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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 18.2
Physical Medicine/Therapy
Issue Date:  April 19, 1983
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-59, February 26, 2020
1.0  CPT PROCEDURE CODES
93668, 96000 - 96004, 97001 - 97002, 97012 - 97530, 97533, 97542 - 97750, 97799
2.0  DESCRIPTION
2.1  The treatment by physical means, hydrotherapy, heat, or similar modalities, physical agents, bio-mechanical and neuro-physiological principles, and devices to relieve pain, restore maximum function, and prevent disability following disease, injury or loss of a body part.
2.2  Physical therapy services consist of the physical evaluation of a patient by muscle testing and other means and the prescribed therapeutic treatment and services of a definite functional nature.
2.3  Physical therapy to improve, restore, or maintain function, or to minimize or prevent deterioration of function of a patient when prescribed by a physician is covered in accordance with the rehabilitative therapy provisions found in Section 18.1.
3.0  POLICY
3.1  Benefits are payable for inpatient or outpatient physical therapy services that are determined to be medically necessary for the treatment of a covered condition, and that are directly and specifically related to an active written regimen.
3.2  Physical therapy services must be prescribed by a physician, certified Physician Assistant (PA working under the supervision of a physician), or certified Nurse Practitioner (NP) and professionally administered to aid in the recovery from disease or injury to help the patient in attaining greater self-sufficiency, mobility, and productivity through exercises and other modalities intended to improve muscle strength, joint motion, coordination, and endurance.
3.3  If physical therapy is performed by other than a physician, a physician (or other authorized individual professional provider acting within the scope of his/her license) should refer the patient for treatment and supervise the physical therapy.
3.4  Reimbursement for covered physical therapy services is based on the appropriate CPT procedure codes for the services billed on the claim.
3.5  Physical therapists are not authorized to bill using Evaluation and Management (E/M) codes listed in the Physician’s Current Procedural Terminology (CPT).
4.0  EXCLUSIONS
The following services are not covered:
4.1  Diathermy, ultrasound, and heat treatments for pulmonary conditions.
4.2  General exercise programs, even if recommended by a physician (or other authorized individual professional provider acting within the scope of their license).
4.3  Electrical nerve stimulation used in the treatment of upper motor neuron disorders such as multiple sclerosis.
4.4  Separate charges for instruction of the patient and family in therapy procedures.
4.5  Repetitive exercise to improve gait, maintain strength and endurance, and assistative walking such as that provided in support of feeble or unstable patients.
4.6  Range of motion and passive exercises which are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities.
4.7  Maintenance therapy that does not require a skilled level after a therapy program has been designed (see Section 18.1).
4.8  Services of chiropractors and naturopaths whether or not such services would be eligible for benefits if rendered by an authorized provider.
4.9  Acupuncture with or without electrical stimulation.
4.10  Athletic training evaluation (CPT procedure codes 97005 and 97006).
4.11  Sensory integration therapy (CPT procedure code 97533) which may be considered a component of cognitive rehabilitation is unproven.
Note:  This policy does not exclude multidisciplinary services, such as physical therapy, occupational therapy, or speech therapy after traumatic brain injury, stroke and children with an autistic disorder.
4.12  Nonsurgical spinal decompression therapy (including Internal or Intervertebral Disc Decompression (IDD), Decompression Reduction Stabilization (DRS), or Vertebral Axial Decompression (VAX-D) therapy) provided by mechanical or motorized traction for the treatment of low back and/or neck pain is unproven. The use of powered traction devices (including, but not limited to, the Accu-SPINA™, VAX-D, and DRX9000) are likewise unproven.
4.13  For beneficiaries under the age of three, services and items provided in accordance with the beneficiary’s Individualized Family Service Plan (IFSP) as required by Part C of the Individuals with Disabilities Education Act (IDEA), and which are otherwise allowable under the TRICARE Basic program or the Extended Care Health Option (ECHO) but determined not to be medically or psychologically necessary, are excluded.
4.14  For beneficiaries aged three to 21, who are receiving special education services from a public education agency, cost-sharing of outpatient physical therapy services that are required by the IDEA and which are indicated in the beneficiary’s Individualized Education Program (IEP), may not be cost-shared except when the intensity or timeliness of physical therapy services as proposed by the educational agency are not sufficient to meet the medical needs of the beneficiary.
4.15  Low Level Laser Therapy (LLLT) (also known as low level light therapy or cold laser therapy) for treatment of soft tissue injuries, pain or inflammation is unproven.
4.16  Spinalator therapy and use of a Spinalator Table for the treatment of neck and low back pain. Spinalator therapy is defined as a type of traction that uses the patient’s weight to create the traction force in the absence of any external pulling force. The Spinalator Table is defined as a table with rollers that applies consistent pressure and movement under the patient in the absence of any external pulling devices.
4.17  Effective June 1, 2020, Transcutaneous Electrical Nerve Stimulation (TENS) for the treatment of acute, subacute, and chronic low back pain (LBP) is excluded from coverage. Physical therapy visits where the sole treatment provided is TENS for LBP are not eligible for cost-sharing. Separate charges for TENS therapy provided during the course of an otherwise-covered physical therapy visit are not eligible for cost-sharing. TENS units for home use, prescribed during the course of physical therapy, for the treatment of LBP, are not covered.
4.18  Dry Needling (DN) is considered unproven.
Note:  If a physical therapist provides DN in the course of an otherwise-covered physical therapy session/visit, TRICARE may cost-share the cost of the covered care; no separate reimbursement is available for DN. Visits for the sole purpose of receiving DN are non-covered.
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