S9117 — Back school, per visit
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Physician prescription/order for back school or physical therapy program (program must be prescribed by the member's doctor).
- Evidence that the back school program is conducted by a physical therapist or other appropriate recognized healthcare professional.
- Documentation that isokinetic/exercise/testing machines are used as part of medically necessary physical therapy (i.e., justification that device use is integral to the course of PT and medically necessary).
- Clinical records supporting chronic or recurrent back pain diagnosis (e.g., ICD-10 dorsalgia codes M54.00–M54.9) when billing covered CPT/HCPCS codes.
Key Coverage Criteria
- Covered ICD-10 diagnosis range for these interventions: "M54.00 - M54.9 Dorsalgia."
- Back school is medically necessary for the treatment of persons with chronic or recurrent back pain when prescribed by the member’s doctor and the program is conducted by a physical therapist or other appropriate recognized healthcare professional.
- Isokinetic devices (e.g., Biodex, Cybex, Kin-Com) and other exercise and testing machines (e.g., Isostation B-2000 and MedX) are considered acceptable alternatives for provision of medically necessary exercise in physical therapy (can be used for muscle testing and/or administering exercise therapy).
- Therapeutic procedures and manual therapy CPT codes (97110, 97140) are covered when criteria are met.
- Therapeutic activities CPT code 97530 is covered when criteria are met (note: not covered when used for Khan Kinetic Treatment).
- HCPCS S9117 (Back school, per visit) is covered if selection criteria are met.
4 Active Policies
CIGNA-CPG155 — Occupational Therapy - (CPG155)
CIGNA-CPG278 — Chiropractic Care - (CPG278)
AETNA-CPB-0198 — Work Hardening Programs
AETNA-CPB-0232 — Back Pain - Non Invasive Treatments
Related Codes
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