CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO4O

Physical Medicine and Rehabilitation Services

Governs coding, documentation, and claims processing requirements for physical medicine and rehabilitation services provided to Blue Cross Blue Shield of New Mexico members; applies to providers billing the Plan for these services.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPhysical Medicine and Rehabilitation Services

Policy CodePolicy CPCPO4O

Change TypeNo material changes

Effective DateSep 22, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation and include an invoice when billing for customized DME lacking a procedure or HCPCS code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15-minbase time unit for many therapy CPT codes and billing

8-min ruleminimum time threshold to report a 15-minute unit

AnnualDME prescription renewal frequency

Examplesnon-customized examples

Coverage and Medical Necessity Criteria

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Link diagnosis to the service and document specificity and medical necessity; use the most appropriate and up-to-date ICD-10-CM codes, including required 7th digits when applicable, and document any diagnosis coding changes for each new episode or re-examination.

Therapy must be skilled, provided by a qualified healthcare professional (QHP), and not maintenance in nature; there must be a documented expectation of reasonable functional improvement over a predictable period and services must achieve a specific diagnosis-related goal.

When services are delegated, document what was delegated and who performed the service.

Do not bill Evaluation and Management (E/M) CPT codes 99202-99499 for services provided by Physical and Occupational Therapists or Therapy Assistants; when billing any E/M service, meet complete CPT guidelines and ensure the service is separately identifiable and distinct from other services performed.

Timed services and modalities: follow the 8-minute rule for 15-minute units (a unit is reportable when the midpoint is passed); record actual start and stop times in the medical record, do not count non‑treatment time (resting, waiting), and do not combine time across different codes when billing multiple timed modalities.

Prescription/written order for DME: must be signed by the treating QHP, readily available if requested, and include member identifiers, diagnosis, ordering provider rationale, description of equipment/supplies, date of order, expected duration/frequency/quantity if appropriate, provider signature and contact information; refills should be renewed at least annually as appropriate.

Plan governance and documentation rights: The Plan may request supporting documentation and reserves discretion in interpretation and application of this policy; in the event of a conflict, applicable plan documents and provider contracts govern.

DME and Radiology Documentation Criteria

Coverage and documentation criteria included in this portion:

Invoice for non-coded customized DME: Include an invoice with billing for any customized DME or prosthetic/orthotic device for which a procedure code or HCPCS code does not exist.

Examples that are NOT considered customized: Adjustable braces with Velcro closures; lightweight wheelchairs with added padding; pull-on elastic braces; add-ons or upgrades intended primarily for convenience do not meet customized DME requirements.

Custom back brace clinical criteria: Custom-fitted back brace (prefabricated brace modified for a specific member) is necessary only after failure, contraindication, or intolerance to an unmodified prefabricated brace; custom-fabricated back brace (individually constructed) is necessary only after failure, contraindication, or intolerance to a custom-fitted brace; a custom-fitted brace may be appropriate as the initial brace after surgical stabilization of the spine following traumatic injury; custom-fitted and custom-fabricated braces are considered experimental/investigational when these criteria are not met.

Radiology report required components: Radiology reports must include patient identification; location where studies were performed; types of studies; study dates; radiographic findings; legible signature with professional qualifications; and diagnostic impressions. Reports may also include follow-up recommendations and comments for further patient evaluation.

DME prescription/order elements: When ordering DME, the prescription/written order must include member name and date of birth; diagnosis; ordering provider rationale; description of equipment/supplies ordered; date of order; expected duration/length of need, frequency of usage and refill frequency if appropriate; quantity (if applicable); ordering provider legible signature and date; and ordering provider name, address, and telephone number.

CPT/HCPCS Coding and Time Rules

Common therapy and evaluation CPT codes (examples)CPT

97110	Exercise therapy, each 15 minutes
97112	Neuromuscular reeducation, each 15 minutes
97140	Manual therapy techniques, each 15 minutes
97530	Therapeutic activities, each 15 minutes
97161	PT eval low complexity
97162	PT eval moderate complexity
97163	PT eval high complexity
97164	PT re-evaluation
97165	OT eval low complexity
97166	OT eval moderate complexity

1–10 of 12

1/2

DME/TENS supply HCPCS examplesHCPCS

A4595	Electrical stimulator supplies
A4556	Electrodes
A4557	Leads
A4558	Conductive paste or gel
A4630	Replacement batteries

Referenced coding systemsmixed

CPT (2024)	CPT copyright 2024 American Medical Association referenced for coding guidance
HCPCS	Healthcare Common Procedure Coding System referenced

8-minute rule for 15-minute unit

8-minute rule (15-minute unit)Report one 15-minute unit for any single timed CPT code when treatment time is greater than or equal to 8 minutes and through and including 22 minutes.

Do not report services <8 minutesProviders should not report services performed for less than 8 minutes for 15-minute unit codes.

Record actual treatment timeAll treatment time, including beginning and ending times of direct treatment, must be recorded in the member's medical record.

Provider Responsibilities, Billing, and Documentation

Documentation Required

Submit accurate documentation; Plan may request supporting records

Providers must submit accurate documentation of services performed and bill using valid industry-standard codes. The Plan reserves the right to request supporting documentation and to interpret and apply this policy; plan documents and provider contracts govern in the event of a conflict.

Submit claims using valid code combinations and appropriate coding systems (CPT, HCPCS, ICD‑10‑CM, etc.).
Be prepared to provide supporting documentation upon Plan request.
When a plan document or provider contract conflicts with this policy, the plan document or contract governs.

Billing Rule

Include invoice when no procedure/HCPCS code exists for customized DME

Include an itemized invoice with claims when billing for a customized DME or prosthetic/orthotic device for which no procedure code or HCPCS code exists.

Provide an invoice whenever a procedure or HCPCS code does not exist for the customized device.
Note that certain items (e.g., adjustable braces with Velcro, lightweight wheelchairs with added padding, pull-on elastic braces, or convenience add‑ons/upgrades) do not meet the definition of customized DME.

Key Definitions

Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME): equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful in the absence of illness or injury, and is appropriate for use in the home.

Home setting examplesIncludes the member's dwelling (house, apartment), a relative's home if the member resides there, or other private living spaces appropriate for home use.

Intended useDME is appropriate for home use and serves a medical purpose rather than convenience or comfort.

Modalities

DefinitionModalities: physical agents applied to produce a therapeutic change to biological tissue, including but not limited to thermal, acoustic, light, mechanical, or electrical energy.

ExamplesThermal (heat/cold), acoustic (ultrasound), light (laser/phototherapy), mechanical (traction), electrical (TENS/EMS).

Treatment classificationModalities may be supervised or constant-attendance time-based services depending on the procedure and must follow plan coverage rules.

Qualified Healthcare Professional (QHP)

DefinitionQualified Healthcare Professional (QHP): an individual qualified by education, training, licensure/regulation and facility privileging (when applicable) who performs a professional service within their scope of practice and independently reports that professional service.

ScopeQHPs must perform services within their scope and documentation should reflect the QHP's role; orders and prescriptions for DME must be signed by the treating QHP as applicable.

AccountabilityServices provided or delegated must be documented, including what was delegated and who performed the service.

Therapeutic Procedure

DefinitionTherapeutic Procedure: a manner of affecting change through the application of clinical skills and/or services that attempt to improve function.

PurposeIntended to produce functional improvement over a predictable period; therapy must be skilled and not maintenance in nature to meet coverage criteria.

DocumentationTime spent in delivery of the therapeutic procedure must be recorded; pre- and post-delivery time should not be counted as treatment time.

Customized DME

DefinitionCustomized DME: DME, prosthetic, or orthotic devices specifically constructed to meet a member's specific need.

Invoice requirementAn invoice should be included with billing for any customized DME or prosthetic/orthotic device for which a procedure code or HCPCS code does not exist.

Custom back brace criteriaCustom-fitted or custom-fabricated back braces require documented failure, contraindication, or intolerance to unmodified prefabricated options; custom-fabricated required if failure to custom-fitted; custom-fitted may be initial brace after surgical spinal stabilization.

Examples NOT considered Customized DME

Adjustable bracesAn adjustable brace with Velcro closures is NOT considered customized DME.

Wheelchair modificationsA lightweight, high-strength wheelchair with padding added does NOT meet customized criteria.

Simple bracesPull-on elastic braces are not considered customized.

Convenience add-onsAdd-ons or upgrades intended primarily for convenience beyond what is necessary to meet the member's needs are not considered customized.