CPT Code Definitions

Practice Intel:

CPT Code Definitions

This is a document to outline the definitions of CPT codes per the "Medicare Local Coverage Determinations" which can be found here. 

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 a physical 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 1 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 a physical therapist and occupational therapist may be covered, if separate and distinct goals are documented in the written plan of treatment.

5. Require one-on-one direct patient contact, unless otherwise stated.

Therapeutic Exercises

1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening, continuous passive motion).

2. Therapeutic exercise may address impairments in 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 1 of the following conditions is present and documented:

        a. The patient is having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint ROM, gait problems, balance and/or coordination deficits, abnormal posture, muscle imbalance;

        b. The patient is needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, ROM, or endurance as part of ADLs 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

1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Biomechanical Ankle Platform [BAP’s] boards, and desensitization techniques).

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, tilt table or standing table, hypo/hypertonicity) and improvement of motor control and motor learning.

Therapeutic Activities

1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involve movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a physical therapist and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active written POC 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 direct supervision of a physician, NPP or physical 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.

Manual Therapy

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. Soft tissue mobilization can be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

        a. The patient has restricted joint or soft tissue motion in an extremity, neck or trunk

        b. Treatment is a necessary adjunct to other PT interventions 

3. Manipulation

This procedure may be considered reasonable and necessary for treatment of painful spasm or restricted motion of soft tissues. It may also be used as an adjunct to other therapeutic procedures.

4. Manual Lymphatic Drainage/Complex Decongestive Therapy

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 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.

Aquatic Therapy with Therapeutic Exercises

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 physical 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:

        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 had a recent amputation

        e. The patient recovering 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

Gait Training

1. This procedure may be reasonable and necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.

2. Specific indications for gait training include:

        a. The patient having suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation

        b. The patient having recently suffered a musculoskeletal trauma requiring gait reeducation

        c. The patient having a chronic, progressively debilitating condition, for which safe ambulation has recently become a concern

        d. The patient having had an injury or condition that requires instruction in the use of a walker, crutches, or cane

        e. The patient having been fitted with a brace/lower limb prosthesis/orthosis and requires instruction in ambulation

        f. The patient having a condition that requires retraining in stairs/steps or chair transfer in addition to general ambulation.

3. Gait evaluation and training furnished to a patient whose ability to walk has been impaired by neurological, muscular or skeletal abnormality require the skills of a qualified physical therapist and constitute skilled PT and are considered reasonable and necessary, if they can be expected to materially improve or maintain the patient's ability to walk or prevent or slow further deterioration of the patient’s ability to walk. Gait evaluation and training which is furnished to a patient whose ability to walk has been impaired by a condition other than a neurological, muscular, or skeletal abnormality would, nevertheless, be covered where PT is reasonable and necessary to restore or maintain function or to prevent or slow further deterioration.

Massage Therapy

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, pétrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least 1 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 requiring relaxation in preparation for neuromuscular reeducation or therapeutic exercise

        f. The patient having contractures and decreased ROM

3. In most cases, postural drainage and pulmonary exercises can be carried out safely and effectively by nursing personnel. To be considered for payment, the physical therapist must identify the intervention that is best suited for the patient, taking into consideration the patient’s condition and any contraindications that may be present. As there can be an overlap of skills between disciplines, i.e., respiratory therapy, skilled nursing and PT, the documentation must clearly support the need for the intervention to be provided by the physical therapist.

Group Therapeutic Procedures

A group for the purpose of performing group therapy will be defined as:

        a. 2 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 physical therapist is instructing all the patients in the group.

Orthotic Training

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 3 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 a lower extremity is done during the same visit as gait training.

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

1. This procedure may be considered reasonable and necessary, if there is an indication for education in the application of the prosthetic, and the functional use of the prosthetic is present and documented.

2. The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training.

3. Periodic revisits beyond the third month would require documentation to support medical necessity.

Orthotic/Prosthetic Checkout

1. These assessments are reasonable and necessary for "established patients who have already received the orthotic or prosthetic device (permanent or temporary)."

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 patient's 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."

Sensory Integrative Techniques

"Sensory integrative techniques are interventions generally intended for the pediatric and/or neurologically impaired populations. The focus of these activities is to train the sensory systems to modulate the vast array of incoming sensory stimuli. This is something that is normally performed without apparent effort. Once the patient/client learns to block the extrasensory 'noise,' the important sensory input can be processed and a coordinated motor response can be generated."

Self-Care/Home Management Training

The coverage criteria of self-care 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 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 may include training the patient/client and/or caregiver in the use of the equipment." 

Community/Work Reintegration

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 §1862(a)(1) of the Social Security Act.

"Community/work reintegration training describes interventions intended to facilitate the patient's/client's ability to perform at work and in the community at large. Training could include accessing transportation systems and businesses, analysis of job site modification and work task analysis." 

This training may be medically necessary when performed in conjunction with a patient's individual treatment plan aimed at improving or restoring specific community functions which were impaired by an identified illness or injury and when realistically expected outcomes are specified in the plan. This includes training in the use of assistive technology to assist with mobility, seating systems, and environmental control systems for use in the community. Services must be necessary for medical treatment of an illness or injury, rather than related solely to specific leisure or employment opportunities, work skills or work settings.

Work Hardening/Conditioning

"Work hardening and work conditioning 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

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 includes 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 a physical therapist and is designed to address specific needs of the patient, and must be part of an active written POC directed at a specific goal.

3. The patient and/or caregiver must have the capacity to learn from instructions.

4. Typically, 3 to 4 sessions should be sufficient to teach the patient and/or caregiver these skills.

5. Documentation should relate training to expected functional goals when providing wheelchair propulsion training.

Physical Performance Test or Measurement

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

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 patients 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 re-evaluation is indicated.

Canalith Repositioning Procedure(s)(e.g., Epley maneuver, Semont maneuver)

Canalith repositioning procedure describes a series of movements of the patient's body and head used for the treatment of benign paroxysmal positional vertigo (BPPV). The procedure is used to move displaced calcium crystal debris from the semicircular canals.