Physical therapy (PT) is a form of rehabilitation with an established theoretical and scientific base and widespread clinical applications in the restoration, maintenance, and promotion of optimal physical function.

Physical therapists diagnose and manage movement dysfunction and enhance physical and functional abilities. Physical therapy services restore, maintain, and promote not only optimal physical functioning but also optimal wellness and fitness and optimal quality of life as it relates to movement and health. These services performed in the outpatient, office or home setting prevent the onset, symptoms, and progression of impairments, functional limitations, and disabilities that may result from diseases, disorders, conditions, or injuries.

The terms "physical therapy" and "physiotherapy" are synonymous.

Note: Many benefit plans include a maximum allowable physical therapy benefit, either in duration of treatment or in number of visits. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria described below are met.

Note:Please see the following related documents for additional information:

• CG-REHAB-05 Occupational Therapy
• MED.00107 Medical and Other Non-Behavioral Health Related Treatments for Pervasive Developmental Disorders

Medically Necessary:

Physical therapy (PT) services are considered medically necessary when the following criteria are met:

1. The therapy is aimed at preventing disability or improving, adapting or restoring functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality;and
2. The therapy is for conditions that require the unique knowledge, skills, and judgment of a physical therapist for education and training that is part of an active skilled plan of treatment; and
3. There is an expectation that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time; and
   • An individual's function could not reasonably be expected to improve as the individual gradually resumes normal activities; and
   • An individual's expected restoration potential would be significant in relation to the extent and duration of the therapy service required to achieve such potential; and
   • The therapy documentation objectively verifies progressive functional improvement over specific time frames; and
4. The services are delivered by a qualified provider of physical therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure; and
5. The services require the judgment, knowledge, and skills of a qualified provider of physical therapy services due to the complexity and sophistication of the therapy and the medical condition of the individual.

Documentation

Evaluation
A comprehensive evaluation is essential to determine if PT services are medically necessary, gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usually completed in a single session. An evaluation is needed before implementing any PT treatment. Evaluation begins with the administration of appropriate and relevant assessments using standardized assessments and tools. The evaluation must include:

• Prior functional level, if acquired condition;
• Specific standardized and non-standardized tests, assessments, and tools;
• Analytic interpretation and synthesis of all data, including a summary of the baseline findings in written report(s);
• Objective, measurable, and functional descriptions of an individual's deficits using comparable and consistent methods;
• Summary of clinical reasoning and consideration of contextual factors with recommendations;
• Plan of care with specific treatment techniques or activities to be used in treatment sessions that should be updated as the individual's condition changes;
• Frequency and duration of treatment plan;
• Functional, measurable, and time-framed long-term and short-term goals based on appropriate and relevant evaluation data;
• Rehabilitation prognosis;
• Discharge plan that is initiated at the start of PT treatment.

Treatment Sessions
A physical therapy session can vary from fifteen minutes to four hours per day; however, treatment sessions lasting more than one hour per day are rare in outpatient settings. Treatment sessions for more than one hour per day may be medically appropriate for inpatient acute settings, day treatment programs, and select outpatient situations, but must be supported in the treatment plan and based on an individual's medical condition. A physical therapy session may include:

• Evaluation;
• Therapeutic exercise, including neuromuscular reeducation, coordination, and balance;
• Functional training in self-care and home management;
• Functional training in and modification of environments (home, work, school, or community), including biomechanics and ergonomics;
• Manual therapy techniques, including soft tissue mobilization, joint mobilization, and manual lymphatic drainage;
• Assessment, design, fabrication, application, fitting, and training in assistive technology, adaptive devices, and orthotic devices;
• Training in the use of prosthetic devices;
• Airway clearance techniques;
• Integumentary repair and protection techniques
• Electrotherapeutic modalities;
• Physical agents and mechanical modalities;
• Functional community mobility;
• Training of the individual, caregivers, and family/parents in home exercise and activity programs;
• Skilled reassessment of the individual's problems, plan, and goals as part of the treatment session;
• Coordination, communication, and documentation;
• Reevaluations, if there is a significant change in the individual's condition.

Documentation of treatment sessions must include:

• Date of treatment;
• Specific treatment(s) provided that match the procedure  codes billed;
• Total treatment time;
• The individual's response to treatment;
• Skilled ongoing reassessment of the individual's progress toward the goals;
• Any progress toward the goals in objective, measurable terms using consistent and comparable methods;
• Any problems or changes to the plan of care;
• Name and credentials of the treating clinician.

Progress Reports
In order to reflect that continued PT services are medically necessary, intermittent progress reports must demonstrate that the individual is making functional progress. Progress reports should include at a minimum:

• Start of care date;
• Time period covered by the report;
• Medical and therapy treatment diagnoses;
• Statement of the individual's functional level at the beginning of the progress report period;
• Statement of the individual's current status as compared to evaluation baseline data and the prior progress report, including objective measures of the individual's function that relate to the treatment goals;
• Changes in prognosis and why;
• Changes in plan of care and why;
• Changes in goals and why;
• Consultations with other professionals or coordination of services, if applicable;
• Signature and title of qualified professional responsible for the therapy services.

Reevaluation
A reevaluation is indicated when there are new clinical findings, a rapid change in the individual's status, or failure to respond to physical therapy interventions. There are several routine reassessments that are not considered reevaluations. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries.

Reevaluation is a more comprehensive assessment that includes all the components of the initial evaluation, such as:

• Data collection with objective measurements taken based on appropriate and relevant assessment tests and tools using comparable and consistent methods;
• Making a judgment as to whether skilled care is still warranted;
• Organizing the composite of current problem areas and deciding a priority/focus of treatment;
• Identifying the appropriate intervention(s) for new or ongoing goal achievement;
• Modification of intervention(s);
• Revision in plan of care if needed;
• Correlation to meaningful change in function; and
• Deciphering effectiveness of intervention(s).

Providers of PT Services

The services are delivered by a qualified provider of physical therapy services acting within the scope of their license as regulated by the Federal and State governments. In addition to licensure, physical therapists must have passed the National Physical Therapy Examination (NPTE). Physical therapy assistants may provide services under the direction and supervision of a physical therapist. Benefits for services provided by these practitioners are dependent upon the member's contract language.

Aides, athletic trainers, exercise physiologists, life skills trainers, and rehabilitation technicians do not meet the definition of a qualified practitioner regardless of the level of supervision. Aides and other nonqualified personnel as listed above are limited to non-skilled services such as preparing the individual, treatment area, equipment, or supplies; assisting a qualified therapist or assistant; and transporting individuals. They may not provide any direct treatments, modalities, or procedures.

Not Medically Necessary:

Physical therapy (PT) services are considered not medically necessary if any of the following is determined:

1. The therapy is not aimed at preventing disability or improving, adapting or restoring functions, which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality.
2. The therapy is for conditions for which therapy would be considered routine educational, training, conditioning, or fitness. This includes treatments or activities that require only routine supervision.  
3. The expectation does not exist that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time.
   • If function could reasonably be expected to improve as the individual gradually resumes normal activities, then the therapy is considered not medically necessary.
   • If an individual's expected restoration potential would be insignificant in relation to the extent and duration of the therapy service required to achieve such potential, the therapy would be considered not medically necessary.
   • The therapy documentation fails to objectively verify functional progress over a reasonable period of time.
4. The physical modalities are not preparatory to other skilled treatment procedures.
5. Treatments that do not generally require the skills of a qualified provider of PT services are considered not medically necessary.  Examples include palliative massages, palliative Jacuzzi /whirlpools, hot or cold packs in the absence of complicating factors, general range of motion or exercise programs, maintenance therapy, repetitive gait or other activities that an individual can self-practice independently or with a caregiver, swimming and routine water aerobics programs, general fitness and training, and general public education/instruction sessions.
6. Routine reevaluations not meeting the above criteria.
7. Treatments that are not supported in peer-reviewed literature.

Duplicate Therapy
Duplicate therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

Maintenance Program
Maintenance programs are considered not medically necessary. A maintenance program consists of treatments or activities that preserve the individual's present level range, strength, coordination, balance, pain, activity, function, etc. and prevent regression of the same parameters. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. In certain circumstances, the specialized knowledge and judgment of a qualified therapist maybe required to establish a maintenance program, however, the repetitive PT services to maintain a level would be considered not medically necessary.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Physical Therapy Association. Access To, Admission To, And Patient/Client Rights Within Physical Therapy Services. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/Access.pdf. Accessed on January 16, 2013.
2. American Physical Therapy Association. APTA Guide for Professional Conduct. American Physical Therapy Association. Updated November 2010. Available at: http://www.apta.org/Ethics/Core/. Accessed on January 16, 2013.
3. American Physical Therapy Association. APTA Guide for Conduct of the Physical Therapist Assistant. Available at: http://www.apta.org/Ethics/Core/. Accessed on January 16, 2013.
4. American Physical Therapy Association. Code of Ethics for the Physical Therapist. Available at: http://www.apta.org/Ethics/Core/. Accessed on January 16, 2013.
5. American Physical Therapy Association. Diagnosis by Physical Therapists. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/Diagnosis.pdf. Accessed on January 16, 2013.
6. American Physical Therapy Association. Direction and Supervision of The Physical Therapist Assistant. American Physical Therapy Association. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/Direction.pdf. Accessed on January 16, 2013.
7. American Physical Therapy Association. Exclusive Use or Use of Physical Agents/Modalities. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/ExclusiveUse.pdf. Accessed on January 16, 2013.
8. American Physical Therapy Association. Guide to Physical Therapist Practice. 2^nd Edition revised. American Physical Therapy Association. January 2003. Originally published as: Guide to Physical Therapist Practice. Phys Ther. 2001; 81: 9-744.
9. American Physical Therapy Association. Guidelines for Physical Therapy Documentation of Patient/Client Management. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Practice/DocumentationPatientClientMgmt.pdf. Accessed on January 16, 2013.
10. American Physical Therapy Association. Physical Therapy and the Older Adult. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/OlderAdults.pdf. Accessed on January 16, 2013.
11. American Physical Therapy Association. Provision of Physical Therapy Interventions and Related Tasks. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/Provision.pdf. Accessed on January 16, 2013.
12. American Physical Therapy Association. Reimbursement for Physical Therapy Services. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Insurance/Reimbursement.pdf. Accessed on January 16, 2013.
13. American Physical Therapy Association. Standards of Practice For Physical Therapy. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/Standards.pdf. Accessed on January 16, 2013.
14. Centers for Medicare & Medicaid Services (CMS). Pub. 100-02, Chapter 15, Sections 220. Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230. Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology. June 9, 2008. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on January 16, 2013.
15. Centers for Medicare & Medicaid Services. Manuals. Available at: http://www.cms.hhs.gov/Manuals/PBM/list.asp. Accessed on January 16, 2013.
    • Home Healthy Agency Manual. Pub. 11. Chapter 2, Section 205.2 Coverage of Services Which Establish Home Health Eligibility. Skilled Therapy Services. Last updated September 8, 2005.
    • Hospital Manual. Pub. 10. Chapter2, Section 210.8. Physical Therapy Furnished by the Hospital or by Others Under Arrangements With the Hospital and Under its Supervision. Last updated September 8, 2005.
    • Outpatient Physical Therapy Comprehensive Outpatient Rehabilitation Facility And Community Mental Health Center Manual. Pub. 9. Chapter 2, Coverage of Services. Last updated September 8, 2005.
16. Centers for Medicare & Medicaid Services. National Coverage Determination for Institutional and Home Care Patient Education Programs. NCD#170.1. Effective date not posted. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on January 16, 2013.
17. NIH Consensus Statement. Rehabilitation of persons with traumatic brain injury. 1998 Oct 26-28; 16(1): 1-41. Available at: http://www.nichd.nih.gov/publications/pubs/TBI_1999/Pages/NIH_Consensus_Statement.aspx. Accessed on January 16, 2013.
18. Sneed RC, May WL, Stencel C. Physicians' reliance on specialists, therapists, and vendors when prescribing therapies and durable medical equipment for children with special health care needs. Pediatrics. 2001; 107(6):1283-1290.

Physical Therapy
Physiotherapy
PT (Physical Therapy)