S46.801A — Unspecified injury of other muscles, fascia and tendons at shoulder and upper arm level, right arm, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation for CPT 97010, 97018, 97022, and 97026 must reflect medical necessity and be made available to the MAC upon request.
- When billing a Z-code as the diagnosis, documentation must include the orthotic/prosthetic device name, date patient received the device, and date training/teaching began.
- Documentation for CPT 97542 wheelchair propulsion training must relate the training to expected, attainable functional goals for the patient and/or caregiver.
- Physical therapists must report patient contact time in 15-minute increments and bill using G0151 for physical therapy time reporting.
Key Coverage Criteria
- CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
- CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
- Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
- Home health physical therapy is covered to improve or restore physical functioning, prevent injury/impairment/activity limitations/participation restrictions, or rehabilitate following disease, injury, or loss of a body part when services require the skills of a qualified physical therapist.
- Maintenance therapy is covered only when the beneficiary requires skilled care to carry out the maintenance program or when a complicating medical factor makes skilled services necessary.
- Fabrication or application of custom splints is covered when used to enhance task performance, support weak joints/muscles, reduce/correct joint limitations/deformities, or protect body parts and when selected/fitted/training is provided by the physical therapist.
2 Active Policies
A53058 — Billing and Coding: Home Health Physical Therapy
L34564 — Home Health Physical Therapy
Related Codes
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