G0295, Electromagnetic therapy, to one or more areas, for wound care other than
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- When a referring/ordering physician is required, the referring/ordering physician’s name and NPI must be reported on the claim.
- Diagnosis code(s) must best describe the patient’s condition for which the service was performed and a valid ICD-10-CM code is required on the claim.
- For an evaluation-only episode, the evaluation serves as the plan of care if it contains a diagnosis or a description from which a referring physician/NPP may determine a diagnosis, and the referral/order certifies the evaluation is needed.
- When a qualified professional allows a student to participate, the qualified professional must be present in the room, direct the service and make skilled judgments, not be treating another patient or performing other tasks, and must sign all documentation appropriately.
- When PTA/OTA services are furnished in a private practice office or physician/NPP office, documentation must reflect required direct supervision by a PT (for PTAs) or OT (for OTAs) in the private practice setting and compliance with enrollment rules if billed by a physician group under the therapist’s PIN/NPI.
- "This treatment must be performed by a healthcare professional in an office or clinic setting." (explicit statement in policy text regarding TMR/PEMF procedure delivery).
Key Coverage Criteria
- Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.
- Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.
- Maintenance therapy is covered only when an individualized clinical assessment documents that specialized judgment, knowledge, and skills of a qualified therapist are necessary to perform the maintenance program safely and effectively.
- Physical therapy (CPT 97161-97163) and occupational therapy (CPT 97165-97167) evaluations are covered; when an evaluation is the only service in an episode, the evaluation serves as the plan of care if it contains a diagnosis or a description sufficient for the referring physician/NPP to determine a diagnosis.
- Therapeutic magnetic resonance (TMR), also known as pulsed electromagnetic field therapy (PEMF), is a type of stimulation that has been purported as treatment for chronic pain. (Descriptive — therapy type identified in policy text.)
- PEMF stimulation has been used as an adjunct to arthrodesis following anterior cervical discectomy and fusion (ACDF) in patients with potential risk factors for non-union (described in randomized trial context).
20 Active Policies
A56566, Billing and Coding: Outpatient Physical and Occupational Therapy Services
J6
NGS-L33631, Outpatient Physical and Occupational Therapy Services
JK
AETNA-CPB-0175, Pulsed Electromagnetic Stimulation
AETNA-CPB-0362, Spasticity Management
AETNA-CPB-0729, Diabetic Neuropathy: Selected Treatments
AETNA-CPB-0406, Tinnitus Treatments
AETNA-CPB-0469, Transcranial Magnetic Stimulation and Cranial Electrical Stimulation
AMBETTER-CP.BH.200, Transcranial Magnetic Stimulation for Treatment Resistant Major Depression
MED201.027, Electrostimulation and Electromagnetic Therapy for Treating Wounds
THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services
BCBSIL-MED201.027, Electrostimulation and Electromagnetic Therapy for Treating Wounds
BCBSIL-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services
BCBSMT-MED201.027, Electrostimulation and Electromagnetic Therapy for Treating Wounds
BCBSMT-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services
BCBSNM-MED201.027, Electrostimulation and Electromagnetic Therapy for Treating Wounds
BCBSNM-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services
BCBSOK-MED201.027, Electrostimulation and Electromagnetic Therapy for Treating Wounds
CARELON-physical-therapy-occupational-therapy-and-speech-therapy-2024-04-14, Physical Therapy Occupational Therapy and Speech Therapy
BCBSOK-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services
REGENCE-DME83.09, Electrical Stimulation for the Treatment of Wounds
Related Codes
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