10-144-101 Me. Code R. § III-85
Current through 2024-51, December 18, 2024
MaineCare coverage of Physical Therapy Services is limited. Refer to Chapter II, Section 85.06 for specific limitations.
Use the following modifiers when appropriate:
TF - Intermediate Level of care - used for PT Assistants and priced 10% below the Allowance rate
GP - Services delivered under an outpatient physical therapy plan of care
TL - Services delivered under an Individualized Family Service Plan (IFSP)
TM - Services delivered under an Individualized Education Plan (IEP) with MaineCare Addendum denoting medical necessity of the service
| CODE | SERVICE | UNIT | MAXIMUM ALLOWANCE |
| 97001 | Physical Therapy Evaluation | per evaluation | $35.94 |
| 97002 | Physical Therapy Re-evaluation (Ongoing therapy) | per session | $19.40 |
| 97150 GP | Therapeutic procedure(s), group (2 or more individuals) | per member per session | $11.98 |
| THERAPEUTIC MODALITIES SUPERVISED | |||
| 97012 | Application of a modality to one or more areas; traction, mechanical | per service | $6.24 |
| 97014 | Application of a modality to one or more areas; | per service | $5.61 |
| 97016 | Application of a modality to one or more areas; vasopneumatic devices | per service | $6.28 |
| 97018 | Application of a modality to one or more areas; paraffin bath | per service | $3.05 |
| 97022 | Application of a modality to one or more areas; whirlpool | per service | $7.06 |
| 97024 | Application of a modality to one or more areas; diathermy | per service | $2.10 |
| 97026 | Application of a modality to one or more areas; infrared | per service | $1.94 |
| 97028 | Application of a modality to one or more areas; ultraviolet | per service | $2.62 |
| THERAPEUTIC MODALITIES CONSTANT ATTENDANCE | |||
| 97032 | Application of a modality to one or more areas; electrical stimulation (manual) | 15 minutes | $6.88 |
| 97033 | Application of a modality to one or more areas; iontophoresis | 15 minutes | $9.90 |
| 97034 | Application of a modality to one or more areas; contrast baths | 15 minutes | $6.00 |
| 97035 | Application of a modality to one or more areas; ultrasound | 15 minutes | $4.89 |
| 97036 | Application of a modality to one or more areas; Hubbard tank | 15 minutes | $10.58 |
| THERAPEUTIC PROCEDURES | |||
| 97110 | Therapeutic procedure, one or more areas; therapeutic exercises to develop strength and endurance, range of motion and flexibility | 15 minutes | $11.93 |
| 97112 | Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities | 15 minutes | $12.46 |
| 97113 | Aquatic therapy with therapeutic exercises | 15 minutes | $14.34 |
| 97116 | Gait training (includes stair climbing) | 15 minutes | $10.46 |
| 97124 | Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) | 15 minutes | $9.59 |
| 97140 | Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions | 15 minutes | $11.15 |
| 97760 | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk | 15 minutes | $13.45 |
| 97761 | Prosthetic training, upper and/or lower extremity(s) | 15 minutes | $12.09 |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) | 15 minutes | $12.60 |
| 97532 | Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training,) direct (one-on-one) patient contact by the provider | 15 minutes | $10.38 |
| 97533 | Sensatory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by provider | 15 minutes | $11.02 |
| 97535 | Self/care/home management training (e.g. activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider | 15 minutes | $12.78 |
| 97542 | Wheelchair management(eg, assessment, fitting, training) | 15 minutes | $11.67 |
| ACTIVE WOUND CARE MANAGEMENT | |||
| 97597 | Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g. high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters | per service | $23.54 |
| 97598 | Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g. high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters | per service | $23.54 |
| 97602 | Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion), including topical applications(s), wound assessment and instructions(s) for ongoing care | per service | $16.86 |
| TESTS AND MEASUREMENTS | |||
| 97762 | Check out for orthotic/prosthetic use, established patient | 15 minutes | $13.31 |
| 97750 | Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report | 15 minutes | $12.39 |
| 97755 | Assistive technology assessment (e.g. to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report | 15 minutes | $14.44 |
| 92605 | Evaluation for prescription of non-speech-generating augmentative and alternative communication device | per service | $34.26 |
| 92607 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with patient; first hour | 60 minutes | $61.67 |
| 92608 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with patient; each additional 30 minutes | 30 minutes | $11.91 |
| MUSCLE AND RANGE OF MOTION TESTING | |||
| 95831 | Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk | per service | $11.37 |
| 95832 | Muscle testing, manual (separate procedure) with report; extremity - hand, with or without comparison with normal side | per service | $10.38 |
| 95833 | Muscle testing, manual (separate procedure) with report; - total evaluation of body, excluding hands | per service | $16.07 |
| 95834 | Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk - total evaluation of body, including hands | per service | $18.94 |
| 95851 | Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) | per service | $7.51 |
| 95852 | Range of motion measurements and report (separate procedure); each extremity - hand, with or without comparison with normal side | per service | $5.84 |
| CENTRAL NERVOUS SYSTEM ASSESSMENTS/TESTS (e.g. NEURO-COGNITIVE, MENTAL STATUS, SPEECH TESTING) | |||
| 96110 | Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen) with interpretation and report | per service | $4.64 |
| 96111 | Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen) with interpretation and report - extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments (e.g., Bayley Scales of Infant Development) with interpretation and report | per service | $56.39 |
10-144 C.M.R. ch. 101, § III-85