPEN DISLOCATION OF MIDCARPAL (JOINT) OPEN DISLOCATION OF CARPOMETACARPAL (JOINT) OPEN DISLOCATION OF METACARPAL (BONE) PROXIMAL END OPEN DISLOCATION OF OTHER PART OF WRIST

67 CLOSED DISLOCATION OF FINGER UNSPECIFIED PART CLOSED DISLOCATION OF METACARPOPHALANGEAL (JOINT) CLOSED DISLOCATION OF INTERPHALANGEAL (JOINT) HAND OPEN DISLOCATION OF FINGER UNSPECIFIED PART OPEN DISLOCATION OF METACARPOPHALANGEAL (JOINT) OPEN DISLOCATION INTERPHALANGEAL (JOINT) HAND CLOSED POSTERIOR DISLOCATION OF HIP CLOSED OBTURATOR DISLOCATION OF HIP OTHER CLOSED ANTERIOR DISLOCATION OF HIP TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT TEAR OF LATERAL CARTILAGE OR MENISCUS OF KNEE CURRENT OTHER TEAR OF CARTILAGE OR MENISCUS OF KNEE CURRENT DISLOCATION OF PATELLA CLOSED ANTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED - OTHER DISLOCATION OF KNEE CLOSED CLOSED DISLOCATION OF ANKLE CLOSED DISLOCATION OF TARSAL (BONE) JOINT UNSPECIFIED - CLOSED DISLOCATION OF OTHER PART OF FOOT CLOSED DISLOCATION STERNUM ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN - 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 SPRAIN OF RADIOCARPAL (JOINT) (LIGAMENT) OF WRIST OTHER WRIST SPRAIN SPRAIN OF UNSPECIFIED SITE OF HAND - OTHER HAND SPRAIN

68 ILIOFEMORAL (LIGAMENT) SPRAIN - SPRAIN OF OTHER SPECIFIED SITES OF HIP AND THIGH SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEE SPRAIN OF CRUCIATE LIGAMENT OF KNEE SPRAIN OF TIBIOFIBULAR (JOINT) (LIGAMENT) SUPERIOR OF KNEE SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG DELTOID (LIGAMENT) ANKLE SPRAIN CALCANEOFIBULAR (LIGAMENT) ANKLE SPRAIN TIBIOFIBULAR (LIGAMENT) SPRAIN DISTAL OTHER ANKLE SPRAIN LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN SACROILIAC (LIGAMENT) SPRAIN SACROSPINATUS (LIGAMENT) SPRAIN SACROTUBEROUS (LIGAMENT) SPRAIN OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN NECK SPRAIN THORACIC SPRAIN LUMBAR SPRAIN SPRAIN OF SACRUM SPRAIN OF COCCYX STERNOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN CHONDROSTERNAL (JOINT) SPRAIN PELVIC SPRAIN CONCUSSION WITH PROLONGED LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE-EXISTING CONSCIOUS LEVEL OPEN WOUND OF MOUTH UNSPECIFIED SITE COMPLICATED - OPEN WOUND OF GUM (ALVEOLAR PROCESS) COMPLICATED

69 OPEN WOUND OF TONGUE AND FLOOR OF MOUTH COMPLICATED - OPEN WOUND OF OTHER AND MULTIPLE SITES COMPLICATED OPEN WOUND OF LARYNX WITH TRACHEA COMPLICATED - OPEN WOUND OF LARYNX COMPLICATED OPEN WOUND OF PHARYNX COMPLICATED OPEN WOUND OF CHEST (WALL) COMPLICATED OPEN WOUND OF BACK COMPLICATED OPEN WOUND OF BUTTOCK COMPLICATED OPEN WOUND OF PENIS COMPLICATED OPEN WOUND OF SCROTUM AND TESTES COMPLICATED OPEN WOUND OF VULVA COMPLICATED OPEN WOUND OF BREAST COMPLICATED OPEN WOUND OF ABDOMINAL WALL ANTERIOR COMPLICATED OPEN WOUND OF ABDOMINAL WALL LATERAL COMPLICATED OPEN WOUND OF OTHER AND UNSPECIFIED PARTS OF TRUNK COMPLICATED OPEN WOUND(S) (MULTIPLE) OF UNSPECIFIED SITE(S) COMPLICATED 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 COMPLICATED OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITH TENDON INVOLVEMENT OPEN WOUND OF FINGERS WITHOUT COMPLICATION OPEN WOUND OF FINGERS COMPLICATED OPEN WOUND OF FINGERS WITH TENDON INVOLVEMENT

70 MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITHOUT COMPLICATION MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB COMPLICATED 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 OPEN WOUND OF HIP AND THIGH WITHOUT COMPLICATION OPEN WOUND OF HIP AND THIGH COMPLICATED OPEN WOUND OF HIP AND THIGH WITH TENDON INVOLVEMENT OPEN WOUND OF KNEE LEG (EXCEPT THIGH) AND ANKLE WITHOUT COMPLICATION OPEN WOUND OF KNEE LEG (EXCEPT THIGH) AND ANKLE COMPLICATED OPEN WOUND OF KNEE LEG (EXCEPT THIGH) AND ANKLE WITH TENDON INVOLVEMENT OPEN WOUND OF FOOT EXCEPT TOE(S) ALONE WITHOUT COMPLICATION OPEN WOUND OF FOOT EXCEPT TOE(S) ALONE COMPLICATED OPEN WOUND OF FOOT EXCEPT TOE(S) ALONE WITH TENDON INVOLVEMENT OPEN WOUND OF TOE(S) WITHOUT COMPLICATION OPEN WOUND OF TOE(S) COMPLICATED OPEN WOUND OF TOE(S) WITH TENDON INVOLVEMENT

71 MULTIPLE AND UNSPECIFIED OPEN WOUND OF LOWER LIMB WITHOUT COMPLICATION MULTIPLE AND UNSPECIFIED OPEN WOUND OF LOWER LIMB COMPLICATED MULTIPLE AND UNSPECIFIED OPEN WOUND OF LOWER LIMB WITH TENDON INVOLVEMENT TRAUMATIC AMPUTATION OF TOE(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION TRAUMATIC AMPUTATION OF TOE(S) (COMPLETE) (PARTIAL) COMPLICATED TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) UNILATERAL WITHOUT COMPLICATION TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) UNILATERAL COMPLICATED TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) BILATERAL WITHOUT COMPLICATION TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) BILATERAL COMPLICATED TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL BELOW KNEE WITHOUT COMPLICATION TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL BELOW KNEE COMPLICATED TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL AT OR ABOVE KNEE WITHOUT COMPLICATION TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL AT OR ABOVE KNEE COMPLICATED TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL LEVEL NOT SPECIFIED WITHOUT COMPLICATION TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL LEVEL NOT SPECIFIED COMPLICATED TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) WITHOUT COMPLICATION TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED LATE EFFECT OF FRACTURE OF SPINE AND TRUNK WITHOUT SPINAL CORD LESION - LATE EFFECT OF TRAUMATIC AMPUTATION

72 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 UNSPECIFIED SITE FOREIGN BODY IN LARYNX FOREIGN BODY IN TRACHEA FOREIGN BODY IN MAIN BRONCHUS 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 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 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 WITH EYE) OF FACE HEAD AND NECK WITHOUT LOSS OF A BODY PART DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FACE AND HEAD UNSPECIFIED SITE WITH 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 - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK WITH LOSS OF A BODY PART

73 BURN OF UNSPECIFIED DEGREE OF UNSPECIFIED SITE OF UPPER LIMB - BURN OF UNSPECIFIED DEGREE MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND ERYTHEMA DUE TO BURN (FIRST 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 - 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 BURN OF UNSPECIFIED DEGREE OF SINGLE DIGIT (FINGER (NAIL) OTHER THAN THUMB BURN OF UNSPECIFIED DEGREE OF THUMB (NAIL) BURN OF UNSPECIFIED DEGREE OF TWO OR MORE DIGITS OF HAND NOT INCLUDING THUMB BURN OF UNSPECIFIED DEGREE OF TWO OR MORE DIGITS OF HAND INCLUDING THUMB BURN OF UNSPECIFIED DEGREE OF PALM OF HAND BURN OF UNSPECIFIED DEGREE OF BACK OF HAND BURN OF UNSPECIFIED DEGREE OF WRIST BURN OF UNSPECIFIED DEGREE OF MULTIPLE SITES OF WRIST(S) AND HAND(S) ERYTHEMA DUE TO BURN (FIRST DEGREE) OF UNSPECIFIED SITE OF HAND ERYTHEMA DUE TO BURN (FIRST DEGREE) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB ERYTHEMA DUE TO BURN (FIRST DEGREE) OF THUMB (NAIL) ERYTHEMA DUE TO BURN (FIRST DEGREE) OF TWO OR MORE DIGITS OF HAND NOT INCLUDING THUMB ERYTHEMA DUE TO BURN (FIRST DEGREE) OF TWO OR MORE DIGITS OF HAND INCLUDING THUMB ERYTHEMA DUE TO BURN (FIRST DEGREE) OF PALM OF HAND ERYTHEMA DUE TO BURN (FIRST DEGREE) OF BACK OF HAND ERYTHEMA DUE TO BURN (FIRST DEGREE) OF WRIST

74 ERYTHEMA DUE TO BURN (FIRST DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) 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 - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) WITH LOSS OF A BODY PART BLISTERS EPIDERMAL LOSS (SECOND DEGREE) OF UNSPECIFIED SITE OF LOWER LIMB (LEG) - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S) WITH LOSS OF A BODY PART BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SPECIFIED SITES - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITH LOSS OF A BODY PART BURN (ANY DEGREE) INVOLVING LESS THAN 10 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT - BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 90% OR MORE OF BODY SURFACE FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) UNSPECIFIED SITE DEEP NECROSIS OF UNDERLYING TISSUE DUE TO BURN (DEEP THIRD DEGREE) UNSPECIFIED SITE WITHOUT LOSS OF A BODY PART DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART INJURY TO FACIAL NERVE INJURY TO ACCESSORY NERVE INJURY TO BRACHIAL PLEXUS INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS INJURY TO AXILLARY NERVE INJURY TO MEDIAN NERVE INJURY TO ULNAR NERVE INJURY TO RADIAL NERVE INJURY TO MUSCULOCUTANEOUS NERVE

75 955.5 INJURY TO CUTANEOUS SENSORY NERVE UPPER LIMB INJURY TO DIGITAL NERVE UPPER LIMB INJURY TO OTHER SPECIFIED NERVE(S) OF SHOULDER GIRDLE AND UPPER LIMB INJURY TO MULTIPLE NERVES OF SHOULDER GIRDLE AND UPPER LIMB INJURY TO UNSPECIFIED NERVE OF SHOULDER GIRDLE AND UPPER LIMB INJURY TO SCIATIC NERVE INJURY TO FEMORAL NERVE INJURY TO POSTERIOR TIBIAL NERVE INJURY TO PERONEAL NERVE VOLKMANN'S ISCHEMIC CONTRACTURE TRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY TRAUMATIC COMPARTMENT SYNDROME OF LOWER 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

76 OTHER COMPLICATIONS DUE TO INTERNAL JOINT PROSTHESIS OTHER COMPLICATIONS DUE TO OTHER INTERNAL ORTHOPEDIC DEVICE IMPLANT AND GRAFT OTHER COMPLICATIONS DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT COMPLICATIONS OF REATTACHED FOREARM COMPLICATIONS OF REATTACHED HAND COMPLICATIONS OF REATTACHED FINGER(S) COMPLICATIONS OF REATTACHED UPPER EXTREMITY OTHER AND UNSPECIFIED COMPLICATION OF REATTACHED FOOT AND TOE(S) COMPLICATION OF OTHER SPECIFIED REATTACHED BODY PART 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 V10.21 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARYNX V15.88 HISTORY OF FALL V40.1 MENTAL AND BEHAVIORAL PROBLEMS WITH COMMUNICATION (INCLUDING SPEECH) V41.2 PROBLEMS WITH HEARING V41.4 PROBLEMS WITH VOICE PRODUCTION V41.6 PROBLEMS WITH SWALLOWING AND MASTICATION V V43.69 UNSPECIFIED JOINT REPLACEMENT - OTHER JOINT REPLACEMENT V43.7 LIMB REPLACED BY OTHER MEANS V43.81 LARYNX REPLACEMENT STATUS V45.4 POSTSURGICAL ARTHRODESIS STATUS

77 V46.3 WHEELCHAIR DEPENDENCE V48.2 MECHANICAL AND MOTOR PROBLEMS WITH HEAD V48.3 MECHANICAL AND MOTOR PROBLEMS WITH NECK AND TRUNK V48.4 SENSORY PROBLEM WITH HEAD V48.5 SENSORY PROBLEM WITH NECK AND TRUNK V48.6 DISFIGUREMENTS OF HEAD V48.7 DISFIGUREMENTS OF NECK AND TRUNK V V49.5 DEFICIENCIES OF LIMBS - OTHER PROBLEMS OF LIMBS V V49.77 V52.0 V52.1 V52.4 V52.8 UNSPECIFIED LEVEL UPPER LIMB AMPUTATION STATUS - HIP AMPUTATION STATUS FITTING AND ADJUSTMENT OF ARTIFICIAL ARM (COMPLETE) (PARTIAL) FITTING AND ADJUSTMENT OF ARTIFICIAL LEG (COMPLETE) (PARTIAL) FITTING AND ADJUSTMENT OF BREAST PROSTHESIS AND IMPLANT 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 V54.01 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 V54.11 V54.12 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF ARM UNSPECIFIED AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF UPPER ARM AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF LOWER ARM V54.13 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF HIP

78 V54.14 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF LEG UNSPECIFIED V54.15 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF UPPER LEG V54.16 V54.17 V54.19 V54.20 V54.21 V54.22 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF LOWER LEG AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF VERTEBRAE AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF OTHER BONE AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF ARM UNSPECIFIED AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF UPPER ARM AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF LOWER ARM V54.23 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF HIP V54.24 V54.25 V54.26 V54.27 V54.29 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF LEG UNSPECIFIED AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF UPPER LEG AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF LOWER LEG AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF VERTEBRAE AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF OTHER BONE V54.81 AFTERCARE FOLLOWING JOINT REPLACEMENT V54.82 AFTERCARE FOLLOWING EXPLANTATION OF JOINT PROSTHESIS V54.89 OTHER ORTHOPEDIC AFTERCARE V54.9 UNSPECIFIED ORTHOPEDIC AFTERCARE V55.0 ATTENTION TO TRACHEOSTOMY V57.81 CARE INVOLVING ORTHOTIC TRAINING V58.30 ENCOUNTER FOR CHANGE OR REMOVAL OF NONSURGICAL WOUND DRESSING

79 V58.31 ENCOUNTER FOR CHANGE OR REMOVAL OF SURGICAL WOUND 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 Diagnoses that Support Medical Necessity All diagnoses listed in ICD-9-CM Codes That Support Medical Necessity above. ICD-9 Codes that DO NOT Support Medical Necessity All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes That Support Medical Necessity ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes That Support Medical Necessity above. Back to Top General Information Documentations Requirements 1. The services are to be furnished according to a written treatment plan determined by the physician, or by the therapist who will provide the treatment, after an appropriate assessment of the condition. All providers rendering therapy must document the appropriate history, examination, diagnosis, functional assessment, measurable goals, type of treatment, the body areas to be treated, the date the therapy was initiated, and expected frequency and number of treatments. This documentation must be maintained in the patient s file. 2. Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time. 3. Documentation in the medical record must support the medical necessity, type, frequency and duration of services provided. Documentation must be available on request to indicate the medical necessity of any and all treatments, especially continued treatment beyond the provisions of this policy. 4. Patients receiving services from private physical or occupational therapists require reviews (dated and signed) of the treatment plan by the attending physician at least once within 90 days or any time the patient's condition changes significantly, making a revision of long term goals necessary. 5. Documentation of the medical necessity of multiple heating modalities (97018, 97024, 97026, 97034) on the same date of service must be available for review. Such use must show all were needed toward the restoration of function. 6. Documentation for or 97598, removal of devitalized tissue must include the fact

80 that devitalized tissue was present, and the specific selective debridement technique used. This code may be billed once per session of debridement regardless of the number and extent of the wounds debrided. If whirlpool is used for the same wound prior to selective debridement, it is bundled into the new code (97597 or 97598). However, if whirlpool is used for a different body part or body area on the same date of service than the area being debrided, it could be billed. 7. Medicare requires a legible identity (including professional degree) and date for services provided/ordered. The method used (e.g. hand written or electronic) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present. Stamped signatures are not acceptable. Providers using alternative signature methods should recognize that there is a potential for misuse or abuse. For example, providers need a system and software products which are protected against modification, etc. and should apply administrative procedures which are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bears the responsibility for the authenticity of the information being attested to. Physicians should check with their attorneys and malpractice insurers in regard to the use of alternative signature methods. All State licensure and State practice regulations continue to apply. Where State law is more restrictive than Medicare, the State law standard will apply. The signature requirements described here do not assure compliance with Medicare conditions of participation. Note that this instruction does not supersede the prohibition for Certificates of Medical Necessity (CMN). CMNs are a term of specifically describing particular Durable Medical Equipment forms. As stated on CMN forms, signature and date stamps are not acceptable for use on CMNs. 8. When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary. 9. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. 10. When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request. Appendices Utilization Guidelines Sources of Information and Basis for Decision Duthie EH, Katz PR. Practice of Geriatrics. 3rd ed. Philadelphia, Pa: W.B. Saunders Company; Noble J. Greene HL, Mulrow C, Scherger JE, eds. Textbook of Primary Care Medicine. 3rd ed. St. Louis, Mo: Mosby, Inc; Harris ED, Budd RC, Genovese MC, Firestein GS, Sargent JS, Sledge CB. Kelley s Textbook of Rheumatology. 7th ed. Philadelphia, Pa: W.B. Saunders; Goetz CG. ed. Textbook of Clinical Neurology. 2nd ed. St. Louis, Mo: W. B. Saunders; Goldman LC, Ausiello DA.eds. Textbook of Medicine. 22nd ed. Philadelphia, PA: W.B. Saunders Company; 2004.

81 Frontera WR. Essentials of Physical Medicine and Rehabilitation. 1st ed. Philadelphia, Pa: Hanley and Belfus; American Academy of Physical Medicine and Rehabilitation Coders Desk Reference. 9th ed. Ingenix, Inc; th ed. Ingenix, Inc; American Physical Therapy Association American Occupational Therapy Association Board Certified Physical Medicine and Rehabilitation physicians Licensed Physical Therapist consultants Licensed Occupational Therapist consultants Carrier Medical Directors PM&R Clinical Workgroup Updated Additional Sources American Speech/Hearing/Language Association; Preferred Practice Patterns for the Professions of Speech-Language Pathology and Audiology American-Speech-Language Hearing Association. Roles of Speech Language Pathologists in the Identification, Diagnosis, and Treatment of Individuals with Cognitive Communication Disorders: Position Statement [Position Statement] Available at: American Speech-Language-Hearing Association. Evidence-Based Practice in Communication Disorders [Position Statement] Available at: American Speech-Language-Hearing Association. Preferred Practice Patterns for the Profession of Audiology [Preferred Practice Patterns] Available at: Nicolosi L, Harryman E, and Kersheck J. Terminology of Communication Disorders: speech, language, hearing. Baltimore, MD: The Williams & Wilkins Company International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization; Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which include representatives from the affected provider community. Contractor Advisory Committee meeting dates: California - 01/11/2012 Hawaii - 01/06/2012 Nevada - 01/12/2012 Start Date of Comment Period 01/06/2012 End Date of Comment Period

82 02/27/2012 Start Date of Notice Period 03/15/2012 Revision History Number Revision #20 Revision History Explanation Revision #20 effective for dates of service on or after 06/28/2012 Revisions made: CMS National Coverage Policy added reference Pub , Chapter 6, Section , Coverage of outpatient therapeutic services incident to a physician s service. Under Source of Information and Basis for Decision added another author, initials and city and state of publication to book titled, "Practice of Geriatrics". Added initials, editors names, and city and state of publication to book titled Textbook of Primary Care Medicine". Added editors names, corrected publishers name and added city and state of publication to book titled "Kelley's Textbook of Rheumatology". Added initials to editor's name, and added city and state of publication and corrected publisher s name to book titled "Textbook of Clinical Neurology". Added editor's name and added city and state of publication for book titled "Textbook of Medicine". Added initials to editor name and added city and state of publication for book titled "Essentials of Physical Medicine and Rehabilitations". Completed the title of the book, corrected the publishing name and added the city of state of publication for book titled Terminology of Communication Disorders: speech, language, hearing. Revision #19 effective 04/30/2012 Revisions from this Draft were accepted and made final and changed the effective date for this LCD. Revision #18 DRAFT Revisions made: Indications and Limitations of Coverage and/or Medical Necessity section of LCD added descriptor and/or criteria for the following CPT codes: 31579, 92506, 92511, 92512, 92526, 92606, 92611, 92612, 92614, 92616, 92618, 92633, 95857, 96116, and Under CPT/HCPCS Codes added CPT Codes 31579, 92511, 92512, 92520, 92606, 92611, 92612, 92614, 92616, 92626, 92627, 95857, and to the LCD. Removed CPT Code as the service described by this code is no longer a covered benefit. Under ICD-9 Codes that Support Medical Necessity added ICD-9 code Revision #17 effective for dates of service on or after 01/01/2012 Revision made: CMS National Coverage Policy Pub , Ch 3, Section B changed to now read CPT/HCPCS Codes added CPT code per CR Annual HCPCS Update. Revision #16 effective for dates of service on or after 10/01/2011 Revisions made: Under 'CMS National Coverage Policy' CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 3, D, G, signature requirements and diagnosis requirement to CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 3, , B, signature requirements and diagnosis code requirement. Under ICD-9 Codes that Support Medical Necessity deleted and added , , 331.6, , , , , , , V54.82, V88.21, V88.22 & V The descriptors for , , , , , , , , , & was revised. This LCD is being revised due to the annual FY 2012 ICD-9-CM code update. Under 'Sources of Information and Basis for Decision' removed "Other carriers policies" as this statement is not specific as to whose policies were used and the name(s) of the policies used. This revision will become effective 10/01/2011.

83 Revision #15 effective for dates of service on or after May 9, 2011 Revisions made - Under CMS National Coverage Policy added the following citations: 42 CFR , out patient speech language pathology services: conditions and exclusions and Pub , Chapter 13, Section 13.5, reasonable and necessary provisions in LCD. Pub Chapter 15, 220 and 230 was corrected to be more specific include all sections which now reads Removed Pub , Chapter 1, Part 1, as this LCD does not cover Cardiac Rehabilitation nor Intensive Cardiac Rehabilitation. Under Indications and Limitations of Coverage and/or Medical Necessity, subheading General PM&R Guidelines, Number 4, bullet 2 changed the word certified to license. In same subheading Number 6 the ICD-9 code (hip-joint replacement by artificial or mechanical device or prosthesis) was replaced with (abnormality of gait). Under subheading C Speech/Language/Hearing/Oral Guidelines, CPT code Audiologic Rehabilitation Group, changed to read Treatment of speech, language, voice, communication and/or auditory processing disorders; group (e.g ). Added the phrase Audiologic rehabilitation is a facilitative process that provides intervention to address the impairments, activity limitations, participation restrictions Moved Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech (e.g ) to combine the paragraph with the paragraph titled Evaluation of patient for prescription of voice prosthetic for ease of readability. Removed the from the LCD as they code was not incorporated into the CPT/HCPCS array and the code is bundled in with any therapy codes under the PFS. Removed the word modality under subheading D to read General Guidelines (e.g ). Treatment Guidelines and changed the word modalities to evaluations and treatments in this paragraph. Under section 2, second sentence, removed the phrase no more than and replaced with generally, are typically. Removed the last sentence in this paragraph as it was felt to no longer be necessary since the word generally was inserted. Under #3 removed the second sentence as it was felt that if a service was medically necessary and documentation supported the service provided the limitation was not necessary. Under subheading E, removed the second sentence under Epley maneuver, and the statement that is a bundled service as these statements are incorrect as of 1/1/2011. Removed language under CPT code and inserted language from J1 Part A Outpatient Physical Therapy LCD to consolidate Part A and B for this particular CPT code. For CPT code added the statement that coverage criteria and definition of fluidized therapy dry heat (dry whirlpool) could be found in Pub , Chapter 1, Section 150. Added the phrase when provided under constant attendance for CPT code Under CPT code added the phrase when provided under constant attendance. Added the phrase but not limited to under specific indications for the use of iontophoresis. Renamed the heading for from Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) (e.g ), to Manual Therapy Techniques (e.g ), and replaced language with language which is under Part A Outpatient Physical Therapy LCD for consistency among Part A and Part B LCDs. Under Therapeutic procedure(s) group, (2 or more individuals), third bullet removed the word and inserted or. Moved Therapeutic activities, direct (one -on-one) patient contact by the provider (use of dynamic activities to improve functional performance) (e.g ) to follow below Therapeutic procedure(s), group (2 or more individuals) (e.g. CPT 97150). Moved and combined Cognitive skills development (e.g ) to follow Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) (e.g ). Moved and combined Sensory Integration (e.g., to follow Cognitive skills development (e.g., 97532) for ease of reading. Changed the title of heading Self-care/Home and community reintegration management training (e.g ) to Self-care/Home Management Training (e.g ) to be consistent with Part A, Out Patient Physical Therapy LCD. Also, changed subheading title Community/work reintegration training (e.g., shopping, transportation, money management, a vocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/ adaptive equipment), direct one on one contact by provider, each 15 minutes to now read Community/work reintegration (e.g ) for consistency between Part A, Out Patient

84 Physical Therapy LCD. Under subheading Orthotic(s) Management and Training added the statement regarding assessment, 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 as these are reported with an appropriate L code(s) to the DME MAC. Under subsection for CPT code removed the part of first bullet when a device is newly issued or there is a modification or re-issue of the device, and replaced with established patients who have already received the orthotic or prosthetic device (permanent or temporary). Bullet #3 was added under subsection for CPT Code to clarify that the service could include, assessments of patient response to wearing the device, whether the patient is donning/doffing the device correctly, patient s need for padding, underwrap or socks and the patient s tolerance to any dynamic forces being applied. Updated description of CPT codes and per CPT Annual Update for Removed the statement, Though more than one wound may have been debrided, either code or may be billed only once per session as this statement no longer applied with the new description of or Removed part of the description for CPT Codes 97602, and 97606, 98710, 98711, 97813, as J1 Palmetto has determined to only giving an example of what a code represents and not restate the entire description of codes.changed subheading title from Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report, each 15 minutes to Assistive Technology Assessment (e.g ) for consistency between Part A LCD Out-Patient Physical Therapy and Part B PM&R LCD. Changed subheading title from Physical Performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes (e.g ) to Physical Performance Test or Measurement (e.g ). Under CPT HCPCS Codes 92610, 96110, 96111, 97024, 97597, 97598, 97605, had descriptor changes due to the 2011 CPT/HCPCS Annual Update were placed in the CPT/HCPCS array of payable codes and the statement of being a bundled service was removed. Under ICD-9 Codes that Support Medical Necessity ICD-9 codes 315.1, and were added to the LCD. Revision #14, Draft Revisions made: Under CMS National Coverage Policy added IOM citations Pub , Medicare Claims Processing Manual, Chapter 5, 20, 20.1, 20.2, 20.3, 20.4, 20.5; Chapter 5, 20, 20.1, 20.2, 20.3, 20.4, 20.5; Chapter 12, 30.3; and Chapter 23, 10. Updated IOM citation of Pub Chapter 3, ,D and ,G. Under Indications and Limitations of Coverage, subsection General PM&R Guidelines, added subheading C. Speech/language/hearing evaluation (92506) concerning the comprehensive evaluation service that requires professional skills and the reevaluation during an episode of care. Under subheading D, added various speech language pathologist CPT codes with a brief description of the CPT code and what that particular code encompasses. Under CPT/HCPCS codes the following codes were added: 92506, 92507, 92508, 92526, 92597, 92605, 92607, 92608, 92609, 92610, 92630, 92633, 96105, and Under ICD-9 Codes that Support Medical Necessity the following ICD-9 codes were added: , 307.0, , , , 307.9, 310.1, 310.2, , , , , , 315.4, 315.5, 315.8, , , , , , , , 359.3, 359.4, , , , , , , , , , , , , , , , , , 389.7, , , , 478.4, 478.5, 478.6, , 507.0, , , , 529.8, 530.0, 530.3, 530.6, , 748.3, , , , 750.0, , , , 784.3, , , , 786.1, 786.2, , , , , 874.5, 933.1, 934.0, 934.1, V10.21, V40.1, V41.2, V41.4, V41.6, V43.81, V48.6, V48.7, V55.0. Under Sources of Information and Basis for Decision added sources to support this draft revision. Revision #13, effective for dates of service on or after 10/01/2010

85 Revisions made: Under ICD-9 Codes that Support Medical Necessity, the following codes were added per the Annual Update of International Classification of Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM) per CR 7006, Transmittal 2017, and dated August 4, 2010: , , , , , and The following ICD-9 code was made invalid: The following ICD-9 code had a description change Revision #12 effective for dates of service on or after 07/01/2010 Revisions made: Under CMS National Coverage Policy, removed the following citations as these citations have been manualized: CMS Manual System, Pub , Medicare Benefit Policy Manual, Transmittal 36, Change Request 3648, dated June 24, 2005 and CMS Transmittal 1706, Change Request 6407, Manual Clarifications for Skilled Nursing Facilities and Therapy Billing, dated March 27, 2009 which was later rescinded with an new date of May 8, Added the following citations: CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 23, 10, ICD-9 CM Diagnosis and Procedure Codes; CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 12, 30.3, Audiological Diagnostic Tests, Speech-Language Evaluations and Treatments. CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 5, 20, 20.1, 20.2, 20.3, 20.5; CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 3, E diagnosis requirement, Chapter 13, , reasonable and necessary provision in LCD; CMS Manual System, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 50.1, 50.2, 50.3 and 50.4; Part 3, 170.1, and 170.3; CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 6, , Diagnostic Services Defined. Title XVIII of the Social Security Act, 1862(a)(7), excludes routine examinations. Title XVIII of the Social Security Act, 1835(2)(D), lists requirements for certification and recertification of speech pathology services. 42CFR , plan of treatment requirements for outpatient rehabilitation including services furnished by a qualified physical or occupational therapist in private practice. 42 CFR , certification and plan of treatment requirements. 42 CFR , Conditions of participation: Specialized Providers for clinics, rehabilitation agencies, public health agencies as providers of outpatient physical therapy and speech-language pathology services, and 42 CFR , Condition of participation: Speech pathology services. Under Indications and Limitations of Coverage and/or medical necessity added the statement that physicians may bill and for appropriate contact. Under ICD-9 codes that Support Medical Necessity added ICD-9 codes and Revision #11 effective for dates of service on or after 05/24/2010 Revisions made: Under Indications and Limitations of Coverage under subheading Qualified Personnel, the word professional was replaced with personnel. The phrase Advanced Beneficiary Notice (ABN) was completed with the phrase Advanced Beneficiary Notice of Noncoverage. Under Direct Supervision in the Office, removed the statements dealing with physical therapist assistants and occupational therapist assistants direct supervision definition as it contradicts the guidance given in the subheading Direct Supervision in the Office. Under General PM&R Guidelines removed the word Medicare as Medicare does not certify therapists. Under bullet number 5 and number 7, replaced the word not covered with not reasonable and necessary. Under General Modality Guidelines, Number 4 added and/or occupational therapy as occupational therapists also use heating modalities. Under Specific Modality Guidelines, coding guidance for 97016, third bullet added with a vasopneumatic device and removed the phrase by the provider. Under coding guidance for removed the sentence These services, in addition to all other therapy services, must be prescribed by the attending physician, as an order or referral is not required for physical therapy services. Under E. General Guidelines for Therapeutic Procedures for coding guidance of removed second bullet, regarding postural drainage and pulmonary exercises. Under coding guidance for removed the parenthesis surrounding speech language pathology services as speech language pathologist are eligible to bill for their services in an outpatient setting

86 independent of physical therapist. Removed duplicative verbiage regarding Microamperage E-stimulation, E-Stim (Vital Stim)Vertebral Axial Decompression and MedX, Spinex or DRX9000. Under CPT /HCPCS Codes, added CPT code to the CPT array, this code is listed as payable in the LCD text. Under Documentation Requirements removed #1 statement regarding the medical record must identify the physician or qualified nonphysician who has prescribed the service for the patient as a prescription is not required for physical therapy services. Revision 10, draft Revision made: Under "CPT Codes" added CPT codes 92548, and Revision #9 effective for dates of service on or after 10/18/2009 Revisions made: Under "Indications and Limitations of Coverage and or Medical Necessity" the opening statement added speech-language pathologist to list of providers affected by this LCD practicing in the home and office setting. Under subheading Suppliers, added Speech-Language Pathologist to list of practitioners who have Medicare provider numbers. Removed statement that Speech language pathologist are not suppliers because the ACT does not provide coverage of any speech-language pathology services furnished by a speech language pathologist as an independent practitioner. Under subheading Other Definitions, Speech-language pathologist in private practice whose services may be billed under one of four different practitioner benefits was added to this section of the LCD. Annual validation completed. Revision #8 effective for dates of service on or after 10/01/2009. Revisions made: Under Indications and Limitations of Coverage and/or Medical Necessity" expanded coverage of iontophoresis (97033) for the following conditions: patient having tendonitis or calcific tendonitis, having bursitis, adhesive capsulitis, hyperhidrosis and/or thick adhesive scar(s). Removed duplicative statement regarding MENS and added CPT code to original statement regarding MENS in that section. The statement regarding the need for two ICD-9-CM codes on a claim to support the causal pathological condition was removed. The example for the need for two ICD-9 codes was also removed. Under "ICD-9 codes that Support Medical Necessity" the following ICD-9 codes were revised and The following ICD-9 codes were added , , , , , , , , , and per the Annual ICD-9-CM Code Annual Update CR 6520, Transmittal 1770 dated July 10, 2009 The following ICD-9 codes were added to consolidate Part B Physical Medicine and Rehabilitation LCD with Part A Out-Patient Physical Therapy LCD, Part A Out-Patient Occupational Therapy LCD and Out Patient Speech and Language Pathology LCD: , 351.0, 357.2, , , , , 496, , 717.9, , , 723.7, 724.9, , , , , , , , , , , 729.4, , , 732.9, , 733.5, 734, , 737.0, , , , 780.4, , , , 794.2, , , V Revision #7 effective for dates of service on or after 04/27/2009. Revisions made: Under "CMS National Coverage Policy" added reference to CR 6407, Transmittal Under Indications and Limitations of Coverage and/or Medical Necessity" removed instructions to use CPT code when performing the Epley maneuver and inserted CPT code and its description with the statement that there is no provision for direct payment to physicians, nonphysician practitioners and audiologist for this therapeutic service. When physical therapists provide this service they should continue to bill CPT code Also stated that is a bundled service and is currently being reimbursed as part of an Evaluation and Management (E and M) service Added CPT code to the CPT/HCPCS Paragraph which states why CPT code would be denied as a bundled service. Under "ICD-9 Codes that Support Medical Necessity" added ICD-9 code , and

87 Revision #6, 02/26/2009 This LCD is being revised to implement the streamlining of the Part B LCDs per the published article Palmetto Team to Streamline Part B LCDs in Jurisdiction 1 (J1). This article can be viewed at by searching for the above article name. This revision will become effective on 02/26/2009. Revision #5 effective for dates of service on or after 01/09/2009. Revisions Made: Under "CPT/HCPCS Codes" the following CPT code descriptors were revised: 97012, 97016, 97018, 97022, and The CPT codes descriptors are effective for dates of service on or after 01/01/2009. Revision #4, 10/17/2008 Under CMS National Coverage Policy changed the date cited for CMS Transmittal AB , Change Request 1793, Medical Review of Services for Patients with Dementia from September 24, 2001 to now read September 25, Revised CMS Transmittal 34, Change Request 3648, dated May 6, 2005 to now read CMS Transmittal 36, Change Request 3648, dated June 24, Deleted Change Request 2083 that was redundant. Verbiage changes were made to the cited references. Under Indications and Limitations of Coverage and/or Medical Necessity General PM&R Guidelines #5 deleted the following statements: Services furnished to a patient who has not been seen by a physician once in 30 days from the initial treatment day and Services not furnished in a therapist s office or in the patient s home are not covered. Under Indications and Limitations of Coverage and/or Medical Necessity Specific Modality Guidelines deleted verbiage. Under ICD-9 Codes That Support Medical Necessity deleted CPT code sections. Added ICD-9 codes 138, , , 344.5, , 344.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 353.0, 353.1, 353.2, 353.3, 353.4, 353.5, 353.6, 353.8, 353.9, 354.0, 354.1, 354.2, 354.3, 354.5, 354.8, 354.9, 355.0, 355.2, 355.3, 355.4, 355.5, 355.6, , 355.9, 356.0, 356.1, 356.2, 356.3, 356.4, 356.8, 356.9, 357.0, 359.0, 359.1, , , , , , , , , , , , , , , , , , , 438.6, , , , , , , 438.9, 443.0, , , , , 494.0, 494.1, 514, , , , , , , , , , , , , , , , 682.0, 682.1, 682.2, 682.3, 682.4, 682.5, 682.6, 682.7, 683, 701.0, 701.4, , , , , 707.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 713.5, 714.0, 714.1, 714.2, , , , , 714.4, , , 714.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

88 718.08, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 720.0, 720.1, 720.2, , , 720.9, 721.0, 721.1, 721.2, 721.3, , , 721.5, 721.6, 721.7, 721.8, , , 722.0, , , 722.2, , , , , 722.4, , , 722.6, , , , , , , , , , , , , 723.0, 723.2, 723.3, 723.4, 723.9, 724.4, 724.6, 724.8, 725, 726.0, , , , , 726.2, , , , , , 726.4, 726.8, , , , 727.2, 727.3, , , , , , , , , , , , , , , , , , 727.9, 728.2, 728.3, 728.4, 728.5, , , , , , , , 729.0, 729.1, 729.2, , , , , , , 731.0, 731.3, 732.8, , , , , , , , , , , , , , , , , , , , , , , 735.0, , , , , , , , , , 736.1, , , , , , , , , , , 736.5, 736.6, , , , , , , , , , , 738.8, 738.9, , , , , , , , , , , , , , , , , , , , , , 757.0, 781.4, , 782.2, 782.3, 782.8, 783.3, 783.7, 784.0, , , , , , , , , , , , , , , , , 805.2, 805.4, 805.6, , , , , , , , , 807.2, 808.0, 808.2, , , , , 809.0, 809.1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 817.0, 817.1, 818.0, 818.1, 819.0, 819.1, , , , , , , , , , , , , , , , , 820.8, 820.9, , , , , , , , , , , , , , , 822.0, 822.1, , , , , , , , , , , , , , , , , , , , , , 824.0, 824.1, 824.2, 824.3, 824.4, 824.5, 824.6, 824.7, 824.8, 824.9, 825.0, 825.1, , , , , , , , , , , , , , , 826.0, 826.1, 827.0, 827.1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 836.0, 836.1, 836.2, 836.3, , , , , , 837.0, , , , , , , , , 840.0, 840.1,

89 840.2, 840.3, 840.4, 840.5, 840.6, 840.7, 840.8, 840.9, 841.0, 841.1, 841.2, 841.3, 841.8, 841.9, , , , , , , , , , 843.0, 843.1, 843.8, 844.0, 844.1, 844.2, 844.3, 844.8, , , , , 846.0, 846.1, 846.2, 846.3, 846.8, 847.0, 847.1, 847.2, 847.3, 847.4, , , 848.5, 850.4, 885.0, 886.0, 890.0, 890.2, 891.0, 891.2, 892.0, 892.2, 893.0, 893.2, 895.0, 905.1, 905.2, 905.3, 905.4, 905.5, 905.6, 905.7, 905.8, 905.9, 906.0, 906.1, 906.2, 906.3, 906.4, 906.5, 906.6, 906.7, 906.8, 906.9, 907.0, 907.1, 907.2, 907.3, 907.4, 907.5, 907.9, 908.6, 909.2, 909.3, , , , , , , , , , 927.3, 927.8, 927.9, 929.0, 929.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 949.3, 949.4, 949.5, 951.4, 951.6, 953.4, 953.8, 955.0, 955.1, 955.2, 955.3, 955.4, 955.5, 955.6, 955.7, 955.8, 955.9, 956.0, 956.1, 956.2, 956.3, 958.6, , , , , , , , , , , , , , , , , , , , , , , , , , , V43.60, V46.3, V48.2, V48.3, V48.4, V48.5, V52.4, V53.90, V54.01, V54.02, V54.10, V54.11, V54.12, V54.13, V54.14, V54.15, V54.16, V54.17, V54.19, V54.20, V54.21, V54.22, V54.23, V54.24, V54.25, V54.26, V54.27, V54.29, V54.89, V54.9, V58.30, V58.31, V Under Sources of Information and Basis for Decision the references were placed in the AMA citation format. This revision becomes effective 10/17/2008. Revision #3, 10/01/2008 This LCD is being revised due to the annual FY2009 ICD-9-CM code update. Under the "ICD-9 Codes that Support Medical Necessity" section the following ICD-9 codes were added , and for CPT/HCPCS codes 97022, 97036, 97597, and G0329. The verbiage for ICD-9 codes , , , , , , and was revised. "CMS National Coverage Policy several citations were added to this section they were the following: CMS Benefit Policy Manual citations, CMS Program Integrity Manual citation, Federal Register citations and SSA citations. In the "Indications and Limitations of Coverage and/or Medical Necessity" duplicative SSA, Federal Regulations, CMS Manual citations were removed. Under the Sources of Information and Basis for Decision section references were placed in the AMA citation format. Under the Documentation Requirements section removed duplicate SSA and CMS Manual citations. This revision will become effective 10/01/2008. Revision #2, 09/02/2008 Under Indications and Limitations of Coverage and/or Medical Necessity-A. General PM&R Guidelines #8 corrected spelling errors. Under Documentation Requirements #5 changed "30 days" to now read "90 days" to support manual instruction. This revision becomes effective 09/02/2008. Revision #1, 09/02/2008 This LCD is being revised to add Bill Type 999X because the automated system transcription process was incomplete. 11/09/ The description for CPT/HCPCS code was changed in group 1 11/09/ The description for CPT/HCPCS code was changed in group 1 11/09/ The description for CPT/HCPCS code was changed in group 1 11/09/ The description for CPT/HCPCS code was changed in group 1 11/09/ The description for CPT/HCPCS code was changed in group 1 11/09/ The description for CPT/HCPCS code was changed in group 1 08/08/ This policy was updated by the ICD Annual Update. 11/15/ The description for CPT/HCPCS code was changed in group 1

90 11/15/ The description for CPT/HCPCS code was changed in group 1 11/15/ The description for CPT/HCPCS code was changed in group 1 11/15/ The description for CPT/HCPCS code was changed in group 1 11/15/ The description for CPT/HCPCS code was changed in group 1 11/15/ The description for CPT/HCPCS code was changed in group 1 11/15/ The description for CPT/HCPCS code was changed in group 1 11/15/ The description for CPT/HCPCS code was changed in group 1 11/15/ The description for CPT/HCPCS code was changed in group 1 11/15/ The description for CPT/HCPCS code was changed in group 1 09/06/ This policy was updated by the ICD Annual Update. 11/21/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group 1 08/27/ This policy was updated by the ICD Annual Update. 11/21/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group 1 Reason for Change Other Related Documents Article(s) A Falls Evaluation: Translating Evidence-based Interventions into Your Practice LCD Attachments There are no attachments for this LCD. Back to Top All Versions Updated on 06/21/2012 with effective dates 06/28/ N/A Updated on 03/08/2012 with effective dates 04/30/ /27/2012 Updated on 12/10/2011 with effective dates 01/01/ /29/2012 Updated on 12/02/2011 with effective dates 01/01/ N/A Updated on 11/21/2011 with effective dates 10/01/ /31/2011 Updated on 09/14/2011 with effective dates 10/01/ N/A

91 Updated on 04/21/2011 with effective dates 05/09/ /30/2011 Updated on 03/18/2011 with effective dates 05/09/ N/A Updated on 11/21/2010 with effective dates 10/21/ /08/2011 Updated on 10/15/2010 with effective dates 10/21/ N/A Some older versions have been archived. Please visit the MCD Archive Site them. to retrieve Read the LCD Disclaimer Back to Top Department of Health & Human Services Medicare.gov USA.gov Web Policies & Important Links Privacy Policy Freedom of Information Act No Fear Act Centers for Medicare & Medicaid Services, 7500 Security Boulevard Baltimore, MD