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

Local Coverage Determination (LCD): Outpatient Occupational Therapy (L31591) Contractor Information Contractor Name Palmetto GBA LCD Information Document Information LCD ID L31591 LCD Title Outpatient Occupational Therapy AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Original Effective Date For services performed on or after 09/07/2012 Revision Effective Date For services performed on or after 01/01/2015 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 12/09/2010 Notice Period End Date N/A

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See 1869(f)(1)(A)(i) of the Social Security Act. Title XVIII of the Social Security Act, 1862 (a)(1)(a) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, 1862(a)(7) excludes routine physical examinations. Title XVIII of the Social Security Act, 1833(e), states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Title 42, Code of Federal Regulations, 424.24 and 410.61 CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 6, 20.5.2 CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 8, 30.2.2.1, 30.4.1.2, and 30.6 CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 12, 10, 20, 20.1, 20.2, 30, 30.1, 40.3 and 40.7 CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.3, 220-220.2, 220.3, 230, 230.2 and 230.4-230.6 CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 10.2, 30.1 and 30.1.1

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 150.5, 150.8, 160.2, 160.7, 160.12, 160.15, and 160.27 CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, 170.1 CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 240.3, 270.1, 270.4 and 270.6 CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, 20B and 100.5 Program Memorandum: AB-02-078; dated May 29, 2002; Change Request 2083 CMS Manual System, Pub. 100-20, One-Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338 CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Transmittal 163, dated November 30, 2012, Change Request 8005 CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Transmittal 2622, dated December 21, 2012, Change Request 8005 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Although rehabilitative services are provided by occupational therapy, speech therapy and physical therapy, this policy only addresses occupational therapy. Occupational therapy (OT) is an integral component of rehabilitative services in the areas of physical, cognitive and psychosocial impairment. Occupational therapy is based on purposeful, goal directed activity (occupation). The goal of occupational therapy is to prevent, improve or restore physical and/or cognitive impairment following disease or injury. Occupational therapists utilize clinical history, observation, interview, standardized testing and assessment of activities of daily living skills, work skills, and leisure skills to characterize individuals with impairments, functional limitations and disabilities. The results of these assessments are used to identify structural impairments and functional limitations and to design an individualized plan of treatment to assist in improving or restoring function. All occupational therapy services must be performed by or under the supervision of a qualified occupational therapist. For the purposes of this Local Coverage Determination (LCD), the following descriptions/definitions of terms are used: Direct Supervision: This requires that the physician or nonphysician practitioner (NPP) or

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

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

practice. Also, the plan of treatment must be for a condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness or injury it is determined that the treatment is not rehabilitative, or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer considered reasonable and necessary and are excluded from coverage. 3. Covered occupational therapy services must be furnished while the individual is or was under the care of a physician. Services must relate directly and specifically to a written plan of treatment. The plan of treatment should address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or non-physician practitioner should periodically review the plan of treatment. 4. The physician, non-physician practitioner and/or therapist must document the patient's functional limitations in terms that are objective and measurable. Documentation serves as the means by which a provider would be able to establish and a contractor would be able to confirm that skilled care is, in fact, needed and received in a given case. 5. Rehabilitation services for vision impairment: The coverage criteria and definition of rehabilitation services for beneficiaries with vision impairment are found in Program Memorandum, Transmittal AB-02-078, dated May 29, 2002, Change Request 2083. SPECIFIC PROCEDURE AND MODALITY GUIDELINES Computerized Dynamic Posturography (CPT code 92548) Computerized dynamic posturography is a "quantitative method for assessing balance functioning under various simulated tasks. Protocols are designed to test the sensory, motor and biomechanical components of balance individually and in concert." Computerized dynamic posturography "may assist with lesion localization, identifying adaptive strategies and functional capabilities." *Note: Results of computerized dynamic posturography must be used in determining the patient centered plan of care. Fabrication/Application of Casts, Splints and Strapping (CPT codes- see below) Fabrication and application of casts, splints, and strapping will be considered reasonable and necessary if used to support weak, post surgical or ineffective joints/muscles, facilitating increased motor response, to assist in compensation in a permanent loss of motor function, reduce/correct joint limitations/deformities and/or protect body parts from injury, thus enhancing the performance of tasks or movements. The casts, splints and strapping are often used in conjunction with therapeutic exercise, functional training, other interventions, and should be selected in the context of patient's needs, social/culture environments, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL).

Note: When identifying orthotics fitting and training see CPT code 97504. BODY AND UPPER EXTREMITY CASTS Application of long arm (CPT code 29065) May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue. Application of short arm (CPT code 29075) May be indicated for the forearm, wrist, and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue. Application of hand and lower forearm (CPT code 29085) May be indicated for the forearm, wrist, and/or hand in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue. Application of finger cast (eg, contracture) (CPT code 29086) May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue. SPLINTS Application of long arm splint (CPT code 29105) May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue. Application of short arm splint (CPT code 29125 and 29126) May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprain/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue. Application of finger splint (CPT code 29130 and 29131) May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities

involving soft tissue. STRAPPING-ANY AGE Strapping of thorax (CPT code 29200) Indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures, or other deformities involving soft tissue. Strapping of low back (CPT code 29799) May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of shoulder (e.g. Velpeau) (CPT code 29240) May be indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of elbow or wrist (CPT code 29260) May be indicated for the elbow or wrist when there is involvement of the humerus, forearm, wrist, or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, edema, scar management, contractures or other deformities involving soft tissue. Strapping of hand or finger (CPT code 29280) May be indicated where there is involvement of the hand or fingers in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, edema, scar management, contractures or other deformities involving soft tissue. LOWER EXTREMITY CASTS Application of long leg cast (CPT code 29345 and 29365) May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue. Application of short leg cast (CPT code 29405) May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of

contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue. SPLINTS Application of long leg splint(cpt code 29505) May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue. Application of short leg splint (CPT code 29515) May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, contractures or other deformities involving soft tissue. STRAPPING ANY AGE Strapping of hip (CPT code 29520) May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op contusions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of knee (CPT code 29530) May be indicated when there is involvement of the lower leg, ankle and /or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op contusions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of ankle and/or foot(cpt code 29540) Indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Strapping of toes (CPT code 29550) May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue. Biofeedback Training by any method and biofeedback training perineal muscles, anorectal or urethral sphincter CPT code 90901 and 90911) The coverage criteria and definition of biofeedback therapy are found in the CMS Internet-Only

Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 30.1 and 30.1.1 "Biofeedback is a tool utilized by occupational therapists to assist with muscle training. This includes facilitation of muscles that are demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can be visual or auditory." Evaluation of oral and pharyngeal swallowing function(cpt code 92610) The evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory, oral/voluntary and pharyngeal in reference to oral and motility problems in the oral cavity and pharynx. The clinical examination may include: a) history of patient's disorder and awareness of swallowing disorder, and indications of localization and nature of disorder b) medical status including nutritional and respiratory status c) oral anatomy/physiology (labial control, lingual control, palatal function) d) pharyngeal function e) laryngeal function f) ability to follow directions; alertness g) efforts and interventions used to facilitate normal swallow; (compensatory strategies such as chin tuck, dietary changes, etc.) h) identifying symptoms during attempts to swallow The clinical examination can be divided into two phases: 1. The preparatory examination with no swallow, and 2. The initial swallow examination with actual swallow while physiology is observed. Note: Based on the findings, an instrumental exam may be recommended. Treatment of swallowing dysfunction and/or oral function for feeding (CPT code 92526) This involves the treatment for impairments/functional limitations of mastication, the preparatory phase, oral phase, pharyngeal stage, and esophageal phase of swallowing. Make appropriate recommendations regarding diet and compensatory techniques and instruct in direct/indirect therapies to facilitate oral motor control for feeding.

Muscle testing, manual (CPT codes 95831-95834) The series of codes 95831-95834 are intended to report manual test of muscles or muscle groups for strength based on grading scales. Muscle testing, manual (separate procedure); extremity (excluding hand) or trunk, with report (CPT code 95831) To use this code for extremity manual muscle testing, every muscle of at least one extremity would need to be tested, with documentation of why such a thorough assessment was warranted. Muscle testing, manual (separate procedure) with report; Hand, with or without comparison with normal side (CPT code 95832) Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands (CPT code 95833 and 95834) The measurement of muscle performance using manual muscle testing only. Range of Motion Measurements (CPT code 95851 and 95852) This is the determination of range of motion using a tape measure, ruler, electronic device or goniometer. To use CPT code 95851 for extremity range of motion testing, every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted. Developmental Testing; extended (CPT code 96111) CPT code 96111 is an assessment/ test code used to report the services provided during testing of the cognitive function of the central nervous system. Extended testing includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, with interpretation and report. Standardized Thought Processing Testing, Interpretation, and Report per hour (CPT 96125) Neuropsychological Testing (eg. Ross Information Processing Assessment, LOTCA- Loewenstein Occupational Therapy Cognitive Assessment, MVPT - Motor-Free Visual Perception Test, ACL - Allen Cognitive Test), per hour of the Occupational Therapist's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. This is usually done outside the OTs initial evaluation/re-evaluation. Occupational Therapy Evaluation (CPT code 97003) and Occupational Therapy Reevaluation (CPT code 97004)

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

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

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

Note: Further treatment on the use of vasopneumatic devices by occupational therapists, after the education and training visits, is usually not reasonable and necessary. Generally, education and training can be completed in three visits. Paraffin Bath (CPT code 97018) Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems or the wrist, hands, and feet. Heat treatments of this type do not ordinarily require the skills of a qualified occupational therapist. However, in a particular case, the skills, knowledge and judgment of a qualified occupational therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled occupational therapy procedure, the treatments would be considered part of the occupational therapy service. Whirlpool and Dry Whirlpool (CPT code 97022)/Hubbard Tank (CPT code 97036) 1. Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified occupational therapist. However, in a particular case, the skills, knowledge and judgment of a qualified occupational therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled occupational therapy procedure, the treatment would be considered part of the skilled occupational therapy service. 2. Whirlpool bath and Hubbard Tanks are the most common forms of hydrotherapy. The use of whirlpool is considered reasonable and necessary when used as part of a plan directed at facilitating the healing of an open wound (e.g., burns). 3. Specific indications for the use of whirlpools include the following: a. The patient having a documented open wound which is draining, has a foul odor, or evidence of necrotic tissue. b. The patient having a documented need for wound debridement/bandage removal. c. Exfoliative skin impairments. Fluidized Therapy Dry Heat For Certain Musculoskeletal Disorders (Dry Whirlpool) The coverage criteria and definition of fluidized therapy dry heat (dry whirlpool) are found in the CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 150.8

Diathermy Treatment (CPT code 97024) Diathermy coverage criteria and definition are found in the CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 150.5 and Part 4, 240.3 Infrared Therapy Devices (CPT code 97026) Noncoverage of Infrared Therapy Devices is described in CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 270.6 Electrical Stimulation (CPT codes 64550 and 97032, HCPCS codes G0281 and G0283) CPT code 97032 requires "visual, verbal and/or manual contact" (i.e. constant attendance). A separate CPT code 64550 is available for "initial application of a TENS unit in which electrodes are placed on the skin for patients that will be operating the TENS unit at home." Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity. Electromagnetic Therapy (HCPCS G0329) Electromagnetic therapy criteria and definition are found in the CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 270.1 Iontophoresis Application (CPT code 97033) 1. Iontophoresis is a process in which electrically charged molecules or atoms (i. e., ions) are driven into tissue with an electrical field. Voltage provides the driving force. Parameters such as drug polarity and electrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites below the skin. 2. The application of iontophoresis is considered reasonable and necessary for the topical delivery of medications into a specific area of the body. 3. Specific indications for the use of iontophoresis application may include but are not limited to patients having: a. tendonitis or calcific tendonitis b. bursitis

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

3. Specific indications for the use of ultrasound application include: a. The patient having tightened structures limiting joint motion that require an increase in extensibility b. The patient having symptomatic soft tissue calcification c. The patient having neuromas Note: Ultrasound is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition. GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES: 1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services. 2. Use of these procedures requires that these services be rendered under the supervision of an occupational therapist. 3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented in the written plan of treatment, affected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of more than one of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal. 4. Services provided concurrently by an occupational therapist, physical therapist and speech therapist may be covered, if separate and distinct goals are documented in the written plan of treatment. 5. Requires (one on one) direct patient contact, unless otherwise stated (i.e., 97150-group therapy). Therapeutic Exercise (CPT code 97110) 1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., isokinetic exercise, stretching, strengthening and gross and fine motor movement). 2. An occupational therapist may use this code when addressing impairments of exercise tolerance due to cardiopulmonary impairments. Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.

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

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

and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure. 2. Soft Tissue Mobilization This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue. Myofascial release/soft tissue mobilization can be considered reasonable and necessary if at least one of the following conditions is present and documented: a. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk b. treatment being a necessary adjunct to other occupational therapy interventions such as 97110, 97112 or 97530 3. 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, 97112 or 97530. 4. Manual Lymphatic Drainage/Complex Decongestive Physiotherapy The goal of this type of therapy is to reduce lymphedema by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain the reduction after therapy is complete. This therapy involves intensive treatment to reduce the size by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program. a. It is expected that during these sessions, education is being provided to the patient and/or caregiver on the correct application of the compression bandage b. It is also expected that after the completion of the therapy, the patient and/or caregiver can perform these activities without supervision Group Therapeutic Procedure(s)(CPT code 97150) A group for the purpose of performing group therapy will be defined as: a. Two or more patients per therapist receiving active therapy but not one on one treatment and b. the patients may be performing the same exercise or a different exercise but the occupational therapist is instructing all the patients in the group

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

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

that are attainable by the patient. 5. Services provided concurrently by physicians, non-physician practitioners, occupational therapists and speech therapists may be covered, if separate and distinct goals are documented in the written plan of treatment. Sensory Integration (CPT code 97533) The use of sensory integrative techniques is considered reasonable and necessary when patients must develop adaptive skills for sensory processing. When there has been a disruption of the auditory, vestibular, proprioceptive, tactile and/or visual system; interventions are required to assist the patient in remaining functional in their environment. The loss of sensory systems often compromises the safety of the patient; therefore therapy should provide adaptations that allow the patient to interact with their environment that promotes well-being. Self-Care/Home Management Training (CPT code 97535) The coverage criteria and definition of self-care/home management training is found in the CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, 170.1 "Self-care/home management training (97535) describes a group of interventions that focuses on activities of daily living skills and compensatory activities needed to achieve independence" or adapt to an evolving deterioration in health and function. "These include activities such as dressing, bathing, food preparation, and cooking. The patient/client may require adaptive equipment and/or assistive technology in the home environment. This code includes training the patient/client and/or caregiver in the use of the equipment." This code should not be used globally for all home instructions. When instructing the patient in a self management program, use the code that best describes the focus of the self management activity. Community/Work Reintegration Training (CPT codes 97537) Services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1) of the Social Security Act. Services that are covered include complex IADLLs a person must do to maintain independence in the community. These tasks involve interaction with the physical and social environment. Examples of these activities may include telephone skills, written communication, handling mail, use of money, shopping, emergency procedure use/skills and use of assistive technology device/adaptive equipment. This service is only covered when the skilled intervention of occupational therapy is required to achieve established goals. Work Hardening/Conditioning (CPT codes 97545 and 97546)

"Work hardening and work conditioning (97545 and 97546) are different interventions. Work hardening is an interdisciplinary program that is focused on tasks required for a specific job and uses real or simulated work activities to restore physical, behavioral, and vocational functions. Work hardening addresses productivity, safety, physical tolerances, and worker behavior. In contrast, work conditioning describes a work-related, intensive treatment program designed to restore strength/flexibility, and function so that the patient/client can return to work." These interventions are not covered. Wheelchair Management Training (CPT code 97542) Wheelchair management "includes assessing if the patient/client needs a wheelchair, determining what kind of wheelchair is appropriate, including its size and components, measuring the patient/client to ensure proper fit, and fitting the patient/client into the chair once it is received. This code is also used for reporting the time associated with training the patient/client and/or caregiver in transfers in and out of the chair as well as propulsion on all surfaces. It is important for the therapist to provide instructions for safety so as not to risk skin breakdown or a fall." 1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who use wheelchairs for mobility may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications. 2. This procedure is reasonable and necessary only when it requires the skills of an occupational therapist and is designed to address specific needs of the patient, and must be part of an active written plan of treatment directed at a specific goal. 3. The patient and/or caregiver must have the capacity to learn from instructions. 4. Typically, three to four sessions should be sufficient to teach the patient and/or caregiver these skills. 5. When billing 97542 for wheelchair propulsion training, documentation should relate the training to expected functional goals that are attainable by the patient. Wound Care Selective Debridement (CPT codes 97597 and 97598) a) Debridement Debridement is indicated whenever necrotic tissue is present on a documented open wound. Debridement may also be indicated in cases of abnormal wound repair. Debridement techniques usually progress from non-selective to selective but can be combined. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. b) Conservative Sharp Debridement

Conservative sharp debridement is a minor procedure that requires no anesthesia and is performed on an outpatient basis. Scalpel, scissors, forceps and high-pressure waterjet may be used and only clearly identified devitalized tissue is removed. Generally, there is no bleeding associated with this procedure. Wound Care Non-Selective Debridement (CPT codes 97602, 97605 and 97606) a) Enzymatic Debridement Debridement with topical enzymes is used when necrotic substances to be removed from a wound are protein, fibrin and collagen. The manufacturer's product insert contains indications, contra-indications, precautions, dosage, and administration. It would be the clinician's responsibility to comply with the product insert/guidelines. b) Autolytic Debridement This type of debridement is indicated where manageable amounts of necrotic tissue are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found in wound fluids are sequestered under synthetic dressings. Autolytic debridement is contraindicated for wounds that contain infection. c) Mechanical Debridement Wet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing. Hydrotherapy and wound irrigation are also forms of mechanical debridement used to remove necrotic tissue. They also should be used cautiously, as maceration of surrounding tissue may hinder healing. d) Negative Pressure Wound Therapy Negative Pressure Wound Therapy is a non-invasive treatment by which controlled localized negative pressure is delivered to a wide variety of acute, sub-acute, and chronic wounds. Negative Pressure Wound Therapy should be used cautiously as maceration of surrounding tissue may hinder healing. Physical Performance Test or Measurement (CPT code 97750) This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific written plan of treatment, or to determine a patient's functional capacity. Assistive Technology Assessment (CPT code 97755)

This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the patient's status since the last visit and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or reevaluation is indicated. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 018x Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 034x Home Health - Other (for medical and surgical services not under a plan of treatment) 071x Clinic - Rural Health 074x Clinic - Outpatient Rehabilitation Facility (ORF) 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 077x Clinic - Federally Qualified Health Center (FQHC) 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. 0430 Occupational Therapy - General Classification

0431 Occupational Therapy - Visit 0432 Occupational Therapy - Hourly 0433 Occupational Therapy - Group 0434 Occupational Therapy - Evaluation or Reevaluation 0439 Occupational Therapy - Other Occupational Therapy CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: 29065 Application of long arm cast 29075 Application of forearm cast 29085 Apply hand/wrist cast 29086 Apply finger cast 29105 Apply long arm splint 29125 Apply forearm splint 29126 Apply forearm splint 29130 Application of finger splint 29131 Application of finger splint 29200 Strapping of chest 29240 Strapping of shoulder 29260 Strapping of elbow or wrist 29280 Strapping of hand or finger 29345 Application of long leg cast 29365 Application of long leg cast 29405 Apply short leg cast 29505 Application long leg splint 29515 Application lower leg splint 29520 Strapping of hip 29530 Strapping of knee 29540 Strapping of ankle and/or ft 29550 Strapping of toes 29799 Casting/strapping procedure 64550 Apply neurostimulator 90901 Biofeedback train any meth 90911 Biofeedback peri/uro/rectal 92526 Oral function therapy 92548 Posturography 92610 Evaluate swallowing function 95831 Limb muscle testing manual

95832 Hand muscle testing manual 95833 Body muscle testing manual 95834 Body muscle testing manual 95851 Range of motion measurements 95852 Range of motion measurements 96111 Developmental test extend 96125 Cognitive test by hc pro 97003 Ot evaluation 97004 Ot re-evaluation 97010 Hot or cold packs therapy 97012 Mechanical traction therapy 97016 Vasopneumatic device therapy 97018 Paraffin bath therapy 97022 Whirlpool therapy 97024 Diathermy eg microwave 97026 Infrared therapy 97032 Electrical stimulation 97033 Electric current therapy 97034 Contrast bath therapy 97035 Ultrasound therapy 97036 Hydrotherapy 97110 Therapeutic exercises 97112 Neuromuscular reeducation 97113 Aquatic therapy/exercises 97124 Massage therapy 97140 Manual therapy 1/> regions 97150 Group therapeutic procedures 97530 Therapeutic activities 97532 Cognitive skills development 97533 Sensory integration 97535 Self care mngment training 97537 Community/work reintegration 97542 Wheelchair mngment training 97545 Work hardening 97546 Work hardening add-on 97597 Rmvl devital tis 20 cm/< 97598 Rmvl devital tis addl 20cm/< 97602 Wound(s) care non-selective 97605 Neg press wound tx </=50 cm 97606 Neg press wound tx >50 cm 97750 Physical performance test 97755 Assistive technology assess

97760 Orthotic mgmt and training 97761 Prosthetic training 97762 C/o for orthotic/prosth use 97799 Physical medicine procedure G0281 Elec stim unattend for press G0283 Elec stim other than wound G0329 Electromagntic tx for ulcers ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: N/A Group 1 Codes: 138 LATE EFFECTS OF ACUTE POLIOMYELITIS 294.11 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE 294.21 DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE 307.50 EATING DISORDER UNSPECIFIED 307.59 OTHER DISORDERS OF EATING 310.1 PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE 310.81 PSEUDOBULBAR AFFECT 310.89 OTHER SPECIFIED NONPSYCHOTIC MENTAL DISORDERS FOLLOWING ORGANIC BRAIN DAMAGE 315.1 MATHEMATICS DISORDER 331.6 CORTICOBASAL DEGENERATION 333.71 - ATHETOID CEREBRAL PALSY - OTHER ACQUIRED TORSION DYSTONIA 333.79 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.85 SUBACUTE DYSKINESIA DUE TO DRUGS 333.91 STIFF-MAN SYNDROME 334.0-336.9 FRIEDREICH'S ATAXIA - UNSPECIFIED DISEASE OF SPINAL CORD 337.21 - REFLEX SYMPATHETIC DYSTROPHY OF THE UPPER LIMB - REFLEX 337.29 SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE 342.00 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.01 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE 342.02 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE

342.12 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 342.80 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.81 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE 342.82 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 342.90 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.91 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE 342.92 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.0-343.4 CONGENITAL DIPLEGIA - INFANTILE HEMIPLEGIA 343.8-343.9 OTHER SPECIFIED INFANTILE CEREBRAL PALSY - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 - MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 - MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA 344.60 - CAUDA EQUINA SYNDROME WITHOUT NEUROGENIC BLADDER - CAUDA 344.61 EQUINA SYNDROME WITH NEUROGENIC BLADDER 344.81 - LOCKED-IN STATE - OTHER SPECIFIED PARALYTIC SYNDROME 344.89 344.9 PARALYSIS UNSPECIFIED 346.00-346.01 346.02 346.03 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

346.10 346.11 346.12 346.13 346.20 346.21 346.22 346.23 346.30 346.31 346.32 346.33 346.40 346.41 346.42 346.43 346.50 346.51 346.52 MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS

346.53 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITHOUT 346.60 MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS 346.62 PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS 346.63 PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 346.70 CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.71 CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS 346.72 CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS 346.73 CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 346.80 OTHER FORMS OF MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.81 OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS 346.82 OTHER FORMS OF MIGRAINE, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS 346.83 OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 346.90 MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.91 MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS 346.92 MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS 346.93 MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 351.0 BELL'S PALSY 353.0-353.8 BRACHIAL PLEXUS LESIONS - OTHER NERVE ROOT AND PLEXUS DISORDERS 353.9 UNSPECIFIED NERVE ROOT AND PLEXUS DISORDER 354.0-354.8 CARPAL TUNNEL SYNDROME - OTHER MONONEURITIS OF UPPER LIMB 354.9 MONONEURITIS OF UPPER LIMB UNSPECIFIED 355.1 MERALGIA PARESTHETICA

355.71 CAUSALGIA OF LOWER LIMB 355.9 MONONEURITIS OF UNSPECIFIED SITE 356.0-356.8 HEREDITARY PERIPHERAL NEUROPATHY - OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY 356.9 UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY 357.0 ACUTE INFECTIVE POLYNEURITIS 357.2 POLYNEUROPATHY IN DIABETES 358.30 LAMBERT-EATON SYNDROME, UNSPECIFIED 358.31 LAMBERT-EATON SYNDROME IN NEOPLASTIC DISEASE 358.39 LAMBERT-EATON SYNDROME IN OTHER DISEASES CLASSIFIED ELSEWHERE 359.0 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY 359.1 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY 359.21 MYOTONIC MUSCULAR DYSTROPHY 359.22 MYOTONIA CONGENITAL 359.23 MYOTONIC CHONDRODYSTROPHY 359.24 DRUG INDUCED MYOTONIA 359.29 OTHER SPECIFIED MYOTONIC DISORDER 359.71 INCLUSION BODY MYOSITIS 359.79 OTHER INFLAMMATORY AND IMMUNE MYOPATHIES, NEC 368.41 SCOTOMA INVOLVING CENTRAL AREA 368.45 GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION 368.46 HOMONYMOUS BILATERAL FIELD DEFECTS 368.47 HETERONYMOUS BILATERAL FIELD DEFECTS 369.01 BETTER EYE: TOTAL VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT 369.03 BETTER EYE: NEAR-TOTAL VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT 369.04 BETTER EYE: NEAR-TOTAL VISION IMPAIRMENT; LESSER EYE: NEAR- TOTAL VISION IMPAIRMENT 369.06 BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT 369.07 BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: NEAR- TOTAL VISION IMPAIRMENT 369.08 BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT 369.12 BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT 369.13 BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: NEAR-TOTAL VISION IMPAIRMENT 369.14 BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT

369.16 BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT 369.17 BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: NEAR- TOTAL VISION IMPAIRMENT 369.18 BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT 369.22 BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: SEVERE VISION IMPAIRMENT 369.24 BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: SEVERE VISION IMPAIRMENT 369.25 BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: MODERATE VISION IMPAIRMENT 386.11 BENIGN PAROXYSMAL POSITIONAL VERTIGO 438.0 COGNITIVE DEFICITS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 - HEMIPLEGIA AFFECTING DOMINANT SIDE - HEMIPLEGIA AFFECTING 438.22 NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 - MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE - 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.40 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 438.41 - MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 - OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE - OTHER 438.52 PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 438.6 ALTERATIONS OF SENSATIONS 438.81 APRAXIA CEREBROVASCULAR DISEASE 438.82 DYSPHAGIA CEREBROVASCULAR DISEASE 438.83 FACIAL WEAKNESS 438.84 ATAXIA 438.85 VERTIGO 438.89 OTHER LATE EFFECTS OF CEREBROVASCULAR DISEASE 438.9 UNSPECIFIED LATE EFFECTS OF CEREBROVASCULAR DISEASE 440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION 440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE 443.0 RAYNAUD'S SYNDROME 457.0 POSTMASTECTOMY LYMPHEDEMA SYNDROME 457.1 OTHER LYMPHEDEMA 459.11 POSTPHLEBETIC SYNDROME WITH ULCER

459.13 POSTPHLEBETIC SYNDROME WITH ULCER AND INFLAMMATION 459.31 CHRONIC VENOUS HYPERTENSION WITH ULCER 459.33 CHRONIC VENOUS HYPERTENSION WITH ULCER AND INFLAMMATION 490 BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC 491.0 SIMPLE CHRONIC BRONCHITIS 491.1 MUCOPURULENT CHRONIC BRONCHITIS 491.20 OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION 491.21 OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION 491.22 OBSTRUCTIVE CHRONIC BRONCHITIS WITH ACUTE BRONCHITIS 491.8 OTHER CHRONIC BRONCHITIS 491.9 UNSPECIFIED CHRONIC BRONCHITIS 492.0 EMPHYSEMATOUS BLEB 492.8 OTHER EMPHYSEMA 493.00 - EXTRINSIC ASTHMA UNSPECIFIED - EXTRINSIC ASTHMA WITH (ACUTE) 493.02 EXACERBATION 493.10 - INTRINSIC ASTHMA UNSPECIFIED - INTRINSIC ASTHMA WITH (ACUTE) 493.12 EXACERBATION 493.20 - CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED - CHRONIC 493.22 OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION 493.81 EXERCISE-INDUCED BRONCHOSPASM 493.82 COUGH VARIANT ASTHMA 493.90 - ASTHMA UNSPECIFIED - ASTHMA UNSPECIFIED WITH (ACUTE) 493.92 EXACERBATION 494.0-494.1 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION - BRONCHIECTASIS WITH ACUTE EXACERBATION 496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED 681.00 - UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER - ONYCHIA AND 681.02 PARONYCHIA OF FINGER 682.3 CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM 682.4 CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB 683 ACUTE LYMPHADENITIS 701.0 CIRCUMSCRIBED SCLERODERMA 701.4 KELOID SCAR 707.00 PRESSURE ULCER, UNSPECIFIED SITE 707.01 PRESSURE ULCER, ELBOW 707.02 PRESSURE ULCER, UPPER BACK 707.03 PRESSURE ULCER, LOWER BACK 707.04 PRESSURE ULCER, HIP 707.05 PRESSURE ULCER, BUTTOCK 707.06 PRESSURE ULCER, ANKLE 707.07 PRESSURE ULCER, HEEL 707.09 PRESSURE ULCER, OTHER SITE

707.10 UNSPECIFIED ULCER OF LOWER LIMB 707.11 ULCER OF THIGH 707.12 ULCER OF CALF 707.13 ULCER OF ANKLE 707.14 ULCER OF HEEL AND MIDFOOT 707.15 ULCER OF OTHER PART OF FOOT 707.19 ULCER OF OTHER PART OF LOWER LIMB 707.20 PRESSURE ULCER, UNSPECIFIED STAGE 707.21 PRESSURE ULCER, STAGE I 707.22 PRESSURE ULCER, STAGE II 707.23 PRESSURE ULCER, STAGE III 707.24 PRESSURE ULCER, STAGE IV 707.8 CHRONIC ULCER OF OTHER SPECIFIED SITES 707.9 CHRONIC ULCER OF UNSPECIFIED SITE 709.2 SCAR CONDITIONS AND FIBROSIS OF SKIN 711.00 - PYOGENIC ARTHRITIS SITE UNSPECIFIED - ARTHROPATHY INVOLVING 711.59 MULTIPLE SITES ASSOCIATED WITH OTHER VIRAL DISEASES 713.5 ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS 714.0-714.9 RHEUMATOID ARTHRITIS - UNSPECIFIED INFLAMMATORY POLYARTHROPATHY OSTEOARTHROSIS GENERALIZED INVOLVING UNSPECIFIED SITE - 715.00 - OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT 715.89 SPECIFIED AS GENERALIZED OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR 715.90 - LOCALIZED INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS 715.98 UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING OTHER SPECIFIED SITES 716.00 - KASCHIN-BECK DISEASE SITE UNSPECIFIED - UNSPECIFIED 716.99 ARTHROPATHY INVOLVING MULTIPLE SITES 718.00 ARTICULAR CARTILAGE DISORDER SITE UNSPECIFIED 718.01 - ARTICULAR CARTILAGE DISORDER INVOLVING SHOULDER REGION - 718.04 ARTICULAR CARTILAGE DISORDER INVOLVING HAND 718.05 ARTICULAR CARTILAGE DISORDER INVOLVING PELVIC REGION AND THIGH 718.07 - ARTICULAR CARTILAGE DISORDER INVOLVING ANKLE AND FOOT - 718.09 ARTICULAR CARTILAGE DISORDER INVOLVING MULTIPLE SITES 718.10 LOOSE BODY IN JOINT SITE UNSPECIFIED 718.11 - LOOSE BODY IN JOINT OF SHOULDER REGION - LOOSE BODY IN HAND 718.14 JOINT 718.15 LOOSE BODY IN JOINT OF PELVIC REGION AND THIGH 718.17 - LOOSE BODY IN ANKLE AND FOOT JOINT - LOOSE BODY IN JOINT OF 718.19 MULTIPLE SITES 718.20 PATHOLOGICAL DISLOCATION OF JOINT SITE UNSPECIFIED

718.21 - PATHOLOGICAL DISLOCATION OF JOINT OF SHOULDER REGION - 718.24 PATHOLOGICAL DISLOCATION OF HAND JOINT 718.25 PATHOLOGICAL DISLOCATION OF JOINT OF PELVIC REGION AND THIGH 718.26 - PATHOLOGICAL DISLOCATION OF JOINT OF LOWER LEG - 718.29 PATHOLOGICAL DISLOCATION OF JOINT OF MULTIPLE SITES 718.30 RECURRENT DISLOCATION OF JOINT SITE UNSPECIFIED 718.31 - RECURRENT DISLOCATION OF JOINT OF SHOULDER REGION - 718.34 RECURRENT DISLOCATION OF HAND JOINT 718.35 RECURRENT DISLOCATION OF JOINT OF PELVIC REGION AND THIGH 718.36 - RECURRENT DISLOCATION OF LOWER LEG JOINT - RECURRENT 718.39 DISLOCATION OF JOINT OF MULTIPLE SITES 718.40 CONTRACTURE OF JOINT SITE UNSPECIFIED 718.41 - CONTRACTURE OF JOINT OF SHOULDER REGION - CONTRACTURE OF 718.44 HAND JOINT 718.45 CONTRACTURE OF JOINT OF PELVIC REGION AND THIGH 718.46 - CONTRACTURE OF LOWER LEG JOINT - CONTRACTURE OF JOINT OF 718.49 MULTIPLE SITES 718.50 ANKYLOSIS OF JOINT SITE UNSPECIFIED 718.51 - ANKYLOSIS OF JOINT OF SHOULDER REGION - ANKYLOSIS OF HAND 718.54 JOINT 718.55 ANKYLOSIS OF JOINT OF PELVIC REGION AND THIGH 718.56 - ANKYLOSIS OF LOWER LEG JOINT - ANKYLOSIS OF JOINT OF MULTIPLE 718.59 SITES 718.65 UNSPECIFIED INTRAPELVIC PROTRUSION OF ACETABULUM PELVIC REGION AND THIGH 718.70 DEVELOPMENTAL DISLOCATION OF JOINT SITE UNSPECIFIED 718.71 - DEVELOPMENTAL DISLOCATION OF JOINT SHOULDER REGION - 718.74 DEVELOPMENTAL DISLOCATION OF JOINT HAND 718.75 DEVELOPMENTAL DISLOCATION OF JOINT PELVIC REGION AND THIGH 718.76 - DEVELOPMENTAL DISLOCATION OF JOINT LOWER LEG - 718.79 DEVELOPMENTAL DISLOCATION OF JOINT MULTIPLE SITES 718.80 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING UNSPECIFIED SITE OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING 718.81 - SHOULDER REGION - OTHER JOINT DERANGEMENT NOT ELSEWHERE 718.84 CLASSIFIED INVOLVING HAND 718.85 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING PELVIC REGION AND THIGH OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING 718.86 - LOWER LEG - OTHER JOINT DERANGEMENT NOT ELSEWHERE 718.89 CLASSIFIED INVOLVING MULTIPLE SITES 718.90 UNSPECIFIED DERANGEMENT OF JOINT SITE UNSPECIFIED 718.91-718.94 UNSPECIFIED DERANGEMENT OF JOINT OF SHOULDER REGION - UNSPECIFIED DERANGEMENT OF HAND JOINT

718.95 UNSPECIFIED DERANGEMENT OF JOINT OF PELVIC REGION AND THIGH 718.97 - UNSPECIFIED DERANGEMENT OF ANKLE AND FOOT JOINT - UNSPECIFIED 718.99 DERANGEMENT OF JOINT OF MULTIPLE SITES 719.01 - EFFUSION OF JOINT OF SHOULDER REGION - EFFUSION OF HAND JOINT 719.04 719.08 EFFUSION OF JOINT OF OTHER SPECIFIED SITES 719.10 - HEMARTHROSIS SITE UNSPECIFIED - PAIN IN JOINT SITE UNSPECIFIED 719.40 719.41 - PAIN IN JOINT INVOLVING SHOULDER REGION - PAIN IN JOINT 719.49 INVOLVING MULTIPLE SITES 719.50 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING UNSPECIFIED SITE STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING 719.51 - SHOULDER REGION - STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED 719.59 INVOLVING MULTIPLE SITES 719.60 OTHER SYMPTOMS REFERABLE TO JOINT SITE UNSPECIFIED 719.61 - OTHER SYMPTOMS REFERABLE TO JOINT OF SHOULDER REGION - OTHER 719.69 SYMPTOMS REFERABLE TO JOINT OF MULTIPLE SITES 719.7 DIFFICULTY IN WALKING 719.80 OTHER SPECIFIED DISORDERS OF JOINT SITE UNSPECIFIED 719.81 - OTHER SPECIFIED DISORDERS OF JOINT OF SHOULDER REGION - OTHER 719.89 SPECIFIED DISORDERS OF JOINT OF MULTIPLE SITES 719.91 - UNSPECIFIED DISORDER OF JOINT OF SHOULDER REGION - UNSPECIFIED 719.94 DISORDER OF HAND JOINT 719.98 UNSPECIFIED JOINT DISORDER OF OTHER SPECIFIED SITES 720.0 ANKYLOSING SPONDYLITIS 720.1 SPINAL ENTHESOPATHY 720.2-723.5 SACROILIITIS NOT ELSEWHERE CLASSIFIED - TORTICOLLIS UNSPECIFIED 723.9 UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK 724.1 PAIN IN THORACIC SPINE 724.2 LUMBAGO 724.5 BACKACHE UNSPECIFIED 724.8 OTHER SYMPTOMS REFERABLE TO BACK 725 POLYMYALGIA RHEUMATICA 726.0 ADHESIVE CAPSULITIS OF SHOULDER 726.10 DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION UNSPECIFIED 726.11 CALCIFYING TENDINITIS OF SHOULDER 726.12 BICIPITAL TENOSYNOVITIS 726.13 PARTIAL TEAR OF ROTATOR CUFF

726.19 OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION 726.2 OTHER AFFECTIONS OF SHOULDER REGION NOT ELSEWHERE CLASSIFIED 726.30 ENTHESOPATHY OF ELBOW UNSPECIFIED 726.31 MEDIAL EPICONDYLITIS 726.32 LATERAL EPICONDYLITIS 726.33 OLECRANON BURSITIS 726.39 OTHER ENTHESOPATHY OF ELBOW REGION 726.4 ENTHESOPATHY OF WRIST AND CARPUS 726.8 OTHER PERIPHERAL ENTHESOPATHIES 727.00 SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED 727.01 SYNOVITIS AND TENOSYNOVITIS IN DISEASES CLASSIFIED ELSEWHERE 727.02 GIANT CELL TUMOR OF TENDON SHEATH 727.03 TRIGGER FINGER (ACQUIRED) 727.04 RADIAL STYLOID TENOSYNOVITIS 727.05 OTHER TENOSYNOVITIS OF HAND AND WRIST 727.2 SPECIFIC BURSITIDES OFTEN OF OCCUPATIONAL ORIGIN 727.3 OTHER BURSITIS DISORDERS 727.40 SYNOVIAL CYST UNSPECIFIED 727.41 GANGLION OF JOINT 727.42 GANGLION OF TENDON SHEATH 727.43 GANGLION UNSPECIFIED 727.49 OTHER GANGLION AND CYST OF SYNOVIUM TENDON AND BURSA 727.50 - RUPTURE OF SYNOVIUM UNSPECIFIED - OTHER RUPTURE OF SYNOVIUM 727.59 727.60 - NONTRAUMATIC RUPTURE OF UNSPECIFIED TENDON - NONTRAUMATIC 727.64 RUPTURE OF FLEXOR TENDONS OF HAND AND WRIST 727.69 NONTRAUMATIC RUPTURE OF OTHER TENDON 727.81 CONTRACTURE OF TENDON (SHEATH) 727.82 - CALCIUM DEPOSITS IN TENDON AND BURSA - UNSPECIFIED DISORDER 727.9 OF SYNOVIUM TENDON AND BURSA 728.10 CALCIFICATION AND OSSIFICATION UNSPECIFIED 728.11 PROGRESSIVE MYOSITIS OSSIFICANS 728.12 TRAUMATIC MYOSITIS OSSIFICANS 728.13 POSTOPERATIVE HETEROTOPIC CALCIFICATION 728.19 OTHER MUSCULAR CALCIFICATION AND OSSIFICATION 728.2 MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED 728.3 OTHER SPECIFIC MUSCLE DISORDERS 728.4 LAXITY OF LIGAMENT 728.5 HYPERMOBILITY SYNDROME

728.6 CONTRACTURE OF PALMAR FASCIA 728.81 INTERSTITIAL MYOSITIS 728.82 FOREIGN BODY GRANULOMA OF MUSCLE 728.83 RUPTURE OF MUSCLE NONTRAUMATIC 728.85 SPASM OF MUSCLE 728.87 MUSCLE WEAKNESS (GENERALIZED) 728.89 OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA 728.9 UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA 729.0 RHEUMATISM UNSPECIFIED AND FIBROSITIS 729.1-729.2 MYALGIA AND MYOSITIS UNSPECIFIED - NEURALGIA NEURITIS AND RADICULITIS UNSPECIFIED 729.4 FASCIITIS UNSPECIFIED 729.5 PAIN IN LIMB 729.71 NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY 729.81 SWELLING OF LIMB 729.82 CRAMP OF LIMB 729.89 OTHER MUSCULOSKELETAL SYMPTOMS REFERABLE TO LIMBS 729.90 DISORDERS OF SOFT TISSUE, UNSPECIFIED 729.91 POST-TRAUMATIC SEROMA 729.92 NONTRAUMATIC HEMATOMA OF SOFT TISSUE 729.99 OTHER DISORDERS OF SOFT TISSUE 731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR 731.3 MAJOR OSSEOUS DEFECTS 732.3 JUVENILE OSTEOCHONDROSIS OF UPPER EXTREMITY 732.8 OTHER SPECIFIED FORMS OF OSTEOCHONDROPATHY 733.10 PATHOLOGICAL FRACTURE UNSPECIFIED SITE 733.11 PATHOLOGICAL FRACTURE OF HUMERUS 733.12 PATHOLOGICAL FRACTURE OF DISTAL RADIUS AND ULNA 733.19 PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE 733.40 ASEPTIC NECROSIS OF BONE SITE UNSPECIFIED 733.41 ASEPTIC NECROSIS OF HEAD OF HUMERUS 733.81 MALUNION OF FRACTURE 733.82 NONUNION OF FRACTURE 733.90 - DISORDER OF BONE AND CARTILAGE UNSPECIFIED - OTHER DISORDERS 733.99 OF BONE AND CARTILAGE 735.0 HALLUX VALGUS (ACQUIRED) 736.00 - UNSPECIFIED DEFORMITY OF FOREARM EXCLUDING FINGERS - VARUS 736.04 DEFORMITY OF WRIST (ACQUIRED) 736.05 WRIST DROP (ACQUIRED) 736.06 CLAW HAND (ACQUIRED) 736.07 CLUB HAND ACQUIRED 736.09 OTHER ACQUIRED DEFORMITIES OF FOREARM EXCLUDING FINGERS

736.1 MALLET FINGER 736.20 UNSPECIFIED DEFORMITY OF FINGER 736.21 BOUTONNIERE DEFORMITY 736.22 SWAN-NECK DEFORMITY 736.29 OTHER ACQUIRED DEFORMITIES OF FINGER 736.30 - UNSPECIFIED ACQUIRED DEFORMITY OF HIP - OTHER ACQUIRED 736.39 DEFORMITIES OF HIP 736.41 - GENU VALGUM (ACQUIRED) - GENU VARUM (ACQUIRED) 736.42 736.5 GENU RECURVATUM (ACQUIRED) 736.6 OTHER ACQUIRED DEFORMITIES OF KNEE 736.70 UNSPECIFIED DEFORMITY OF ANKLE AND FOOT ACQUIRED 736.71 ACQUIRED EQUINOVARUS DEFORMITY 736.72 - EQUINUS DEFORMITY OF FOOT ACQUIRED - OTHER ACQUIRED 736.76 CALCANEUS DEFORMITY 736.79 OTHER ACQUIRED DEFORMITIES OF ANKLE AND FOOT 736.81 UNEQUAL LEG LENGTH (ACQUIRED) 736.89 OTHER ACQUIRED DEFORMITY OF OTHER PARTS OF LIMB 737.0 ADOLESCENT POSTURAL KYPHOSIS 737.10 KYPHOSIS (ACQUIRED) (POSTURAL) 737.11 KYPHOSIS DUE TO RADIATION 737.12 KYPHOSIS POSTLAMINECTOMY 737.19 OTHER KYPHOSIS ACQUIRED 737.20 LORDOSIS (ACQUIRED) (POSTURAL) 737.21 LORDOSIS POSTLAMINECTOMY 737.22 OTHER POSTSURGICAL LORDOSIS 737.29 OTHER LORDOSIS ACQUIRED 737.30 SCOLIOSIS (AND KYPHOSCOLIOSIS) IDIOPATHIC 737.31 RESOLVING INFANTILE IDIOPATHIC SCOLIOSIS 737.32 PROGRESSIVE INFANTILE IDIOPATHIC SCOLIOSIS 737.33 SCOLIOSIS DUE TO RADIATION 737.34 THORACOGENIC SCOLIOSIS 737.39 OTHER KYPHOSCOLIOSIS AND SCOLIOSIS 737.40 UNSPECIFIED CURVATURE OF SPINE ASSOCIATED WITH OTHER CONDITIONS 737.41 KYPHOSIS ASSOCIATED WITH OTHER CONDITIONS 737.42 LORDOSIS ASSOCIATED WITH OTHER CONDITIONS 737.43 SCOLIOSIS ASSOCIATED WITH OTHER CONDITIONS 737.8 OTHER CURVATURES OF SPINE ASSOCIATED WITH OTHER CONDITIONS 737.9 UNSPECIFIED CURVATURE OF SPINE ASSOCIATED WITH OTHER CONDITIONS

738.8-738.9 ACQUIRED MUSCULOSKELETAL DEFORMITY OF OTHER SPECIFIED SITE - ACQUIRED MUSCULOSKELETAL DEFORMITY OF UNSPECIFIED SITE 754.1 CONGENITAL MUSCULOSKELETAL DEFORMITIES OF STERNOCLEIDOMASTOID MUSCLE 755.20 UNSPECIFIED REDUCTION DEFORMITY OF UPPER LIMB CONGENITAL 755.21 TRANSVERSE DEFICIENCY OF UPPER LIMB 755.22 LONGITUDINAL DEFICIENCY OF UPPER LIMB NOT ELSEWHERE CLASSIFIED 755.23 LONGITUDINAL DEFICIENCY COMBINED INVOLVING HUMERUS RADIUS AND ULNA (COMPLETE OR INCOMPLETE) 755.24 LONGITUDINAL DEFICIENCY HUMERAL COMPLETE OR PARTIAL (WITH OR WITHOUT DISTAL DEFICIENCIES INCOMPLETE) 755.25 LONGITUDINAL DEFICIENCY RADIOULNAR COMPLETE OR PARTIAL (WITH OR WITHOUT DISTAL DEFICIENCIES INCOMPLETE) 755.26 LONGITUDINAL DEFICIENCY RADIAL COMPLETE OR PARTIAL (WITH OR WITHOUT DISTAL DEFICIENCIES INCOMPLETE) 755.27 LONGITUDINAL DEFICIENCY ULNAR COMPLETE OR PARTIAL (WITH OR WITHOUT DISTAL DEFICIENCIES INCOMPLETE) 755.28 LONGITUDINAL DEFICIENCY CARPALS OR METACARPALS COMPLETE OR PARTIAL (WITH OR WITHOUT INCOMPLETE PHALANGEAL DEFICIENCY) 755.29 LONGITUDINAL DEFICIENCY PHALANGES COMPLETE OR PARTIAL 755.50 - UNSPECIFIED ANOMALY OF UPPER LIMB CONGENITAL - RADIOULNAR 755.53 SYNOSTOSIS 755.54 MADELUNG'S DEFORMITY 755.55 - ACROCEPHALOSYNDACTYLY - OTHER CONGENITAL ANOMALIES OF 755.59 UPPER LIMB INCLUDING SHOULDER GIRDLE 756.10 CONGENITAL ANOMALY OF SPINE UNSPECIFIED 756.11 CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION 756.12 SPONDYLOLISTHESIS CONGENITAL 756.13 ABSENCE OF VERTEBRA CONGENITAL 756.14 HEMIVERTEBRA 756.15 FUSION OF SPINE (VERTEBRA) CONGENITAL 756.16 KLIPPEL-FEIL SYNDROME 756.17 SPINA BIFIDA OCCULTA 756.19 OTHER CONGENITAL ANOMALIES OF SPINE 757.0 HEREDITARY EDEMA OF LEGS 780.4 DIZZINESS AND GIDDINESS 781.0 ABNORMAL INVOLUNTARY MOVEMENTS 781.2 ABNORMALITY OF GAIT 781.3 LACK OF COORDINATION 781.4 TRANSIENT PARALYSIS OF LIMB 781.8 NEUROLOGIC NEGLECT SYNDROME 781.92 ABNORMAL POSTURE

781.93 OCULAR TORTICOLLIS 781.94 FACIAL WEAKNESS 781.99 OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS 782.0 DISTURBANCE OF SKIN SENSATION 782.2 LOCALIZED SUPERFICIAL SWELLING MASS OR LUMP 782.3 EDEMA 782.8 CHANGES IN SKIN TEXTURE 783.3 FEEDING DIFFICULTIES AND MISMANAGEMENT 783.7 ADULT FAILURE TO THRIVE 784.0 HEADACHE 784.60 SYMBOLIC DYSFUNCTION UNSPECIFIED 784.61 ALEXIA AND DYSLEXIA 784.69 OTHER SYMBOLIC DYSFUNCTION 785.4 GANGRENE 787.20 DYSPHAGIA, UNSPECIFIED 787.21 DYSPHAGIA, ORAL PHASE 787.22 DYSPHAGIA, OROPHARYNGEAL PHASE 787.23 DYSPHAGIA, PHARYNGEAL PHASE 787.24 DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE 787.29 OTHER DYSPHAGIA 787.60 FULL INCONTINENCE OF FECES 788.31 URGE INCONTINENCE 788.32 STRESS INCONTINENCE MALE 788.33 MIXED INCONTINENCE (MALE) (FEMALE) 788.34 INCONTINENCE WITHOUT SENSORY AWARENESS 788.99 OTHER SYMPTOMS INVOLVING URINARY SYSTEM 794.2 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM 799.51 ATTENTION OR CONCENTRATION DEFICIT 799.52 COGNITIVE COMMUNICATION DEFICIT 799.53 VISUOSPATIAL DEFICIT 799.54 PSYCHOMOTOR DEFICIT 799.55 FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT 808.44 MULTIPLE CLOSED PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE 808.54 MULTIPLE OPEN PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE 810.00 CLOSED FRACTURE OF CLAVICLE UNSPECIFIED PART 810.01-810.03 CLOSED FRACTURE OF STERNAL END OF CLAVICLE - CLOSED FRACTURE OF ACROMIAL END OF CLAVICLE

810.10 - OPEN FRACTURE OF CLAVICLE UNSPECIFIED PART - OPEN FRACTURE OF 810.13 ACROMIAL END OF CLAVICLE 811.00 CLOSED FRACTURE OF SCAPULA UNSPECIFIED PART 811.01 - CLOSED FRACTURE OF ACROMIAL PROCESS OF SCAPULA - CLOSED 811.09 FRACTURE OF OTHER PART OF SCAPULA 812.00 FRACTURE OF UNSPECIFIED PART OF UPPER END OF HUMERUS CLOSED 812.01 - FRACTURE OF SURGICAL NECK OF HUMERUS CLOSED - OTHER CLOSED 812.09 FRACTURES OF UPPER END OF HUMERUS 812.10 - FRACTURE OF UNSPECIFIED PART OF UPPER END OF HUMERUS OPEN - 812.19 OTHER OPEN FRACTURE OF UPPER END OF HUMERUS 812.20 - FRACTURE OF UNSPECIFIED PART OF HUMERUS CLOSED - FRACTURE OF 812.21 SHAFT OF HUMERUS CLOSED 812.30 - FRACTURE OF UNSPECIFIED PART OF HUMERUS OPEN - FRACTURE OF 812.31 SHAFT OF HUMERUS OPEN 812.40 - FRACTURE OF UNSPECIFIED PART OF LOWER END OF HUMERUS CLOSED 812.49 - OTHER CLOSED FRACTURES OF LOWER END OF HUMERUS 812.50 - FRACTURE OF UNSPECIFIED PART OF LOWER END OF HUMERUS OPEN - 812.59 OTHER FRACTURE OF LOWER END OF HUMERUS OPEN 813.00 - CLOSED FRACTURE OF UPPER END OF FOREARM UNSPECIFIED - 813.01 FRACTURE OF OLECRANON PROCESS OF ULNA CLOSED 813.02 - FRACTURE OF CORONOID PROCESS OF ULNA CLOSED - FRACTURE OF 813.08 RADIUS WITH ULNA UPPER END (ANY PART) CLOSED 813.10 - OPEN FRACTURE OF UPPER END OF FOREARM UNSPECIFIED - FRACTURE 813.18 OF RADIUS WITH ULNA UPPER END (ANY PART) OPEN 813.20 - FRACTURE OF SHAFT OF RADIUS OR ULNA UNSPECIFIED CLOSED - 813.23 FRACTURE OF SHAFT OF RADIUS WITH ULNA CLOSED 813.30 - FRACTURE OF SHAFT OF RADIUS OR ULNA UNSPECIFIED OPEN - 813.33 FRACTURE OF SHAFT OF RADIUS WITH ULNA OPEN 813.40 - CLOSED FRACTURE OF LOWER END OF FOREARM UNSPECIFIED - 813.44 FRACTURE OF LOWER END OF RADIUS WITH ULNA CLOSED 813.45 TORUS FRACTURE OF RADIUS (ALONE) 813.46 TORUS FRACTURE OF ULNA (ALONE) 813.47 TORUS FRACTURE OF RADIUS AND ULNA 813.50 - OPEN FRACTURE OF LOWER END OF FOREARM UNSPECIFIED - FRACTURE 813.54 OF LOWER END OF RADIUS WITH ULNA OPEN 813.80 - CLOSED FRACTURE OF UNSPECIFIED PART OF FOREARM - FRACTURE OF 813.83 UNSPECIFIED PART OF RADIUS WITH ULNA CLOSED 813.90 - FRACTURE OF UNSPECIFIED PART OF FOREARM OPEN - FRACTURE OF 813.93 UNSPECIFIED PART OF RADIUS WITH ULNA OPEN 814.00 - CLOSED FRACTURE OF CARPAL BONE UNSPECIFIED - OPEN FRACTURE 814.19 OF OTHER BONE OF WRIST 815.00 - CLOSED FRACTURE OF METACARPAL BONE(S) SITE UNSPECIFIED - OPEN 815.19 FRACTURE OF MULTIPLE SITES OF METACARPUS

816.00-816.13 CLOSED FRACTURE OF PHALANX OR PHALANGES OF HAND UNSPECIFIED - OPEN FRACTURE OF MULTIPLE SITES OF PHALANX OR PHALANGES OF HAND 817.0 - MULTIPLE CLOSED FRACTURES OF HAND BONES - MULTIPLE OPEN 817.1 FRACTURES OF HAND BONES 818.0 - ILL-DEFINED CLOSED FRACTURES OF UPPER LIMB - ILL-DEFINED OPEN 818.1 FRACTURES OF UPPER LIMB MULTIPLE CLOSED FRACTURES INVOLVING BOTH UPPER LIMBS AND 819.0 - UPPER LIMB WITH RIB(S) AND STERNUM - MULTIPLE OPEN FRACTURES 819.1 INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF 820.00 - FEMUR CLOSED - OTHER TRANSCERVICAL FRACTURE OF FEMUR 820.09 CLOSED 820.10 - FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF 820.19 FEMUR OPEN - OTHER TRANSCERVICAL FRACTURE OF FEMUR OPEN FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR 820.20 - CLOSED - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR 820.22 CLOSED 820.30 - FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR OPEN - 820.32 FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR OPEN 820.8 FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR CLOSED 820.9 FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN 821.00 - FRACTURE OF UNSPECIFIED PART OF FEMUR CLOSED - OTHER 821.39 FRACTURE OF LOWER END OF FEMUR OPEN 831.00 CLOSED DISLOCATION OF SHOULDER UNSPECIFIED SITE 831.01 - CLOSED ANTERIOR DISLOCATION OF HUMERUS - CLOSED DISLOCATION 831.09 OF OTHER SITE OF SHOULDER 831.10 - OPEN DISLOCATION OF SHOULDER UNSPECIFIED - OPEN DISLOCATION 831.19 OF OTHER SITE OF SHOULDER 832.00 CLOSED DISLOCATION OF ELBOW UNSPECIFIED SITE 832.01 - CLOSED ANTERIOR DISLOCATION OF ELBOW - CLOSED DISLOCATION OF 832.09 OTHER SITE OF ELBOW 832.10 - OPEN DISLOCATION OF ELBOW UNSPECIFIED SITE - OPEN DISLOCATION 832.19 OF OTHER SITE OF ELBOW 832.2 NURSEMAID'S ELBOW 833.00 CLOSED DISLOCATION OF WRIST UNSPECIFIED PART 833.01 - CLOSED DISLOCATION OF RADIOULNAR (JOINT) DISTAL - CLOSED 833.09 DISLOCATION OF OTHER PART OF WRIST 833.10 - OPEN DISLOCATION OF WRIST UNSPECIFIED PART - OPEN DISLOCATION 833.19 OF OTHER PART OF WRIST 834.00 CLOSED DISLOCATION OF FINGER UNSPECIFIED PART 834.01 - CLOSED DISLOCATION OF METACARPOPHALANGEAL (JOINT) - CLOSED 834.02 DISLOCATION OF INTERPHALANGEAL (JOINT) HAND

834.10 - OPEN DISLOCATION OF FINGER UNSPECIFIED PART - OPEN DISLOCATION 834.12 INTERPHALANGEAL (JOINT) HAND 836.0 - TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT - 836.3 DISLOCATION OF PATELLA CLOSED 840.0 - ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN - SPRAIN OF OTHER 840.8 SPECIFIED SITES OF SHOULDER AND UPPER ARM 840.9 SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM 841.0 - RADIAL COLLATERAL LIGAMENT SPRAIN - SPRAIN OF UNSPECIFIED SITE 841.9 OF ELBOW AND FOREARM 842.00 SPRAIN OF UNSPECIFIED SITE OF WRIST 842.01 - SPRAIN OF CARPAL (JOINT) OF WRIST - OTHER WRIST SPRAIN 842.09 842.10 SPRAIN OF UNSPECIFIED SITE OF HAND 842.11 - SPRAIN OF CARPOMETACARPAL (JOINT) OF HAND - OTHER HAND SPRAIN 842.19 CONCUSSION WITH PROLONGED LOSS OF CONSCIOUSNESS WITHOUT 850.4 RETURN TO PRE-EXISTING CONSCIOUS LEVEL OPEN WOUND OF SHOULDER REGION WITHOUT COMPLICATION - OPEN 880.00 - WOUND OF MULTIPLE SITES OF SHOULDER AND UPPER ARM WITH 880.29 TENDON INVOLVEMENT 881.00-881.22 882.0-882.2 883.0-883.2 884.0-884.2 885.0-885.1 886.0-886.1 887.0-887.7 897.0-897.7 OPEN WOUND OF FOREARM WITHOUT COMPLICATION - OPEN WOUND OF WRIST WITH TENDON INVOLVEMENT OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITHOUT COMPLICATION - OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITH TENDON INVOLVEMENT OPEN WOUND OF FINGERS WITHOUT COMPLICATION - OPEN WOUND OF FINGERS WITH TENDON INVOLVEMENT MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITHOUT COMPLICATION - MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITH TENDON INVOLVEMENT TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) COMPLICATED TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) COMPLICATED TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) UNILATERAL BELOW ELBOW WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL BELOW KNEE WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

905.1-905.9 LATE EFFECT OF FRACTURE OF SPINE AND TRUNK WITHOUT SPINAL CORD LESION - LATE EFFECT OF TRAUMATIC AMPUTATION 906.0-906.9 LATE EFFECT OF OPEN WOUND OF HEAD NECK AND TRUNK - LATE EFFECT OF BURN OF UNSPECIFIED SITE 907.0-907.9 LATE EFFECT OF INTRACRANIAL INJURY WITHOUT SKULL FRACTURE - LATE EFFECT OF INJURY TO OTHER AND UNSPECIFIED NERVE 908.6 LATE EFFECT OF CERTAIN COMPLICATIONS OF TRAUMA 909.2 LATE EFFECT OF RADIATION 909.3 LATE EFFECT OF COMPLICATIONS OF SURGICAL AND MEDICAL CARE 925.1 CRUSHING INJURY OF FACE AND SCALP 925.2 CRUSHING INJURY OF NECK 927.00 - CRUSHING INJURY OF SHOULDER REGION - CRUSHING INJURY OF 927.8 MULTIPLE SITES OF UPPER LIMB 927.9 CRUSHING INJURY OF UNSPECIFIED SITE OF UPPER LIMB 929.0 CRUSHING INJURY OF MULTIPLE SITES NOT ELSEWHERE CLASSIFIED 929.9 CRUSHING INJURY OF UNSPECIFIED SITE 941.20 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FACE AND HEAD UNSPECIFIED SITE 941.21-941.29 941.30 941.31-941.39 941.40-941.59 942.20 942.21-942.24 942.25-942.29 942.30 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF EAR (ANY PART) - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF FACE AND HEAD FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF EAR (ANY PART) - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF FACE AND HEAD WITHOUT LOSS OF BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES (EXCEPT EYE) OF FACE HEAD AND NECK WITH LOSS OF A BODY PART BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF TRUNK BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF BREAST - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF BACK (ANY PART) BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF GENITALIA - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF TRUNK

942.31-942.34 942.35-942.39 942.40-942.59 943.00-943.19 943.20 943.21-943.29 943.30 943.31-943.39 943.40-943.59 944.00-944.20 944.21-944.28 944.30 944.31-944.38 944.40-944.58 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF BREAST - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF BACK (ANY PART) FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF GENITALIA - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF OTHER AND MULTIPLE SITES OF TRUNK DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TRUNK UNSPECIFIED SITE WITHOUT LOSS OF BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK WITH LOSS OF A BODY PART BURN OF UNSPECIFIED DEGREE OF UNSPECIFIED SITE OF UPPER LIMB - ERYTHEMA DUE TO BURN (FIRST DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF UPPER LIMB BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FOREARM - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF UPPER LIMB FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOREARM - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF UPPER LIMB WITHOUT LOSS OF A BODY PART - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND WITH LOSS OF UPPER LIMB BURN OF UNSPECIFIED DEGREE OF UNSPECIFIED SITE OF HAND - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF HAND BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF HAND FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF HAND WITHOUT LOSS OF HAND - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD

DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) WITH LOSS OF A BODY PART BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF 945.22 - FOOT - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND 945.29 DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S) FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF 945.32 - FOOT - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) 945.39 OF MULTIPLE SITES OF LOWER LIMB(S) BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF 946.2 - MULTIPLE SPECIFIED SITES - FULL-THICKNESS SKIN LOSS DUE TO BURN 946.3 (THIRD DEGREE NOS) OF MULTIPLE SPECIFIED SITES DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD 946.4 DEGREE) OF MULTIPLE SPECIFIED SITES WITHOUT LOSS OF A BODY PART 946.5 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITH LOSS OF A BODY PART FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) 949.3-949.5 UNSPECIFIED SITE - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART 953.4 INJURY TO BRACHIAL PLEXUS 953.8 INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS 955.0-955.8 INJURY TO AXILLARY NERVE - INJURY TO MULTIPLE NERVES OF SHOULDER GIRDLE AND UPPER LIMB 955.9 INJURY TO UNSPECIFIED NERVE OF SHOULDER GIRDLE AND UPPER LIMB 956.0 INJURY TO SCIATIC NERVE 958.6 VOLKMANN'S ISCHEMIC CONTRACTURE 958.91 TRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY 996.40 UNSPECIFIED MECHANICAL COMPLICATION OF INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT 996.41 MECHANICAL LOOSENING OF PROSTHETIC JOINT 996.42 DISLOCATION OF PROSTHETIC JOINT 996.43 BROKEN PROSTHETIC JOINT IMPLANT 996.44 PERI-PROSTHETIC FRACTURE AROUND PROSTHETIC JOINT 996.45 PERI-PROSTHETIC OSTEOLYSIS 996.46 ARTICULAR BEARING SURFACE WEAR OF PROSTHETIC JOINT 996.47 OTHER MECHANICAL COMPLICATION OF PROSTHETIC JOINT IMPLANT 996.49 OTHER MECHANICAL COMPLICATION OF OTHER INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT 996.66 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS 996.67 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL ORTHOPEDIC DEVICE IMPLANT AND GRAFT

996.77-996.79 OTHER COMPLICATIONS DUE TO INTERNAL JOINT PROSTHESIS - OTHER COMPLICATIONS DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT 996.91 - COMPLICATIONS OF REATTACHED FOREARM - COMPLICATIONS OF 996.94 REATTACHED UPPER EXTREMITY OTHER AND UNSPECIFIED 997.60 UNSPECIFIED LATE COMPLICATION OF AMPUTATION STUMP 997.61 - NEUROMA OF AMPUTATION STUMP - INFECTION (CHRONIC) OF 997.62 AMPUTATION STUMP 997.69 OTHER LATE AMPUTATION STUMP COMPLICATION OTHER SPECIFIED COMPLICATIONS OF PROCEDURES NOT ELSEWHERE 998.89 CLASSIFIED V15.88 HISTORY OF FALL V43.60 UNSPECIFIED JOINT REPLACEMENT V43.61 - SHOULDER JOINT REPLACEMENT - KNEE JOINT REPLACEMENT V43.65 V43.66 ANKLE JOINT REPLACEMENT V43.69 OTHER JOINT REPLACEMENT V43.7 LIMB REPLACED BY OTHER MEANS V46.3 WHEELCHAIR DEPENDENCE V49.60 - UNSPECIFIED LEVEL UPPER LIMB AMPUTATION STATUS - SHOULDER V49.67 AMPUTATION STATUS V49.75 - BELOW KNEE AMPUTATION STATUS - ABOVE KNEE AMPUTATION V49.76 STATUS V52.0 FITTING AND ADJUSTMENT OF ARTIFICIAL ARM (COMPLETE) (PARTIAL) V52.1 FITTING AND ADJUSTMENT OF ARTIFICIAL LEG (COMPLETE) (PARTIAL) V52.4 FITTING AND ADJUSTMENT OF BREAST PROSTHESIS AND IMPLANT V52.8 FITTING AND ADJUSTMENT OF OTHER SPECIFIED PROSTHETIC DEVICE V53.7 FITTING AND ADJUSTMENT OF ORTHOPEDIC DEVICES V53.8 FITTING AND ADJUSTMENT OF WHEELCHAIR V53.90 FITTING AND ADJUSTMENT OF UNSPECIFIED DEVICE 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 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF ARM UNSPECIFIED V54.11 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF UPPER ARM V54.12 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF LOWER ARM V54.17 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF VERTEBRAE V54.19 AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF OTHER BONE AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF ARM V54.20 UNSPECIFIED V54.21 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF UPPER ARM V54.22 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF LOWER ARM V54.27 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF VERTEBRAE

V54.29 AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF OTHER BONE V54.81 AFTERCARE FOLLOWING JOINT REPLACEMENT V54.89 OTHER ORTHOPEDIC AFTERCARE V54.9 UNSPECIFIED ORTHOPEDIC AFTERCARE V57.81 CARE INVOLVING ORTHOTIC TRAINING ENCOUNTER FOR CHANGE OR REMOVAL OF NONSURGICAL WOUND V58.30 DRESSING ENCOUNTER FOR CHANGE OR REMOVAL OF SURGICAL WOUND V58.31 DRESSING V58.49 OTHER SPECIFIED AFTERCARE FOLLOWING SURGERY V88.21 ACQUIRED ABSENCE OF HIP JOINT V88.22 ACQUIRED ABSENCE OF KNEE JOINT V88.29 ACQUIRED ABSENCE OF OTHER JOINT ICD-9 Codes that DO NOT Support Medical Necessity Paragraph: N/A N/A General Information Associated Information Documentation Requirements Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 220. 1. Documentation supporting the medical necessity should be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request. 2. The documentation in the medical records should have sufficient information to determine that a service was performed on specific dates, and the medical necessity of the service(s) rendered. 3. If the signed order includes a plan of care, no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the

plan. 4. Required documentation: - Evaluation/and Plan of care including any other pertinent characteristics of the beneficiary; - Certifications and recertifications; - The history and physical exam pertinent to the patient s care, (including the response or changes in behavior to previously administered skilled services); - The skilled services provided; - A detailed rationale that explains the need for the skilled service in light of the patient s overall medical condition and experiences; - The complexity of the service to be performed; - Progress reports written by the clinician-services related to progress reports are to be furnished on or before every 10th treatment day; - Treatment notes for each visit detailing the patient s response to the skilled services provided (may also serve as progress notes); - When appropriate, a justification statement for services that are more extensive than is typical for the condition treated; - Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. It is not required that the same physician/npp who participated initially in recommending or planning the patient's care certify and/or recertify the plans. Occupational therapy services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient's response to treatment. Such visits would be considered covered therapy services when the skills of a therapist are required to perform the services. The patient s needs, course of therapy and response to therapy must be documented. Functional reporting uses nonpayable G-codes and related modifiers to convey information about the patient s functional status at specified points during treatment. This functional data reporting is effective for therapy services with dates of service on and after January 1, 2013. The functional reporting requirements apply to the therapy services furnished by the following providers: CAHs, SNFs, CORFs, rehabilitation agencies, and HHAs (where a beneficiary is not under a home health plan of care. In the medical record, functional documentation must be included: at the beginning of a therapy episode of care in the therapy plan of care as functional limitations and expressed as part of the patient s long term goals as the patient s current status, projected goal, and discharge status (for each date of service) in the progress report at the end of each progress reporting period, i.e. at least once every tenth treatment day

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

deterioration of the patient s condition, the efficacy of the services could be established by documenting that the natural progression of the patient s medical or functional decline has been interrupted. Assessments of all goals must be performed in a frequent and regular manner so that the resulting documentation provides a sufficient basis for determining the appropriateness of coverage. The maintenance program provisions do not apply to the OT services furnished in a comprehensive outpatient rehabilitation facility (CORF) because the statute specifies that CORF services are rehabilitative. 8. CORF social and/or psychological services do not include services for mental health diagnoses. Social and/or psychological services are covered only if the patient's physician or the CORF physician establishes that the services directly relate to the patient's rehabilitation plan of treatment and are needed to achieve the goals in the rehabilitation plan of treatment. Social and/or psychological services are those services that address the patients response and adjustment to the rehabilitation treatment plan: rate of improvement and progress towards the rehabilitation goals, or other services as they directly relate to the occupational therapy plan of treatment being provided to the patient. Sources of Information and Basis for Decision Applegate WB, Blass JP, Williams TF. Instruments for the functional assessment of older patients. New Engl J Med. 1990;322:1207-1214. The Institute of Medicine's Committee on a National Agenda for Prevention of Disabilities. Executive Summary in Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press;1991. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9:179-186. Occupational Therapy Practice Guidelines for Adults With Neurodegenerative Diseases. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Adults With Rheumatoid Arthritis. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Adults With Spinal Cord Injury. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Adults With Stroke. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury. The AOTA Practice Guidelines Series. AOTA;1999. Occupational Therapy Practice Guidelines for Chronic Pain. The AOTA Practice Guidelines Series. AOTA;1999.

Occupational Therapy Practice Guidelines for Tendon Injuries. The AOTA Practice Guidelines Series. AOTA;1999. Fife TD, Iverson DJ, Lempert JM, et al. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Am Acad Neur. 2008;2067-2074. Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 01/01/2015 R6 03/29/2014 R5 03/27/2014 R4 Revision History Number Revision History Explanation Under CPT/HCPCS Codes revisions were made to the description for 97605 and 97606. Under CMS National Coverage Policy added statutory requirement Title XVIII of the Social Security Act, 1833(e), states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Under CMS National Coverage Policy added CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 8, 30.2.2.1, 30.4.1.2, and 30.6. The following manual reference was deleted: CMS Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.1 (B). Under Coverage Indications, Limitations and/or Medical Necessity deleted the second paragraph referencing the psychiatric therapy LCDs as these LCDs were retired. Throughout this section of the LCD CMS Manual System was revised to now read CMS Internet-Only Manual. Verbiage was added related to restorative/rehabilitative therapy, and maintenance therapy. A note Reason(s) for Change Revisions Due To CPT/HCPCS Code Changes Provider Education/Guidance Other (Added statutory requirement.) Provider Education/Guidance Typographical Error Other (Change Request 8458, Transmittal 179, dated January 14, 2014)

01/16/2014 R3 04/12/2013 R2 was added related to occupational therapy assistants furnishing skilled maintenance program services in the outpatient setting and the skilled nursing facility (SNF) settings. Verbiage was also added to statement #5. Under Maintenance Programs the entire section of narrative was revised. Under Aquatic Therapy with Therapeutic Exercise-h. and Massage Therapy 2. typographical spelling errors were corrected. Under Self-Care/Home Management Training (CPT code 97535) added additional verbiage to the second paragraph. Under Documentation Requirements verbiage was added to statements #1, #4, #6, and #7. This LCD was revised due to the implementation of Change Request 8458, Transmittal 179 effective January 7, 2014. This LCD revision becomes effective 03/27/2014. Under Coverage Indications, Limitations, and/or Medical Necessity-Standard Cognitive Performance Testing (CPT 96125) the CPT/HCPCS code long description for 96125 was revised and the title of the LCD section was changed to now read, Standardized Thought Processing Testing, Interpretation and Report per hour. Under Coverage Indications, Limitations, and/or Medical Necessity-Ultrasound (CPT code 97035) deleted and 0183T ) from the title and deleted sentence #4 related to 0183T as literature was inconclusive to support the services are reasonable and necessary for wound assessment and care. Under CPT/HCPCS Codes deleted 0183T. These revisions were due to the 2014 CPT/HCPCS Annual Update. These CPT/HCPCS updates became effective 01/01/2014. This LCD revision becomes effective 01/16/2014. Under CMS National Coverage Policy added change request 8005. Documentation Requirements and Utilization Guidelines have been moved Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes Provider Education/Guidance

under Associated Information. Under Associated Information added verbiage regarding the functional reporting uses nonpayable G-codes for dates of service on or after January 1, 2013. Revision #7, 01/01/2013 Under CMS National Coverage Policy added change request 8005. Under CPT/HCPCS Codes the following codes had description changes: 97140, 97530, 97532, 97533, 79535, 97537, 97598, 97605, 97606 and 97755. Under Documentation Requirements #4 added verbiage regarding the progress notes to be furnished on or before every 10th visit. This revision becomes effective on 01/01/2013. 01/01/2013 R1 Revision #6, 10/04/2012 Under CMS National Coverage Policy section added the following manual citation: CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 160.27. Under Indications and Limitations of Coverage and/or Medical N/A Necessity-Electrical Stimulation Therapy (CPT codes 64550 and 97032, HCPCS codes G0281 and G0283) added verbiage regarding TENS used for treatment of chronic low back pain. This revision becomes effective 10/04/2012. Revision #5, 03/29/2012 Under CMS National Coverage Policy added the following manual citation: CMS Manual System, Pub. 100-02, Chapter 6, 20.5.2. Under Indications and Limitations of Coverage and/or Medical Necessity added the 4th-6th paragraphs regarding the descriptions/definitions of direct and general supervision used in the LCD and the definition of a qualified occupational therapist to reflect Change Request 7672, Transmittal 152. The verbiage in the Change Request was

manualized. Correction of revision #2, under CPT/HCPCS Codes added 97799, but inadvertently omitted it from the revision history. Under ICD-9 Codes That Support Medical Necessity it states that ICD-9 code 780.0 was added when it should have read 780.4 was added. Also ICD-9 code 732.3 was added to the LCD but was inadvertently omitted from the revision history. This revision becomes effective on 03/29/2012 Revision #4, 01/01/2012 Under Indications and Limitations of Coverage and/or Medical Necessity deleted CPT code 96110 and the accompanying verbiage as the code description for this service was revised to now indicate a screening. The service described by CPT code 96110 is no longer a covered benefit and is therefore not covered by Medicare. The examples cited in the verbiage of this type of testing were deleted. Under CPT/HCPCS Codes added the NOTE to indicate that the service described by CPT code 96110 is no longer a covered benefit and is therefore not covered by Medicare and deleted CPT code 96110 from the list. The code description was revised for CPT code 96111. This revision to the LCD was due to the 2012 CPT/HCPCS Annual Update. This revision becomes effective 01/01/2012. Revision #3, 10/01/2011 Under ICD-9 Codes That Support Medical Necessity the following ICD-9 codes have been added: 294.21, 331.6, 310.81, 310.89, 358.30, 358.31, 358.39, 726.13, 808.44, 808.54, V88.21, V88.22 and V88.29. ICD-9 codes 346.01, 346.11, 346.21, 346.31, 346.41, 346.51, 346.61, 346.71, 346.81 and 346.91 had verbiage revisions. ICD-9 code 718.60 was deleted and not replaced. This revision becomes

effective 10/01/2011. Revision #2, 08/11/2011 Under CMS National Coverage Policy the following citations have been deleted: CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 12, 40, 40.1 and 40.3 CMS Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, 13.5.1 CMS Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, 13.1.1-13.13.14 CMS Manual System, Pub. 100-04, Medicare Claims Processing, Transmittal 1625, dated October 31, 2008, Change Request 6254 CMS Manual System, Pub 100-02, Medicare Benefit Policy, Transmittal 111, dated September 25, 2009, Change Request 6005 The following citations have been added; CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 12, 30.1 and 40.7 CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.3 CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, 20B and 100.5 Under Indications and Limitations of Coverage and/or Medical Necessity added 2nd paragraph, "For specific coverage of...". Under CPT code 97010 added #3. Added a "note" under CPT code 97016, Under the following CPT codes: 95831-95834, 95851, 95852, 97010, 97016, 97018, 97022 & 97036, 64550 & 97032 & G0281 & G0283, 97033, 97034, 97035 & 0183T, 97110, 97113, 97140 and 97762 verbiage was added or changed. Under CPT code 97140, deleted myofascial release from the subtitle. CPT

codes 92548, 96110 and 96111 have been added. Under CPT/HCPCS Codes added 92548, 96110 and 96111. Under ICD-9 Codes That Support Medical Necessity the following codes have been added: 294.11, 307.50, 307.59, 310.1, 315.1, 334.0-336.9, 351.0, 357.2, 359.71, 359.79, 386.11, 490, 491.0, 491.1, 491.20, 490.21, 491.22, 491.8, 491.9, 492.0, 492.8, 493.00-493.02, 493.10-493.12, 493.20-493.22, 493.81, 493.82, 493.90-493.92, 496, 719.01-719.04, 719.08, 719.91-719.94, 719.98, 727.00, 727.01, 727.02, 728.10, 728.11, 728.12, 728.13, 728.19, 728.81, 728.82, 728.89, 728.9, 729.4, 729.82, 729.89, 737.0, 737.10, 737.11, 737.12, 737.19, 737.20, 737.21, 737.22, 737.29, 737.30, 737.31, 737.32, 737.33, 737.34, 737.39, 737.40, 737.41, 737.42, 737.43, 737.8, 737.9, 756.10, 756.11, 756.12, 756.13, 756.14, 756.15, 756.16, 757.17, 757.19, 780.0, 781.93, 784.60, 784.61, 788.34, 794.2, 799.51, 799.55, 925.1 and 925.2. Under Documentation Requirements #4 added last statement. This revision becomes effective 08/11/2011. Revision #1, 05/16/2011 Per scheduled J11 implementation, contractor numbers 11301 (Virginia) and 11401 (West Virginia) were added to this LCD. This revision becomes effective on 05/16/2011. 01/24/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, in compliance with the J11 AB MAC Statement of Work (SOW), C.5.1.8.2 Consolidation of Local Coverage Determinations, this LCD has been selected for implementation within the Palmetto GBA J11 AB MAC territory. Effective date of this implementation is January 24, 2011.

Associated Documents Attachments N/A Related Local Coverage Documents Article(s) A50466 - CPT Code 97755 - Assistive Technology Assessment A53759 - Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) A51957 - Outpatient Occupational Therapy Supplemental Instructions Article Related National Coverage Documents N/A Public Version(s) Updated on 12/12/2014 with effective dates 01/01/2015 - N/A Updated on 03/07/2014 with effective dates 03/29/2014-12/31/2014 Updated on 02/20/2014 with effective dates 03/27/2014-03/28/2014 Updated on 01/11/2014 with effective dates 01/16/2014-03/26/2014 Updated on 04/04/2013 with effective dates 04/12/2013-01/15/2014 Local Coverage Article: CPT Code 97755 - Assistive Technology Assessment (A50466) Contractor Information Contractor Name Palmetto GBA Contractor Information Table Article Information General Information Article ID A50466 General Article Information Table Original Effective Date 01/24/2011

Article Title CPT Code 97755 - Assistive Technology Assessment AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Revision Effective Date 09/18/2014 Revision Ending Date N/A Retirement Date N/A Article Guidance Article Text:

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

N/A CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: CPT/HCPCS Codes Information Table 97535 97755 SELF-CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF DAILY LIVING (ADL) AND COMPENSATORY TRAINING, MEAL PREPARATION, SAFETY PROCEDURES, AND INSTRUCTIONS IN USE OF ASSISTIVE TECHNOLOGY DEVICES/ADAPTIVE EQUIPMENT) DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES ASSISTIVE TECHNOLOGY ASSESSMENT (EG, TO RESTORE, AUGMENT OR COMPENSATE FOR EXISTING FUNCTION, OPTIMIZE FUNCTIONAL TASKS AND/OR MAXIMIZE ENVIRONMENTAL ACCESSIBILITY), DIRECT ONE-ON-ONE CONTACT, WITH WRITTEN REPORT, EACH 15 MINUTES Covered ICD-9 Codes N/A Non-Covered ICD-9 Codes N/A Revision History Information Please note: The Revision History information included in this Article prior to 06/20/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 06/20/2013 will display as a row in the Revision History section of the Article and numbering will begin with "R2". Revision History Date 09/18/2014 R4 Revision History Number Revision History Explanation Added CPT codes from Text to the CPT/HCPCS Coding Section. Added Keywords.

Under Article Text deleted "is" from the last sentence of the second 02/27/2014 R3 paragraph. This article revision becomes effective 02/27/2014. 12/20/2012 R2 Annual Review, no changes made. Revision #2, 12/20/2012 Annual review completed 12/20/2012 R1 Revision #1, 05/16/2011 Per scheduled J11 implementation, contractor numbers 11301 (Virginia) and 11401 (West Virginia) were added to this LCD. This revision becomes effective on 05/16/2011. 01/24/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, in compliance with the J11 AB MAC Statement of Work (SOW), C.5.1.8.2 Consolidation of Local Coverage Determinations and articles, this article has been selected for implementation within the Palmetto GBA J11 AB MAC territory. Effective date of this implementation is January 24, 2011. Associated Documents Related Local Coverage Document(s) LCD(s) L31591 - Outpatient Occupational Therapy L31581 - Outpatient Physical Therapy Related National Coverage Document(s) N/A Statutory Requirements URL(s) N/A Rules and Regulations URL(s) N/A CMS Manual Explanations URL(s) N/A Other URL(s) N/A Public Version(s) Updated on 09/11/2014 with effective dates 09/18/2014 - N/A Updated on 02/19/2014 with effective dates 02/27/2014 - N/A Updated on 01/09/2014 with effective dates 12/20/2012 - N/A Updated on 12/12/2012 with effective dates 12/20/2012 - N/A

Local Coverage Article: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A53759) Contractor Information Contractor Name Palmetto GBA Contractor Information Table Article Information General Information Article ID A53759 General Article Information Table Article Title Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Original Effective Date 10/03/2014 Revision Effective Date 10/03/2014 Revision Ending Date N/A Retirement Date N/A

Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Article Guidance Article Text: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) describes a system employed in wound care that uses continuous low frequency ultrasonic energy to atomize a liquid and deliver continuous low frequency ultrasound to the wound bed. MIST therapy or other similar products are included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597, 97598,97602,97605,97606) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598). Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. N/A Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. N/A CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: CPT/HCPCS Codes Information Table 11042 11043 11044 11045 11046 11047 97597 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS,

97598 97602 97605 97606 97610 BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON- SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO- MOIST DRESSINGS, ENZYMATIC, ABRASION), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS LOW FREQUENCY, NON-CONTACT, NON-THERMAL ULTRASOUND, INCLUDING TOPICAL APPLICATION(S), WHEN PERFORMED, WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER DAY Covered ICD-9 Codes N/A Non-Covered ICD-9 Codes N/A

Revision History Information Please note: The Revision History information included in this Article prior to 06/20/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 06/20/2013 will display as a row in the Revision History section of the Article and numbering will begin with "R2". Revision History Date 10/03/2014 R1 Revision History Number Revision History Explanation Under Article Text, deleted the following, "Effective October 3, 2014, MIST Therapy or other similar treatments would be separately billable if other active wound management and/or wound debridement is NOT performed" as this is a bundled service that would not be provided alone. Associated Documents Related Local Coverage Document(s) LCD(s) L31591 - Outpatient Occupational Therapy L31581 - Outpatient Physical Therapy Related National Coverage Document(s) N/A Statutory Requirements URL(s) N/A Rules and Regulations URL(s) N/A CMS Manual Explanations URL(s) N/A Other URL(s) N/A Public Version(s) Updated on 12/06/2014 with effective dates 10/03/2014 - N/A Updated on 09/10/2014 with effective dates 10/03/2014 - N/A Updated on 09/08/2014 with effective dates 10/03/2014 - N/A Local Coverage Article: Outpatient Occupational Therapy Supplemental Instructions Article (A51957)

Contractor Information Contractor Name Palmetto GBA Contractor Information Table Article Information General Information Article ID A51957 General Article Information Table Article Title Outpatient Occupational Therapy Supplemental Instructions Article AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA Original Effective Date 11/03/2011 Revision Effective Date 09/18/2014 Revision Ending Date N/A Retirement Date N/A

SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Article Guidance Article Text: Language quoted from the Centers for Medicare and Medicaid Services (CMS)Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual is italicized throughout the article. Electrical Stimulation (CPT codes 64550 and 97032, HCPCS codes G0281 and G0283), and Electromagnetic Therapy (HCPCS code G0329) CPT code 97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Attended Electrical stimulation requires direct (one-on-one) contact with the patient by the qualified professional/qualified personnel in providing electrical stimulation manually through the use of probes or other devices. Types of electrical stimulation that may require constant attendance and direct one-on-one contact by the qualified professional/qualified personnel include but are not limited to: Direct motor point stimulation Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES). If performed with therapeutic exercise, neuromuscular reeducation or functional activities, 97032 may be billed for the time the qualified professional/qualified personnel spends applying/instructing and adjusting the FES application, but 97110, 97112, or 97530 should not be billed during the same time period Ultrasound with electrical stimulation provided concurrently should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period Determining trigger points associated with application of a TENS unit using a hand held probe, would be reported by 97032.

The actual application of a TENS unit including the instruction in use and appropriate settings would be described by reporting 64550(Application of surface (transcutaneous) neurostimulator). Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity. Non-Implantable Pelvic Floor Electrical Stimulation (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 230.8.) Nonimplantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Stimulation is generally delivered by vaginal or anal probes connected to an external pulse generator and may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283. The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (ma), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis. Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing four weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength. The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training. Utilization of electrical stimulation may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement. Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring). Documentation must clearly support the medical necessity of electrical stimulation for more than 12 visits as adjunctive therapy or for muscle retraining. Typically patients can be trained in the use of a home muscle stimulator for retraining weak muscles. Up to two visits should be

necessary to complete the training. Once training is successfully completed, this procedure should not be billed as a treatment modality in the clinic, as the patient would be independent in application and use of the modality. Non-covered Indications Electrical Stimulation (CPT code 97032) used in the treatment of facial nerve paralysis, commonly known as Bell s palsy (CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 160.15 Electrical Stimulation (CPT code 97032) used to treat motor function disorders such as multiple sclerosis (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 160.2) Electrical Stimulation (CPT code 97032) for the treatment of strokes when it is determined there is no potential for restoration of function Electrical Stimulation when it is an isolated intervention utilized purely for strengthening of a muscle with at least fair graded strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activities. Supportive Documentation Recommendations for 97032 Type of electrical stimulation used (in addition to the description specifying manual and attended ) Area(s) being treated If used for muscle weakness, objective rating of strength and functional deficits If used for pain include pain rating, location of pain, effect of pain on function HCPCS G0283 - Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care. See 97032 for instructions in manual electrical stimulation Most non-wound care electrical stimulation treatment provided as part of a therapy plan of care should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/assistive personnel) without constant, direct contact required throughout the treatment. Code G0283 is classified as a supervised modality. A supervised modality does not require direct (one-on-one) patient contact by the provider. Typically electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples of unattended electrical stimulation modalities include, but are not limited to, Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation). Utilization of electrical stimulation may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement.

Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring) Documentation must clearly support the medical necessity of unattended electrical stimulation used for control of pain and swelling, with objective and/or subjective changes noted in swelling and/or pain within 12 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality. Typically patients can be trained in the use of a TENS unit for self-management of their pain. Up to two visits should be necessary to complete the training. Once training is successfully completed, this procedure should not be billed as a treatment modality in the clinic, as the patient would be independent in application and use of the modality. The cost of electrodes used with unattended electrical stimulation is included in the practice expense portion of G0283. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality. CPT code 97014 is an invalid code on the Medicare fee schedule and should not be reported in the claim form. Supportive Documentation Recommendations for G0283 Type of electrical stimulation used (e.g., TENS, IFC) Area(s) being treated Objective/subjective measures of how treatment is impacting pain (intensity, location, impact on function) and/or swelling HCPCS G0329 - Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care HCPCS Code G0281 Electrical stimulation, (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care Supportive Documentation Recommendations for G0281 and G0329 Etiology and duration of wound Type of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatment Stage of wound Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate Evidence of infection, undermining, or tunneling Nutritional status Co-morbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use

Patient s functional level Skilled plan of treatment, including specific frequency of the modality Changing plan of treatment based on clinical judgment of the patient s response or lack of response to treatment Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session) Self-Care Home Management Training (CPT code 97535) When instructing the patient in a self management program, use the code that best describes the focus of the self management activity. For example, if the instruction given is for exercises to be done at home to improve ROM or strength, use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if teaching the patient aquatic exercises to use as an independent program in the community pool, use 97113. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. N/A Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. N/A CPT/HCPCS Codes Group 1 Paragraph: CPT Group 1 Codes:

CPT/HCPCS Codes Information Table 64550 97032 97035 97113 97535 APPLICATION OF SURFACE (TRANSCUTANEOUS) NEUROSTIMULATOR APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; AQUATIC THERAPY WITH THERAPEUTIC EXERCISES SELF-CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF DAILY LIVING (ADL) AND COMPENSATORY TRAINING, MEAL PREPARATION, SAFETY PROCEDURES, AND INSTRUCTIONS IN USE OF ASSISTIVE TECHNOLOGY DEVICES/ADAPTIVE EQUIPMENT) DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES Group 2 Paragraph: HCPCS Group 2 Codes: CPT/HCPCS Codes Information Table G0281 G0283 G0329 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR CHRONIC STAGE III AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS, AND VENOUS STATSIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL CARE, AS PART OF A THERAPY PLAN OF CARE ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE ELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS FOR CHRONIC STAGE III AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS AND VENOUS STASIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL CARE AS PART OF A THERAPY PLAN OF CARE

Group 3 Paragraph: CPT: If Billing 97032,cannot bill 97110, 97112 or 97530 on the same claim. Group 3 Codes: CPT/HCPCS Codes Information Table 97110 97112 97530 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES Covered ICD-9 Codes N/A Non-Covered ICD-9 Codes N/A Revision History Information Please note: The Revision History information included in this Article prior to 06/20/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 06/20/2013 will display as a row in the Revision History section of the Article and numbering will begin with "R2". Revision History Date 09/18/2014 R1 Revision History Number Revision History Explanation Added CPT/HCPCS from Text to the CPT/HCPCS Coding Section. Added Keywords. Associated Documents

Related Local Coverage Document(s) LCD(s) L31591 - Outpatient Occupational Therapy Related National Coverage Document(s) N/A Statutory Requirements URL(s) N/A Rules and Regulations URL(s) N/A CMS Manual Explanations URL(s) N/A Other URL(s) N/A Public Version(s) Updated on 09/11/2014 with effective dates 09/18/2014 - N/A Updated on 08/27/2014 with effective dates 11/03/2011 - N/A