CPT® Code 97026

Quick Reference:

• What 97026 means: Application of a modality to one or more areas; infrared. Clinically, this refers to delivery of infrared radiant energy (typically via lamp/diode array) to produce local tissue warming and related physiologic effects (e.g., vasodilation) as part of a therapy plan.
• Supervised modality (not a timed 15-minute code): CPT 97026 is categorized with other physical medicine “modalities” that are generally billed per session when provided under appropriate supervision, rather than by the 8-minute rule used for many timed therapeutic procedure codes. CMS therapy billing guidance specifically highlights that several modality codes (including 97026) require patient supervision during the intervention.
• Medicare national noncoverage for neuropathy/wounds/ulcers: CMS’s National Coverage Determination (NCD 270.6) concludes that infrared therapy devices (including infrared/near-infrared light and monochromatic infrared energy) are not reasonable and necessary for treating diabetic or non-diabetic peripheral neuropathy, skin wounds, and ulcers (and related conditions such as pain arising from those conditions).
• Expect commercial payer scrutiny: Many commercial plans classify infrared therapy as experimental/investigational for broad pain indications. For example, Aetna’s CPB lists CPT 97026 among codes not covered for indications addressed in the policy (with extensive diagnosis restrictions).
• NCCI edits and modifier reality: Infrared (97026) is commonly subject to procedure-to-procedure (PTP) edits when billed with other modalities in the same visit. The appropriate bypass modifier (e.g., 59 or a relevant X-modifier when accepted) is only defensible when documentation supports a distinct service (e.g., separate anatomic region or separate encounter). APTA summarizes common PT code pairs affected by Medicare NCCI PTP edits, including combinations involving 97026.
• Documentation is the payment determinant: For covered indications, the record must show skilled therapy rationale, measurable functional goals, modality parameters (area treated, supervision, patient tolerance), and how infrared supports the plan of care—especially because payer policies may view infrared as low-value compared with standard heat modalities.

CPT 97026 (infrared therapy) is straightforward to describe but frequently difficult to reimburse cleanly because payers evaluate it through two lenses at once:

1. whether the service is covered for the diagnosis and clinical intent, and
2. whether the service is correctly reported as a supervised modality consistent with Medicare therapy billing conventions and NCCI bundling rules.

CMS’s national noncoverage policy for neuropathy/wounds/ulcers is the single most important compliance anchor for this code because it directly controls Medicare coverage for many of the most commonly marketed uses of infrared therapy.

Coverage Decision Tree

flowchart TD
    A[Infrared Therapy<br/>CPT 97026] --> B{What is the<br/>treatment intent?}
    B -->|Neuropathy, wounds,<br/>or ulcers| C[Medicare: DENIED<br/>NCD 270.6 noncoverage]
    B -->|Musculoskeletal<br/>adjunct therapy| D{Which payer?}
    D -->|Medicare| E{Documented as part of<br/>skilled plan of care?}
    E -->|Yes| F[Bill 97026<br/>with supervision documentation]
    E -->|No| G[Likely denied as<br/>routine comfort care]
    D -->|Commercial| H{Check payer policy:<br/>investigational exclusion?}
    H -->|Excluded| I[Denied as<br/>investigational]
    H -->|Covered| J{Prior auth<br/>required?}
    J -->|Yes| K[Obtain PA, then bill 97026]
    J -->|No| F

1. Definition and Procedure Scope

CPT 97026 describes the application of infrared therapy to one or more body areas. In practice, infrared therapy is delivered via devices that emit infrared energy to produce local tissue warming. The intended physiologic effects include vasodilation (improved superficial circulation), temporary reduction of muscle spasm, and short-term pain modulation—commonly as a comfort modality used before or after active therapy (therapeutic exercise, neuromuscular reeducation, gait training).

The CPT code represents the service of applying the modality in the therapy setting; it does not represent purchase of a device or home-use equipment.

Infrared therapy is often operationally grouped with “superficial heat” modalities. That grouping is relevant to audit risk because payers frequently treat infrared as a low-complexity adjunct unless the chart shows a clear and functional reason for selecting the modality and how it supports the plan of care.

What 97026 includes (typical expectations):

• Selection and safe application of infrared modality to the treatment area(s), including basic patient screening (contraindications such as impaired sensation/thermal injury risk).
• Supervision consistent with therapy modality requirements when billed to Medicare, as applicable to setting and provider type. CMS therapy guidance explicitly lists 97026 among modality codes requiring patient supervision during the intervention.
• Therapy record documentation of treated area(s), setup parameters used by the clinic (device type, distance/positioning as locally documented), patient tolerance/response, and integration with the overall therapy plan.

What 97026 does not include:

• The evaluation itself (e.g., PT evaluation codes), which must be separately documented and billed when performed and allowed.
• Active skilled interventions (therapeutic exercise, manual therapy, neuromuscular reeducation), which are billed with distinct codes and require their own documentation.
• Coverage for conditions that CMS has determined are nationally noncovered under NCD 270.6 (notably peripheral neuropathy, wounds, and ulcers).

Compliance boundary (Medicare): If the clinical purpose of the infrared therapy is treatment of diabetic or non-diabetic peripheral neuropathy, or treatment of wounds/ulcers (or closely related indications), Medicare coverage is nationally denied under NCD 270.6. Documentation and modifiers do not override a national noncoverage determination.

2. Clinical Uses and Evidence Boundaries

In rehabilitation settings, infrared therapy is typically used as an adjunct modality rather than a primary intervention. The most common operational roles are:

• Pre-activity warming: short-term comfort before therapeutic exercise or stretching when superficial heat may improve tolerance.
• Post-activity symptom modulation: temporary relief of pain or muscle tightness after active interventions.
• Localized soft tissue warming: as part of a broader plan to reduce guarding and facilitate movement in a painful region.

The major clinical limitation is that many highly marketed uses of infrared therapy—particularly for neuropathy and chronic wound conditions—are precisely the categories addressed by CMS’s national noncoverage determination. CMS indicates that infrared therapy devices have been proposed for diabetic neuropathy, other peripheral neuropathy, and skin ulcers/wounds. Still, the agency concluded the evidence is insufficient for Medicare coverage for those uses.

From a payer perspective, infrared therapy competes against other superficial heat modalities that are widely accepted and inexpensive. Therefore, medical necessity is rarely established by “pain” alone. Instead, the record must connect the modality to:

• a specific functional limitation,
• a measurable treatment goal, and
• an explanation of why the modality was selected as part of skilled therapy rather than routine comfort care.

Practical evidence-aware positioning: When infrared is used, the defensible clinical claim is usually modest: short-term symptom modulation and facilitation of participation in active therapy. Claims that infrared “treats neuropathy,” “heals ulcers,” or provides disease modification are the types of assertions that collide directly with payer noncoverage language and may elevate audit risk.

3. Medicare and Commercial Coverage Rules

3.1 Medicare (CMS) – National Coverage Determination controls high-risk indications

CMS’s NCD 270.6 (Infrared Therapy Devices) is the most authoritative single policy source for coverage risk. It states that infrared therapy devices have been proposed for neuropathy and wound/ulcer conditions and concludes these uses are not reasonable and necessary for Medicare coverage.

Operationally, this means Medicare claims for infrared therapy aimed at:

• diabetic peripheral neuropathy,
• non-diabetic peripheral neuropathy,
• skin wounds,
• skin ulcers,
• and closely related conditions (including pain arising from these conditions)

are expected to deny under national policy regardless of documentation quality. The CMS tracking sheet for the related National Coverage Analysis provides additional policy context that CMS evaluated infrared therapy for these indications at a national level.

3.2 Medicare therapy billing rules – supervision and modality reporting expectations

Even when infrared therapy is used for an indication not explicitly subject to NCD noncoverage, Medicare therapy billing rules remain central to compliance. CMS’s therapy billing article explicitly states that multiple modality codes—including 97026—require supervision by qualified personnel during the intervention. This is a frequent documentation gap: notes may describe the modality but omit supervision context, clinical rationale, and how it connects to skilled goals.

3.3 Commercial payers – frequent investigational classifications

Commercial insurers often apply technology assessment frameworks and may classify infrared therapy as investigational for broad pain and chronic diagnoses. Aetna’s Clinical Policy Bulletin 0604 is a clear example of a payer policy that lists CPT 97026 among codes not covered for indications addressed in the policy and includes extensive diagnosis-based exclusions. While each payer differs, this illustrates the common commercial posture: coverage is limited, diagnosis- and documentation-sensitive, and subject to prior authorization or outright noncoverage.

Payer reality check: If your organization bills 97026 at meaningful volume, the payer mix matters. Medicare policy has a national noncoverage determination for several high-volume marketing indications (neuropathy/wounds/ulcers), and large commercial payers often treat infrared as investigational for broad pain diagnoses. Always confirm coverage by payer and benefit design before assuming reimbursement.

4. Documentation Standards and Medical Necessity

Infrared therapy documentation must do more than prove “a modality was applied.” It must prove that the modality was part of a skilled plan of care and that the patient has potential to improve (or requires skilled maintenance where applicable) in functional outcomes. Because infrared is typically an adjunct modality, auditors commonly look for evidence that it was not billed as routine comfort care.

4.1 Minimum documentation elements (defensible baseline)

• Treated region(s): specify the anatomic area(s) treated (e.g., right knee, lumbar paraspinals).
• Clinical rationale: why infrared was selected in that visit (e.g., “to reduce pain and guarding to enable participation in therapeutic exercise”).
• Supervision and personnel: identify that the modality was provided under appropriate supervision consistent with Medicare therapy modality expectations when applicable.
• Patient response/tolerance: subjective response (pain rating change) and any objective response if measured (ROM tolerance, gait tolerance after modality).
• Connection to goals: document how the modality supports functional goals (e.g., “improve sit-to-stand tolerance,” “increase walking duration”).

4.2 Show that the plan is not “modality-only” care

A recurring risk pattern is repeated visits where infrared is the primary billed service without meaningful skilled therapeutic procedures. In most payer frameworks, modalities alone rarely justify ongoing skilled therapy unless they are part of a broader active plan with measurable progress. If infrared is used repeatedly, document:

• why the patient still requires the modality,
• what objective/functional limitation it addresses, and
• how it facilitates active therapy progression.

4.3 Noncoverage diagnoses: document intent to avoid miscoding

If the patient has multiple conditions (e.g., osteoarthritis plus diabetic neuropathy), documentation must clarify the treatment intent. Medicare’s noncoverage is tied to infrared therapy used for neuropathy/wound/ulcer indications. If infrared is applied to a knee for osteoarthritis-related pain relief, document the musculoskeletal intent explicitly and avoid language suggesting neuropathy treatment. National noncoverage remains a major audit risk when documentation blurs these lines.

5. Billing Mechanics and Unit Reporting

5.1 Unit reporting: supervised modality conventions

CPT 97026 is generally treated as a supervised modality in therapy billing workflows. In Medicare therapy contexts, supervised modalities are typically billed as one unit per date of service per modality (subject to payer-specific rules and documentation), rather than using the 8-minute rule used for timed therapeutic procedures. CMS therapy billing guidance groups 97026 with other modality codes that require supervision during the intervention.

Common billing error: Treating 97026 like a timed “15-minute unit” code and applying the 8-minute rule. That approach can create unit inflation risk and inconsistency with modality billing conventions. Align unit reporting with payer guidance for supervised modalities and your MAC/contract rules.

5.2 Place of service and therapy benefit context

97026 is typically billed within outpatient therapy/rehabilitation services when furnished by qualified therapy personnel under the relevant benefit structure. Because payer rules vary, organizations should confirm: (a) whether 97026 is covered at all for the intended diagnosis, (b) whether prior authorization is required, (c) whether any modality caps/limits apply, and (d) whether certain diagnosis families trigger automatic denial as investigational. Aetna’s policy is an example of a payer rule set that restricts coverage for infrared therapy across many indications.

6. NCCI Edits and Modifier Guidance (59/X)

Infrared therapy is frequently billed in visits that also include other modalities or therapeutic procedures. Medicare NCCI Procedure-to-Procedure edits can bundle certain code pairs. APTA’s Medicare NCCI summary provides a practical list of common PT code pairs with PTP edits and includes multiple modality interactions involving 97026.

6.1 When modifier 59 (or X-modifiers) may be appropriate

Modifier 59 (or payer-accepted X-modifiers) is only defensible when the record supports a distinct procedural service:

• Different anatomic region: e.g., hot/cold pack to shoulder and infrared to knee, with separate documentation of each region and clinical rationale.
• Separate encounter/session: e.g., distinct therapy sessions separated by time and documented as separate encounters on the same day (rare in routine outpatient therapy and payer-sensitive).
• Different clinical purpose: clearly distinct treatment objectives supported by documentation (not simply “two heat modalities”).

In general, when a modality-to-modality code pair is edited, the bypass modifier—if allowed—belongs on the column 2 code (the code that is bundled) only when distinctness is supported. APTA’s summary table of common PTP edits is used by many therapy practices as a practical reference for these scenarios.

6.2 What modifiers cannot do

Modifiers do not:

• override Medicare national noncoverage for neuropathy/wounds/ulcers under NCD 270.6,
• convert routine comfort care into skilled therapy, or
• justify billing two superficial heat modalities to the same region without a documented distinct purpose.

Audit trigger pattern: Frequent use of modifier 59 on modality pairs (especially heat-based modalities) without explicit documentation of distinct body region and distinct therapeutic purpose. Use modifiers only when the chart makes “distinct” obvious.

7. ICD-10-CM Pairing Strategy (Practical)

There is no universal ICD-10 list that guarantees payment for 97026 across payers. Instead, clean claims depend on matching the diagnosis to (a) payer coverage policy and (b) the documented therapeutic intent. The most important ICD-10 principle for 97026 is negative: avoid pairing infrared therapy with diagnoses tied to Medicare national noncoverage intent (neuropathy/wounds/ulcers) when the service is billed to Medicare, because claims are expected to deny under NCD 270.6.

For musculoskeletal therapy episodes where a payer does cover supervised modalities, common clinical contexts may include pain and mobility limitations associated with arthritis, sprain/strain recovery, or post-procedural rehabilitation. However, commercial payer policies may still restrict coverage by diagnosis family (for example, broad back pain and osteoarthritis categories may be denied as investigational under certain policies). Aetna’s CPB illustrates how extensive diagnosis restrictions can be.

Documentation-first pairing approach:

• Select the ICD-10 that most directly reflects the functional problem being treated (e.g., region-specific pain/impairment diagnosis),
• Ensure the treatment note describes that same problem as the reason for infrared use,
• Avoid vague “pain, unspecified” diagnoses when a more specific musculoskeletal diagnosis exists (specificity helps medical necessity review),
• Explicitly separate comorbid conditions (e.g., diabetes with neuropathy) from the musculoskeletal intent when infrared is used for a joint or soft tissue region.

8. Comparison Table: 97026 vs Common Modality and Procedure Codes

9. Real-World Coding Scenarios

Scenario 1: Musculoskeletal pain episode where payer covers supervised modalities

Setting: Outpatient PT clinic.

Presentation: Patient with knee pain and reduced tolerance to therapeutic exercise due to guarding.

Service: Infrared applied to the knee region under supervision, followed by progression of therapeutic exercise.

Coding logic: Bill 97026 (infrared modality) and any timed therapeutic procedures separately when documented as distinct portions of care. Document the rationale (“reduce guarding to enable exercise”), the treated region, supervision, and response. CMS therapy guidance emphasizes supervision requirements for modality codes including 97026.

Compliance focus: Ensure the plan is active and functional (exercise progression and measurable goals), not modality-only care.

Scenario 2: Patient has diabetes with neuropathy—avoid Medicare noncoverage intent

Setting: Outpatient therapy clinic billing Medicare.

Presentation: Patient has diabetes with documented peripheral neuropathy but is treated for a separate musculoskeletal complaint (e.g., shoulder mobility limitation).

Service: Infrared applied to the shoulder region to facilitate ROM work.

Coding logic: If infrared is billed to Medicare, documentation must make the intent unmistakably musculoskeletal and not neuropathy treatment. Medicare national noncoverage applies when infrared therapy is used for peripheral neuropathy and wound/ulcer conditions.

Documentation tip: Avoid language implying neuropathy treatment (e.g., “improves neuropathy symptoms”) because it aligns the record with nationally noncovered indications.

Scenario 3: Two modalities in one visit—NCCI edit risk and modifier discipline

Setting: Outpatient therapy session with multiple modalities.

Service: Infrared to lumbar region and another modality to a separate anatomic region.

Coding logic: Medicare NCCI PTP edits may bundle certain modality pairs. If an edit exists and the services are truly distinct (separate region, separately documented), a bypass modifier (59 or payer-accepted X-modifier) may be appropriate on the column 2 code. APTA summarizes common therapy PTP edit pairs involving 97026.

Audit-proofing: Document separate regions, separate clinical purposes, and separate patient responses.

Scenario 4: Commercial payer denial based on investigational policy

Setting: Private insurance plan with restrictive modality coverage.

Service: Infrared therapy billed for a broad chronic pain diagnosis.

Outcome risk: Denial as investigational/experimental is common under commercial technology policies. Aetna’s CPB 0604 is an example of a commercial payer policy that restricts infrared therapy coverage and lists CPT 97026 among codes not covered for indications addressed in the policy.

Mitigation: Verify plan policy and prior authorization requirements before providing high-volume infrared therapy services.