Counterstrain therapy, a gentle, indirect manual therapy method, is often provided by Doctors of Osteopathic Medicine (DOs) or physical therapists. This technique involves positioning the body to shorten tissues containing painful “tender points,” holding the position for a specific time, and then returning the body to a neutral position. This process aims to resolve musculoskeletal and fascial pain. Determining whether this specific treatment is covered by health insurance is complex, as coverage depends on the individual policy’s benefits, the provider’s professional license, and the specific codes used for billing.
How Counterstrain Therapy is Coded for Insurance
Counterstrain therapy itself does not have a unique Current Procedural Terminology (CPT) code assigned by the American Medical Association (AMA) for billing purposes. Instead, coverage is determined by the broader category of manual therapy techniques used by the licensed healthcare professional. The provider’s license dictates which primary codes are utilized, which is a significant factor in determining reimbursement.
When performed by a Doctor of Osteopathic Medicine (DO), Counterstrain is categorized as a type of Osteopathic Manipulative Treatment (OMT). OMT is billed using a specific range of CPT codes, from 98925 to 98929, which correspond to the number of body regions treated. For example, code 98925 represents OMT applied to one or two body regions, while 98929 covers nine or ten regions.
If the therapy is delivered by a licensed physical therapist, it is often billed under the general manual therapy CPT code, 97140. This is a timed code, typically billed in 15-minute increments, and includes various hands-on techniques like mobilization, manipulation, and myofascial release. Because Counterstrain is considered a medical practice and a type of manual physical therapy, insurance companies generally cover it as they would any other physical therapy appointment, provided the plan includes physical therapy benefits.
Key Factors That Influence Coverage Approval
Approval for Counterstrain therapy coverage moves beyond the billing code and is heavily influenced by several external and internal factors. The foundational requirement for any medical service to be covered is that it must be deemed “medically necessary.” This means the provider must document a diagnosed condition using International Classification of Diseases (ICD-10) codes. They must also demonstrate that the treatment is an appropriate and effective intervention for that specific diagnosis.
The provider’s network status is another variable, which drastically affects the patient’s out-of-pocket costs. Seeing an in-network provider means the provider has a contract with the insurance company, resulting in lower costs and a higher likelihood of coverage. Conversely, an out-of-network provider may be covered only partially or not at all, potentially leaving the patient responsible for the entire, often higher, billed amount.
The type of insurance plan also plays a substantial role, as plans like Health Maintenance Organizations (HMOs) typically offer less flexibility in provider choice compared to Preferred Provider Organizations (PPOs). Most plans impose strict coverage limits, such as an annual cap on the number of physical or manual therapy sessions. These limits can range from 20 to 60 visits per year, and many policies require a pre-authorization after a small number of initial visits, such as six to eight.
Steps for Confirming Your Specific Coverage
To avoid unexpected expenses, patients should proactively confirm their specific coverage details before beginning treatment. The most reliable first step is to contact the insurance provider directly using the member services number on the back of the insurance card.
Key Questions to Ask Your Insurer
- Ask specifically about coverage for Osteopathic Manipulative Treatment (OMT) codes (98925–98929) if seeing a DO.
- Inquire about coverage for Manual Therapy (CPT code 97140) if seeing a physical therapist.
- Inquire about any annual visit limits or dollar maximums for physical medicine services.
- Confirm the requirement for a physician referral or pre-authorization.
- Confirm the provider’s in-network status to accurately estimate the copayment, coinsurance, or deductible.
Obtaining this information in advance ensures a clear understanding of the financial commitment involved.