Guidelines in Therapy LCDs Updated

on Thursday, 04 March 2010. All News Items

Cahaba updated the guidelines in several sections of the therapy Local Coverage Determinations for Outpatient Physical Therapy, Outpatient Occupational Therapy, Speech Language Pathology, and Dysphagia/ Swallowing Therapy. 

In the General Therapy Guidelines, the following statement:

“The patient must be under the care of and referred for therapy services by a 'qualified professional':
 a. Physician
 b. Optometrist - for low vision services
 c. Podiatrist - subject to each state’s Scope of Practice
 d. Nurse Practitioner, Physician’s Assistant, or Clinical Nurse Specialist –        subject to each state’s Scope of Practice”

was replaced with:

“The conditions of coverage and payment must be met as outlined in the Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 220.1.”

Sections 220.1 and 220.1.1 of Chapter 15 of the Benefit Policy Manual state:

Outpatient therapy services furnished to a beneficiary by a provider or supplier are payable only when furnished in accordance with certain conditions. The following conditions of coverage apply. The requirements noted (*) are also conditions of payment in 42CFR424.24(c) and according to the Act §1835 (a)(2)(D) are the three conditions that must be certified:

  • (i) such services are or were required because the individual needed therapy services* (see §220.1.3); and
  • (ii) a plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP* (see §220.1.2); and
  • (iii) such services are or were furnished while the individual is or was under the care of a physician* (see §220.1.1); and
  • Services must be furnished on an outpatient basis. (See §220.1.4)
  • All of the conditions are met when a physician/NPP certifies an outpatient plan of care for therapy. Certification is required for coverage and payment of a therapy claim. Each of these conditions is discussed separately in the sections that follow.

220.1.1 - Outpatient Therapy Must be Under the Care of a Physician/Nonphysician Practitioners (NPP) (Orders/Referrals and Need for Care)

(Rev. 36, Issued: 06-24-05, Effective: 06-06-05, Implementation: 06-06-05)
An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. However, the certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care (see essential requirements of plan in §220.1.2), 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.
(The CORF services benefit does not recognize an NPP for orders and certification.)

MMP, Inc. recommends providers review the additional sections of 220.1 for complete information on the coverage requirements for therapy services.Cahaba also removed the following statement from the General Therapy Guidelines:


“Physical therapy is only covered when it is rendered under a written treatment plan approved by the individual’s physician, to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency, and duration.”

This statement appears duplicative of the following statement which remains in the updated LCDs:

“Covered physical therapy services must relate directly and specifically to an active written treatment plan and must be reasonable and necessary to the treatment of the individual’s illness or injury. The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency and duration. The plan of care must be certified/approved by the physician or optometrist.”In the Evaluation Documentation Requirements for CPT codes 97001 and 97003 in the PT and OT policies respectively, the required element “Reason for referral and specific treatment requested” was replaced with “When provided by referral source, reason for referral and specific treatment requested.”


In the Speech Language Pathology LCD, the following statement regarding requirements for Speech Evaluation CPT code 92506 was removed completely:
“The referring/attending physician must:
 i. Document via referral the patient’s symptoms or disorder
 ii. Order the evaluation”
The following statement regarding non-implantable pelvic floor electrical stimulation was moved from the section on Biofeedback (CPT 90901, 90911) to the section on Electrical Stimulation for NON wound care (CPT 97032, HCPCS G0283) in the PT and OT policies:


“Non-implantable pelvic floor electrical stimulation is covered for the treatment of stress and/or urge 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 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.”In the PT and OT policies’ Guidelines for CPT 97124, Massage, the following highlighted, underlined words were added to the statement concerning percussion for use in postural drainage:


“In most cases, percussion, for the use in postural drainage, can be carried out safely and effectively by the patient or other caregivers. If the attending physician or physical therapist under the certified plan of care determines that for the safe and effective administration of these procedures, the professional skills of a physical therapist are required, coverage may be allowed. Documentation should support the above requirements.”In the Guidelines for CPT 97542, Wheelchair Management / Propulsion Training, in the PT and OT policies, the following section was added:


“Should wheelchair management be part of a greater plan of care (e.g. new amputee addressing gait, strength, etc.), then wheelchair management may be part of a greater issue and an evaluation would be appropriate. The evaluation should meet the requirements as set forth in this LCD.”Language in the “Utilization Guidelines” section relating to “Treatment Time” in the PT, OT, and Speech policies was clarified.  The statement


“The beginning and ending time of the treatment should be recorded in the patient’s medical record along with the note describing the treatment. The time spent delivering each service, described by a timed code, should be recorded. (The length of the treatment to the minute could be recorded instead.)”

was replaced with

“Total timed code treatment minutes and total treatment time in minutes must be documented.”

The complete updated therapy LCDs can be viewed on the Cahaba web site at Local Coverage Determinations (LCDs) and Articles (choose your state and select ‘LCDs’).

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