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29.2.2 Physical Medicine, Physical Therapy (PT), and Occupational Therapy (OT)
Physical medicine is the use of one or more modalities to produce therapeutic changes to biologic tissue. It includes, but is not limited to, thermal, acoustic, light, mechanical, or electric energy.
Physical medicine may be provided by physicians, podiatrists (for services below the ankle), licensed physical therapists, or licensed occupational therapists under the direction of a physician.
The CSHCN Services Program may reimburse for physical medicine under the following conditions:
• The client has a disability requiring therapy to improve or maintain function, range of motion, strength, or to prevent or decrease the risk of deformity or osteoporosis.
•The client has an exacerbation of chronic illness or condition (e.g., juvenile rheumatoid arthritis [JRA], hemophilia, or sickle cell crisis).
•The client has sustained a traumatic injury or is experiencing late effects of a traumatic injury requiring therapy to restore or maintain function, range of motion, strength, or to prevent or decrease the risk of deformity or osteoporosis.
•The client requires short-term therapy related to surgery or casting.
•The client or family requires training on the use of equipment, orthotics, or prosthetics.
•The client or family requires instruction in activities for daily living specific to their home environment.
•The client requires an assessment for appropriate equipment, seating, braces, orthotics, or prosthetics.
Providers must use the following procedure codes for authorization and for claim submission when billing for physical medicine services:
The following procedure codes are billed in 15-minute increments. Providers should not bill for services performed less than 8 minutes. Treatment procedure codes are limited to 1 hour of physical therapy and 1 hour of occupational therapy on the same day, any provider, with GP or GO modifiers.
The following procedure codes are not payable in 15-minute increments and are limited to a quantity of once per day, per distinct therapy type (physical or occupational):
Physical therapists must use procedure code 97001 for evaluation and procedure code 97002 for reevaluation. Occupational therapists must use procedure code 97003 for evaluation and procedure code 97004 for reevaluation. These codes do not require modifiers.
Reimbursement of an evaluation (procedure codes 97001 and 97003) is limited to once every 180 days to the same provider. Reimbursement for reevaluation (procedure codes 97002 and 97004) is limited to once per 30 days to the same provider.
Evaluation and reevaluation may be considered on appeal with supporting documentation that a comprehensive reevaluation and assessment was provided by a different provider.
Evaluation and reevaluation procedure codes are comprehensive codes.
Physical therapy treatment will be denied when billed by any provider on the same day as physical evaluation or reevaluation.
Occupational therapy treatment will be denied when billed by any provider on the same day as occupational evaluation or reevaluation.
Procedure codes 97750 and 97760 are comprehensive codes and include an office visit. Providers are not reimbursed for an office visit with the same date of service as procedure codes 97750 and 97760.
Procedure codes 97010, 97014, 97545, and 97546 are not benefits of the CSHCN Services Program.
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