Policy Name: Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy & Physical Therapy – Coding Guidelines
Effective 06/01/2024
Evolent Healthcare manages precertification of Physical Medicine services on behalf of HMSA. The tables below provide guidance on coding physical medicine services.
*Please note: Services rendered in an Emergency Room, Observation Room, Surgery Center, or Hospital Inpatient Setting are not managed by Evolent Healthcare.
Services Requiring Precertification
The following service codes require precertification. Refer to the Physical Medicine medical policy for full medical necessity criteria, limitations, frequency of precertification, and documentation requirements.
Precertification is required for chiropractic services for commercial members, including Fed 87 members and HMSA Plan for Postal Service Employees. Precertification is not required for chiropractic services for Medicare Advantage members.
Precertification is required for occupational therapy and physical therapy services for commercial, Medicaid and Medicare Advantage members.
The ordering physician may obtain precertification or consult with Evolent Healthcare by accessing their website at RadMD.com or by calling 1-866-306-9729, from 6 a.m. to 6 p.m., weekdays, Hawaii Time.
| Service Code | Description | Service(s) |
|---|---|---|
| 97012 | Application of a modality to 1 or more areas; traction, mechanical |
Chiropractic Occupational Therapy Physical Therapy |
| 97014 | Application of a modality to 1 or more areas; electrical stimulation (unattended) |
Chiropractic Occupational Therapy Physical Therapy |
| 97016 | Application of a modality to 1 or more areas; vasopneumatic devices |
Chiropractic Occupational Therapy Physical Therapy |
| 97018 | Application of a modality to 1 or more areas; paraffin bath. |
Occupational Therapy Physical Therapy |
| 97022 | Application of a modality to 1 or more areas; whirlpool |
Chiropractic Occupational Therapy Physical Therapy |
| 97024 | Application of a modality to 1 or more areas; diathermy (e.g., microwave) |
Chiropractic Occupational Therapy Physical Therapy |
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes |
Chiropractic Occupational Therapy Physical Therapy |
| 97034 | Application of a modality to 1 or more areas; contrast baths, each 15 minutes |
Occupational Therapy Physical Therapy |
| 97035 | Application of a modality to 1 or more areas; ultrasound, each 15 minutes |
Chiropractic Occupational Therapy Physical Therapy |
| 97036 | Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes |
Occupational Therapy Physical Therapy |
| 97039 | Unlisted modality (specify type and time if constant attendance) |
Chiropractic Occupational Therapy Physical Therapy |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
Chiropractic Occupational Therapy Physical Therapy |
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities |
Chiropractic Occupational Therapy Physical Therapy |
| 97113 | Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises |
Occupational Therapy Physical Therapy |
| 97116 | Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) | Physical Therapy |
| 97124 | Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) |
Occupational Therapy Physical Therapy |
| 97139 | Unlisted therapeutic procedure (specify) |
Chiropractic Occupational Therapy Physical Therapy |
| 97140 | Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes |
Chiropractic Occupational Therapy Physical Therapy |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes |
Chiropractic Occupational Therapy Physical Therapy |
| 97535 | Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment), direct one-on-one contact , each 15 minutes |
Chiropractic Occupational Therapy Physical Therapy |
| 97542 | Wheelchair management (eg, assessment, fitting, training), each 15 minutes |
Occupational Therapy Physical Therapy |
| 97750 | Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes |
Chiropractic Occupational Therapy Physical Therapy |
| 97760 | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes |
Occupational Therapy Physical Therapy |
| 97761 | Prosthetic training, upper and/or lower extremity(s), each 15 minutes |
Occupational Therapy Physical Therapy |
| 97763 | Orthotic prosthetic management and/or training upper extremity, lower extremity and/or trunk, each 15 minutes |
Occupational Therapy Physical Therapy |
| 97799 | Unlisted physical medicine/rehabilitation service or procedure |
Occupational Therapy Physical Therapy |
| 98940 | Chiropractic manipulative treatment (CMT); spinal, one or two regions | Chiropractic |
| 98941 | Chiropractic manipulative treatment (CMT); spinal, three to four regions | Chiropractic |
| 98942 | Chiropractic manipulative treatment (CMT); spinal, five regions | Chiropractic |
| G0283 | Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care |
Chiropractic Occupational Therapy Physical Therapy |
| S8950 | Complex lymphedema therapy, each 15 minutes |
Occupational Therapy Physical Therapy |
Applicable Modifier Codes
| Code | Description |
|---|---|
| GO | Services delivered under an outpatient occupational therapy plan of care |
| GP | Services delivered under an outpatient physical therapy plan of care |
| SZ |
Report that habilitative services were rendered; distinguish habilitative from rehabilitative services. Note: Rehabilitative and habilitative services should not be combined. SZ modifier use when billing habilitative services supports the ability to ensure visit limits are not combined with rehabilitation services. |
Services that Do Not Meet Payment Determination Criteria
| Service Code | Description |
|---|---|
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscle(s) |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles |
| 97026 | Application of a modality to 1 or more areas; infrared |
| 97028 | Application of a modality to 1 or more areas; ultraviolet |
| 97033 | Application of a modality to 1 or more areas; iontophoresis, each 15 minutes |
| 97039 | Unlisted modality; laser therapy |
| 97537 | Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes |
| 97545 | Work hardening/conditioning; initial 2 hours |
| 97546 | Work hardening/conditioning; each additional hour |
Services Not Separately Reimbursable
| Service Code | Description |
|---|---|
| 97010 | Application of hot or cold packs |
Notes:
- When a CPT code for a service is billed (e.g., TENS), a HCPCS code billed for the device or DME supplies used for that service will not be covered.
- Chiropractic manipulation treatment codes include a pre- and post-manipulation patient assessment. Consequently, evaluation and management (E&M) codes 99202 – 99215 are not separately billable when 98940, 98941 or 98942 are billed.
The use of an E&M code is considered medically necessary no more often than once a month unless it is clearly documented that there has been significant interval change to warrant re-evaluation and/or change in treatment plan. It may be appropriate to bill a separate E&M service in the following situations:
- In the evaluation of a new patient
- If the patient has new injuries or exacerbations
- For periodic monthly reevaluations.
Claims for additional E&M visits after the first E&M visit in a month must include clinical notes. When submitting an E&M service (CPT® codes 99202-99215), all of the components of the E&M level must be documented in the medical record.
Services Excluded From HRS § 442-1 Scope of Chiropractic Licensure
Services outside the chiropractor scope of practice defined in HRS § 442-1 are not covered, including but not necessarily limited to the following:
| Service Code | Description |
|---|---|
| 97124 | Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) |
| 97139 | Unlisted therapeutic procedure – Lomilomi |
| 98943 | Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |