S9131, Physical therapy; in the home, per diem
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation that 'The burn is of documented significance to place the member at risk of a post-burn contracture.'
- Documentation that 'The burn garment and physical and occupational therapies are being used with the intent of preventing the need for skin grafting or contractures as a result of hypertrophic scarring.'
- Documentation that 'The burn garment is authorized by the primary care physician and/or the treating specialist.'
- When billing covered HCPCS codes, documentation must support that the 'selection criteria are met' (i.e., medical necessity criteria above) and include relevant ICD-10 burn diagnosis codes (T20.00x+ - T26.92x+; T30.0 - T32.99) as appropriate.
Key Coverage Criteria
- Aetna considers burn garments and associated physical and occupational therapy medically necessary when all of the following criteria are met:
- The burn is of documented significance to place the member at risk of a post-burn contracture;
- The burn garment and physical and occupational therapies are being used with the intent of preventing the need for skin grafting or contractures as a result of hypertrophic scarring;
- The burn garment is authorized by the primary care physician and/or the treating specialist.
- ICD-10 codes covered if selection criteria are met: T20.00x+ - T26.92x+ T30.0 - T32.99 (Burns).
- HCPCS codes covered if selection criteria are met: A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513 (Compression burn garments and compression burn mask, custom fabricated).
6 Active Policies
ANTHEM-CG-REHAB-12, CG-REHAB-12 Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology
ANTHEM-CG-MED-23, CG-MED-23 Home Health
AETNA-CPB-0062, Burn Garments
AETNA-CPB-0107, Chiropractic Services
AETNA-CPB-0665, Constraint-Induced Therapy
Related Codes
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