CurrentCignaPolicy 0600

Outpatient hospital-based physical therapy and occupational therapy services (site-of-care)

Defines medical necessity criteria for provision of physical therapy (PT) and occupational therapy (OT) in an outpatient hospital setting for adult and pediatric patients, when hospital-based site of care is required instead of freestanding PT/OT facilities.

Policy Summary

PayerCigna

PolicyOutpatient hospital-based physical therapy and occupational therapy services (site-of-care)

Policy CodePolicy 0600

Change TypeNew Policy (effective 10/1/2025)

Effective DateOct 1, 2025

Next Review DateJul 15, 202639d

Key ActionWhen billing, providers must submit documentation that one or more listed criteria are met and use the most appropriate codes as of the effective date.

POLICY UPDATE CHANGES

New Policy created effective 10/1/2025

11Example clinical criteria listed

2Site-of-service revenue codes referenced

1Policy number

Coverage Summary

This policy defines medical necessity criteria for provision of physical therapy (PT) and occupational therapy (OT) in an outpatient hospital setting and is applied to both adult and pediatric patients. Coverage stance: covered_with_criteria.

It applies when a hospital-based outpatient clinic (on-campus or off-campus outpatient hospital) is required instead of freestanding PT/OT facilities — for example when specialized equipment or personnel are needed, a freestanding facility is not reasonably available, or specific high-acuity clinical criteria or recent events are present.

Key thresholds (examples): amputation within the last 12 months; major organ transplant within the last 3 months; myocardial infarction within past 3 months; plain angioplasty within 90 days; bare metal stent within 90 days; drug eluting stent within 1 year; stage 3 HTN e.g., BP > 180/110; CVA within last 3 months; severe TBI within last 3 months; spinal cord injury within last 12 months.

Key clinical timing 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 hypertension exampleBP > 180/110

CVA recencywithin the last 3 months

Severe TBI recencywithin the last 3 months

Spinal cord injury recencywithin last 12 months

Medical-Necessity Criteria

Medically necessary when hospital outpatient site is required

Physical therapy or occupational therapy services provided in an outpatient hospital setting is considered medically necessary for an adult or pediatric patient when ANY of the following criteria is met:

ANY of the following

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
examples provided in text
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
examples provided in text
A freestanding PT/OT facility is not available within a reasonable geographical location/distance

Clinical high-acuity or recent major events requiring hospital outpatient PT/OT

OR the individual of any age meets ANY of the following clinical criteria:

Cardiovascular and related

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 monthswithin the last 3 months
History of cardiovascular diagnoses requiring higher acuity monitoring (examples listed)

Neurological and other high-risk diagnoses

OR the individual of any age meets ANY of the following clinical criteria:

ANY of the following

History of neurological diagnoses that increase risk or require higher acuity monitoring (examples listed)
- 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

Not medically necessary

Physical therapy and occupational therapy services provided in an outpatient hospital site of care setting are considered not medically necessary for any other indication.

Any indication not specifically listed in the medically necessary criteria above

exclusion

Coding

Outpatient hospital revenue/site of service codes referencedmixed

19	Off Campus-Outpatient Hospital (revenue/site designation referenced in policy)
22	On Campus-Outpatient Hospital (revenue/site designation referenced in policy)

CPT referenceCPT

No codes listed

Provider Actions

Documentation Required

Document reason for hospital outpatient site

When billing for PT/OT provided in an outpatient hospital setting, providers must submit documentation that supports that one or more of the listed criteria for hospital outpatient site care are met.

Specialized equipment or specialized PT/OT personnel required
Freestanding PT/OT facility not available within a reasonable geographical distance
One or more listed clinical high-acuity or recent major-event criteria (e.g., amputation within 12 months, major organ transplant within 3 months, listed cardiovascular or neurological diagnoses)

Billing Rule

Use appropriate site-of-service codes

Use the most appropriate site-of-service codes when billing for PT/OT services provided in an outpatient hospital setting.

19 — Off Campus-Outpatient Hospital (revenue/site designation)
22 — On Campus-Outpatient Hospital (revenue/site designation)

Denial Risk

Claims denial for non-covered indications

Claims submitted for PT/OT in an outpatient hospital site that are not accompanied by covered diagnosis and/or procedure codes under this policy will be denied as not covered.

Remediation: submit supporting documentation that meets one or more hospital-site criteria or bill with the appropriate covered diagnosis/procedure codes per this policy.

Background

Site-of-care rationale: PT/OT can be provided in multiple settings. Hospital-based outpatient clinics are appropriate when specialized equipment (for example overhead harness systems or exoskeletons) or specialized personnel (for example Board Certified specialists or wound care–certified clinicians) are required and are not available in freestanding PT/OT facilities, or when patient complexity requires higher-acuity monitoring during therapy (e.g., telemetry, ECG).

Freestanding clinics are generally acceptable when those specialized equipment, personnel, or higher-acuity monitoring needs are not present and the patient's condition can be safely managed in that setting.

Definition — 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 other hospital-affiliated clinic location, versus freestanding clinics.

Medicare Determinations

Medicare determinations: No National Coverage Determination found (NCD) and No Local Coverage Determination found (LCD).

Note: reviewers should consult current Medicare policy for any updates.

Revision History

2025-10-01addedLatest

New Policy created effective 10/1/2025. Revision details state 'New Policy, Date = 10/1/2025'.

Policy Summary

PayerCigna

PolicyOutpatient hospital-based physical therapy and occupational therapy services (site-of-care)

Policy CodePolicy 0600

Change TypeNew Policy (effective 10/1/2025)

Effective DateOct 1, 2025

Next Review DateJul 15, 202639d

Key ActionWhen billing, providers must submit documentation that one or more listed criteria are met and use the most appropriate codes as of the effective date.

On This Page

Implanted cardioverter-defibrillator

Myocardial infarction (MI) within past three monthswithin past 3 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 stents within 90 days; drug eluting stents within 1 year

examples listed

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])

Normal pressure hydrocephalus (NPH)

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