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This policy governs coverage and medical-necessity criteria for physical performance tests and measurements, including Functional Capacity Evaluations (FCEs), and addresses non-covered work-related rehabilitation and quantitative muscle-testing devices. It applies to providers submitting these services under Cigna-administered benefit plans, subject to the member's specific plan terms.
Policy Summary
PayerCigna
PolicyPhysical Performance Test or Measurement
Policy CodePolicy N/A
Change TypeNo material change
Effective DateNov 15, 20261d
Next Review DateNov 15, 2027
Key ActionObtain a written referral stating the FCE purpose and clearly defined goals before testing.
No material clinical or coverage changes in this revision.
97750Covered physical performance testing code
2–4 hoursTypical FCE duration
1/12 monthsTypical FCE frequency
3 monthsTypical post-injury interval
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Functional Capacity Evaluation (FCE) is medically necessary when ALL of the following criteria are met:
ALL of the following
A written referral from a physician, carrier, or employer is forwarded to the evaluator. The referral explicitly states the purpose of the FCE, including clearly defined goals to guide test selection, and identifies one or more appropriate FCE applications.
The evaluation is designed to determine return-to-work capabilities following a defined injury or medically necessary rehabilitation.
The evaluation is structured to answer specific question(s) about the worker's performance abilities, and those questions are addressed in the evaluation report.
Reported results are compared with meaningful standardized norms.
The FCE is performed by a qualified provider/evaluator meeting the applicable requirements.
Before the FCE, the qualified evaluator obtains a subjective pain assessment, including the individual's self-reported effect on functional abilities and activities of daily living; performs a screening examination; and obtains informed consent.
FCE Safety, Facility, and Evaluator Requirements
FCE safety, setting, and evaluator requirements include ALL of the following applicable principles:
ALL of the following
The FCE is approached on a case-by-case basis, and comprehensive functional activities related to the individual's work duties are observed and measured. Isometric or isokinetic extremity or trunk torque tests alone are insufficient because these values correlate poorly with functional performance.
Risks and contraindications are communicated.
Professional judgment is used to determine a safe maximal level for each test component, and testing focuses only on critical job demands.
The cardiovascular system is monitored, and the FCE is modified if heart rate, blood pressure, or respiratory rate changes excessively.
Standardized criteria for ceasing a test are established in advance, including pain, nausea, dizziness, blurred vision, radicular symptoms, or continued use of unsafe body mechanics.
Not Medically Necessary Work-Related Programs
The following services are not medically necessary because they are nonmedical, educational, or training in nature:
ALL of the following
Vocational rehabilitation programs and programs whose primary goal is returning an individual to work.
Community/work reintegration training, including shopping, transportation, money management, avocational activities, work-environment or modification analysis, work-task analysis, and use of assistive technology or adaptive equipment (CPT 97537).
Work hardening or conditioning programs, including initial two-hour services and each additional hour (CPT 97545 and 97546).
Experimental, Investigational, or Unproven Quantitative Muscle Testing
Quantitative muscle testing devices used to assess muscle strength are considered experimental, investigational, or unproven.
ALL of the following
Quantitative or isokinetic muscle testing devices, including MedX, Isostation B-200, Cybex II, Kin-Com, and Biodex, are experimental, investigational, or unproven for assessment of muscle strength.
Evidence in the peer-reviewed scientific literature does not demonstrate that these devices provide better diagnostic utility than established manual muscle testing.
Isokinetic devices apply constant-speed resistance over a range of motion and may measure strength, fatigue, torque, velocity, power, endurance, or range of motion; however, evidence has not demonstrated the clinical utility of these specific devices for muscle testing or strengthening therapy or standard procedures and exercise.
Functional Capacity Evaluation Requirements
FCE requirements include ALL of the following applicable elements:
ALL of the following
The FCE is typically not performed before three months after injury unless a significant, documented change in the individual's status justifies an earlier evaluation.
FCEs are limited to 2–4 hours per date of service and generally to one evaluation every 12 months when necessary. An FCE within 12 months is reviewed individually using objective client or patient data compared with standardized norms.
An FCE may extend beyond four hours or two days when needed to further quantify the individual's ability to sustain work tasks over a regular work schedule.
The duration is based on the complexity of the illness or injury and resulting impairments and the availability of clearly defined, work-related physical demands.
FCE Evaluator Qualifications
The FCE must be performed in its entirety by an appropriately qualified evaluator meeting ALL applicable qualification requirements:
ALL of the following
The evaluator is a physical therapist or occupational therapist holding a current valid license, or another licensed provider qualified within the provider's scope of practice.
The evaluator has education, training, and competency in performing FCEs.
Competency is evidenced by certification when certification is required for the FCE system used and by experience performing at least five FCEs.
Competency may be verified through review by the Credentialing and Risk Management Committee of a sample of previously completed FCE reports.
Physical Performance Test Documentation
Because CPT 97750 is time-based, the following three time elements must be documented to determine the number of units reported:
ALL of the following
Total time spent with the patient providing the test and measurement, including time spent preparing the patient for the procedure.
Time spent performing the selected testing protocol.
Time spent with the patient providing post-testing instructions.
Do not report a code from the CPT 95851–95852 series in addition to CPT 97750 for the same physical performance testing service.
Quantitative or isokinetic devices used as therapeutic exercise—such as MedX, Isostation B-200, Biodex, or Kin-Com—are not appropriately billed with the physical performance testing codes in this guideline.
Testing and evaluation codes are not appropriate when these devices are being used as therapeutic exercise. CPT codes in this guideline refer to use of the devices for testing and evaluation, not strengthening or rehabilitation exercise.
Vocational rehabilitation and return-to-work programs whose primary purpose is returning an individual to work are not medically necessary because they are nonmedical, educational, or training in nature.
Work hardening or conditioning programs are educational, training, or otherwise nonmedical in nature and are not medically necessary.
Coding and Service Parameters
Considered Medically Necessary when criteria are metCPTCovered
Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes
Physical performance test or measurement, with written report, per 30 minutes
Typical FCE Timing After Injury
Typical timingAn FCE is not typically indicated before 3 months post-injury.
ExceptionEarlier testing may be performed when there is a significant documented change in the individual's status that justifies the evaluation.
Clinical contextThe evaluation is intended to determine return-to-work capabilities following a defined injury or medically necessary rehabilitation.
FCE Duration
Typical duration2–4 hours per date of service.
Extended testingAn FCE may extend beyond 4 hours or two days when needed to further quantify the individual's ability to sustain work tasks over a regular work schedule.
Provider Documentation and Billing Actions
Documentation Required
Document the FCE Referral and Evaluation Purpose
Before performing an FCE, obtain a written referral from a physician, carrier, or employer that explicitly states the evaluation’s purpose, clearly defined goals, and the specific question(s) to be answered. Retain the referral and document the evaluation purpose, goals, and how they guided test selection.
The FCE must assess return-to-work capabilities after a defined injury or medically necessary rehabilitation.
The evaluation report must address the specific performance question(s), compare results with meaningful standardized norms, and document subjective pain assessment, screening examination, and informed consent before testing.
Documentation Required
Document a Safe, Valid FCE Setting
Perform the FCE in a setting that can safely and validly measure the patient’s relevant work activities. Document the test methods, applicable standards, equipment validity and reliability, maintenance and calibration, and emergency readiness.
Observe and measure comprehensive functional activities related to the work duties; isometric or isokinetic torque testing alone is insufficient.
Background
Physical performance testing evaluates a patient's ability to perform specific physical tasks and may be reasonable and necessary for neurological or musculoskeletal conditions when task performance must be assessed. Testing may include manual or equipment-based measures, functional capacity testing, standardized testing batteries, isokinetic testing, balance measures such as the timed up-and-go test, or a six-minute walk test. These services require direct one-on-one patient contact and should not be used in place of a routine evaluation or re-evaluation.
Definitions
Physical Performance Test or Measurement
DefinitionTests and measurements performed by a physician or other qualified health care professional.
PurposeEvaluation of the ability to perform specific physical tasks.
MethodsTesting may include multiple tests or measurements of one or more physical areas and may be performed manually or with equipment.
Functional Capacity Evaluation (FCE)
Assessment typeA comprehensive, objective assessment of a person's ability to perform work-related functional tasks.
Work applicationMatches physical abilities with essential and critical job demands.
Policy Summary
PayerCigna
PolicyPhysical Performance Test or Measurement
Policy CodePolicy N/A
Change TypeNo material change
Effective DateNov 15, 20261d
Next Review DateNov 15, 2027
Key ActionObtain a written referral stating the FCE purpose and clearly defined goals before testing.
Equipment appropriately reflects the work duties, including relevant tests and normative standards with acceptable reliability and validity.
The environment and available space meet the equipment and work specifications.
The evaluator understands the equipment used during the FCE, including completion of required training.
Appropriate equipment maintenance and calibration are documented and available for review.
Planning, facilities, and equipment are available to respond to emergencies.
Expected outcomes include recommendations regarding body mechanics, movements, techniques, and modifications that facilitate return to work, such as safe manual handling, and specification of proposed return-to-work duties or different duties.
Duration factorsThe length of the FCE depends on the complexity of the illness or injury, resulting impairments, and availability of clearly defined work-related physical demands.
FCE Frequency
Typical frequencyOne evaluation every 12 months if necessary.
Repeat evaluation within 12 monthsAn FCE performed within 12 months is reviewed individually.
Review basisIndividual review uses objective patient data compared with standardized norms.
Evaluator FCE Experience
Minimum experienceAt least five (5) satisfactorily performed FCEs.
Evaluator qualificationsThe evaluator must be a currently licensed physical therapist, occupational therapist, or other licensed provider qualified by scope of practice.
Competency evidenceCompetency should be demonstrated by appropriate education, training, certification where required for the FCE system, and experience.
Communicate risks and contraindications, use professional judgment to establish safe maximal levels, and focus on critical job demands.
Monitor cardiovascular status and modify testing for excessive changes in heart rate, blood pressure, or respiratory rate.
Establish and document criteria for stopping a test, including pain, nausea, dizziness, blurred vision, radicular symptoms, or continued unsafe body mechanics.
Document equipment and space appropriate to the work demands, evaluator training on the equipment, maintenance and calibration, and emergency facilities and equipment.
Documentation Required
Verify Evaluator Qualifications
Ensure the FCE is performed in its entirety by a currently licensed physical or occupational therapist, or another licensed provider qualified within the applicable scope of practice. Maintain documentation of education, training, competencies, system-specific certification when required, and experience.
The evaluator must have satisfactorily performed at least five FCEs.
Proof of competency may include certification and review by the Credentialing and Risk Management Committee of sampled completed FCE reports.
Documentation Required
Complete the Performance Testing Report
Prepare and submit a written performance-testing report when reporting physical performance testing or an FCE. CPT 97750 requires direct one-on-one patient contact; testing codes must not substitute for an evaluation or re-evaluation service or be billed as part of a routine rehabilitation assessment.
Relate findings to the patient’s functional abilities and, when identified, the physical demands of the job.
Document recommendations for body mechanics, movement, techniques, modifications, and proposed return-to-work or alternative duties.
Do not report CPT 95851–95852 in addition to CPT 97750 for the same testing.
Documentation Required
Support Every CPT 97750 Unit
When billing CPT 97750, document all direct patient-contact time and the test and measurement work, including analysis and interpretation performed in the patient’s presence. The documented time determines the number of units reported.
Total time with the patient providing testing and measurement, including preparation.
Time spent performing the selected protocol.
Time with the patient providing post-testing instructions.
Testing elements and protocols, the problem requiring testing, and the specific test performed.
A separate measurement report with graphic reports when applicable, interpretation of collected data, application to functional activity, and impact on the plan of care, such as discharge, return to sport or ADLs, or treatment modification.
Documentation Required
Complete Pre-Evaluation Review
Before testing, obtain the written referral and review the clinical and occupational information needed to select appropriate tests and interpret return-to-work capacity. Document the review and any resulting adjustments to the FCE.
Review relevant medical records, work duties, prior return-to-work attempts or FCEs, and reasons for failure.
Identify return-to-work goals and potential options in advance.
Consider comorbidities and their effect on the FCE and return to work.
Ensure results are relevant to and comparable with the physical demands of the identified job.
Documentation Required
Include Required FCE Report Contents
Submit a written FCE report with sufficient patient, occupational, methodological, quantitative, normative, and interpretive detail to support the conclusions and recommendations.
Patient demographics, including work history.
Indication for evaluation and type of evaluation performed.
Raw and tabulated data and normative data values; compare test results with the norms for the FCE used.
A narrative coversheet at the beginning describing evaluation results and recommendations.
When relevant, include the subjective interview, self-reported disability measures, physical examination or screening, pain behavior and effort, pace of work, clinical observations and body mechanics, and functional abilities for assessed physical demands.
Denial Risk
Avoid Noncompliant Billing or Testing Formats
Use only the appropriate covered procedure and diagnosis codes, and submit claims in the format supported by the policy and the patient’s benefit plan. Claims may be denied when services are billed with unsupported codes, diagnoses, conditions, or testing formats.
Do not bill CPT 97750 for a routine rehabilitation assessment or evaluation/re-evaluation service.
Direct one-on-one patient contact is required for physical performance testing.
Do not report CPT 95851–95852 with CPT 97750 for the same testing.
Use the most appropriate codes in effect on the submission date; services lacking covered codes or billed for noncovered diagnoses or conditions are not reimbursable.
Denial Risk
Meet All FCE Medical-Necessity Criteria
Do not bill or expect coverage for an FCE unless the required referral, purpose, goals, return-to-work question, qualified evaluator, standardized comparison, and pre-testing steps are documented. Missing performance criteria can support denial.
Document a written referral with explicitly stated purpose and clearly defined goals.
Show that testing addresses return-to-work capability after a defined injury or medically necessary rehabilitation and answers specific performance questions.
Compare results with meaningful standardized norms.
Document a qualified provider, subjective pain assessment, screening examination, and informed consent before testing.
Denial Risk
Support Timing, Frequency, and Duration
Schedule FCEs only when timing, frequency, and duration are clinically supported and documented. Testing is typically not indicated before three months after injury unless a significant documented change justifies earlier evaluation.
Limit an FCE to 2–4 hours per date of service and generally one evaluation every 12 months when necessary.
If an FCE is needed within 12 months, support the request with individual objective data compared with standardized norms for case-by-case review.
An FCE may extend beyond four hours or two days when needed to quantify sustained work-task ability over a regular work schedule.
Document the complexity of the illness or injury, resulting impairments, and availability of clearly defined work-related physical demands supporting the duration.
Denial Risk
Separate Work-Related Training Services
Do not bill work-related training or conditioning services as medically necessary FCE or physical performance testing. These services are considered educational, training, or nonmedical in nature when their primary purpose is return to work.
Vocational rehabilitation programs and programs primarily intended to return an individual to work are not medically necessary.
CPT 97545: work hardening/conditioning, initial two hours.
CPT 97546: work hardening/conditioning, each additional hour.
Denial Risk
Do Not Rely on Unproven Quantitative Devices
Do not represent quantitative or isokinetic muscle-testing devices as covered medically necessary testing when the policy classifies their use for muscle-strength assessment as experimental, investigational, or unproven.
Named devices include MedX, Isostation B-200, Cybex II, Kin-Com, and Biodex.
The policy does not find sufficient evidence that these devices provide better diagnostic utility than established manual muscle testing or support their testing or strengthening use.
Denial Risk
Prevent Insufficient CPT 97750 Documentation
CPT 97750 documentation is insufficient when the record does not support the billed time, testing protocol, results, interpretation, direct patient contact, or clinical application. Missing elements can result in denial or incorrect unit reporting.
Record total patient-contact time, protocol time, and post-testing instruction time.
Include the specific problem and test performed, testing elements or protocols, separate measurement results, graphics when applicable, and interpretation.
Explain how findings apply to functional activity and affect the plan of care.
Use direct patient-contact time to determine units.
Billing Rule
Do Not Bill Therapeutic Exercise as Testing
Do not use physical performance testing or evaluation codes to report therapeutic exercise performed with quantitative or isokinetic devices. When the device is used for strengthening or rehabilitation exercise, report the service according to the applicable therapeutic-exercise rules rather than as testing.
Examples include Biodex, Kin-Com, MedX, and Isostation B-200 used as therapeutic exercise or rehabilitation tools.
Testing protocols and strength-ratio reports do not convert therapeutic exercise into covered testing.
Denial Risk
Complete the Referral and FCE Report
An incomplete referral or report does not establish that the FCE was medically necessary or that its conclusions are supported. Obtain missing information before testing or complete the report before submitting the claim.
The referral must identify the source, purpose, clearly defined goals, and FCE application.
The report must contain demographics and work history, indication, evaluation type, raw and tabulated data, normative comparisons, and a results-and-recommendations coversheet.
Add relevant interview, disability, screening, behavioral, pace, body-mechanics, and functional-demand findings when applicable.
Common use
Assesses residual capacity and readiness for return to work, particularly following a medically stable musculoskeletal injury with persistent functional limitations.
Work Hardening
Program typeA highly specialized rehabilitation program.
Work simulationSimulates workplace activities and surroundings in a monitored environment.
Progression and goalUses systematically progressive work-related activities to physically and psychologically recondition the patient and facilitate return to full employment.
Isokinetic Testing
Movement controlUses an apparatus that controls the speed of movement through a range of motion.
ResistanceApplies variable resistance while allowing movement at a constant speed.
MeasurementMeasures the force applied by the user.
Functional Capacity Evaluation (FCE)
Job-demand relationshipTest results should relate to identified physical demands of the job.
Assessment areasThe evaluation may assess physical capacity, work-related function, effort, behavior, and body mechanics.
Return-to-work useThe evaluation may provide information about readiness for return to work and recommendations for work-related planning.
Quantitative Muscle Testing Devices
ExamplesDevices include MedX, Isostation B-200, Biodex, and Kin-Com.
Measurement purposeUsed under specified protocols to measure muscle performance, strength ratios, torque, power, rate of force development, or endurance.
Use distinctionUse of these devices for therapeutic exercise is distinct from testing and evaluation.