HI 00601.050 Therapy Services
Physical, speech, occupational, and respiratory therapy services furnished by a participating hospital or by others under arrangements with and under the supervision of the hospital are reimburseable under the Medicare program. (Physical, speech, and occupational therapy services are also covered SNF and HHA benefits. Respiratory therapy services furnished to inpatients of an SNF would be covered under the extended care benefit when provided by a hospital with which the facility has a transfer agreement (see HI 00601.230.)
A. Physical therapy
To be covered as physical therapy all of the following conditions must be met;
The services are directly and specifically related to an active written treatment regimen designed by the physician after any needed consultation with the qualified physical therapist;
The services are of such a level of complexity and sophistication or the condition of the patient is such that the judgment, knowledge and skills of a qualified physical therapist are required;
The services are, in fact, performed by or under the supervision of a qualified physical therapist, i.e., the qualified physical therapist provides authoritative procedural guidance for the rendering of the services with initial direction and periodic inspection of the actual act and is on the premises if the person performing the services does not meet the assistant-level qualifications;
The services are provided with the expectation, based on the assessment made by the physician of the patient's restoration potential after any needed consultation with the qualified physical therapist, that the patient will improve significantly in a reasonable and generally predictable, period of time (see 2. below) or must be necessary to the establishment of a safe and effective maintenance program required in connection with a specific disease state (see 3. below);
The services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition; and
The services are reasonable and necessary to the treatment of the patient's condition.
Many inpatients who do not require physical therapy services as defined above do require services involving procedures which are routine in nature in the sense that they can be rendered by supportive personnel, e.g., aides or nursing personnel, without the supervision of a qualified physical therapist. Such services as well as services involving activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute physical therapy services for Medicare purposes. However, since they constitute an essential and integral part of good inpatient care, such services can be billed through the physical therapy cost center even though they do not constitute physical therapy for Medicare purposes, if the following conditions are met: the services are medically necessary; the treatment furnished is prescribed by a physician; all services are provided by salaried employees of the physical therapy department of the provider; the cost incurred is reasonable in amount; and charges are equally imposed on all patients.
2. Restorative therapy
As indicated in 1. above, to constitute physical therapy, a service furnished an individual must, among other things be reasonable and necessary to the treatment of his illness. If an individual's expected restoration potential would be insignificant in relation to the extent and duration of physical therapy services required to achieve such potential the physical therapy would not be considered reasonable and necessary to the treatment of the individual's illness or injury. Accordingly, there must be a medically appropriate expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time based on the assessment made by the physician of the patient's restoration potential after any needed consultation with the qualified physical therapist. Such expectations may not always prove to be valid, and the realization that restoration will not occur can and should also be reached in a reasonable and generally predictable period of time.
3. Maintenance therapy
Generally, the repetitive services required to maintain function do not involve the use of complex and sophisticated physical therapy procedures, and consequently the judgement and skill of a qualified physical therapist are not required for the safe and effective rendition of such services. However, the specialized knowledge and judgment of a qualified physical therapist may be required to establish a maintenance program if the program is to be safely carried out and the treatment aims of the physician achieved. In such situations, the initial evaluation of the patient's needs, the designing by the qualified physical therapist of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient or supportive personnel, e.g., aides or nursing personnel (or family members where physical therapy is being furnished on an outpatient basis) in the carrying out of such program and such infrequent reevaluations as may be required would constitute physical therapy under the program.
4. Examples of covered physical therapy
a. Hot Pack, Hydrocollator, Infra-red Treatments and Whirlpool baths
In particular cases, the skills, knowledge and judgment of a qualified physical therapist might be required in the giving of such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, or other complications. Also, if such treatments are given as a prerequisite to a skilled physical therapy procedure, they are considered part of the physical therapy service.
b. Gait training
Gait evaluation and training furnished a patient whose ability to walk has been impaired by neurological, muscular or skeletal abnormality requires the skills of a qualified physical therapist and constitutes reimbursable physical therapy provided that it can reasonably be expected to significantly improve the patient's ability to walk.
Repetitious exercises to improve gait, maintain strength, endurance and assistive walking, such as provided insupport for feeble or unstable patients, do not require the skills of a qualified physical therapist.
c. Ultrasound, short wave and microwave diathermy treatments
Program payment will be made for these services. They must always be performed by or under the supervision of a qualified physical therapist.
d. Therapeutic exercises
Therapeutic exercises which must be performed by or under the supervision of the qualified physical therapist due either to the type of exercise employed or to the condition of the patient constitute covered physical therapy. Range of motion exercises require the skills of a qualified physical therapist only when they are part of the active treatment of a specific disease which has resulted in a loss or restriction of mobility and such exercises, either because of their nature or the condition of the patient, may only be performed safely and effectively by or under the supervision of a qualified physical therapist.
e. Range of motion tests
Only the qualified physical therapist may perform range of motion tests and, therefore, such tests constitute reimbursable physical therapy.
Generally, range of motion exercises which are not related to the restoration of a specific loss of function but rather are related to the maintenance of function do not require the skills of a qualified physical therapist and are, therefore, not covered.
For outpatient physical therapy see HI 00610.370.
B. Speech pathology
Speech pathology services are those services necessary for the diagnosis and treatment of speech and language disorders which result in communication disabilities. They must relate directly and specifically to a written treatment regimen established by the physician after any needed consultation with the qualified speech pathologist.
2. Coverage criteria
Speech pathology services must be reasonable and necessary to the treatment of the individual's illness or injury. To be considered reasonable and necessary, the following conditions must be met:
The services must be considered under accepted standards of practice to be a specific and effective treatment for the patient's condition;
The services must be of such a level of complexity and sophistication, or the patient's condition must be such that the services required can be safely and effectively performed only by or under the supervision of a qualified speech pathologist. (See 42 CFR 405.1202(u)(1)(2).)
There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time based on the assessment by the physician of the patient's restoration potential after any needed consultation with the qualified speech pathologist, or the services must be necessary to the establishment of a safe and effective maintenance program required in connection with a specific disease state; and
The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.
3. Restorative therapy
If an individual's expected restoration potential would be insignificant in relation to the extent and duration of speech pathology services required to achieve such potential, the services would not be considered reasonable and necessary. In addition, there must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time. If at any point in the treatment of an illness or injury it is determined that the expectations will not materialize, the services will no longer constitute covered speech pathology services, as they would no longer be reasonable and necessary for the treatment of the patient's condition and would be excluded from coverage under section 1862(a)(1).
4. Maintenance program
After the initial evaluation of the extent of the disorder or illness, if the restoration potential is judged insignificant or, after a reasonable period of trial, the patient's response to treatment is judged insignificant or at a plateau, an appropriate functional maintenance program may be established. The specialized knowledge and judgment of a qualified speech pathologist may be required if the treatment aim of the physician is to be achieved; e.g., a multiple sclerosis patient may require the services of a speech pathologist to establish a maintenance program designed to fit the patient's level of function. In such a situation, the initial evaluation of the patient's needs, the designing by the qualified speech pathologist of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient and supportive personnel (e.g., aides or nursing personnel, or family members where speech pathology is being furnished on an outpatient basis) in carrying out the program, and such infrequent reevaluations as may be required, would constitute covered speech therapy. After the maintenance program has been established and instructions have been given for carrying out the program, the services of the speech pathologist would no longer be covered, as they would no longer be considered reasonable and necessary for the treatment of the patient's condition and would be excluded from coverage under section 1862(a)(1).
5. Types of services
Speech pathology services can be grouped into two main categories: services concerned with diagnosis or evaluation and therapeutic services.
a. Diagnostic and evaluation services
Unless excluded by section 1862(a)(7) of the law, these services are covered if they are reasonable and necessary. The speech pathologist employs a variety of formal and informal language assessment tests to ascertain the type, casual factor(s), and severity of the speech and language disorders. Reevaluation would be covered only if the patient exhibited a change in functional speech or motivation, clearing of confusion, or the remission of some other medical condition which previously contra-indicated speech pathology. However, monthly reevaluations, e.g., a Porch Index of Communicative Ability (PICA) for a patient undergoing a restorative speech pathology program, are to be considered a part of the treatment session and could not be covered as a separate evaluation for billing purposes.
b. Therapeutic services
The following are examples of common medical disorders and resulting communication deficits which may necessitate active restorative therapy:
Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia/dysphasia, apraxia, and dysarthria;
Neurological disease such as Parkinsonism or Multiple Sclerosis may exhibit dysarthria, dysphagia, or inadequate respiratory volume/control;
Mental retardation with disorders such as aphasia or dysarthria; and
Laryngeal carcinoma requiring laryngectomy resulting in aphonia may warrant therapy of the laryngectomized patient so he can develop new communication skills through esophageal speech and/or use of the electrolarynx.
NOTE: Many patients who do not require speech pathology services as defined above do require services involving nondiagnostic, nontherapeutic, routine, repetitive, and reinforced procedures or services for their general good and welfare; e.g., the practicing of word drills. Such services do not constitute speech pathology services for Medicare purposes and would not be covered since they do not require performance by or the supervision of a qualified speech pathologist.
C. Occupational therapy
Occupational therapy is medically prescribed treatment concerned with improving or restoring functions which have been impaired by illness or injury or, where function has been permanently lost or reduced by illness or injury, to improve the individual's ability to perform those tasks required for independent functioning. Such therapy may involve:
the evaluation, and reevaluation as required, of a patient's level of function by administering diagnostic and prognostic tests;
the selection and teaching of task oriented therapeutic activities designed to restore physical function;
the planning, implementing, and supervising of individualized therapeutic activity programs as part of an overall “active treatment” program for a patient with a diagnosed psychiatric illness;
the planning and implementing of therapeutic tasks and activities to restore sensory-integrative function;
the teaching of compensatory technique to improve the level of independence in the activities of daily living;
the designing, fabricating, and fitting of orthotic and self-help devices; and
vocational and prevocational assessment and training.
2. Coverage criteria
Occupational therapy furnished by a participating hospital or by others under arrangements with the hospital and under its supervision is reimbursable when all the following conditions are met:
The services are prescribed by a physician;
The services are performed by a qualified occupational therapist or a qualified occupational therapy assistant under the general supervision of a qualified occupational therapist. (“General supervision” requires initial direction and periodic inspection of the actual activity; however, the supervisor need not always be physically present or on the premises when the assistant is performing services.);
The services are reasonable and necessary for the treatment of the individual's illness or injury. The guidelines in A.2. on an individual's restoration potential also apply to occupational therapy. Generally speaking, occupational therapy is not reasonable or necessary when a patient suffers a temporary loss or reduction of function which could be expected to spontaneously improve as the patient gradually resumes normal activities. Occupational therapy is also not usually considered reasonable and necessary in meeting motivational needs which are not related to a specific diagnosed psychiatric illness. As indicated in C.1, item g, occupational therapy includes vocational and prevocational assessment and training. When services provided by an occupational therapist and/or assistant are related solely to specific employment opportunities, work skills or work settings, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are excluded from coverage.
Occupational therapy frequently necessitates the use of various supplies, e.g., looms, ceramic tiles, leather, etc. The cost of such supplies may be included in the occupational therapy cost center.
For outpatient occupational therapy see HI 00610.380.
D. Respiratory therapy
Respiratory therapy (respiratory care) services are prescribed by a physician for the assessment, diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function.
Respiratory therapy services include but are not limited to:
The application of techniques for support of oxygenation and ventilation in the acutely ill patient. These techniques include, but are not limited to:
establishment and maintenance of artificial airways:
ventilator therapy and other means of airway pressure manipulation;
precise delivery of oxygen concentration; and
techniques to aid removal of secretions from the pulmonary tree.
The therapeutic use and monitoring of medical gases (especially oxygen), bland and pharmacologically active mists and aerosols and such equipment as resuscitators and ventilators;
Bronchial hygiene therapy, including deep breathing and coughing exercises, IPPB, postural drainage, chest percussion and vibration, and nasotracheal suctioning;
Diagnostic tests for evaluation by a physician, e.g., pulmonary function tests, spirometry, and blood gas analyses;
Pulmonary rehabilitation techniques which include:
breathing retraining; and
patient education regarding the management of the patient's respiratory problems; and
Periodic assessment and monitoring of the acute and chronically ill patients for indications for, and the effectiveness of, respiratory therapy services.
Such services are performed by respiratory therapists or technicians, physical therapists, nurses and other qualified personnel.
2. Coverage criteria
To qualify for reimbursement under Medicare, such therapy must qualify as a covered service and must be reasonable and necessary for the diagnosis or treatment of an illness or injury. To be considered reasonable and necessary, respiratory therapy services furnished to a beneficiary must be:
Consistent with the nature and severity of the individual's symptoms and diagnosis.
Reasonable in terms of modality, amount, frequency and duration of the treatment.
Generally accepted by the professional community as being safe and effective treatment for the purpose used.