CurrentCignaPolicy 0600

Site of Care: Outpatient Hospital Setting for Physical and Occupational Therapy

Defines medical necessity criteria for PT/OT services provided in an outpatient hospital setting (on-campus or off-campus) for adult and pediatric patients, including clinical situations requiring hospital outpatient site of care and exclusions.

Policy Summary

PayerCigna

PolicySite of Care: Outpatient Hospital Setting for Physical and Occupational Therapy

Policy CodePolicy 0600

Change TypeNew policy

Effective DateOct 1, 2025

Next Review DateJul 15, 202640d

Key ActionDocument clinical indications, specialized equipment/personnel needs, or lack of nearby freestanding PT/OT facility that justify outpatient hospital site of care; claims without covered codes under this policy will be denied.

SourceLink

POLICY UPDATE CHANGES

New policy created.

MultipleCovered Indications

All othersNot Medically Necessary

2Place of Service codes listed

Coverage Summary

Policy 0600 (effective 10/01/2025, next review 07/15/2026) addresses Outpatient Hospital Site of Care for Physical and Occupational Therapy. It applies to both adult and pediatric patients and covers services delivered in hospital-based outpatient settings (on-campus and off-campus) when specified clinical, facility, personnel, or equipment criteria are met. The policy stance is covered with criteria: multiple specific clinical indications and facility/personnel/equipment needs are listed as covered, while other indications are not medically necessary. Place-of-service codes referenced include 19 (Off Campus-Outpatient Hospital) and 22 (On Campus-Outpatient Hospital).

Key Clinical Thresholds

Amputation recencywithin the last 12 months

Major organ transplant recencywithin the last 3 months

Myocardial infarction recencywithin past 3 months

Plain angioplasty recencywithin 90 days

Bare metal stent recencywithin 90 days

Drug eluting stent recencywithin 1 year

Stage 3 hypertensionBP > 180/110

Spinal cord injury recencywithin last 12 months

Severe TBI recencywithin the last 3 months

CVA recencywithin the last 3 months

Medically Necessary: Site of Care Criteria

Physical therapy or occupational therapy services provided in an outpatient hospital setting are medically necessary when ANY of the following facility/personnel/equipment or clinical criteria are met:

ANY of the following

Facility/personnel/equipment criteria
- Specialized equipment (e.g., overhead harness system for gait training, exoskeleton for gait) is required for medically necessary PT/OT services not available in a free-standing PT/OT facility.
- Specialized PT/OT personnel (e.g., Board Certified Cardiovascular and Pulmonary Clinical Specialist, wound care certified) who are not available in a free-standing PT/OT facility are required to provide medically necessary services.
- A freestanding PT/OT facility is not available within a reasonable geographical location/distance.
Clinical cardiovascular/high-acuity monitoring criteria (ANY of the following)
- Amputation within the last 12 months (i.e., Symes, transtibial, knee disarticulation, transfemoral, hip disarticulation, transradial, transhumeral, shoulder disarticulation).within the last 12 months
- Severe burn injuries requiring debridement and frequent dressing changes.
- Major organ transplant surgery (i.e., heart, lung, liver, kidney) within the last three months.within the last 3 months
- History of cardiovascular diagnoses that would increase risk and/or would require ongoing higher acuity monitoring (e.g., telemetry, ECG) during therapy, including but not limited to:
  - Aortic stenosis

History of neurological diagnoses that would increase risk and/or would require ongoing higher acuity monitoring (e.g., telemetry, ECG) during therapy, including but not limited to:

Cerebellar ataxias
Corticobasal degeneration
Dysautonomia with blood pressure and heart rate instability
History of a cerebrovascular accident (CVA) within the last three monthswithin the last 3 months
Multisystem atrophy
Normal pressure hydrocephalus (NPH)

Not Medically Necessary

Physical therapy and occupational therapy services provided in an outpatient hospital site of care setting are considered not medically necessary when:

The service is for any indication other than those listed above (i.e., none of the criteria under 'Medically Necessary' are met).

Coding

Place of Service - Off Campus Outpatient Hospitalmixed

19	Off Campus-Outpatient Hospital

Place of Service - On Campus Outpatient Hospitalmixed

22	On Campus-Outpatient Hospital

Provider Actions

Documentation Required

Support site-of-care selection

Document the clinical indications that justify outpatient hospital site-of-care selection, including need for specialized equipment or specialized PT/OT personnel, or that a freestanding PT/OT facility is not available within a reasonable geographical distance. Note that claims submitted without covered code(s) under this policy will be denied as not covered.

Billing Rule

Use appropriate place of service codes

When billing, use the most appropriate Place of Service codes as of the effective date. Examples include Place of Service 19 (Off Campus‑Outpatient Hospital) and 22 (On Campus‑Outpatient Hospital).

Background

Site of care is defined as the physical location where a procedure or service is performed. Hospital-based outpatient (on-site hospital-operated or hospital-affiliated clinic) may be required when the clinical situation demands specialized equipment or personnel, or when patients have complex medical conditions requiring higher-acuity monitoring. In contrast, physical therapy is often appropriate in freestanding clinics; however, hospital outpatient care is indicated when freestanding facilities cannot provide required specialized equipment or personnel, or when higher-acuity monitoring is necessary (e.g., telemetry, ECG).

Site of Care: The location where a procedure or service is performed; hospital-based outpatient refers to an on-site hospital-operated outpatient clinic or hospital-affiliated clinic location, distinct from freestanding clinics.

Stage 3 hypertension: Example threshold provided as BP > 180/110.

Medicare Determinations

Type	Name	Number	Effective
NCD	No National Coverage Determination found
LCD	No Local Coverage Determination found

Revision History

2025-10-01New PolicyLatest

New policy created.

Policy Summary

PayerCigna

PolicySite of Care: Outpatient Hospital Setting for Physical and Occupational Therapy

Policy CodePolicy 0600

Change TypeNew policy

Effective DateOct 1, 2025

Next Review DateJul 15, 202640d

SourceLink

On This Page

Implanted cardioverter-defibrillator

Myocardial infarction (MI) within past three monthswithin past three months

Recent coronary intervention (i.e., plain angioplasty within 90 days, bare metal stents placed within 90 days, drug eluting stents placed within one year)plain angioplasty within 90 days; bare metal stent within 90 days; drug eluting stent within 1 year

Severe/significant valvular disease

Stage 3 hypertension (HTN) (e.g., BP > 180/110)BP > 180/110

Symptomatic/unstable cardiac arrhythmia

Unstable coronary syndromes (i.e., unstable or severe angina [Canadian Class III or IV], uncompensated chronic heart failure [CHF] [NYHA class III or IV])

Progressive motor neuron disease (e.g., spinal muscular atrophy, amyotrophic lateral sclerosis, primary lateral sclerosis)

Progressive supranuclear palsy

Severe traumatic brain injury within the last three monthswithin the last 3 months

Spinal cord injury (e.g., paralysis, central cord syndrome) within last 12 monthswithin last 12 months