Contractor’s Determination Number


Contractor Name

LCD Database ID Number

L28992 – Florida
L29024 – Puerto Rico/Virgin Islands

First Coast Service Options, Inc.

Contractor Number

09101 – Florida
09201 – Puerto Rico/Virgin Islands

LCD Title

Therapy and Rehabilitation Services

Coding Guidelines

Physical medicine and rehabilitation services utilize the therapeutic properties of exercise, heat, cold, electricity, ultraviolet, ultrasound, hydrotherapy, massage, and manual therapy to improve circulation, strengthen muscles, maintain or restore motion, and train or retrain an individual to perform the activities of daily living.

Physical Medicine and Rehabilitation services must be furnished to a patient who is under the care of a physician or non-physician practitioner.  All personnel who are involved in providing therapy services must be legally authorized (licensed, or if applicable, certified or registered) to practice by the state in which they provide the services and must act only within the scope of their state license, certification or registration.

Effective January 1, 2000, optometrists may refer patients for therapy services as well as establish and review the plan of treatment.  The plan of treatment established and/or reviewed by an optometrist must relate to disease conditions that are treated by an optometrist.

Effective 01/01/2009 CPT code 95992 –Canalith repositioning procedure(s), (eg, Epley maneuver, Semont maneuver), per day – is considered a “sometimes therapy” code. 

Effective 01/01/2010 CPT code 95992 – Canalith repositioning procedure(s) (e.g., Epley maneuver, semont maneuver), per day, is removed from the online therapy code list, which is available at

Effective 01/01/2011 CPT code 95992 –Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver), per day has been assigned a status indicator of A and therefore, can be performed and billed by qualified physicians, and other qualified health care providers.  CPT code 95992 is listed on the CMS online therapy code list, which is available at                                    ]

Effective 01/01/2010 CPT code 92520 – Laryngeal function studies (i.e., aerodynamic testing and acoustic testing) – which is considered a “sometimes therapy” code, is added to the online therapy code list. 

The online therapy code list includes all of the “always” and “sometimes” therapy procedure codes. (Pub. 100-04, Section 20, B).

Effective 01/01/2009 CPT code 0183T – low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment and instruction(s) for ongoing care, per day – is considered a “sometime therapy” code.  0183T is currently in the List of Medicare Noncovered Services LCD as an investigational procedure.  Therefore this service is not payable by Medicare and will be denied as such when billed.

Effective for dates of service on or after July 1, 2008, the applicable revenue codes for 75x type of bills are as follows: 0270, 0274, 0279, 029X, 0410, 0412, 0419, 042X, 043X, 044X, 0550, 0559, 0560, 0569, 0636, 0771, 0900, 0911, 0914 and 0919.

Speech-Language Pathology Services

Speech-language pathology (SLP) services are included in the list of therapy services in Pub. 100-04, chapter 5, section 20. Policies for outpatient therapy services are in Pub. 100-02, chapter 15, section 220 and 230. Most of the CPT codes that apply to SLP services are un-timed codes that may only be billed once for each encounter. A common error is the billing of un-timed codes for multiple units of time. For example, the evaluation code 92506 is billed once a day regardless of the number of types of evaluation included or the length of time that is involved. Bill the code that most appropriately describes the service that is being provided.

General policy for evaluation and treatment of conditions related to the auditory system

For evaluation of auditory processing disorders and speech-reading or lip-reading, by a speech-language pathologists use the un-timed code 92506 with “1” as the unit of service, regardless of the duration of the service on a given day. This “always therapy” evaluation code must be provided by speech-language pathologists according to the policies in Pub. 100-02, chapter 15, sections 220 and 230. The codes 92620 and 92621 are diagnostic audiological tests and may not be used for SLP services. For treatment of auditory processing disorders or auditory rehabilitation/auditory training (including speech-reading or lip-reading), 92507, and 92508 are used to report a single encounter with “1” as the unit of service, regardless of the duration of the service on a given day. These codes always represent SLP services. See Pub. 100-02, chapter 15, sections 220 and 230 for SLP policies. These SLP evaluation and treatment services are not covered when performed or billed by audiologists, even if they are supervised by physicians or nonphysician practitioners. For evaluation of auditory rehabilitation to instruct the use of residual hearing provided by an implant or hearing aid related to hearing loss, the timed codes 92626 and 92627 are used. These are not “always therapy” codes. Evaluation of auditory rehabilitation shall be appropriately provided by an audiologist or speech-language pathologist. Evaluation services may be billed by an audiologist. Also, these services may be provided incident to a physician or nonphysician ractitioner’s service by a speech language pathologist, or personally by a physician or nonphysician practitioner within their scope of practice. Evaluation of auditory rehabilitation is a covered diagnostic test when performed and billed by an audiologist and is a SLP evaluation service covered under the SLP benefit when performed by a speech-language pathologist. General policies for post implant services. The services of a speech-language pathologist may be covered for SLP services provided after implantation of auditory devices. For example, a speech-language pathologist may provide evaluation and treatment of speech, language, cognition, voice, and auditory processing using code 92506 and 92507. Use 92626 and 92627 for auditory (aural) rehabilitation evaluation following cochlear implantation or for other hearing impairments.

Hot or Cold Modality (CPT code 97010)

Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm and reduce inflammation and edema.  The payment for hot or cold packs is bundled into the payment for other services.  Therefore, when hot or cold packs are used in conjunction with other procedures or modalities, the payment for the hot or cold packs is not separately reimbursable.

Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not medically necessary and therefore, are not covered.

Electrical Stimulation (Manual) (CPT code 97032)

This modality requires direct (one-on-one) patient contact by the provider.

Ultrasound Application (CPT code 97035)

When phonopheresis is performed, use procedure code 97035.

Therapeutic Exercise (CPT code 97110)

For guidelines regarding Complex Decongestive Physiotherapy services, please refer to the Complex Decongestive Physiotherapy Policy (97110).

Aquatic Therapy with Therapeutic Exercise (CPT code 97113)

Aquatic therapy (CPT code 97113) should not be billed in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).

Aquatic therapy with therapeutic exercise (97113) should not be billed when there is not one-on-one contact between therapist and patient.  For example, an aqua aerobic class of more than one patient with the instructor directing the class from a distance would not be considered reasonable and necessary and therefore, not a covered service.

Manual Therapy (CPT code 97140)

For guidelines regarding Complex Decongestive Physiotherapy services, please refer to the Complex Decongestive Physiotherapy Policy (97110).

Therapeutic Procedure(s), group (2 or more individuals) (CPT code 97150)

Documentation must be submitted with the claim identifying the specific treatment technique(s) used in the group, how the treatment technique will restore function, the frequency and duration of the particular group setting, and the treatment goal in the individualized plan.  The number of persons in the group must also be furnished.

Other Therapeutic Procedures (CPT codes 97532 and 97533)

This service is not considered to be outpatient physical therapy and is, therefore, noncovered when billed by an Independent Practicing Physical Therapist (Specialty 65).

Wheelchair Management (CPT code 97542)

When billing 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient.

Physical Performance Test or Measurement (CPT code 97750)

These services are not to be used in lieu of evaluation or re-evaluation services.   It would not be appropriate to report a code from the 95831-95834 or the 95851-95852 series in addition to 97750.  It is not medically reasonable and necessary to bill this service as part of a routine assessment/evaluation of rehabilitation services (97001, 97002, 97003 or 97004).

Orthotics Management and Training (97760):

Orthotic training (CPT code 97760) for a lower extremity performed during the same visit as gait training (CPT code 97116) or self-care/home management training (CPT code 97535) should not be reported unless documentation in the medical record shows that distinct treatments were rendered.

In addition, the casting and strapping codes should not be reported in addition to code 97760.  If casting and strapping of a fracture, injury, or dislocation is performed, procedure codes 29000-29590 should be reported.  Please refer to the LMRP/LCD policy (29580) for further guidelines regarding strapping.

Manual Muscle Testing and Range of Motion Services

Codes 95831-95834 identify manual muscle testing procedures. Use of these codes specifies testing of muscle strength as graded by the examiner according to standardized grading scales. The code descriptors defines the use of these codes including the body area(s) addressed, manual muscle testing, and the preparation of a formal, written report of the findings as a necessary component of the procedure.

Use of the manual muscle testing codes requires testing of muscle strength, comparison of values by the examiner to a standardized grading scale and creation of a formal, written report of the findings. Muscle testing performed without recording specific values for the muscles tested, or one that does not include a separate report, should not be reported with codes 95831-95834. Instead, this effort should be included as part of the E/M service or part of 97001-97002.

It would not be expected that these services would be routinely billed as a re-evaluation, as this is not the purpose of these codes.

Timed and Untimed Codes

When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units.  For untimed codes, units are reported based on the number of times the procedure is performed, as described in the HCPCS code definition (often once per day).

Example: A beneficiary received a speech-language pathology evaluation represented by HCPCS “untimed” code 92506. Regardless of the number of minutes spent providing this service only one unit of service is appropriately billed on the same day.

Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. Providers report procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute units of service.

Example: A beneficiary received occupational therapy (HCPCS “timed” code 97530 which is defined in 15 minute units) for a total of 60 minutes. The provider would then report revenue code 043X and 4 units.

Counting Minutes for Timed Codes in 15 Minute Units

When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be billed. Time intervals for 1 through 8 units are as follows:


Number of Minutes

1 unit

   8 minutes through 22 minutes

2 units

   23 minutes through 37 minutes

3 units

   38 minutes through 52 minutes

4 units

   53 minutes through 67 minutes

5 units

   68 minutes through 82 minutes

6 units

   83 minutes through 97 minutes

7 units:

   98 minutes through 112 minutes

8 units

   113 minutes through 127 minutes

The pattern remains the same for treatment times in excess of 2 hours.

If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit. If the service is performed for at least 30 minutes, that service shall be billed for at least two units, etc.  It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes. When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of units billed.

If any 15 minute timed service that is performed for 7 minutes or less than 7 minutes on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total time of the two is 8 minutes or greater than 8 minutes, then bill one unit for the service performed for the most minutes . This is correct because the total time is greater than the minimum time for one unit. The same logic is applied when three or more different services are provided for 7 minutes or less than 7 minutes.

Pub. 100-02, chapter 15, section 230.3B Treatment Notes indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units for the total therapy minutes provided.

Example 1:

24 minutes of neuromuscular reeducation, code 97112,

23 minutes of therapeutic exercise, code 97110,

Total timed code treatment time was 47 minutes.

See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.  Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.

Example 2:

20 minutes of neuromuscular reeducation (97112)

20 minutes therapeutic exercise (97110),

40 Total timed code minutes.

Appropriate billing for 40 minutes is 3 units. Each service was done at least 15 minutes and should be billed for at least one unit, but the total allows 3 units. Since the time for each service is the same, choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes.

Example 3:

33 minutes of therapeutic exercise (97110),

7 minutes of manual therapy (97140),

40 Total timed minutes

Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.

Example 4:

18 minutes of therapeutic exercise (97110),

13 minutes of manual therapy (97140),

10 minutes of gait training (97116),

8 minutes of ultrasound (97035),

49 Total timed minutes

Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed). You would still document the ultrasound in the treatment notes.

Example 5:

7 minutes of neuromuscular reeducation (97112)

7 minutes therapeutic exercise (97110)

7 minutes manual therapy (97140)

21 Total timed minutes

Appropriate billing is for one unit. The qualified professional (See definition in Pub 100-02/15, sec. 220) shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only one unit is allowed.

NOTE: The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the eighth should be excluded from the total count. The total minutes of active treatment counted for all 15 minute timed codes includes all direct treatment time for the timed codes. Total treatment minutes-- including minutes spent providing services represented by untimed codes — are also documented. For documentation in the medical record of the services provided see Pub. 100-02, chapter 15, section 230.3: Documentation, Treatment Notes.

Specific Limits for HCPCS

The following list of codes may be billed, when covered, only at or below the number of units indicated in the chart per treatment day. Chart does not include all of the codes identified as therapy codes. Use this chart in the following manner:

·         The codes that are allowed one unit for “allowed units” in the chart may be billed no more than once per provider, per discipline, per date of service, per patient.

·         The codes allowed 0 units in the column for “allowed units”, may not be billed under a plan of care indicated by the discipline in that column. Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP).

·         When physicians/NPPs bill “always therapy” codes they must follow the policies of the type of therapy they are providing, e.g., utilize a plan of care, bill with the appropriate therapy modifier (GP, GO, GN), bill the allowed units on the chart below for PT, OT or SLP depending on the plan. A physician/NPP shall not bill an “always therapy” code unless the service is provided under a therapy plan of care. Therefore, NA stands for “Not Applicable” in the chart below.

·         When a “sometimes therapy” code is billed by a physician/NPP, but as a medical service, and not under a therapy plan of care, the therapy modifier shall not be used, but the number of units billed must not exceed the number of units indicated in the chart below.

*Please note that this chart only contains the codes that apply to this LCD. To view the entire chart please see the Internet only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2.


Code description

Timed or Untimed

PT allowed units

OT allowed units

SLP allowed units

Physician/NPP NOT under therapy POC


Speech/hearing evaluation







Limb muscle testing, manual







Limb muscle testing, manual







PT evaluation







PT re-evaluation







OT evaluation







OT re-evaluation






The progress notes should be written using measurements and functional accomplishments.  Use statements which can be used to assess the patient s response to therapy such as:

·         “able to perform exercises as prescribed for 15 reps”

·         “able to safely transfer from bed to wheelchair with standby assistance”

·         “can now abduct shoulder 120 degrees”

·         “can bridge now sufficiently to pull slacks up over hips”

Avoid terms such as:

·         doing well

·         improving

·         less pain

·         increased range of motion

·         increased strength

·         tolerated treatment well

Use of the KX Modifier:  When services qualify for an automatic process exception, provider/suppliers should add a KX modifier to each line of the claim that contains a service that exceeds caps.  This modifier represents the provider/supplier’s attestation of medical necessity.  Medical records continue to be subject to review for possible misrepresentation, fraud or patterns of abuse.  If the contractor determines that the provider/supplier has inappropriately used the modifier, the provider/supplier may be subject to sanctions resulting from providing inaccurate information on a claim.  The exception process for therapy services is effective until further notice.

CMS has identified HCPCS codes that are “always therapy” services.  These codes are listed in the Claims Processing Manual, Chapter 5, Section 20(B), Applicable Outpatient Rehabilitation HCPCS Codes.”  Therapy services include only physical therapy, occupational therapy and speech-language pathology services.  Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology.  Underlined codes are always therapy services, regardless of who performs them.  These codes always require therapy modifiers (GP, GO, GN).

The provider/supplier should notify beneficiaries of the therapy financial limitations at their first therapy encounter with the beneficiary. Providers/suppliers should inform beneficiaries that beneficiaries are responsible for 100 percent of the costs of therapy services above each respective therapy limit, unless this outpatient care is furnished directly or under arrangements by a hospital.  Patients who are residents in a Medicare certified part of a SNF may not utilize outpatient hospital services for therapy services over the financial limits, because consolidated billing rules require all services to be billed by the SNF.

NEMB - It is the provider’s responsibility to present each beneficiary with accurate information about the therapy limits, and that, where necessary, appropriate care above the limits can be obtained at a hospital outpatient therapy department.  Although use of the NEMB form is not a Medicare requirement the provider/supplier should use the Notice of Exclusion from Medicare Benefits (NEMB Form No.  CMS 20007), or a similar form of their own design to inform beneficiaries of the therapy financial limitation and the cap exclusion process.  When using the NEMB form, the beneficiary checks the appropriate box, and the provider and writes the reason for denial in the space provided at the top of the form. The following reason is suggested: “Services do not qualify for exception to therapy caps. Medicare will not pay for physical therapy and speech-language pathology services over (add the dollar amount of the cap and the year or the dates of service to which it applies, e.g., $1740 in 2006 or $1780 in 2007 or $1810 in 2008) unless the beneficiary qualifies for a cap exception.”  Providers are to supply this same information for occupational therapy services over the limit for the same time period, as appropriate.  The NEMB form can be found at:

The therapy cap for 2011 for physical therapy and speech language pathology services combined is $1870.  The therapy cap for  2011 for occupational therapy service is $1870.

For 2012, the annual limit on the allowed amount for outpatient physical therapy and speech-language pathology combined is $1880; the limit for occupational therapy is $1880.

Note:  The NEMB form will be discontinued beginning March 1, 2009.  Beginning on this date, providers may use the revised ABN (CMS-R-131) in place of the NEMB or a similar form of their own design.

ABN - An Advance Beneficiary Notice (ABN) is required to be given to a beneficiary whenever the treating clinician determines that the services being provided are no longer expected to be covered because they do not satisfy Medicare’s medical necessity requirements.  The ABN informs the beneficiary of their potential financial obligation to the provider and provides guidance regarding appeal rights.  The ABN applies to services that are provided BEFORE the cap is exceeded.

Note:  The ABN-G will no longer be effective beginning March 1, 2009.  Beginning on this date, providers must use the revised ABN (CMS-R-131).  The revised ABN can be found at: 

After the cap is exceeded, only voluntary notice, such as the NEMB or the revised ABN (beginning 3/1/09) is appropriate, regardless of whether the services were excepted from the cap.  For example, if services are provided over the cap for an excepted condition, when the therapist determines that the services no longer meet the criteria for reasonable and necessary services, a voluntary notice, such as the NEMB or the revised ABN may be provided to the patient.

At the time the clinician determines that skilled services are not necessary, the clinical goals have been met, or that there is no longer potential for the rehabilitation of health and/or function in a reasonable time, the beneficiary should be informed.  If the beneficiary requests further services, inform the beneficiary that Medicare will not likely provide additional coverage.  Use the ABN form for this purpose if the services are within the cap, and use the NEMB/revised ABN for services after the cap is exceeded.

Access to Accrued Amount - All providers and contractors may access the accrued amount of therapy services from the ELGA screen inquiries into CWF.  Providers/suppliers may access remaining therapy services limitation dollar amount through the 270/271 eligibility inquiry and response transaction.  Providers who bill to FIs will also find the amount a beneficiary has accrued toward the financial limitations on the HIQA.  Some suppliers and providers billing to carriers may, in addition, have access the accrued amount of therapy services from the ELGB screen inquiries into CWF.  Suppliers who do not have access to these inquiries may call the contractor to obtain the amount accrued.


For additional Coverage Guidelines, please see:

Pub. 100-02, Medicare Benefit Policy Manual, Chapters 12 and 15

Pub. 100-04, Medicare Claims Processing Manual, Chapter 5

Revision History






7- Revised the coding Guidelines to change language per Technical Direction Letter TDL-12245 regarding the therapy cap extension.  This effective date of this revision is based on dates of service on or after March 1, 2012 until further notice.


6- Revised the Coding Guidelines to change language per CR 7529 regarding the change in the dollar amount of the therapy cap.  The effective date of this revision is based on date of service.


5- Revised the Coding Guidelines to change language per CR7300 regarding the change in dollar amount of the therapy cap.  Claims processed on or after January 14, 2012 for dates of service on or after January 1, 2011.


4- Annual 2011 HCPCS Update.  Revised references to Canalith repositioning procedure. The effective date of this revision is based on date of service.


3 - Revised the Coding Guidelines per CR 6719, regarding therapy services online list of therapy procedure codes.  The effective date of this revision is based on date of service.


2 - Revised to change language per CR 6321, regarding Notice of Exclusion from Medicare Benefits (NEMB) form; Advance Beneficiary Notice (ABN) form; access to accrued amount information, and change in dollar amount of the therapy cap.  Changes in language per CR 6397, regarding billing information for the Canalith repositioning procedures.  This revision is effective for claims processed on or after 04/06/2009 for dates of service on or after 01/01/2009.


1 – Revision to add language regarding CPT codes 0183T and 95992 in conjunction with Change Request 6254 dated October 31, 2008 and JSM/TDL – 09132, dated January 21, 2009.  Revisions are effective for 0183T for claims processed on or after 01/05/2009 for dates of service on or after 01/01/2009.  Revisions are effective for 95992 for claims processed on or after 03/02/2009 for dates of service on or after 01/01/2009.

02/16/2009 – Florida
03/02/2009 – Puerto Rico/Virgin Islands



Document formatted: 03/23/2012 (RA/et)