Description
Physical therapy (PT) is the treatment of disease or injury by the use of therapeutic exercise and other interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, a person’s ability to go through the functional activities of daily living and on alleviating pain.

Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiological principles.

Policy
Physical therapy services are considered MEDICALLY NECESSARY when performed to meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies or prior therapeutic intervention.

Policy Guidelines
Physical therapy services must meet all of the following criteria:

• Meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies or prior therapeutic intervention
• Achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time
• Provide specific, effective and reasonable treatment for the patient’s diagnosis and physical condition
• Be delivered by a qualified provider of physical therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure
• Require the judgment, knowledge and skills of a qualified provider of physical therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient

Augmented soft tissue mobilization is considered INVESTIGATIONAL because it has not been proven to be more effective than standard soft tissue mobilization. There is no reliable evidence that outcomes of soft tissue mobilization (myofascial release) are improved with the use of hand-held tools (so-called "augmented soft tissue mobilization").

Kinesio taping/taping is considered INVESTIGATIONAL for all conditions because its clinical value has not been established.

MEDEK therapy is considered INVESTIGATIONAL because its clinical value has not been established.

Hands-free ultrasound and low-frequency sound (infrasound) are considered INVESTIGATIONAL because their clinical values have not been established.

Hivamat therapy (deep oscillation therapy) is considered INVESTIGATIONAL because its clinical value has not been established.

NOTE: Homebound status is defined as an individual who normally would be able to leave the home, but due to illness or injury, leaving the home will now require considerable and taxing effort. An aged person who does not travel from his or her home because of feebleness and insecurity brought on by advanced age is NOT considered homebound.

PLEASE SEE CAM 191 MEDICAL RECORDS DOCUMENTATION STANDARDS.

Benefit Application
Plans may wish to review their contract language on physical therapy services to ensure that the contract language is consistent with the Plan’s medical policy on PT.

Many Plans have visit or dollar maximums for PT services, or these services may be provided as a separate contractual benefit.

Sessions
A physical therapy session is defined as up to one hour of PT (treatment and/or evaluation) or up to three PT modalities provided on any given day. These sessions may include:

• Therapeutic exercise programs, including coordination and resistive exercises, to increase strength and endurance.
• Various modalities including, but not limited to, thermotherapy, cryotherapy, hydrotherapy and electrical stimulation.
• Massage, traction or mobilization techniques.
• Patient and family education in home exercise programs.

Plan of Care
The plan of care should include:

• Specific statements of long- and short-term goals.
• Measurable objectives.
• A reasonable estimate of when the goals will be reached.
• The specific modalities and exercises to be used in treatment.
• The frequency and duration of treatment.

Rationale
A search of literature was completed through the MEDLINE database for the period of January 1980 through December 1995. The search strategy focused on references containing the following medical subject headings:

• Physical therapy (including review or meta-analysis or practical clinical trial or guidelines) as indexed in the Abridged Index Medicus
• Physical therapy and Iontophoresis
• Rehabilitation (massage or effleurage or pétrissage or tapotement)

See also:
Occupational Therapy, medical policy No. 80303.

Research was limited to English-language journals on humans.

Augmented Soft Tissue Mobilization:
Augmented soft tissue mobilization (ASTM), a non-invasive mobilization technique, is used by chiropractors, as well as massage, occupational and physical therapists, to treat chronic musculoskeletal disorders that result from scarring and fibrosis. It entails the use of handheld tools made from bone or stone or metal and a lubricant on the skin to scrape and mobilize scar tissue. Scraping is done to promote circulation, thus promoting healing. Manual and other treatments may also be used with exercise to guide the healing process. Treatments with ASTM are often administered on non-consecutive days, one to two times per week. A typical 30-minute session usually includes 15 minutes of treatment and 15 minutes of exercise and assessment. Less severe conditions reportedly can respond well in two to four sessions, whereas difficult chronic cases may require eight to 16 sessions. However, there is insufficient evidence to support the effectiveness of ASTM.

In a case report, Melham et al. (1998) described their finding on the use of ASTM in the treatment of excessive scar tissue around an athlete's injured ankle. Surgery and several months of conventional physical therapy failed to alleviate the athlete's symptoms. As a final resort, ASTM was administered. It used ergonomically designed instruments that assist therapists in the rapid localization and effective treatment of areas exhibiting excessive soft tissue fibrosis, followed by a stretching and strengthening program. Upon the completion of six weeks of ASTM, the athlete had no pain and had regained full range of motion and function.

Kinesio Taping/Taping:
Kinesio taping is a method of taping using a specialized type of tape. It differs from traditional white athletic tape in the sense that it is elastic and can be stretched to 140 percent of its original length before being applied to the skin. It subsequently provides a constant pulling (shear) force to the skin over which it is applied, unlike traditional white athletic tape. The fabric of this specialized tape is air permeable and water resistant and can be worn for repetitive days. Kinesio tape is being used immediately following injury and during the rehabilitation process. However, its effectiveness has yet to be established.

Halseth et al. (2004) examined whether Kinesio taping the anterior and lateral portion of the ankle would enhance ankle proprioception compared to the untaped ankle. A total of 30 subjects (15 men, 15 women, aged 18 to 30 years) participated in this study. Exclusion criteria included ankle injury less than six months before testing, significant ligament laxity as determined through clinical evaluation or any severe foot abnormality. Experiment used a single group, pre-test and post-test. Plantar flexion and inversion with 20° of plantar flexion reproduction of joint position sense (RJPS) was determined using an ankle RJPS apparatus. Subjects were bare-footed, blind-folded and equipped with headphones playing white noise to eliminate auditory cues. They had five trials in both plantar flexion and inversion with 20° plantar flexion before and after application of the Kinesio tape to the anterior/lateral portion of the ankle. Constant error and absolute error were determined from the difference between the target angle and the trial angle produced by the subject. The treatment group (Kinesio-taped subjects) showed no change in constant and absolute error for ankle RJPS in plantar flexion and 20º of plantar flexion with inversion when compared to the untaped results using the same motions. The application of Kinesio tape does not appear to enhance proprioception (in terms of RJPS) in healthy individuals as determined by measures of RJPS at the ankle in the motions of plantar flexion and 20º of plantar flexion with inversion. The authors stated that in order to fully understand the effect of Kinesio tape on proprioception, further research needs to be conducted on other joints, on the method of application of Kinesio tape and the health of the subject to whom it is applied. In addition, further research may provide vital information about a possible benefit of Kinesio taping during the acute and sub-acute phases of rehabilitation, thus facilitating earlier return to activity participation.

In a pilot study, Yasukawa and colleagues (2006) described the use of the Kinesio taping method for the upper extremity in enhancing functional motor skills in children admitted into an acute rehabilitation program. A total of 15 children (10 females and five males, 4 to 16 years of age), who were receiving rehabilitation services at the Rehabilitation Institute of Chicago, participated in this study. For 13 of the inpatients, this was the initial rehabilitation following an acquired disability, which included encephalitis, brain tumor, cerebral vascular accident, traumatic brain injury and spinal cord injury. The Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment) was used to measure upper-limb functional change prior to use of Kinesio tape, immediately after application of the tape and three days after wearing tape. Children's upper-limb function was compared over the three assessments using analysis of variance. The improvement from pre- to post-taping was statistically significant, F(1, 14) = 18.9; p < 0.02. The authors concluded that these results suggested that Kinesio tape may be associated with improvement in upper-extremity control and function in the acute pediatric rehabilitation setting. The use of Kinesio tape as an adjunct to treatment may assist with the goal-focused occupational therapy treatment during the child's inpatient stay. Moreover, they stated that further study is recommended to test the effectiveness of this method and to determine the lasting effects on motor skills and functional performance once the tape is removed.

In a pilot study, Fu and associates (2008) examined the possible immediate and delayed effects of Kinesio taping on muscle strength in quadriceps and hamstring when taping is applied to the anterior thigh of healthy young athletes. A total of 14 healthy young athletes (seven males and seven females) free of knee problems were enrolled in this study. Muscle strength of the subject was assessed by the isokinetic dynamometer under three conditions: (i) without taping; (ii) immediately after taping; (iii) 12 hours after taping with the tape remaining in situ. The result revealed no significant difference in muscle power among the three conditions. Kinesio taping on the anterior thigh neither decreased nor increased muscle strength in healthy non-injured young athletes.

In a prospective, randomized, double-blinded, clinical study using a repeated-measures design, Thelen et al. (2008) determined the short-term clinical efficacy of Kinesio tape when applied to college students with shoulder pain, as compared to a sham tape application. A total of 42 subjects with clinically diagnosed rotator cuff tendonitis and/or impingement were randomly assigned to one of two groups: therapeutic Kinesio tape group or sham Kinesio tape group. Subjects wore the tape for two consecutive three-day intervals. Self-reported pain and disability and pain-free active ranges of motion (ROM) were measured at multiple intervals to evaluate for differences between groups. The therapeutic Kinesio tape group showed immediate improvement in pain-free shoulder abduction (mean +/- SD increase, 16.9 degrees +/- 23.2 degrees; p = 0.005) after tape application. No other differences between groups regarding ROM, pain or disability scores at any time interval were found. The authors concluded that Kinesio tape may be of some assistance to clinicians in improving pain-free active ROM immediately after tape application for patients with shoulder pain. Use of Kinesio tape for decreasing pain intensity or disability for young patients with suspected shoulder tendonitis/impingement is not supported.

McConnell (2002) noted that the management of chronic low back pain (LBP) and leg pain has always provided a challenge for therapists. This researcher examined the influence of a repetitive movement such as walking as a possible causative factor of chronic LBP. Diminished shock absorption, as well as limited hip extension and external rotation, are hypothesized to affect the mobility of the lumbar spine, resulting in lumbar spine dysfunction. Treatment must therefore be directed not only at increasing the mobility of the hips and thoracic spine, but also the stability of the lumbar spine. However, the symptoms can sometimes be exacerbated by treatment, so the neural tissue needs to be unloaded to optimize the treatment outcome. This can be achieved by taping the buttock and down the leg following the dermatome to shorten the inflamed tissue.

While taping has a role in the management of musculoskeletal pain and injuries, its use in the management of LBP has not been established. In a review of LBP in athletes, Baker and Patel (2005) stated that most of the adult population experiences LBP at some time in life. Athletes may be at increased risk, but outcomes are good. The majority of LBP in adult athletes is mechanical in nature. Herniated discs, spinal stenosis, sacoilitis and sacral stress fractures can also cause LBP in these individuals. Low back conditions mentioned above may be treated with rest, medication, as well as specific exercise programs. Surgery is indicated for severe spinal stenosis, pain with evidence of neurological compromise and some painful deformities. Newer treatments for back pain are emerging, but few controlled clinical trials are available. Taping was not mentioned as an option for managing individuals with LBP. Additionally, in a review of current concepts in the diagnosis and treatment of spondylolysis, McCleary and Congeni (2007) noted that treatment usually consists of rest and/or bracing to allow healing to occur, followed by rehabilitation that includes core strengthening. They stated that more large-scale controlled studies are needed to clarify the most effective diagnostic and therapeutic protocols. Furthermore, in reviews of treatment for subacute and chronic LBP (Chou, 2009) and occupational LBP (Kraeciw and Atlas, 2009), as well as review of rehabilitation program for the low back (Sheon and Duncombe, 2009), taping is not mentioned as an option.

Greig et al. (2008) noted that greater thoracic kyphosis is associated with increased biomechanical loading of the spine, which is potentially problematic in individuals with osteoporotic vertebral fractures. Conservative interventions that reduce thoracic kyphosis warrant further investigation. These researchers examined the effects of therapeutic postural taping on thoracic posture. Secondary aims explored the effects of taping on trunk muscle activity and balance. A total of 15 women with osteoporotic vertebral fractures participated in this within-participant design study. Three taping conditions were randomly applied: (i) therapeutic taping, (ii) control taping and (iii) no taping. Angle of thoracic kyphosis was measured after each condition. Force plate-derived balance parameters and trunk muscle electromyographic activity (EMG) were recorded during three static standing tasks of 40-second duration. There was a significant main effect of postural taping on thoracic kyphosis (p = 0.026), with a greater reduction in thoracic kyphosis after taping, compared with both control tape and no tape. There were no effects of taping on EMG or balance parameters. The authors concluded that these findings showed that the application of postural therapeutic tape in a population with osteoporotic vertebral fractures induced an immediate reduction in thoracic kyphosis. They stated that further research is needed to investigate the underlying mechanisms associated with this decrease in kyphosis.

The American College of Occupational and Environmental Medicine's practice guidelines on "Evaluation and management of common health problems and functional recovery in workers" (Hegmann, 2007) did not recommend taping or Kinesio taping for acute, subacute or chronic LBP, radicular pain syndromes or other back-related conditions.

González-Iglesias et al. (2009) examined the short-term effects of Kinesio taping, applied to the cervical spine, on neck pain and cervical ROM in individuals with acute whiplash-associated disorders (WADs). A total of 41 patients (21 females) were randomly assigned to one of two groups: (i) the experimental group received Kinesio taping to the cervical spine (applied with tension), and (ii) the placebo group received a sham Kinesio taping application (applied without tension). Both neck pain (11-point numerical pain rating scale) and cervical ROM data were collected at baseline, immediately after the Kinesio tape application and at a 24-hour follow-up by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. The group-by-time interaction for the two-by-three mixed-model ANOVA was statistically significant for pain as the dependent variable (F = 64.8; p < 0.001), indicating that patients receiving Kinesio taping experienced a greater decrease in pain immediately post-application and at the 24-hour follow-up (both, p < 0.001). The group-by-time interaction was also significant for all directions of cervical ROM: flexion (F = 50.8; p < 0.001), extension (F = 50.7; p < 0.001), right (F = 39.5; p < 0.001) and left (F = 3.8, p < 0.05) lateral flexion, and right (F = 33.9, p < 0.001) and left (F = 39.5, p < 0.001) rotation. Patients in the experimental group obtained a greater improvement in ROM than those in the control group (all, p < 0.001). The authors concluded that patients with acute WAD receiving an application of Kinesio taping, applied with proper tension, exhibited statistically significant improvements immediately following application of the Kinesio tape and at a 24-hour follow-up. However, the improvements in pain and cervical ROM were small and may not be clinically meaningful. They stated that future studies should investigate if Kinesio taping provides enhanced outcomes when added to physical therapy interventions with proven efficacy or when applied over a longer period.

In a single-center, randomized and double-blind study, Karadag-Saygi and colleagues (2010) evaluated the effect of Kinesio taping as an adjuvant therapy to botulinum toxin A (BTX-A) injection in lower extremity spasticity. A total of 20 hemiplegic patients with spastic equinus foot were enrolled into the study and randomized into two groups. The first group (n = 10) received BTX-A injection and Kinesio taping, and the second group (n = 10) received BTX-A injection and sham taping. Clinical assessment was done before injection and at two weeks and one, three and six months. Outcome measures were modified Ashworth scale (MAS), passive ankle dorsiflexion, gait velocity and step length. Improvement was recorded in both kinesiotaping and sham groups for all outcome variables. No significant difference was found between groups other than passive range of motion (ROM), which was found to have increased more in the kinesio-taping group at two weeks. The authors concluded that there is no clear benefit in adjuvant Kinesio taping application with botulinum toxin for correction of spastic equinus in stroke.

In a pilot feasibility study, Kalichman and colleagues (2010) evaluated the effect of Kinesio taping treatment approach on meralgia paresthetica (MP) symptoms. Men (n = 6) and women (n = 4) with clinically and electromyographically diagnosed MP received application of Kinesio tape, twice weekly for four weeks (eight treatment sessions in total). Main outcome measures were visual analog scale (VAS) of MP symptoms (pain/burning sensation/paresthesia), VAS global quality of life (QOL) and the longest and broadest parts of the symptom area were measured. All outcome measures significantly improved after four weeks of treatment. Mean VAS QOL +/- SD decreased from 69.0 +/- 23.4 to 35.3 +/- 25.2 (t = 4.3; p = 0.002). Mean VAS of MP symptoms +/- SD decreased from 60.5 +/- 20.8 to 31.4 +/- 26.6 (t = 5.9; p > 0.001). Length and width of affected area decreased from 25.5 +/- 5.5 to 13.7 +/- 6.7 (t = 5.1; p > 0.001) and 15.3 +/- 2.1 to 7.4 +/- 4.3 (t = 5.3; p >.001), respectively. The authors concluded that Kinesio taping can be used in the treatment of MP. Moreover, they stated that future randomized, placebo-controlled trials should be designed with patients and assessors blind to the type of intervention.

Kaya et al. (2011) compared the effectiveness of Kinesio tape and physical therapy modalities in patients with shoulder impingement syndrome. Patients (n = 55) were treated with Kinesio tape (n = 30) three times by intervals of three days or a daily program of local modalities (n = 25) for two weeks. Response to treatment was evaluated with the Disability of Arm, Shoulder and Hand scale. Patients were questioned for night pain, daily pain and pain with motion. Outcome measures, except for the Disability of Arm, Shoulder and Hand scale, were assessed at baseline, first and second weeks of the treatment. Disability of Arm, Shoulder and Hand scale was evaluated only before and after the treatment. Disability of Arm, Shoulder and Hand scale and VAS scores decreased significantly in both treatment groups as compared with the baseline levels. The rest, night and movement median pain scores of the Kinesio taping (20, 40 and 50, respectively) group were statistically significantly lower (p values were 0.001, 0.01 and 0.001, respectively) at the first week examination as compared with the physical therapy group (50, 70 and 70, respectively). However, there was no significant difference in the same parameters between the two groups at the second week (0.109, 0.07 and 0.218 for rest, night and movement median pain scores, respectively). Disability of Arm, Shoulder and Hand scale scores of the Kinesio taping group were significantly lower at the second week as compared with the physical therapy group. No side effects were observed. Kinesio tape has been found to be more effective than the local modalities at the first week and was similarly effective at the second week of the treatment. The authors stated that Kinesio taping may be an alternative treatment option in the treatment of shoulder impingement syndrome, especially when an immediate effect is needed. The findings of this small study need to be validated by well-designed studies.

Ankle sprains are common in sports, and the fibularis muscles play a role in providing functional stability of the ankle. Prophylactic ankle taping with non-elastic sports tape has been used to restrict ankle inversion, while Kinesio tape is elastic and has not been studied for that purpose. In a controlled study, Briem and colleagues (2011) examined the effect of two adhesive tape conditions compared to a no-tape condition on muscle activity of the fibularis longus during a sudden inversion perturbation in male athletes (soccer, team handball, basketball). A total of 51 male premier-league athletes were tested for functional stability of both ankles with the Star Excursion Balance Test. Based on the results, those with the 15 highest and those with the 15 lowest stability scores were selected for further testing. Muscle activity of the fibularis longus was recorded with surface electromyography during a sudden inversion perturbation. Each participant was tested under three conditions: (i) with the ankle taped with non-elastic, white sports tape, (ii) Kinesio tape and (iii) with no tape. Differences in mean muscle activity were evaluated with a three-way mixed model ANOVA for the three conditions across four 500-ms time-frames (within subject factors) and between the two groups of stable versus unstable participants (between subjects factor). Differences in peak muscle activity and in the time to peak muscle activity were evaluated with a two-way mixed model ANOVA for the three conditions (within subjects factor), between the two groups (between subjects factor). Significantly greater mean muscle activity was found when ankles were taped with non-elastic tape compared to no tape, while Kinesio tape had no significant effect on mean or maximum muscle activity compared to the no-tape condition. Neither stability level nor taping condition had a significant effect on the amount of time from perturbation to maximum activity of the fibularis longus muscle. The authors concluded that non-elastic sports tape may enhance dynamic muscle support of the ankle. The efficacy of Kinesio tape in preventing ankle sprains via the same mechanism is unlikely, as it had no effect on muscle activation of the fibularis longus.

MEDEK Therapy:
MEDEK, a form of physiotherapy, refers to Metodo Dinamico de Estimulacion Kinesica or Dynamic Method for Kinetic Stimulation. It was developed by a Chilean physical therapist in the 1970s. MEDEK is used for developing gross motor skills in children with physical disabilities and movement disorders (e.g., cerebral palsy, Down syndrome, hypotonia, muscular dystrophy and developmental motor delay). It does not focus on modifying muscle tone, primitive reflexes or abnormal patterns of movement. It focuses on training movements leading to sitting, standing and walking. Muscles are trained in postural and functional tasks rather than in isolation. Tight muscles are stretched in dynamic situations. The motor developmental sequence is not used. MEDEK assumes that different skills require different movement strategies. Unlike other interventions, tasks are performed without the child’s attention, conscious thought or cooperation. It is assumed that motivation will increase temporary performance only but will not create a permanent change. The therapist’s task is to provoke automatic postural reactions that contribute to the postural control needed for functional tasks. Well-designed clinical studies are needed to ascertaine the effectiveness of MEDEK.

Hands-Free Ultrasound:
Gulick (2010) noted that a "hands-free" ultrasound (US) device was recently introduced by Rich-Ma, Inc. This unit allows the clinician to choose the mode of US delivery, using either a hand-held (manual) transducer or a hands-free device that pulses the US beam through the transducer. However, the Centers for Medicare & Medicaid Services has deemed delivery of US via a hands-free unit to be investigational. This investigator examined the effectiveness of tissue heating with a hands-free US technique compared to a hand-held US transducer using the Rich-Mar AutoSound unit. A total of 40 volunters over 18 years of age participated. Treatment was provided at a 3-MHz US frequency. Muscle temperature was measured with 26-gauge, 4-cm Physiotemp thermistors placed in the triceps surae muscle. The depth of thermistor placement was at 1-cm and 2-cm deep. One calf was treated with a manual transducer (5-cm(2) US head at three times the effective radiating area [ERA]), and one calf was treated with the hands-free transducer (14-cm(2) [ERA]). Both methods used a 1.5 W/cm(2) intensity for 10 minutes. The manual technique used an overlapping circular method at 4 cm/sec, and the hands-free method used a sequential pulsing at 4 cm/sec. Tissue temperatures were recorded at baseline and every 30 seconds. The hands-free technique resulted in a tissue temperature increase from 33.68 to 38.7 degrees C and an increase from 33.45 to 40.1 degrees C using the manual technique at 1-cm depth. The tissue temperature increase at the 2-cm depth was from 34.95 to 35.44 degrees C for the hands-free device and 34.44 to 38.42 degrees C for the manual device. Thus, there was a significant difference between the hands-free and the manual mode of US delivery for the 3-MHz frequency (5.02 degrees C versus 6.65 degrees C at 1 cm and 1.49 degrees C versus 3.98 degrees C at 2 cm). In this study, the "hands-free" device did not result in the same level of tissue heating as the manual technique. The hands-free device has the advantage of not needing a clinician present to deliver the modality, but a therapeutic level of heating was not achieved at the 2-cm tissue depth. Thus, the effectiveness of the "hands-free" treatment is in question.

Hivamat Therapy (Deep Oscillation Therapy):
Hivamat therapy (deep oscillation therapy) uses an intermittent electrostatic field via a Hivamat machine. It supposedly penetrates deeper into the body tissue than manual methods, allowing previously "untreatable" injuries to be manipulated with a minimum of physical pressure. Electrostatic waves create a kneading effect deep within the damaged tissues, restoring flexibility and blood supply to the affected area.

Aliyev (2009) noted that in Germany, approximately 2 million sports injuries occur per year. Most common are distortions and ligamentous injury going along with post-traumatic lymphedema. Deep oscillation therapy provided very good results in lymph drainage and in other indications. The purpose of this experimental study was the evaluation of the effects of deep oscillation therapy in immediate therapy and after-care of different sports injuries in addition to usual care (complex physical and medical therapy). Two soccer teams were supported by a sports medicine section of a rehabilitation hospital. In 14 people (mean age of 23.9 years), 49 sports injuries of different kinds were treated. Subjective rating of the symptoms by VAS improved significantly (p = 0.001) from 8.7 (baseline) to 2.1 points (post-treatment). Objective rating by the attending physician according to different clinically relevant parameters led to "very good" or "good" results in 90 percent of the patients. The authors concluded that deep oscillation therapy is an easy to use and comparably cost-effective adjuvant therapy option. These investigators already had good experience with it in other indications concerning re-absorption of edema, reducing pain, anti-inflammatory effect, promotion of motoricity, promotion of wound healing, anti-fibrotic effect and improvement in trophicity and quality of the tissue. All these mentioned effects can be confirmed in the treatment of patients with acute sports injury and trauma. The soft mode of action is the reason that in contrast to other electric and mechanical therapies it is no contraindication in immediate therapy. In general, the authors noted no side effects. Patients were highly compliant and rated this therapy as very good. Limitations of this small study (n = 14) were its retrospective and uncontrolled nature. Findings were also confounded by the concomitant use of usual care.

Definitions:

1. Activities of Daily Living (ADL) Training — Training of severely impaired individuals in essential ADL, including bathing; feeding; preparing meals; toileting; walking; making a bed; and transferring from bed to chair, wheelchair or walker.
2. Aquatic Therapy/Hydrotherapy/Hubbard Tank — Hubbard tank involves a full-body immersion tank for treating severely burned, debilitated and/or neurologically impaired individuals. Pool therapy (aquatic therapy, hydrotherapy) is provided individually, in a pool, to severely debilitated or neurologically impaired individuals. (The term is not intended to refer to relatively normal individuals who exercise, swim laps or relax in a hot tub or Jacuzzi). Develops and/or maintains muscle strength, including range of motion, by eliminating forces of gravity through total body immersion (except for head) — requires constant attention.
3. Contrast Baths — Blood vessel stimulation with alternate hot and cold baths — constant attendance is needed. 
4. Diathermy (e.g., microwave) — Deep, dry heat with high frequency current or microwave to relieve pain and increase movement — supervised. The objective of diathermy is to cause vasodilatation and relieve pain from muscle spasm. Diathermy using deep dry heat with high frequency achieves a greater rise in deep tissue temperature than does microwave.
5. Hot/Cold Packs — Hot packs increase blood flow, relieve pain and increase movement. Cold packs decrease blood flow to an area to reduce pain and swelling immediately after an injury. These are used in Contrast Therapy under supervision.
6. Infrared Light Therapy — Dry heat with a special lamp to increase circulation to an area under supervision. The objective is to cause vasodilatation and relieve pain from muscle spasm. 
7. Iontophoresis — Electric current used to transfer certain chemicals (medications) into body tissues. 
8. Kinetic Therapy — Use of dynamic activities to improve functional performance.
9. Massage Therapy — Massage involves manual techniques that include applying fixed or movable pressure, holding and/or causing movement of or to the body, using primarily the hands. These techniques affect the musculoskeletal, circulatory-lymphatic, nervous and other systems of the body with the intent of improving a person's well-being or health. The most widely used forms of massage therapy include Swedish massage, deep-tissue massage, sports massage, neuromuscular massage and manual lymph drainage. 
10. Myofascial Release — Soft tissue mobilization through manipulation. Skilled manual techniques (active and/or passive) are applied to soft tissue 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 connective tissue.
11. Neuromuscular Re-education — This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture and proprioception to a person who has had muscle paralysis and is undergoing recovery or regeneration. Goal is to develop conscious control of individual muscles and awareness of position of extremities.
12. Orthotic Training — Training and re-education with braces and/or splints (orthotics).
13. Paraffin Bath — Also known as hot wax treatment, this involves supervised application of heat (via hot wax) to an extremity to relieve pain and facilitate movement. 
14. Prosthetic Training — Training and re-education with artificial devices (prosthetics). 
15. Therapeutic activities — This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, pushing, pulling, stooping, 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 professional skills of a provider and are designed to address a specific functional need of the member. This intervention may be appropriate after a patient has completed exercises focused on strengthening and range of motion but need to be progressed to more function-based activities. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.
16. Therapeutic Exercises — Instructing a person in exercises and directly supervising the exercises. Purpose is to develop and/or maintain muscle strength and flexibility including range of motion, stretching and postural drainage. Therapeutic exercise is performed with a patient either actively, active-assisted or passively (e.g., treadmill, isokinetic exercise lumbar stabilization, stretching, strengthening).
17. Traction — Manual or mechanical pull on extremities or spine to relieve spasm and pain — supervised. This modality, when provided by physicians or physical therapists, is typically used in conjunction with therapeutic procedures, not as an isolated treatment. 
18. Ultrasound — Deep heat by high frequency sound waves to relieve pain, improve healing — constant attendance.
19. Vasopneumatic Device — Pressure application by special equipment to reduce swelling — supervised. 
20. Whirlpool — These modalities involve supervised use of agitated water in order to relieve muscle spasm, improve circulation or cleanse wounds, e.g., ulcers, exfoliative skin conditions. 

Documentation Requirements:
Provider Record-Keeping Requirements for Modalities and Therapeutic Procedures
Definitions
Modality/Modalities: Current Procedural Terminology ("CPT") Codes 97010 through 97039.

Therapeutic Procedure(s): CPT Codes 97110 through 97564.

Timed Codes: Those modalities and therapeutic procedures that contain the phrase "each 15 minutes" in their code descriptors. For example, CPT Code is a timed code. The descriptor for CPT Code 97110 reads "Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility."

General Requirements
Providers must maintain medical records that comport with the record-keeping standards of their profession. However, to the extent the provider’s profession’s record-keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, his or her medical records must also comply with the following requirements: 

1. The date and the patient’s name must appear on each page of the patient’s medical records.
2. Each patient encounter must be a separate record.
3. The patient’s entire record must be legible (i.e., must be legible to someone other than the writer).
4. Entries in the medical record must be made within a week of the provider performing the modalities and/or therapeutic procedures.
5. The medical record must demonstrate that the modalities and/or therapeutic procedures are medically necessary.
6. The medical records must demonstrate that the patient’s treatment plan is consistent with his or her diagnoses.
7. CPT codes and ICD codes reported on claim forms or billing statements are supported by the documentation in the medical record.
8. The provider must provide a definition sheet of abbreviations specific to his or her office to assist BlueCross BlueShield of South Carolina in interpreting patients’ medical records.
9. Documentation corrections should be a single line drawn through the error with the corrected text in close proximity, initialed and dated by the person who made the error.

Treatment Notes/Patient Encounter Notes
In addition, to the extent the provider’s profession’s record-keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, the following information must be recorded by the provider in each individual record of a patient encounter:

1. A description, not a reiteration of the CPT Code, of each individual modality and therapeutic procedure provided and billed in language that can be compared with the billing on the claim to verify correct coding
2. For Timed Codes, an indication of the total number of minutes each individual modality and therapeutic procedure was performed
3.  A description of the specific area of the patient’s body to which each individual modality and therapeutic procedure was directed and/or performed 
4. The legible signature and professional identification of the individual who furnished each individual modality or therapeutic procedure
5. The patient’s response to the treatment
6. A skilled ongoing reassessment of the patient’s progress toward treatment goals
7. A description of the patient’s progress toward the goals in objective, measurable terms using consistent and comparable methods
8. A description of any patient problems or changes to the plan of care
9. A description of the reason for the encounter
10. A date for a return visit or follow-up plan

REMINDER:
This health plan does not recognize incident to billing but requires that claims be billed under the name of the provider who actually rendered the service, modality or therapeutic procedure.

References:

1. Melham TJ, Sevier TL, Malnofski MJ, et al. Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue mobilization technique (ASTM): A case report. Med Sci Sports Exerc. 1998;30(6):801-804.
2. Halseth T, McChesney JW, DeBeliso M, et al. The Effects of Kinesio Taping on proprioception at the ankle. J Sports Sci Med. 2004;3:1-7.
3. Yasukawa A, Patel P, Sisung C. Pilot study: Investigating the effects of Kinesio Taping in an acute pediatric rehabilitation setting. Am J Occup Ther. 2006;60(1):104-110.
4. Fu TC, Wong AM, Pei YC, et al. Effect of Kinesio taping on muscle strength in athletes-a pilot study. J Sci Med Sport. 2008;11(2):198-201.
5. Thelen MD, Dauber JA, Stoneman PD. The clinical efficacy of kinesio tape for shoulder pain: A randomized, double-blinded, clinical trial. J Orthop Sports Phys Ther. 2008;38(7):389-395.
6. Fink E. The Medek therapy, an alternative physiotherapy intervention. Toronto, ON: The Canadian Medek Centre; 2001.
7. McConnell J. Recalcitrant chronic low back and leg pain — a new theory and different approach to management. Man Ther. 2002;7(4):183-192.
8. Baquie P. Taping. General principles. Aust Fam Physician. 2002;31(2):155-157.
9. Greig AM, Bennell KL, Briggs AM, Hodges PW. Postural taping decreases thoracic kyphosis but does not influence trunk muscle electromyographic activity or balance in women with osteoporosis. Man Ther. 2008;13(3):249-257.
10. Gulick DT. Comparison of tissue heating between manual and hands-free ultrasound techniques. Physiother Theory Pract. 2010;26(2):100-106.
11. González-Iglesias J, Fernández-de-Las-Peñas C, Cleland JA, et al. Short-term effects of cervical kinesio taping on pain and cervical range of motion in patients with acute whiplash injury: A randomized clinical trial. J Orthop Sports Phys Ther. 2009;39(7):515-521.
12. Karadag-Saygi E, Cubukcu-Aydoseli K, Kablan N, Ofluoglu D. The role of kinesiotaping combined with botulinum toxin to reduce plantar flexors spasticity after stroke. Top Stroke Rehabil. 2010;17(4):318-322.
13. Kalichman L, Vered E, Volchek L. Relieving symptoms of meralgia paresthetica using Kinesio taping: A pilot study. Arch Phys Med Rehabil. 2010;91(7):1137-1139.
14. Kaya E, Zinnuroglu M, Tugcu I. Kinesio taping compared to physical therapy modalities for the treatment of shoulder impingement syndrome. Clin Rheumatol. 2011;30(2):201-207.
15. Briem KE, Eythorsdóttir H, Magnúsdóttir RG, et al. Effects of Kinesio tape compared with non-elastic sports tape and the untaped ankle during a sudden inversion perturbation in male athletes. J Orthop Sports Phys Ther. 2011;41(5):328-335.
16. Aliyev R. Clinical effects of the therapy method deep oscillation in treatment of sports injuries. Sportverletz Sportschaden. 2009;23(1):31-34.

Coding Request

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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