Showing posts with label Therapy services. Show all posts
Showing posts with label Therapy services. Show all posts
What is the new Therapy Cap process
New Therapy Cap Process: Frequently Asked Questions
What is the new Therapy Cap process?
Answer:
Starting October 1, 2012, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to prior authorization. For outpatient therapy services that exceed $3700 there will be a prior authorization approval process that will be implemented in three distinct phases. Providers will be assigned to one of three phases for manual medical review and will receive notification from CMS by letter and contractor websites regarding which phase they are included.
Why is CMS doing this?
Answer:
This process is required by Section 1833(g)(5)(C) of the Social Security Act, as added by Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJA), which was signed into law on February 22, 2012.
What is the prior authorization threshold?
Answer:
Starting October 1, 2012, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to prior authorization. For outpatient therapy services that exceed $3700 there will be a prior authorization approval process that will be implemented in three distinct phases.
How is the $3,700 calculated?
Answer:
The $3,700 is calculated using all outpatient therapy services provided (except those provided in Critical Access Hospitals) within the category of physical therapy/speech language therapy and then a separate category for occupational therapy services.
What does the $3,700 threshold represent?
Answer:
The threshold represents the total allowed charges under Part B for services furnished by independent practitioners, and institutional services under Part B (hospital outpatient departments, skilled nursing facilities, and home health agencies).
Does therapy provided in a critical access hospital (CAH) count?
Answer:
No. Services provided in a CAH are not counted and CAHs are not subject to the prior authorization process.
What are the Phases?
Answer:
Phase I October 1, 2012 to December 31, 2012
Phase II November 1, 2012 to December 31, 2012
Phase III December 1, 2012 to December 31, 2012
How do I know what Phase I am in?
Answer:
Each provider subjected to a phase will be notified via US Mail. There will also be a posting to the CMS website external link with the providers in phase I and II. Providers not on the list are deemed to be in Phase III.
How did CMS come up with the phases?
Answer:
The phases were developed taking into account specific provider characteristics (e.g., claims volume and payment) and then adjusted to distribute workload evenly at the Medicare Administrative Contractor.
If I am in Phase III, what happens to my claims during the timeframe of October 1, 2012 to November 30, 2012?
Answer:
Phase III is scheduled to begin for services expected to be furnished on or after December 1, 2012. Claims for services furnished before this time will be treated in the same manner as claims for services below the $3,700 threshold.
If I am in Phase III would a Medicare contractor conduct review of my claims from October 1, 2012 to November 30, 2012?
Answer:
Medicare contractors have the authority to review any claim at any time. However, pre-approval requests shall not be reviewed any sooner than 15 calendar days before the start of each Phase.
How to I know where to submit my request for prior authorization?
Answer:
We prefer you submit your request via Faxgate. The Faxgate numbers and addresses are noted on the job aids and on the forms located on the Palmetto GBA website.
What are the guidelines CMS contractors will use when conducting the review?
Answer:
The contractors will use the coverage and payment policy requirements contained within Pub. 100-02, Section 220 of the Medicare Benefit Policy manual and any applicable local coverage decisions when making decisions as to whether a service shall be preapproved.
How long will a contractor have to make a decision on a pre-approval request?
Answer:
10 business days.
What happens if a contractor’s decision about request for an exception is not made within 10 business days?
Answer:
If a decision is not made within 10 business days, the request for exception will be deemed to be approved. You will receive a letter from Palmetto GBA indicating the approval of your request.
If a decision was made within 10 business days and the request for an exception was denied, and the provider furnishes the service to the beneficiary and submits a claim, what happens?
Answer:
The claim is not payable under Medicare, the claim will be denied, and the
beneficiary will be liable for the services. You will receive a decision letter that will detail the reason for the denial.
Will claims that are pre-approved be guaranteed payment?
Answer:
Authorization does not guarantee payment. Retrospective review may still be performed.
Why would a Medicare contractor review therapy that has been preapproved?
Answer:
There are many reasons retrospective review would be needed after a preapproval:
Clinically inappropriate modalities
Patient’s clinical therapy needs do not match what was reported, e.g.
Patient’s functional level is greater than reported
Patient reached functional independence more quickly than predicted
Excessive or inappropriate therapy was furnished, e.g.
Therapy more often or of longer duration than is reasonable and medically necessary
Therapy provided to clinical treatment area not reasonable and necessary, e.g. therapy to shoulder when knee is the issue
Can I appeal the claim?
Answer:
Yes you may appeal unapproved services.
Why is the beneficiary liable?
Answer:
Medicare only covers therapy services up to $1,880 cap in 2012. For services between $1,880 and $3,700, if the conditions for an exception are not met, the beneficiary is financially responsible. For services above the $3,700 threshold, if a request for an exception to the $3,700 threshold is not met, the beneficiary is financially responsible.
Am I required to provide the beneficiary an Advanced Beneficiary Notice (ABN) for services above the therapy cap of $1,880?
Answer:
There is no legal requirement for issuance of an ABN. However, CMS strongly recommends a voluntary ABN where the provider believes that Medicare may not cover the services.
What happens if I request pre-approval and gain approval for 20 treatment days and I actually furnish 30 treatments?
Answer:
The claim will be subject to prepayment medical review.
How is CMS educating beneficiaries about the therapy cap and the threshold?
Answer:
CMS conducted a mailing in September to beneficiaries who have received therapy services at or near the cap. The mailing informed them of the cap and of the fact that if services above the cap are denied, that they will be financially liable.
What is the therapy cap amount for 2012?
Answer:
The annual per beneficiary therapy cap amount for 2012 is $1880 for physical therapy and speech language pathology services combined (PT/SLP). There is a separate $1880 amount allotted for occupational therapy services.
What provider settings are subject to the therapy cap in 2012?
Answer:
Effective January 1, 2012, the $1880 therapy cap with an exceptions process, applies to services furnished in the following outpatient therapy settings: physical therapists in private practice, physician offices, skilled nursing facilities (SNF) (Part B), rehabilitation agencies (or ORFs), and comprehensive outpatient rehabilitation facilities (CORFs). In addition, the therapy cap with an exceptions process will apply to hospital outpatient departments no later than October 1, 2012, until the end of 2012.
Does the therapy cap with no exceptions process go back into effect on January 1, 2013?
Answer:
Unless Congress passes legislation by the end of the year there will be a therapy cap with no exceptions process for all outpatient therapy settings, except hospitals. Effective January 1, 2013, the therapy cap would not apply to hospitals unless Congress passes legislation.
Does the therapy cap apply to Medicare beneficiaries enrolled in a Medicare Advantage plan?
Answer:
The Medicare Advantage Plan may apply the $1880 therapy cap with an exceptions process if it chooses; however, many Medicare Advantage plans chose not to apply the therapy cap in the past. You should check with your Medicare Advantage plan regarding its payment policies.
If we are not contracted with a Medicare Advantage Plan and they are not required to pay our normal Medicare payment then would we apply the therapy cap for beneficiaries with those plans?
Answer:
The cap will only be tracked through outpatient therapy claims that process through the regular fee for service Medicare system.
Does the cap amount 'reset' for each diagnosis? For instance, if a patient receives PT services January-March for a hip replacement and is discharged, then returns in September as a result of a stroke, is there one cap for the first episode of treatment and a new cap for the second episode of treatment?
Answer:
No. The therapy cap is an annual per beneficiary cap.
With the cap for 2012 of $1880 for Part B PT/SLP benefits, how does the cap count toward the patient responsibility of 20%?
Answer:
For example, the patient is responsible for 20% of allowable charges as an outpatient. Medicare will pay 80% of the allowed charges ($1504.00) and the beneficiary will be responsible for the remaining 20% ($376.00).
Where do I find information about the amount of dollars that my patient has accrued toward the therapy cap?
Answer:
All providers and contractors may access the accrued amount of therapy services from the ELGA screen inquiries into CWF. Providers/suppliers may access the remaining therapy services limitation dollar amount through the 270/271 eligibility inquiry and response transaction. Providers who bill to fiscal intermediaries (FIs) will find the amount a beneficiary has accrued toward the financial limitations on the HIQA. Some suppliers and providers billing to carriers may, in addition, have access to the accrued amount of therapy services from the ELGB screen inquiries into CWF. Suppliers who do not have access to these inquiries may call the contractor to obtain the amount accrued.
Do providers need to include national provider identifiers of the physician who reviews the therapy plan of care on the claim form?
Answer:
Yes. Starting October 1, 2012, each request for payment must include the national provider identifier (NPI) of the physician who periodically reviews the therapy plan of care. APTA anticipates CMS will issue further guidance to providers regarding placement of the NPI on the claim form.
Where can I find additional resources regarding the therapy cap?
Answer:
CMS has issued a fact sheet and a question and answer document external link regarding manual medical review which are now available.
Why was my redetermination request denied when I submitted a letter showing my patient was no longer incarcerated at the time of my service?
Answer:
The claim cannot be allowed until the Common Working File (CWF) is updated with the incarceration end date. Your patient will need to contact the Social Security Administration to have their record updated.
If I submit my Appeal through Palmetto GBA's eServices, do I need to submit the Appeal request and documentation hard copy as well?
Answer:
There is no need to mail or fax a hard copy form once an eAppeals is submitted via Palmetto GBA's eServices. You will receive an acceptance message confirming receipt and then another message with the Document Control Number (DCN) when the appeal has started processing.
CPT Code 97760. 97761 and 97762, 97763 -Orthotic, prosthetic training
CPT CODE, DESCRIPTION AND FEE amount
97760 - Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes - Average Fee amount -$40
97761 - Prosthetic training, upper and/or lower extremity(s), each 15 minutes - Average Fee amount - $35
97762 - Checkout for orthotic/prosthetic use, established patient, each 15 minutes - Average Fee amount - $48
Orthotics Fitting (CPT code 97760)
1. This procedure may be considered reasonable and necessary, if there is an indication for education for the application of orthotics, and the functional use of the orthotic is present and documented.
2. Generally, orthotic training can be completed in three visits; however for modification of the orthotic due to healing of tissue, change in edema, or impairment in skin integrity additional visits may be required.
3. The medical record should document the distinct treatments rendered when orthotic training for upper and lower extremity is done.
4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to apply the device.
Prosthetic Training (CPT code 97761)
1. This procedure and training may be considered reasonable and necessary, if there is an indication for education in the application of the prosthesis, and the functional use of the prosthesis is present and documented.
2. The medical record should document the distinct goals and service rendered when prosthetic training for upper and lower extremity is done.
3. Periodic revisits beyond the third month would require documentation to support medical necessity.
Orthotic/Prosthetic Checkout (CPT Code 97762)
1. These assessments are reasonable and necessary when there is a modification or reissue of a recently issued device or a reassessment of a newly issued device.
2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls).
3. These assessments may be reasonable and necessary for determining "the patients response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, underwrap, or socks and determining the patient's tolerance to any dynamic forces being applied."
Medicare Policy:
Some of the policies implemented in this notification were 1) discussed in the CY 2006 OPPS final rule, or 2) discussed in the CY 2006 MPFS final rule or reflected in its Addendum B. Other policies contained in this notification correct or clarify our previous policy noted in Transmittal 515, CR 3647, issued April 1, 2005 in Pub. 100-04. This CR updates the therapy code list and associated policies for CY 2006, as follows:
1) “Orthotic Management and Prosthetic Management” Services.
In order to create a new category under the section for physical medicine and rehabilitation services, HCPCS/CPT modified the descriptor of one of these codes, CPT 97504 (2005), and renumbered it as well as two other HCPCS/CPT codes. The new therapy code list removes the CY 2005 CPT codes, 97504, 97520 and 97703 and replaces them with CPT codes 97760, 97761 and 97762, respectively, for use in CY 2006.
Constant Attendance Modalities (97010-97039), Therapeutic Procedures (97110-97542), Orthotic Management (97760, 97762), and the unlisted Physical Medicine code (97799) will be limited to a maximum 4 therapeutic modalities per treatment session, not to exceed one hour (4 units) for the combinations of codes submitted.
Generally, CPT code 97116 should not be reported with 97760. However, if a service represented by code 97760 was performed on an upper extremity and a service represented by code 97116© (gait training) was also performed, both codes may be billed with modifier 59 to denote separate anatomic sites.
Orthotic Management and Prosthetic Management:
CPT codes 97760-97762 describe orthotic and prosthetic assessment, management, and training
services. These codes also contain a 15 minute time component
The “Rule of Eight” reporting requirements described in the policy section below apply to all of the 15 minute time-based codes listed above under Modalities, Therapeutic Procedures, Tests and
Measurements, and Orthotic Management and Prosthetic Management. However, this policy focuses
on Constant Attendance Modalities and Therapeutic Procedures
I. “Rule of Eight”
The Health Plan has adopted The Centers for Medicare & Medicaid Services (CMS) reporting guidelines for determining the appropriate number of units to report with respect to physical medicine CPT codes that are subject to a 15-minute time component. The Health Plan refers to this guideline as the “Rule of Eight.”
The “Rule of Eight” addresses the relationship between the direct (one-on-one) time spent with the patient, and the billing and reimbursement of a unit of service. According to the “Rule of Eight”, the provider must spend more than one-half (8 minutes or more) of a given 15-minute time component with the patient in order to properly submit that unit to the Health Plan for reimbursement
II. Reporting Guidelines
The Health Plan requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the performance of procedures that are reported to Health Plan as direct treatment services.
• The time reported should be the time actually spent in the delivery of the modality and/or therapeutic procedure. This means that pre and post-delivery services should not be counted in determining the treatment time.
• The time that the patient spends not being treated, due to resting periods or waiting for a piece of equipment to become available, is not considered treatment time.
• All treatment time, including the beginning and ending time of the direct treatment, must be recorded in the patient’s medical record, along with the note describing the specific modality or procedure.
III. Determining Units
A. A provider should not report a direct treatment service if only one attended modality or therapeutic procedure is provided in a day, and the procedure is performed for less than 8 minutes.
B. A single 15-minute unit of direct treatment service may be billed when the duration of direct treatment is equal to or greater than 8 minutes, and less than 23 minutes. If the duration of a single modality or procedure is between 23 minutes but less than 38 minutes, then two 15-minute units of direct treatment service may be billed.
The following table indicates the appropriate protocol for reporting each additional unit:
Number of units billed: Number of minutes provided in treatment:
1 unit 8 minutes to < 23 minutes
2 units 23 minutes to < 38 minutes
3 units 38 minutes to < 53 minutes
4 units 53 minutes to < 68 minutes
5 units 68 minutes to < 83 minutes
6 units 83 minutes to < 98 minutes
7 units 98 minutes to < 113 minutes
8 units 113 minutes to < 128 minutes*
TMJ Orthotic Adjustments
Adjustments for TMJ orthotics are normally billed under CPT codes 97760 or 97762. These services are not separately covered with a TMJ diagnosis. These adjustments are considered an integral part of the splint therapy and as such will be denied regardless if billed alone or with another service.
Modifier Invalid Combination Special Coding Instructions
G8 QS Modifier G8 should only be used with the following anesthesia codes: 00100, 00160, 00300, 00400, 00532, and 00920. KMAP will deny the service if this modifier is billed with any code other than those listed. G9 Submit this modifier only with anesthesia services (such as codes 00100 – 01999). KMAP will deny services billed with modifier G9 on codes other than the anesthesia series of codes.
GA
GB At this time, there are no special coding instructions applicable to Medicaid claims billing for these modifiers.
GC Modifier GC must be used by the physician for teaching physician services. A teaching physician service billed using this modifier is certifying that he or she has been present during the key portion of the service and was immediately available during the other parts of the service.
GD At this time, there are no special coding instructions applicable to Medicaid claims billing for this modifier.
GE Submit this modifier with services performed by a resident in a teaching facility without the presence of a teaching physician. This modifier is informational and can only be submitted with procedure codes included in the primary care exception. HCPCS code: G0344
CPT® codes: 99201 – 99203, 99211 – 99213, 93005 and 93041
GF For services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA), use this modifier.
GG Modifier GG is used when a diagnostic and a screening mammogram are performed on the same day for the same patient. Modifier GG is added to the diagnostic mammography code only. Both the diagnostic and screening codes must be billed on the same claim form. Submit modifier GG with the diagnostic mammography code. CMS uses this modifier for tracking and data collection purposes. This modifier can be submitted with the following:
CPT® codes: 76082, 76090, 76091, 77051, 77055 and 77056 HCPCS codes: G0204, G0206, and G0236 KMAP will deny the service if this modifier is billed with any code other than those listed.
GH When a screening mammogram indicates a potential problem, the interpreting radiologist can order additional films during the same visit on the same day without an additional order from the treating physician. The radiologist must report to the treating physician the condition of the patient. These additional films, with the report to the treating physician, convert a screening mammogram to a diagnostic mammogram. The procedure code is reported with modifier GH to indicate the radiologist converted the screening mammogram to a diagnostic mammogram.
This modifier can be submitted with CPT® codes: 76090, 76091, 77055 and 77056. KMAP will deny the service if this modifier is billed with any code other than those listed.
GJ This modifier is used specific to Medicare. Medicare rules: Physicians who have opted out of Medicare (also called private contracting) are not permitted to submit services toMedicare; however, the exception to this rule is when services are provided on an emergent or urgent basis. Opt-out physicians and practitioners must submit these services to Medicare with modifier GJ. In order to opt out of Medicare, physicians and practitioners who are permitted to opt out must follow certain procedures and guidelines.
GK
GL At this time, there are no special coding instructions applicable to Medicaid claims billing for these modifiers.
GM This modifier can be submitted only with claims for ambulance transport, A0021 – A0999. KMAP will deny the service if this modifier is billed with any code other than those listed.
GN Submit modifier GN to indicate the services were delivered under an outpatient speech language pathology plan of care. KMAP has determined it is appropriate to use modifier GN on the following codes: 64550, G0281, G0283, G0329, 0019T, 0029T, 0183T, 90901, 92520, 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92607, 92608, 92609, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 96105, 96110, 96111, 96125, 97001, 97002, 97003, 97004, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97597, 97598, 97602, 97605, 97606, 97750, 97755, 97760, 97761, 97762 and 97799.
KMAP will deny the service if this modifier is billed with any code other than those listed
GO Submit modifier GO to indicate services delivered under an outpatient occupational plan of care. KMAP has determined it is appropriate to use modifier GO on the following codes:
• 97010 through 97546; 97760 through 97799
* These codes must be billed separately.
* If you deliver more than one unit of service the number must be recorded in the units field of the CMS 1500 claim form.
* When the same modality is applied to two different locations on the same day, always identify the areas (i.e., right shoulder and left elbow) on claim attachment.
* When two modalities are performed by one machine at the same time only one modality may be billed.
Multiple Concurrent Physical Medicine Procedures and Modalities: “Multiple concurrent physical medicine procedures are subject to the following rules and limitations.
• No more than four physical medicine procedures, modalities or time units will be reimbursed in one visit by each type of medical provider. No more than two of the four CPT code charges can be modality codes (CPT codes 97010-97039). The only exceptions to this are:
1) if injured employee is diagnosed as “catastrophic”
2) 2) CPT codes 97545 and 97546 (see page 12, Physical Medicine Maximum Per Visit and/or Day for more details)
3) CPT code 97750 when used for Functional capacity evaluation (FCE) only with a limit of $600.00
4) CPT code 97750 must be used by physical/occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. Additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI - Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day.
CPT code 99455 or 99456 should be used by the treating physician when performing an impairment rating.
Under the guidelines above, Physical Performance Test/Measurement testing and functional capacity evaluation can be performed on the same day by physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day.
5) CPT Code 97760, Management and training (including assessment and fitting when not otherwise reported) for custom-made orthotics, CPT code 97761, Prosthetic training, and CPT code 97762, Checkout for Orthotic/prosthetic use, established patient. CPT code 97762 is used to checkout the custom-made Orthotic/prosthetic for any medically necessary adjustments
6) by mutual agreement of all parties
CPT Deletion and modification update
The policies implemented in CR10303 were discussed in CY 2018 Medicare Physician Fee Schedule (MPFS) rulemaking. CR10303 updates the therapy code list and associated policies for CY 2018, as follows:
* The Current Procedural Terminology (CPT) Editorial Panel revised the set of codes physical and occupational therapists use to report orthotic and prosthetic management and training services by differentiating between initial and subsequent encounters through the: (a) addition of the term “initial encounter” to the code descriptors for CPT codes 97760 and 97761, (b) creation of CPT code 97763 to describe all subsequent encounters for orthotics and/or prosthetics management and training services, and (c) deletion of CPT code 97762. The new long descriptors for CPT codes 97760 and 97761
– now intended only to be reported for the initial encounter with the patient – are:
o CPT code 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes)
o CPT code 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes)
* The Centers for Medicare & Medicaid Services (CMS) will add CPT code 97763 to the therapy code list and CPT code 97762 will be deleted.
* The panel also created, for CY 2018, CPT code 97127 to replace/delete CPT code 97532. CMS will recognize HCPCS code G0515, instead of CPT code 97127, and add HCPCS code G0515 to the therapy code list. CPT code 97127 will be assigned a Medicare Physician Fee Schedule (MPFS) payment status indicator of “I” to indicate that it is “invalid” for Medicare purposes and that another code is used for reporting and payment for these services.
* Just as its predecessor code was, CPT code 97763 is designated as “always therapy” and must always be reported with the appropriate therapy modifier, GN, GO or GP, to indicate whether it’s under a Speech-language pathology (SLP), Occupational Therapy (OT) or Physical Therapy (PT) plan of care, respectively.
* HCPCS code G0515 is designated as a “sometimes therapy” code, which means that an appropriate therapy modifier - GN, GO or GP, to reflect it’s under an SLP, OT, or PT plan of care – is always required when this service is furnished by therapists; and, when it’s furnished by or incident to physicians and certain Nonphysician Practitioners (NPPs), that is, nurse practitioners, physician assistants, and clinical nurse specialists when the services are integral to an SLP, OT, or PT plan of care. Accordingly, HCPCS code G0515 is sometimes appropriately reported by physicians, NPPs, and psychologists without a therapy modifier when it is appropriately furnished outside an SLP, OT, or PT plan of care. When furnished by psychologists, the services of HCPCS code G0515 are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier.
* The therapy code list is updated with one new “always therapy” code and one new “sometimes therapy” code, using their HCPCS/CPT long descriptors, as follows:
o CPT code 97763 – This “always therapy” code replaces/deletes CPT code 97762.
o CPT code 97763: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
o HCPCS code G0515 – This “sometimes therapy” code replaces/deletes CPT code 97532
o HCPCS code G0515: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
Physical Medicine Maximum per Visit and/or Day:
No more than four charges will be reimbursed per visit/day regardless of medical necessity. No more than two of the charges can be modality codes (CPT codes 97010-97039). Each unit (15 minutes) reported counts as one charge. Exemptions to this rule are as follows:
1) An injured worker has been diagnosed with a catastrophic injury, O.C.G.A. §34-9- 200.1(g).
2) CPT codes 97545 and 97546 report work hardening/work conditioning. CPT code 97545 reports the first two hours and CPT code 97546 reports each additional hour. The total dollar amount reimbursed for work hardening/work conditioning reported with these two CPT codes shall not exceed $267.00 per visit/day.
3) CPT code 97750 - Physical Performance Test/Measurements with Report 15 Minutes. This code must be used for billing functional capacity evaluations (not to exceed $600.00).
CPT code 97750 must be used by physical/occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. Additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI - Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day.
CPT code 99455 or 99456 should be used by the treating physician when performing an impairment rating.
Under the guidelines above, Physical Performance Test/Measurement testing and functional capacity evaluation can be performed on the same day by physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day.
4) CPT code 97760, Orthotic management and training (including assessment and fitting when not otherwise reported) for custom-made orthotics, CPT code 97761, Prosthetic training, and CPT code 97762, Checkout for orthotic/prosthetic use, established patient.
97760 - Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes - Average Fee amount -$40
97761 - Prosthetic training, upper and/or lower extremity(s), each 15 minutes - Average Fee amount - $35
97762 - Checkout for orthotic/prosthetic use, established patient, each 15 minutes - Average Fee amount - $48
Orthotics Fitting (CPT code 97760)
1. This procedure may be considered reasonable and necessary, if there is an indication for education for the application of orthotics, and the functional use of the orthotic is present and documented.
2. Generally, orthotic training can be completed in three visits; however for modification of the orthotic due to healing of tissue, change in edema, or impairment in skin integrity additional visits may be required.
3. The medical record should document the distinct treatments rendered when orthotic training for upper and lower extremity is done.
4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to apply the device.
Prosthetic Training (CPT code 97761)
1. This procedure and training may be considered reasonable and necessary, if there is an indication for education in the application of the prosthesis, and the functional use of the prosthesis is present and documented.
2. The medical record should document the distinct goals and service rendered when prosthetic training for upper and lower extremity is done.
3. Periodic revisits beyond the third month would require documentation to support medical necessity.
Orthotic/Prosthetic Checkout (CPT Code 97762)
1. These assessments are reasonable and necessary when there is a modification or reissue of a recently issued device or a reassessment of a newly issued device.
2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls).
3. These assessments may be reasonable and necessary for determining "the patients response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, underwrap, or socks and determining the patient's tolerance to any dynamic forces being applied."
Medicare Policy:
Some of the policies implemented in this notification were 1) discussed in the CY 2006 OPPS final rule, or 2) discussed in the CY 2006 MPFS final rule or reflected in its Addendum B. Other policies contained in this notification correct or clarify our previous policy noted in Transmittal 515, CR 3647, issued April 1, 2005 in Pub. 100-04. This CR updates the therapy code list and associated policies for CY 2006, as follows:
1) “Orthotic Management and Prosthetic Management” Services.
In order to create a new category under the section for physical medicine and rehabilitation services, HCPCS/CPT modified the descriptor of one of these codes, CPT 97504 (2005), and renumbered it as well as two other HCPCS/CPT codes. The new therapy code list removes the CY 2005 CPT codes, 97504, 97520 and 97703 and replaces them with CPT codes 97760, 97761 and 97762, respectively, for use in CY 2006.
Constant Attendance Modalities (97010-97039), Therapeutic Procedures (97110-97542), Orthotic Management (97760, 97762), and the unlisted Physical Medicine code (97799) will be limited to a maximum 4 therapeutic modalities per treatment session, not to exceed one hour (4 units) for the combinations of codes submitted.
Generally, CPT code 97116 should not be reported with 97760. However, if a service represented by code 97760 was performed on an upper extremity and a service represented by code 97116© (gait training) was also performed, both codes may be billed with modifier 59 to denote separate anatomic sites.
Orthotic Management and Prosthetic Management:
CPT codes 97760-97762 describe orthotic and prosthetic assessment, management, and training
services. These codes also contain a 15 minute time component
The “Rule of Eight” reporting requirements described in the policy section below apply to all of the 15 minute time-based codes listed above under Modalities, Therapeutic Procedures, Tests and
Measurements, and Orthotic Management and Prosthetic Management. However, this policy focuses
on Constant Attendance Modalities and Therapeutic Procedures
I. “Rule of Eight”
The Health Plan has adopted The Centers for Medicare & Medicaid Services (CMS) reporting guidelines for determining the appropriate number of units to report with respect to physical medicine CPT codes that are subject to a 15-minute time component. The Health Plan refers to this guideline as the “Rule of Eight.”
The “Rule of Eight” addresses the relationship between the direct (one-on-one) time spent with the patient, and the billing and reimbursement of a unit of service. According to the “Rule of Eight”, the provider must spend more than one-half (8 minutes or more) of a given 15-minute time component with the patient in order to properly submit that unit to the Health Plan for reimbursement
II. Reporting Guidelines
The Health Plan requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the performance of procedures that are reported to Health Plan as direct treatment services.
• The time reported should be the time actually spent in the delivery of the modality and/or therapeutic procedure. This means that pre and post-delivery services should not be counted in determining the treatment time.
• The time that the patient spends not being treated, due to resting periods or waiting for a piece of equipment to become available, is not considered treatment time.
• All treatment time, including the beginning and ending time of the direct treatment, must be recorded in the patient’s medical record, along with the note describing the specific modality or procedure.
III. Determining Units
A. A provider should not report a direct treatment service if only one attended modality or therapeutic procedure is provided in a day, and the procedure is performed for less than 8 minutes.
B. A single 15-minute unit of direct treatment service may be billed when the duration of direct treatment is equal to or greater than 8 minutes, and less than 23 minutes. If the duration of a single modality or procedure is between 23 minutes but less than 38 minutes, then two 15-minute units of direct treatment service may be billed.
The following table indicates the appropriate protocol for reporting each additional unit:
Number of units billed: Number of minutes provided in treatment:
1 unit 8 minutes to < 23 minutes
2 units 23 minutes to < 38 minutes
3 units 38 minutes to < 53 minutes
4 units 53 minutes to < 68 minutes
5 units 68 minutes to < 83 minutes
6 units 83 minutes to < 98 minutes
7 units 98 minutes to < 113 minutes
8 units 113 minutes to < 128 minutes*
TMJ Orthotic Adjustments
Adjustments for TMJ orthotics are normally billed under CPT codes 97760 or 97762. These services are not separately covered with a TMJ diagnosis. These adjustments are considered an integral part of the splint therapy and as such will be denied regardless if billed alone or with another service.
Modifier Invalid Combination Special Coding Instructions
G8 QS Modifier G8 should only be used with the following anesthesia codes: 00100, 00160, 00300, 00400, 00532, and 00920. KMAP will deny the service if this modifier is billed with any code other than those listed. G9 Submit this modifier only with anesthesia services (such as codes 00100 – 01999). KMAP will deny services billed with modifier G9 on codes other than the anesthesia series of codes.
GA
GB At this time, there are no special coding instructions applicable to Medicaid claims billing for these modifiers.
GC Modifier GC must be used by the physician for teaching physician services. A teaching physician service billed using this modifier is certifying that he or she has been present during the key portion of the service and was immediately available during the other parts of the service.
GD At this time, there are no special coding instructions applicable to Medicaid claims billing for this modifier.
GE Submit this modifier with services performed by a resident in a teaching facility without the presence of a teaching physician. This modifier is informational and can only be submitted with procedure codes included in the primary care exception. HCPCS code: G0344
CPT® codes: 99201 – 99203, 99211 – 99213, 93005 and 93041
GF For services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA), use this modifier.
GG Modifier GG is used when a diagnostic and a screening mammogram are performed on the same day for the same patient. Modifier GG is added to the diagnostic mammography code only. Both the diagnostic and screening codes must be billed on the same claim form. Submit modifier GG with the diagnostic mammography code. CMS uses this modifier for tracking and data collection purposes. This modifier can be submitted with the following:
CPT® codes: 76082, 76090, 76091, 77051, 77055 and 77056 HCPCS codes: G0204, G0206, and G0236 KMAP will deny the service if this modifier is billed with any code other than those listed.
GH When a screening mammogram indicates a potential problem, the interpreting radiologist can order additional films during the same visit on the same day without an additional order from the treating physician. The radiologist must report to the treating physician the condition of the patient. These additional films, with the report to the treating physician, convert a screening mammogram to a diagnostic mammogram. The procedure code is reported with modifier GH to indicate the radiologist converted the screening mammogram to a diagnostic mammogram.
This modifier can be submitted with CPT® codes: 76090, 76091, 77055 and 77056. KMAP will deny the service if this modifier is billed with any code other than those listed.
GJ This modifier is used specific to Medicare. Medicare rules: Physicians who have opted out of Medicare (also called private contracting) are not permitted to submit services toMedicare; however, the exception to this rule is when services are provided on an emergent or urgent basis. Opt-out physicians and practitioners must submit these services to Medicare with modifier GJ. In order to opt out of Medicare, physicians and practitioners who are permitted to opt out must follow certain procedures and guidelines.
GK
GL At this time, there are no special coding instructions applicable to Medicaid claims billing for these modifiers.
GM This modifier can be submitted only with claims for ambulance transport, A0021 – A0999. KMAP will deny the service if this modifier is billed with any code other than those listed.
GN Submit modifier GN to indicate the services were delivered under an outpatient speech language pathology plan of care. KMAP has determined it is appropriate to use modifier GN on the following codes: 64550, G0281, G0283, G0329, 0019T, 0029T, 0183T, 90901, 92520, 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92607, 92608, 92609, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 96105, 96110, 96111, 96125, 97001, 97002, 97003, 97004, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97597, 97598, 97602, 97605, 97606, 97750, 97755, 97760, 97761, 97762 and 97799.
KMAP will deny the service if this modifier is billed with any code other than those listed
GO Submit modifier GO to indicate services delivered under an outpatient occupational plan of care. KMAP has determined it is appropriate to use modifier GO on the following codes:
• 97010 through 97546; 97760 through 97799
* These codes must be billed separately.
* If you deliver more than one unit of service the number must be recorded in the units field of the CMS 1500 claim form.
* When the same modality is applied to two different locations on the same day, always identify the areas (i.e., right shoulder and left elbow) on claim attachment.
* When two modalities are performed by one machine at the same time only one modality may be billed.
Multiple Concurrent Physical Medicine Procedures and Modalities: “Multiple concurrent physical medicine procedures are subject to the following rules and limitations.
• No more than four physical medicine procedures, modalities or time units will be reimbursed in one visit by each type of medical provider. No more than two of the four CPT code charges can be modality codes (CPT codes 97010-97039). The only exceptions to this are:
1) if injured employee is diagnosed as “catastrophic”
2) 2) CPT codes 97545 and 97546 (see page 12, Physical Medicine Maximum Per Visit and/or Day for more details)
3) CPT code 97750 when used for Functional capacity evaluation (FCE) only with a limit of $600.00
4) CPT code 97750 must be used by physical/occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. Additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI - Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day.
CPT code 99455 or 99456 should be used by the treating physician when performing an impairment rating.
Under the guidelines above, Physical Performance Test/Measurement testing and functional capacity evaluation can be performed on the same day by physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day.
5) CPT Code 97760, Management and training (including assessment and fitting when not otherwise reported) for custom-made orthotics, CPT code 97761, Prosthetic training, and CPT code 97762, Checkout for Orthotic/prosthetic use, established patient. CPT code 97762 is used to checkout the custom-made Orthotic/prosthetic for any medically necessary adjustments
6) by mutual agreement of all parties
CPT Deletion and modification update
The policies implemented in CR10303 were discussed in CY 2018 Medicare Physician Fee Schedule (MPFS) rulemaking. CR10303 updates the therapy code list and associated policies for CY 2018, as follows:
* The Current Procedural Terminology (CPT) Editorial Panel revised the set of codes physical and occupational therapists use to report orthotic and prosthetic management and training services by differentiating between initial and subsequent encounters through the: (a) addition of the term “initial encounter” to the code descriptors for CPT codes 97760 and 97761, (b) creation of CPT code 97763 to describe all subsequent encounters for orthotics and/or prosthetics management and training services, and (c) deletion of CPT code 97762. The new long descriptors for CPT codes 97760 and 97761
– now intended only to be reported for the initial encounter with the patient – are:
o CPT code 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes)
o CPT code 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes)
* The Centers for Medicare & Medicaid Services (CMS) will add CPT code 97763 to the therapy code list and CPT code 97762 will be deleted.
* The panel also created, for CY 2018, CPT code 97127 to replace/delete CPT code 97532. CMS will recognize HCPCS code G0515, instead of CPT code 97127, and add HCPCS code G0515 to the therapy code list. CPT code 97127 will be assigned a Medicare Physician Fee Schedule (MPFS) payment status indicator of “I” to indicate that it is “invalid” for Medicare purposes and that another code is used for reporting and payment for these services.
* Just as its predecessor code was, CPT code 97763 is designated as “always therapy” and must always be reported with the appropriate therapy modifier, GN, GO or GP, to indicate whether it’s under a Speech-language pathology (SLP), Occupational Therapy (OT) or Physical Therapy (PT) plan of care, respectively.
* HCPCS code G0515 is designated as a “sometimes therapy” code, which means that an appropriate therapy modifier - GN, GO or GP, to reflect it’s under an SLP, OT, or PT plan of care – is always required when this service is furnished by therapists; and, when it’s furnished by or incident to physicians and certain Nonphysician Practitioners (NPPs), that is, nurse practitioners, physician assistants, and clinical nurse specialists when the services are integral to an SLP, OT, or PT plan of care. Accordingly, HCPCS code G0515 is sometimes appropriately reported by physicians, NPPs, and psychologists without a therapy modifier when it is appropriately furnished outside an SLP, OT, or PT plan of care. When furnished by psychologists, the services of HCPCS code G0515 are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier.
* The therapy code list is updated with one new “always therapy” code and one new “sometimes therapy” code, using their HCPCS/CPT long descriptors, as follows:
o CPT code 97763 – This “always therapy” code replaces/deletes CPT code 97762.
o CPT code 97763: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
o HCPCS code G0515 – This “sometimes therapy” code replaces/deletes CPT code 97532
o HCPCS code G0515: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
Physical Medicine Maximum per Visit and/or Day:
No more than four charges will be reimbursed per visit/day regardless of medical necessity. No more than two of the charges can be modality codes (CPT codes 97010-97039). Each unit (15 minutes) reported counts as one charge. Exemptions to this rule are as follows:
1) An injured worker has been diagnosed with a catastrophic injury, O.C.G.A. §34-9- 200.1(g).
2) CPT codes 97545 and 97546 report work hardening/work conditioning. CPT code 97545 reports the first two hours and CPT code 97546 reports each additional hour. The total dollar amount reimbursed for work hardening/work conditioning reported with these two CPT codes shall not exceed $267.00 per visit/day.
3) CPT code 97750 - Physical Performance Test/Measurements with Report 15 Minutes. This code must be used for billing functional capacity evaluations (not to exceed $600.00).
CPT code 97750 must be used by physical/occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. Additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI - Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day.
CPT code 99455 or 99456 should be used by the treating physician when performing an impairment rating.
Under the guidelines above, Physical Performance Test/Measurement testing and functional capacity evaluation can be performed on the same day by physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day.
4) CPT code 97760, Orthotic management and training (including assessment and fitting when not otherwise reported) for custom-made orthotics, CPT code 97761, Prosthetic training, and CPT code 97762, Checkout for orthotic/prosthetic use, established patient.
CPT CODE 64550 - Surface neurostimulator
CPT CODE 64550 - Application of surface (transcutaneous) neurostimulator - Average fee amount $17
Billing Codes
physical and occupational therapists must use the appropriate CPT® and HCPCS codes 64550, 95831-95852, 95992, 97001-97799 and G0283, with the exceptions noted later in the Noncovered and Bundled Codes section. They must bill the appropriate covered HCPCS codes for miscellaneous materials and supplies. For information on surgical dressings dispensed for home use, refer to the Supplies, Materials and Bundled Services section, page 136. If more than 1 patient is treated at the same time use CPT® code 97150. Refer to the Physical Medicine CPT® Codes Billing Guidance section, page 70 for additional information.
Electrical Stimulation Therapy (CPT codes 64550 and 97032, HCPCS code G0283)
CPT code 97032 requires "visual, verbal and/or manual contact "(i.e. constant attendance). A separate CPT code 64550 is available for "initial application of a TENS unit in which electrodes are placed on the skin" for patients that will be operating the TENS unit at home.
Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity.
Daily Maximum for Services
The daily maximum allowable fee for physical and occupational therapy services
(see WAC 296-23-220and WAC 296-23-230 ......................................................... $ 118.07
The daily maximum applies to CPT® codes 64550, 95831-95852 and 97001-97799 and HCPCS code G0283 when performed for the same claim for the same date of service. If physical, occupational, and massage therapy services are provided on the same day, the daily maximum applies once for each provider type.
If the worker is treated for 2 separate claims with different allowed conditions on the same date, the daily maximum will apply for each claim.
If part of the visit is for a condition unrelated to an accepted claim and part is for the accepted condition, therapists must apportion their usual and customary charges equally between the insurer and the other payer based on the level of service provided during the visit. In this case, separate chart notes for the accepted condition should be sent to the insurer since the employer doesn‘t have the right to see information about an unrelated condition.
The daily maximum allowable fee doesn‘t apply to:
* Performance based physical capacities examinations (PCEs),
* Work hardening services,
* Work evaluations or
* Job modification/prejob accommodation consultation services.
Billing and Coding Guidelines
Comment: Several commenters suggested that CPT code 64550 (application of surface neurostimulator) is not an operative/postoperative code and that it may be used for the initial instruction and issuing of a TENS unit for
home use.
Response: CPT 64550 is in the surgery section of the CPT manual. The LCD advises that when one-to-one patient teaching is provided, to ensure safe, effective use of a home TENS unit, the timed code 97032 better reflects the 1:1 nature when providing this skilled service.
CPT Codes 64550, 90901, 92520, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 95992, 96105, 96110, 96111, 97532, 97597, 97598, 97602, 97605, 97606 and HCPCS Codes 0019T, 0183T
These codes sometimes represent therapy services, as described below:
* They always represent therapy services (limited when limits are in effect) and require therapy modifiers when the service is: • Performed by or, where allowed, under the supervision of therapists; or • Furnished by other qualified personnel and the service provided is integral to an outpatient rehabilitation therapy POC; and * They do not represent therapy services, and therapy limits (when in effect) will not apply when: • It is not appropriate to bill the services under a therapy POC; and • They are billed by practitioners (physicians, clinical nurse specialists, nurse practitioners, and psychologists) who are not therapists; or • They are billed to A/MACs by hospitals for outpatient services furnished by non-therapists.
Medical Necessity:
Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.
1. Heat Treatment, Including the Use of Diathermy (CPT code 97024) and Ultra-Sound (CPT code 97035) for Pulmonary Conditions
2. There is no physiological rationale or valid scientific documentation of effectiveness of diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition and for such purpose this treatment cannot be considered reasonable and necessary within the meaning of §1862(a)(1) of the Act.
3. Electrical stimulation (HCPCS code G0283; CPT code 97032) is considered not reasonable and necessary and is excluded from Medicare coverage for the following:
a. motor nerve disorders such as Bell’s Palsy. (ICD-9 code 351.0)
b. TENS treatments and related services (i.e. CPT code 64550), furnished in physicians/NPP or therapist’s office. (See CMS Pub.100-2 Ch.16 §180, CMS Pub.100-3 §160.3)
c. Electrical Stimulation is not medically necessary for the treatment of strokes when there is no potential for restoration of function.
Improper Coding of Claims
We identified inappropriate claims for TENS services submitted by Totalcare with CPT code 64550. We referred these claims to United for review by its medical policy staff. Based on this review, United officials concluded that TotalCare performed regular, recurrent physical therapy services in an office setting. However, claims for these services were often submitted under code 64550 (the code normally used for TENS services). United further determined that TotalCare should have submitted such claims with a CPT code for physical therapy procedures, which generally correspond to payment rates that are considerably lower than the rates for TENS services (code 64550). This is consistent with information provided by the American Academy of Physical Medicine and Rehabilitation, which concluded that recurrent therapy, provided in an offi ce setting, should not be billed with the CPT code for TENS (code 64550).
As noted previously, CPT code 64550 is intended for the initial application of the TENS unit, and therefore, it generally should not be billed multiple times for the same patient. However, we found many instances where TotalCare billed code 64550 multiple times for individual patients without explanation of the need for the additional TENS sessions. In one instance, TotalCare billed that code 98 times for a patient within one year, with the payments totaling $4,880. In addition, we determined that United paid these claims because it did not have sufficient claims processing controls (for example, claims payment system edits) to limit the number of times code 64550 is allowed per patient.
As a non-participating provider in United’s Empire Plan provider network, TotalCare’s claims for physical therapy services are subject to considerable benefi t rate reductions. However, United did not apply these rate reductions because code 64550 does not correspond to physical therapy. If TotalCare billed appropriately for physical therapy services, United would have paid TotalCare up to $8 for each service claimed. Instead, United paid up to $100 for each service. As a result, United overpaid TotalCare $248,202 for 4,633 inappropriate claims for TENS services during our audit period.
United officials agreed with our audit findings, and they indicated that they have initiated actions to recover the overpayments made to TotalCare. In addition, United has taken steps to prevent such overpayments from occurring in the future. We also discussed our findings with the Departmentof Civil of Service (Department). Department officials likewise agreed with our findings and stated that United should have procedures to identify and deny multiple claims for TENS services (code 64550).
Billing Codes
physical and occupational therapists must use the appropriate CPT® and HCPCS codes 64550, 95831-95852, 95992, 97001-97799 and G0283, with the exceptions noted later in the Noncovered and Bundled Codes section. They must bill the appropriate covered HCPCS codes for miscellaneous materials and supplies. For information on surgical dressings dispensed for home use, refer to the Supplies, Materials and Bundled Services section, page 136. If more than 1 patient is treated at the same time use CPT® code 97150. Refer to the Physical Medicine CPT® Codes Billing Guidance section, page 70 for additional information.
Electrical Stimulation Therapy (CPT codes 64550 and 97032, HCPCS code G0283)
CPT code 97032 requires "visual, verbal and/or manual contact "(i.e. constant attendance). A separate CPT code 64550 is available for "initial application of a TENS unit in which electrodes are placed on the skin" for patients that will be operating the TENS unit at home.
Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity.
Daily Maximum for Services
The daily maximum allowable fee for physical and occupational therapy services
(see WAC 296-23-220and WAC 296-23-230 ......................................................... $ 118.07
The daily maximum applies to CPT® codes 64550, 95831-95852 and 97001-97799 and HCPCS code G0283 when performed for the same claim for the same date of service. If physical, occupational, and massage therapy services are provided on the same day, the daily maximum applies once for each provider type.
If the worker is treated for 2 separate claims with different allowed conditions on the same date, the daily maximum will apply for each claim.
If part of the visit is for a condition unrelated to an accepted claim and part is for the accepted condition, therapists must apportion their usual and customary charges equally between the insurer and the other payer based on the level of service provided during the visit. In this case, separate chart notes for the accepted condition should be sent to the insurer since the employer doesn‘t have the right to see information about an unrelated condition.
The daily maximum allowable fee doesn‘t apply to:
* Performance based physical capacities examinations (PCEs),
* Work hardening services,
* Work evaluations or
* Job modification/prejob accommodation consultation services.
Billing and Coding Guidelines
Comment: Several commenters suggested that CPT code 64550 (application of surface neurostimulator) is not an operative/postoperative code and that it may be used for the initial instruction and issuing of a TENS unit for
home use.
Response: CPT 64550 is in the surgery section of the CPT manual. The LCD advises that when one-to-one patient teaching is provided, to ensure safe, effective use of a home TENS unit, the timed code 97032 better reflects the 1:1 nature when providing this skilled service.
CPT Codes 64550, 90901, 92520, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 95992, 96105, 96110, 96111, 97532, 97597, 97598, 97602, 97605, 97606 and HCPCS Codes 0019T, 0183T
These codes sometimes represent therapy services, as described below:
* They always represent therapy services (limited when limits are in effect) and require therapy modifiers when the service is: • Performed by or, where allowed, under the supervision of therapists; or • Furnished by other qualified personnel and the service provided is integral to an outpatient rehabilitation therapy POC; and * They do not represent therapy services, and therapy limits (when in effect) will not apply when: • It is not appropriate to bill the services under a therapy POC; and • They are billed by practitioners (physicians, clinical nurse specialists, nurse practitioners, and psychologists) who are not therapists; or • They are billed to A/MACs by hospitals for outpatient services furnished by non-therapists.
Medical Necessity:
Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.
1. Heat Treatment, Including the Use of Diathermy (CPT code 97024) and Ultra-Sound (CPT code 97035) for Pulmonary Conditions
2. There is no physiological rationale or valid scientific documentation of effectiveness of diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition and for such purpose this treatment cannot be considered reasonable and necessary within the meaning of §1862(a)(1) of the Act.
3. Electrical stimulation (HCPCS code G0283; CPT code 97032) is considered not reasonable and necessary and is excluded from Medicare coverage for the following:
a. motor nerve disorders such as Bell’s Palsy. (ICD-9 code 351.0)
b. TENS treatments and related services (i.e. CPT code 64550), furnished in physicians/NPP or therapist’s office. (See CMS Pub.100-2 Ch.16 §180, CMS Pub.100-3 §160.3)
c. Electrical Stimulation is not medically necessary for the treatment of strokes when there is no potential for restoration of function.
Improper Coding of Claims
We identified inappropriate claims for TENS services submitted by Totalcare with CPT code 64550. We referred these claims to United for review by its medical policy staff. Based on this review, United officials concluded that TotalCare performed regular, recurrent physical therapy services in an office setting. However, claims for these services were often submitted under code 64550 (the code normally used for TENS services). United further determined that TotalCare should have submitted such claims with a CPT code for physical therapy procedures, which generally correspond to payment rates that are considerably lower than the rates for TENS services (code 64550). This is consistent with information provided by the American Academy of Physical Medicine and Rehabilitation, which concluded that recurrent therapy, provided in an offi ce setting, should not be billed with the CPT code for TENS (code 64550).
As noted previously, CPT code 64550 is intended for the initial application of the TENS unit, and therefore, it generally should not be billed multiple times for the same patient. However, we found many instances where TotalCare billed code 64550 multiple times for individual patients without explanation of the need for the additional TENS sessions. In one instance, TotalCare billed that code 98 times for a patient within one year, with the payments totaling $4,880. In addition, we determined that United paid these claims because it did not have sufficient claims processing controls (for example, claims payment system edits) to limit the number of times code 64550 is allowed per patient.
As a non-participating provider in United’s Empire Plan provider network, TotalCare’s claims for physical therapy services are subject to considerable benefi t rate reductions. However, United did not apply these rate reductions because code 64550 does not correspond to physical therapy. If TotalCare billed appropriately for physical therapy services, United would have paid TotalCare up to $8 for each service claimed. Instead, United paid up to $100 for each service. As a result, United overpaid TotalCare $248,202 for 4,633 inappropriate claims for TENS services during our audit period.
United officials agreed with our audit findings, and they indicated that they have initiated actions to recover the overpayments made to TotalCare. In addition, United has taken steps to prevent such overpayments from occurring in the future. We also discussed our findings with the Departmentof Civil of Service (Department). Department officials likewise agreed with our findings and stated that United should have procedures to identify and deny multiple claims for TENS services (code 64550).
CPT CODE 99183 AND G0277 - COVERAGE AND ICD code
Coverage Indications, Limitations, and/or Medical Necessity
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere (atm) pressure. Either a mono-place chamber pressurized with pure O2 or a larger multi-place chamber pressurized with compressed air where the patient receives pure O2 by mask, head tent, or endotracheal tube may be used.
Hyperbaric Oxygen Therapy serves four primary functions:
It increases the concentration of dissolved oxygen in the blood, which augments oxygenation to all parts of the body; and
It replaces inert gas in the bloodstream with oxygen, which is then metabolized by the body; and
It may stimulate the formation of a collagen matrix and angiogenesis; and
It acts as a bactericide for certain susceptible bacteria.
Developed as treatment for decompression illness, this modality is an established therapy for treating medical disorders such as carbon monoxide poisoning, gas gangrene, acute decompression illness and air embolism. HBO is also considered acceptable as adjunctive therapy in the treatment of sequelae of acute vascular compromise and in the management of some disorders that are refractory to standard medical and surgical care or the result of radiation injury.
Covered Conditions:
Program reimbursement for HBO therapy is limited to the following conditions:
Acute carbon monoxide intoxication,
Decompression illness,
Gas embolism,
Gas gangrene,
Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.
Progressive necrotizing infections (necrotizing fasciitis),
Acute peripheral arterial insufficiency,
Preparation and preservation of compromised skin grafts (not for primary management of wounds),
Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management,
Osteoradionecrosis as an adjunct to conventional treatment,
Soft tissue radionecrosis as an adjunct to conventional treatment,
Cyanide poisoning,
Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment,
Diabetic wounds of the lower extremities in patients who meet the following three criteria:
a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
b. Patient has a wound classified as Wagner grade III or higher; and
c. Patient has failed an adequate course of standard wound therapy.
The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 –days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.
Limitations
Topical Application of Oxygen
This method of administering oxygen does not meet the definition of HBO therapy as stated above, as its clinical efficacy has not been established. Therefore, Medicare considers the topical application of oxygen not reasonable and necessary. Medicare reimbursement will be limited to therapy that is administered in a chamber (including single or multi-place units)
CPT/HCPCS Codes
99183 Hyperbaric oxygen therapy
G0277 Hbot, full body chamber, 30m
Covered ICD-10 diagnoses codes may be downloaded at:
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR9252.zip, choose the spreadsheet 20.29 HBO Therapy.
Billing Multiple Infusion Therapies - Revenue code 0640, 0641, 0644
When billing home health services to Florida Blue, revenue codes and CPT/HCPCS should be reported using the most current publications. The matrix below indicates the commonly used the revenue codes to be used in billing home health/home infusion services.
• Multiple infusion therapies apply to patients who require multiple concurrent infusion treatments including, but not limited to, multiple antibiotics, hydration and chemotherapy.
• Reimbursement for multiple medications may be allowed with payment reductions, as noted per payment policy.
• The only exception to this is aerosolized AIDS drug therapy. It is the only therapy that must be billed in conjunction with another mode of home IV therapy administration. It is also the only drug therapy that, while provided as part of a multiple-therapy treatment, can be billed as a separate service.
• Use procedure code S9061 to report aerosolized AIDS drug therapy.
NOTE: Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.
Revenue Codes Used
• General Classification Home IV Therapy
o 0640
o Non-routine nursing, central line 0641
o Site Care, central line 0642
o Start/Change, peripheral line 0643
o Routine Nursing, peripheral line 0644
• Drugs
o 0250-0252
o 0630-0636
Rehabilitation Therapy Coverage Guidelines
The goal of rehabilitative medicine is recognizable, functional progress toward the restoration or maximization of impaired neuromuscular and musculoskeletal function.
Medicare covers therapy services personally performed only by one of the following:
Licensed Physical Therapists
Occupational Therapists
Speech Language Pathologists
Licensed physical therapy assistants when supervised directly by a licensed Physical Therapist
Licensed occupational therapy assistants when supervised directly by a licensed Occupational Therapist
Medical Doctors (MDs)
Doctors of Osteopathy (DOs)
Doctors of Optometry (ODs)
Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency
Qualified Non-Physician Practitioners
Advanced Nurse Practitioners (ANPs)
Physician Assistants (PAs)
Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency.
“Qualified” personnel when directly supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met. Qualified personnel have met the educational and degree requirements of a licensed therapy professional (PT, OT, SLP), but are not required to be licensed.
Please note that unless these therapy services are performed by a “qualified” person, the services are not covered and must not be reported for Medicare payment.
The 3 major factors in therapy coverage are:
Mobilization
Education
Therapeutic exercise
The dynamic component of therapy, mobilization and patient education should predominate.
Passive modalities should be used in the “warm-up” phase of the patient encounter as preparation for or as an adjunct to therapeutic procedures, and in the “cool-down” phase for reduction of pain, swelling and other post-treatment symptoms.
Though passive modalities may predominate in the earlier phases of rehabilitation where the patient’s ability to participate in therapeutic exercise is restricted, Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care.
Medicare expects the patient’s record to clearly reflect medical necessity for passive modalities, especially those that exceed 25 percent of the cumulative service hours of rehabilitative therapy provided for any beneficiary under a plan of care.
Complicating factors that may influence treatment:
Type
Frequency and/or duration of treatment
Diagnoses
Patient factors
Age
Severity
Acuity
Multiple conditions
Co-morbidities
Motivation
Patient’s social circumstances
In more difficult cases, the practitioner should have documentation that will support the need for continued care that clearly outlines the factors that affect the rate of recovery and reinforces the anticipation that further improvement is expected.
Medicare recognizes variability in strength, recovery time and the ability to be educated, and allows for a recertification for additional therapy, as long as adequate medical documentation by the supervising physician or therapist is recorded in the medical record and the patient continues to demonstrate progress.
Please keep in mind when the duration and intensity of rehabilitative services rendered are limited or extensive, Medicare expects the patient’s medical record to demonstrate clear medical reasonableness and necessity for all therapy services, both active and passive.
Physical Medicine and Rehabilitation (PM&R) is recommended when an assessment by a physician/ NPP /or therapist supports the need for therapy services. Documentation of signs and symptoms, and the written plan of care to incorporate treatment elements that are expected to result in improvement of these limitations in a reasonable period of time.
Physical Medicine and Rehabilitation services must be furnished on an outpatient basis and provided while the patient is or was under the care of a physician or Non-Physician Practitioner.
Other specific requirements include the following:
Medicare covers therapy services that require the skill of a trained and licensed practitioner to perform or supervise.
Medicare does not cover therapy services that do not require the skill of a trained and licensed practitioner to perform even when one of the persons in the list above performs them.
A written plan of care must have diagnoses, and long-term treatment goals consisting of: type, amount, duration, frequency of therapy services.
The plan must be established by the physician, NPP or therapist providing the services before they start.
A therapist should not alter the plan of care established or certified by the physician/NPP without documented written/verbal approval.
New or significantly modified plans of care must be certified within 30 calendar days after the initial treatment under that plan, unless delayed certification criteria are met.
If certification is obtained verbally, it must be followed by a signature within 14 days to be timely.
The plan must be certified and recertified periodically by the physician or NPP.
Recertification must be obtained within the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whichever is less.
Services provided concurrently by a physician, PT and OT may be covered if separate and distinct goals are documented in the treatment plans.
The type, frequency and duration of services must be medically necessary for the patient’s condition under accepted medical, physical therapy and occupational therapy practice standards and relate directly to a written treatment plan.
There must be an expectation that the condition or level of function will improve within a reasonable (and generally predictable) time or the services must be necessary to establish a safe and effective maintenance regimen required in connection with a specific disease.
It is not medically necessary for a qualified professional to perform or supervise maintenance programs that do not require the professional skills of a qualified professional.
These situations include:
Services related to activities for the general good and welfare of patients (i.e., general exercises to promote overall fitness and flexibility).
Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients.
Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities.
Maintenance therapy after the patient has achieved therapeutic goals or, for patients who show no further meaningful progress, should become patient or caregiver directed.
For all Physical Medicine and Rehabilitation modalities and therapeutic procedures on a given day, it is usually not medically necessary to have more than one treatment session per discipline.
Treatment times per session vary based upon the patient’s medical initial therapy needs and progress to date toward established goals. Treatment times per session typically will not exceed 45–60 minutes. Additional time is sometimes required for more complex and/or slow-to-respond patients. However, documentation of the exceptional circumstances must be maintained in the patient’s medical record and available upon request.
Maintenance therapy after therapeutic goals and/or rehabilitative potentials are reached is medically reasonable and necessary but is not covered. However, a qualified professional may develop a maintenance program for the patient to pursue outside of a therapy program and plan of care, generally administered and supervised by family or caregivers. Periodic evaluations of the patient’s condition and response to treatment may be covered when medically necessary if the judgment and skills of a qualified professional are required.
Examples include:
Design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease.
Instructing the patient, family member(s) or caregiver(s) in carrying out the maintenance program.
Infrequent re-evaluations required to assess the patient’s condition and adjust the program.
If a maintenance program is not established until after the therapy program has been completed (and the skills of a therapist are not necessary), development of a maintenance program is not considered reasonable and necessary for the patient’s condition.
Viscosupplementation therapy for knee CPT CODE 20610, J7321, J7327 and covered DX
Medicare will consider viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations medically reasonable and necessary when ALL of the following conditions are met:
• The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness
• The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts
• If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, laboratory and imaging studies (i.e. the pain and functional disability is not considered likely to be due to a diagnosis other than osteoarthritis of the knee.
• The patient has failed at least three months of conservative therapy. Conservative therapy is defined as:
o Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, physical therapy if indicated); and
o If not contraindicated, simple analgesics and NSAIDS.
• The patient has failed to respond to aspiration of the knee and intra-articular corticosteroid injection therapy when inflammation is a significant component of the patient’s symptoms and intra-articular corticosteroids are not contraindicated.
Limitations
• Drugs and biologicals approved for marketing by the FDA are considered safe and effective when used for indications specified on the labeling. The labeling lists the safe and effective, i.e., medically reasonable and necessary dosage and frequency. Therefore, doses and frequences that exceed the accepted standard of recommended dosage and/or frequency, as described in the package insert, are considered not reasonable and necessary and therefore, not subject to coverage.
• Intra-articular injections of other therapeutic agents, such as corticosteroids, should not be performed in the same knee during the course of viscosupplementation therapy.
• If the first course of treatment produces relief, subsequent courses of treatment may be reasonable if symptoms return. Subsequent courses of treatment will be allowed six (6) months after the last injection of a previous course of treatment.
• Per the FDA package insert, the effectiveness of Monovisc™ has not been established for more than one course of treatment.
• Viscosupplementation of joints other than the knee(s) will be considered not reasonable and necessary and will not be subject to coverage.
• Treatment for diagnoses other than those included in the "ICD-9 Codes that Support Medical Necessity" section of this LCD will not be covered.
• Imaging procedures (e.g., 20611, 77012, 77021, 76881, 76882 or 76942) performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Flouroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient’s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.
• Arthrography to provide needle guidance for knee injections will not be covered. (See Utilization Guidelines).
• Coverage of viscosupplementation therapy of the knee assumes that knee arthroplasty is not being considered as a current treatment option.
• Viscosupplementation will not be covered:
o When the diagnosis is anything other than osteoarthritis
o For intra-articular injection in joints other than the knee
o As the initial treatment of osteoarthritis of the knee
o When failure of/or contraindication to conservative therapy and/or corticosteroid injections are not documented in the medical record
o When the dose and treatment regimen exceeds those approved under the FDA label
o When a repeat series of injections is initiated prior to six months after completion of the previous course of treatment
o When a repeat series of injections is administered when there was no symptomatic/functional improvement evidenced from the previous series of injections
o For topical application of hyaluronate preparations
CPT/HCPCS Codes
Group 1 Paragraph
N/A
Group 1 Codes
20610 Drain/inj joint/bursa w/o us
J7321 Hyalgan/supartz inj per dose
J7323 Euflexxa inj per dose
J7324 Orthovisc inj per dose
J7325 Synvisc or Synvisc-One
J7326 Gel-one
J7327 Monovisc inj per dose
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph
For HCPCS codes J7321, J7323, J7324,J7325,J7326, and J7327:
Group 1 Codes
715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG
715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG
715.36 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING LOWER LEG
715.96 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING LOWER LEG
Therapy Functional Reporting G-codes– Short Descriptors
Mobility: Walking & Moving Around
G8978 - Mobility current status
G8979 - Mobility goal status
G8980 - Mobility D/C status
Changing & Maintaining Body Position
G8981 - Body pos current status
G8982 - Body pos goal status
G8983 - Body pos D/C status
Carrying, Moving and Handling Objects
G8984 - Carry current status
G8985 - Carry goal status
G8986 - Carry D/C status
Self-Care
G8987 - Self-care current status
G8988 - Self-care goal status
G8989 - Self--care D/C status
Other PT/OT Primary
G8990 - Other PT/OT current status
G8991 - Other PT/OT goal status
G8992 - Other PT/OT D/C status
Other PT/OT Subsequent
G8993 - Sub PT/OT current status
G8994 - Sub PT/OT goal status
G8995 - Sub PT/OT D/C status
Swallowing
G8996 - Swallow current status
G8997 - Swallow goal status
G8998 - Swallow D/C status
Motor Speech
G8999 - Motor speech current status
G9186 - Motor speech goal status
G9158 - Motor speech D/C status
Spoken Language Comprehension
G9159 - Lang comp current status
G9160 - Lang comp goal status
G9161 - Lang comp D/C status
Spoken Language Expression
G9162 - Lang express current status
G9163 - Lang express goal status
G9164 - Lang express D/C status
Attention
G9165 - Atten current status
G9166 - Atten goal status
G9167 - Atten D/C status
Memory
G9168 - Memory current status
G9169 - Memory goal status
G9170 - Memory D/C status
Voice
G9171 - Voice current status
G9172 - Voice goal status
G9173 - Voice D/C status
Other SLP
G9174 - Speech lang current status
G9175 - Speech lang goal status
G9176 - Speech lang D/C status
Does Medicare require pre authorization for therapy services
Pre-approval requests for therapy services
First Coast is continuing to receive the form “Request for pre-approval of therapy services above the $3700 threshold” for prior authorization of therapy services. In December 2012, First Coast notified providers that the prior authorization of therapy services ended December 17, 2012. First Coast asks that you discontinue submitting pre-approval requests for therapy services. All fax telephone lines for that project have been discontinued.
Claims for dates of service January 1, 2013, that are over the $3,700 threshold are subject to prepayment and/or post payment reviews. Effective April 1, 2013, recovery auditors began the process of reviewing all therapy claims which have exceeded the $3,700 threshold for the year. When responding to additional documentation requests (ADR) for review of claims over the $3,700 threshold, submit the medical documentation to the following recovery auditor for jurisdiction 9.
Connolly Healthcare
Attention: Medical Record Department
555 North Lane
Suite 6125
Conshohocken, PA 19428
racinfo@connolly.com
866-360-2507 (telephone)
203-529-2995 (fax)
First Coast is continuing to receive the form “Request for pre-approval of therapy services above the $3700 threshold” for prior authorization of therapy services. In December 2012, First Coast notified providers that the prior authorization of therapy services ended December 17, 2012. First Coast asks that you discontinue submitting pre-approval requests for therapy services. All fax telephone lines for that project have been discontinued.
Claims for dates of service January 1, 2013, that are over the $3,700 threshold are subject to prepayment and/or post payment reviews. Effective April 1, 2013, recovery auditors began the process of reviewing all therapy claims which have exceeded the $3,700 threshold for the year. When responding to additional documentation requests (ADR) for review of claims over the $3,700 threshold, submit the medical documentation to the following recovery auditor for jurisdiction 9.
Connolly Healthcare
Attention: Medical Record Department
555 North Lane
Suite 6125
Conshohocken, PA 19428
racinfo@connolly.com
866-360-2507 (telephone)
203-529-2995 (fax)
Documentation Requirements for Therapy Services
Documentation Required
List of required documentation. These types of documentation of therapy services are expected to be submitted in response to any requests for documentation, unless the contractor requests otherwise. The timelines are minimum requirements for Medicare payment. Document as often as the clinician’s judgment dictates but no less than the frequency required in Medicare policy:
• Evaluation /and Plan of Care (may be one or two documents). Include the initial evaluation and any re-evaluations relevant to the episode being reviewed;
• Certification (physician/NPP approval of the plan) and recertifications when records are requested after the certification/recertification is due. See definitions in section 220 and certification policy in section 220.1.3 of this chapter. Certification (and recertification of the plan when applicable) are required for payment and must be submitted when records are requested after the certification or recertification is due.
• Progress Reports (including Discharge Notes, if applicable) when records are requested after the reports are due.
• Treatment Notes for each treatment day (may also serve as Progress Reports when required information is included in the notes); and
• A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands their reasoning for services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation.
Limits on Requirements
. Contractors shall not require more specific documentation unless other Medicare manual policies require it. Contractors may request further information to be included in these documents concerning specific cases under review when that information is relevant, but not submitted with records.
Dictated Documentation.
For Medicare purposes, dictated therapy documentation is considered completed on the day it was dictated. The qualified professional may edit and electronically sign the documentation at a later date.
Dates for Documentation
. The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan. However, contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the Progress Report or Treatment
Note refers. For example, if treatment began on the first of the month at a frequency of twice a week, a Progress Report would be required at the end of the month. Contractors may require that the Progress Report that describes that month of treatment be dated not more than 1 week after the end of the month described in the report.
List of required documentation. These types of documentation of therapy services are expected to be submitted in response to any requests for documentation, unless the contractor requests otherwise. The timelines are minimum requirements for Medicare payment. Document as often as the clinician’s judgment dictates but no less than the frequency required in Medicare policy:
• Evaluation /and Plan of Care (may be one or two documents). Include the initial evaluation and any re-evaluations relevant to the episode being reviewed;
• Certification (physician/NPP approval of the plan) and recertifications when records are requested after the certification/recertification is due. See definitions in section 220 and certification policy in section 220.1.3 of this chapter. Certification (and recertification of the plan when applicable) are required for payment and must be submitted when records are requested after the certification or recertification is due.
• Progress Reports (including Discharge Notes, if applicable) when records are requested after the reports are due.
• Treatment Notes for each treatment day (may also serve as Progress Reports when required information is included in the notes); and
• A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands their reasoning for services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation.
Limits on Requirements
. Contractors shall not require more specific documentation unless other Medicare manual policies require it. Contractors may request further information to be included in these documents concerning specific cases under review when that information is relevant, but not submitted with records.
Dictated Documentation.
For Medicare purposes, dictated therapy documentation is considered completed on the day it was dictated. The qualified professional may edit and electronically sign the documentation at a later date.
Dates for Documentation
. The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan. However, contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the Progress Report or Treatment
Note refers. For example, if treatment began on the first of the month at a frequency of twice a week, a Progress Report would be required at the end of the month. Contractors may require that the Progress Report that describes that month of treatment be dated not more than 1 week after the end of the month described in the report.
What is skilled therapy
Skilled Therapy.
Rehabilitative therapy occurs when the skills of a therapist, (See definition of therapist in section 220 of this chapter) are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation.
Skilled therapy may be needed, and improvement in a patient’s condition may occur, even where a chronic or terminal condition exists. For example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety dependence requiring skilled therapy services. The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patient’s condition. In the case of a progressive degenerative disease, for example, service may be intermittently necessary to determine the need for assistive equipment and establish a program to maximize function. The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel without the supervision of qualified professionals.
Services that can be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without the supervision of therapists are not rehabilitative therapy services. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative, or does not legitimately require the services of a qualified professional for management of a maintenance program as described below, the services will no longer be considered reasonable and necessary. Services that are not reasonable or necessary should be excluded from coverage.
Potential for Improvement Due to Treatment
. If an individual’s expected rehabilitation potential would be insignificant in relation to the extent and duration of physical therapy services required to achieve such potential, therapy would not be covered because it is not considered rehabilitative or reasonable and necessary.
Improvement is evidenced by successive objective measurements whenever possible (
Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction of function (e.g., temporary weakness which may follow a brief period of bed rest following abdominal surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities. Therapy furnished in such situations is not considered reasonable and necessary for the treatment of the individual’s illness or injury and the services are not covered.
Rehabilitative therapy occurs when the skills of a therapist, (See definition of therapist in section 220 of this chapter) are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation.
Skilled therapy may be needed, and improvement in a patient’s condition may occur, even where a chronic or terminal condition exists. For example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety dependence requiring skilled therapy services. The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patient’s condition. In the case of a progressive degenerative disease, for example, service may be intermittently necessary to determine the need for assistive equipment and establish a program to maximize function. The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel without the supervision of qualified professionals.
Services that can be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without the supervision of therapists are not rehabilitative therapy services. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative, or does not legitimately require the services of a qualified professional for management of a maintenance program as described below, the services will no longer be considered reasonable and necessary. Services that are not reasonable or necessary should be excluded from coverage.
Potential for Improvement Due to Treatment
. If an individual’s expected rehabilitation potential would be insignificant in relation to the extent and duration of physical therapy services required to achieve such potential, therapy would not be covered because it is not considered rehabilitative or reasonable and necessary.
Improvement is evidenced by successive objective measurements whenever possible (
Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction of function (e.g., temporary weakness which may follow a brief period of bed rest following abdominal surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities. Therapy furnished in such situations is not considered reasonable and necessary for the treatment of the individual’s illness or injury and the services are not covered.
What is Rehabilitative Therapy
Description of Rehabilitative Therapy.
The concept of rehabilitative therapy includes recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, or decrease in severity, or rationalization for an optimistic outlook to justify continued treatment.
Covered therapy services shall be rehabilitative therapy services unless they meet the criteria for maintenance therapy requiring the skills of a therapist described below. Rehabilitative therapy services are skilled procedures that may include but are not limited to:
Evaluations; reevaluations
Establishment of treatment goals specific to the patient’s disability or dysfunction and designed to specifically address each problem identified in the evaluation;
Design of a plan of care addressing the patient’s disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment;
Continued assessment and analysis during implementation of the services at regular intervals;
Instruction leading to establishment of compensatory skills;
Selection of devices to replace or augment a function (e.g., for use as an alternative communication system and short-term training on use of the device or system); and
Patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family should be ongoing through treatment and instructions may have to be modified intermittently if the patient’s status changes.
The concept of rehabilitative therapy includes recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, or decrease in severity, or rationalization for an optimistic outlook to justify continued treatment.
Covered therapy services shall be rehabilitative therapy services unless they meet the criteria for maintenance therapy requiring the skills of a therapist described below. Rehabilitative therapy services are skilled procedures that may include but are not limited to:
Evaluations; reevaluations
Establishment of treatment goals specific to the patient’s disability or dysfunction and designed to specifically address each problem identified in the evaluation;
Design of a plan of care addressing the patient’s disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment;
Continued assessment and analysis during implementation of the services at regular intervals;
Instruction leading to establishment of compensatory skills;
Selection of devices to replace or augment a function (e.g., for use as an alternative communication system and short-term training on use of the device or system); and
Patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family should be ongoing through treatment and instructions may have to be modified intermittently if the patient’s status changes.
Initial Certification of Plan on therapy services
The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of the certification requirements noted above in §220.1 for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less. The initial treatment includes the evaluation that resulted in the plan.
Timing of Initial Certification. The provider or supplier (e.g., facility, physician/NPP, or therapist) should obtain certification as soon as possible after the plan of care is established, unless the requirements of delayed certification are met. “As soon as possible” means that the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment. Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is established. Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification.
Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation). If the order to certify is verbal, it must be followed within 14 days by a signature to be timely. A dated notation of the order to certify the plan should be made in the patient’s medical record.
Recertification is not required if the duration of the initially certified plan of care is more than the duration (length) of the entire episode of treatment.
Timing of Initial Certification. The provider or supplier (e.g., facility, physician/NPP, or therapist) should obtain certification as soon as possible after the plan of care is established, unless the requirements of delayed certification are met. “As soon as possible” means that the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment. Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is established. Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification.
Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation). If the order to certify is verbal, it must be followed within 14 days by a signature to be timely. A dated notation of the order to certify the plan should be made in the patient’s medical record.
Recertification is not required if the duration of the initially certified plan of care is more than the duration (length) of the entire episode of treatment.
what is EPISODE, Evaluation, and interval in outpatient therapy billing
The EPISODE of Outpatient Therapy – For the purposes of therapy policy, an outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that discipline in that setting.
During the episode, the beneficiary may be treated for more than one condition; including conditions with an onset after the episode has begun. For example, a beneficiary receiving PT for a hip fracture who, after the initial treatment session, develops low back pain would also be treated under a PT plan of care for rehabilitation of low back pain. That plan may be modified from the initial plan, or it may be a separate plan specific to the low back pain, but treatment for both conditions concurrently would be considered the same episode of PT treatment. If that same patient developed a swallowing problem during intubation for the hip surgery, the first day of treatment by the SLP would be a new episode of SLP care.
EVALUATION is a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions.
RE-EVALUATION provides additional objective information not included in other documentation. Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient's condition or functional status that was not anticipated in the plan of care. Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines. The decision to provide a reevaluation shall be made by a clinician.
INTERVAL of certified treatment (certification interval) consists of 90 calendar days or less, based on an individual’s needs. A physician/NPP may certify a plan of care for an interval length that is less than 90 days. There may be more than one certification interval in an episode of care. The certification interval is not the same as a Progress Report period.
CPT CODE 97010, 97124, 97140, 97012 - Massage Therapy billing
CPT code and description
97010 - Application of a modality to 1 or more areas; hot or cold packs - average fee amount - $10 - $20
97012 - Application of a modality to 1 or more areas; traction, mechanical
97016 - Application of a modality to 1 or more areas; vasopneumatic devices
97018 - Application of a modality to 1 or more areas; paraffin bath
97022 - Application of a modality to 1 or more areas; whirlpool
97024 - Application of a modality to 1 or more areas; diathermy (eg, microwave)
Medical Necessity
Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation, do not constitute (covered) therapy services for Medicare purposes. Services related to recreational activities such as golf, tennis, running, etc., are also not covered as therapy services.
To be considered reasonable and necessary, the services must meet Medicare guidelines. The guidelines for coverage of outpatient therapies have basic requirements in common.
In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
Improvement is evidenced by successive objective measurements whenever possible. If an individual’s expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.
Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities (CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 220.2(C)). For example, therapy may not be covered for a fully functional patient who developed temporary weakness from a brief period of bed rest following abdominal surgery. It is reasonably expected that as discomfort reduces and the patient gradually resumes daily activities, function will return without skilled therapy intervention.
In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.
A therapy plan of care is developed either by the physician/NPP, or by the physical therapist who will provide the physical therapy services, or the occupational therapist who will provide the occupational therapy services, (only a physician may develop the plan of care in a CORF). The plan must be certified by a physician/NPP.
If the goal of the plan of care is to improve functioning, the documentation must establish that the patient needs the unique skills of a therapist to improve functioning.
If the goal of the plan of care is to maintain, prevent or slow further deterioration of functional status function or prevent deterioration, the documentation must establish that the patient needs the unique skills of a therapist to maintain, prevent or slow further deterioration of functional status.
All services provided are to be specific and effective treatments for the patient’s condition according to accepted standards of medical practice; and the amount, frequency, and duration of the services must be reasonable.
The services that are provided must meet the description of skilled therapy below.
Billing Codes for Massage Therapists
CPT (Current Procedural Terminology) codes for massage therapy and related procedures - identifies the type of care or the procedure that is used in that care. The best way to know what codes the insurance company will accept is to call and ask them! You can not just bill whatever code that they accept. You have to bill what ever code you are trained in. Setting your fees for these codes are another issue. Just because you can get paid more for certain codes, you have to charge the same amount you charge cash clients (plus whatever additional billing fee there is) or else it is considered insurance fraud.
97010- modality; hot or cold packs- 15 minute increment
97124- massage treatment-15 minute increment
97140- myofascial release, manual therapy- 15 minute increment
97112- neuromuscular re-education- 15 minute increment
Diagnosis codes (ICD codes-International Classification of Disease)- Diagnosis codes are often needed when billing even though we are not able to diagnose. This information should come from the referring physician. If the physician does not write the code on the prescription, call them directly to get the code. I highly recommend that you do not try to select your own code from the online code finder or the information below as each physician may code things differently. I am providing this information because physicians often write the code but they don't say what it means.
Call the Physician to get the correct code.
33 minutes of therapeutic exercise (97110), 7 minutes of manual therapy (97140), 40 Total timed minutes
Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.
18 minutes of therapeutic exercise (97110),
13 minutes of manual therapy (97140),
10 minutes of gait training (97116),
8 minutes of ultrasound (97035),
49 Total timed minutes
Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed). You would still document the ultrasound in the treatment notes.
7 minutes of neuromuscular reeducation (97112)
7 minutes therapeutic exercise (97110)
7 minutes manual therapy (97140)
21 Total timed minutes
Appropriate billing is for one unit. The qualified professional (See definition in Pub. 100-02, chapter 15, section 220) shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only one unit is allowed.
NOTE: The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the eighth should be excluded from the total count. The total minutes of active treatment counted for all 15 minute timed codes includes all direct treatment time for the timed codes. Total treatment minutes - including minutes spent providing services represented by untimed codes - are also documented
General Modality Guidelines
(CPT 97010, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, G0281, G0283)
CPT 97016, 97018, 97022, 97024, and 97028 require supervision by the provider.
CPT 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another code at the same time. Only the actual time of the provider’s direct contact with the patient, providing services requiring the skills of a licensed therapist, is covered for these codes. These codes are designated for one or more areas.
The use of modalities as stand-alone treatments are rarely therapeutic, and usually not required or indicated as the sole treatment approach to a patient’s condition. The use of exercise and activities has proven to be an essential part of a therapeutic program. Therefore, a treatment plan should not consist solely of modalities, but include therapeutic procedures. Examples of exceptions are wound care or when a patient is unable to endure therapeutic procedures due to the acuteness of the condition. If a patient is unable to endure therapeutic procedures due to the acuteness of the condition, the number of visits for modalities should not exceed 2-4 visits.
Greater than two (2) modalities should not be used on each visit date.
A balance of supervised and constant attendance modalities should be used.
Multiple heating modalities should not be used on the same day. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation must support the medical necessity of multiple heating modalities. The documentation must support the use of multiple modalities as contributing to the patient’s progress and restoration of function.
These modalities apply to one or more areas treated per day (e.g. paraffin bath used for the left and right hand is billed as one unit).
CPT code 97010 - Application of a modality to one or more areas; hot or cold packs
Hot or cold packs (including Aquamed) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a licensed therapist. Regardless of whether CPT 97010 is billed alone or in conjunction with another therapy code, these modalities are considered non-skilled services and are not separately reimbursable. Hot and cold packs are a covered service; however not separately reimbursable. When CPT 97010 is billed there will be no separate payment (i.e. bundled).
Physical Medicine and Rehabilitation
The selection of appropriate physical medicine modalities and procedures should be based on the desired physiological response in correlation to the stages of healing. In most conditions or injuries, utilization of one carefully selected modality or procedure in combination with CMT is adequate to achieve a successful clinical outcome.
All decisions made by a chiropractor regarding the use of supportive physical medicine modalities and procedures shall be predicated upon a properly documented clinical rationale, which is consistent with current educational and practice standards. The details of all modalities or procedures provided shall be recorded when performed, including time for all constant attendance modalities and therapeutic procedures.
CPT 97140, manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction, one or more regions, each 15 minutes) cannot be reported or billed if the chiropractor also reports or bills for a chiropractic manipulative treatment (CMT) on the same anatomical region4 as the therapeutic procedure. If a chiropractor reports both a CPT 98940-series service and CPT 97140 on the same date of service, the chiropractor’s medical records must document the differences between the two procedures and that each was conducted on a different anatomical site. To document this, you may use Modifier 59 (Distinct procedural service) when billing for these procedures (i.e., CPT 97140-59).
It is not appropriate to bill CPT 97124, massage, for myofascial release. For myofascial release, CPT 97140 should be reported. When reporting or billing for CPT 97112 (neuromuscular re-education) and CPT 97124 (massage), as well as all other physical medicine modalities and therapeutic procedures, the details of the procedure shall be recorded in the medical record, including clinical rationale, anatomical site, description of service, and time (as required by the selected CPT code).
Payment Policy:
The physical medicine codes 97010-97028, 97032-97036, 97039 require a physician or therapist to be in constant attendance.
The codes 97110- 97124 should be used for physical therapy procedures.
Additional physical therapy codes 97140-97542 and 97597-97606 should be used as defined in CPT.
Physical therapists evaluation and re-evaluation services should be submitted using CPT codes 97001 and 97002. These codes may be reported separately if the patient’s condition requires significant separately identifiable services, above and beyond the usual pre-service and post-service work associated with the procedure performed. The modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service) is not valid with the physical therapy (PT) evaluations and re-evaluation codes 97001-97002. The evaluation or reevaluation codes will be allowed, as appropriate, when billed with other physical or occupational services on the same date. Because the modifier -25 is not valid with 97001-97002, if submitted, the service will be denied.
Modalities:
The CPT Manual defines a modality as “any physical agent applied to produce therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.” CPT codes within the code range of 97032-97036 are “Constant Attendance” codes that require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance.
Therapeutic Procedures:
The CPT Manual defines a therapeutic procedure as “a manner of affecting change through the application of clinical skills and/or services that attempt to improve function.”
CPT codes within the code ranges of 97110-97124, 97140, and 97530-97542 require direct (one-onone) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one-attendance.
Tests and Measurements:
CPT codes 97750 and 97755 require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance.
Orthotic Management and Prosthetic Management:
CPT codes 97760-97762 describe orthotic and prosthetic assessment, management, and training services. These codes also contain a 15 minute time component.
Definition
CPT Code 97140: Manual therapy techniques (e.g. mobilization, manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes.[1] Description Code 97140 is used to report manual therapy (‘hands-on’) techniques that consist of , but are not limited to connective tissue massage, joint mobilization, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. Manual therapy techniques may be applied to one or more regions for 15-minute intervals. These services are not diagnosis or region specific.
CPT® code 97140 is to be reported for each 15 minutes of manual therapy techniques provided to one or more regions.
For example, if 30 minutes of manual therapy techniques were provided to one or more regions, code 97140 would be reported two times, one for each 15-minute interval.
It is important to recognize that 15 minutes must be spent in performing the pre-, intra, and post-service work in order to report code 97140.
Under certain circumstances, it may be appropriate to additionally report CMT/OMT codes in addition to code 97140. For example, a patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques as described by code 97140 to the neck region and CMT to the lumbar region. As separate body regions are addressed, it would be appropriate in this instance to report both codes 97140 and 98940. In this example, the modifier -59 should be appended to indicate that a distinct procedural
service was provided.
Coding Modifiers:
The application of coding modifiers is not a consideration when rendering UR determinations. This section is intended to provide a summary of the related Optum Reimbursement policy No. 0050 – Modifier-59. Under certain circumstances, it may be appropriate for chiropractors to report CPT code 97140 in addition to a CMT code. On these occasions it is appropriate to append the CPT procedural code 97140 with a modifier (-59).
A modifier provides the means by which the reporting health care practitioner can indicate that a CPT descriptor code (service or procedure), which has been performed, has been altered by a specific circumstance or in some way without changing the definition of the CPT code. Modifiers increase the specificity of certain CPT codes.
Modifier -59 indicates that the procedure (97140) represents a distinct service from others reported on the same date of service. This modifier was developed explicitly for the purpose of identifying services not typically performed together.
General Modality Guidelines
(CPT codes 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, G0281, G0283, and G0329)
CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.
CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another procedure at the same time. Only the actual time of the provider’s direct contact with the patient, providing services requiring the skills of a therapist, is covered for these codes.
Modalities chosen to treat the patient’s symptoms/conditions should be selected based on the most effective and efficient means of achieving the patient’s functional goals. Seldom should a patient require more than one (1) or two (2) modalities to the same body part during the therapy session. Use of more than two (2) modalities on each visit date is unusual and should be carefully justified in the documentation.
The use of modalities as stand-alone treatments is rarely therapeutic, and usually not required or indicated as the sole treatment approach to a patient’s condition. The use of exercise and activities has proven to be an essential part of a therapeutic program. Therefore, a treatment plan should not consist solely of modalities, but should also include therapeutic procedures. (There are exceptions, including wound care or when patient care is focused on modalities because the acute patient is unable to endure therapeutic procedures.) Use of only passive modalities that exceeds 4 visits should be very well supported in the documentation.
Multiple heating modalities should not be used on the same day. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation must support the use of multiple modalities as contributing to the patient’s progress and restoration of function. For example, it would not be medically necessary to perform both thermal ultrasound and thermal diathermy on the same area, in the same visit, as both are considered deep heat modalities.
When the symptoms that required the use of certain modalities begin to subside and function improves, the medical record should reflect the discontinuation of those modalities, so as to determine the patient’s ability to self-manage any residual symptoms. As the patient improves, the medical record should reflect a progression of the other procedures of the treatment program (therapeutic exercise, therapeutic activities, etc.). In all cases, the patient and/or caregiver should be taught aspects of self-management of his/her condition from the start of therapy.
Based on the CPT descriptors, these modalities apply to one or more areas treated (e.g., paraffin bath used for the left and right hand is billed as one unit).
CPT 97010 - hot or cold packs (to one or more areas)
Hot or cold packs (including ice massage) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a therapist.
Code 97010 is bundled. It may be bundled with any therapy code. Regardless of whether code 97010 is billed alone or in conjunction with another therapy code, this code is never paid separately. If billed alone, this code will be denied.
Applicable Outpatient Rehabilitation HCPCS Codes
The CMS identifies the following codes as therapy services, regardless of the presence of a financial limitation. Therapy services include only physical therapy, occupational therapy and speech-language pathology services. Therapist means only a physical therapist, occupational therapist or speech-language pathologist. Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology. Check the notes below the chart for details about each code.
When in effect, any financial limitation will also apply to services represented by the following codes, except as noted below.
NOTE: Listing of the following codes does not imply that services are covered or applicable to all provider settings.
96110+? 96111+? 96125 97001 97002 97003 97004 97010**** 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034
Billing - CPT Codes: Permitted
In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 - 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.
Supportive Documentation Requirements for 97010
The area(s) treated
The type of hot or cold application
CPT 97012 - Traction, Mechanical (to one or more areas)
Traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas.
Specific indications for the use of mechanical traction include cervical and/or lumbar radiculopathy and back disorders such as disc herniation, lumbago, and sciatica.
This modality is typically used in conjunction with therapeutic procedures, not as an isolated treatment.
Documentation should support the medical necessity of continued traction treatment in the clinic for greater than 12 visits. For cervical conditions, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home. The time devoted to patient education related to the use of home traction should be billed under 97012.
Only 1 unit of CPT code 97012 is generally covered per date of service.
Equipment and tables utilizing roller systems are not considered true mechanical traction. Services using this type of equipment are non-covered.
Non-Surgical Spinal Decompression Non-surgical spinal decompression is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, non-surgical spinal decompression is not covered by Medicare (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: Section 160.16). Examples of this type of non-covered procedure include, but are not limited to, VAX-D™, DRX-3000, DRX9000, Decompression Reduction Stabilization (DRS) System, IDD, MedX., Spina System, Accua-Spina System, SpineMED Decompression Table, Lordex Traction Unit, Triton DTS, and Z-Grav. If billed for purpose of receiving a denial, these services should be billed using CPT code 97039 and not with CPT 97012.
Supportive Documentation Requirements for 97012
Type of traction and part of the body to which it is applied, etiology of symptoms requiring treatment.
CPT 97014 – Electrical stimulation (unattended) (to one or more areas)
CPT 97014 is not a Medicare recognized code. See HCPCS code G0283 for electrical stimulation (unattended).
CPT 97016 - Vasopneumatic Devices (to one or more areas)
The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema or lymphedema.
Specific indications for the use of vasopneumatic devices include reduction of edema after acute injury or lymphedema of an extremity. Education on the use of a lymphedema pump for home use is covered when medically necessary and can typically be completed in three (3) or fewer visits once the patient has demonstrated measurable benefit in the clinic environment.
Note: Further treatment of lymphedema by a vasopneumatic device rendered by a clinician after the educational visits is generally not reasonable and necessary unless the patient presents with a condition or status requiring the skills and knowledge of a physical or occupational therapist.
The use of vasopneumatic devices is generally not covered as a temporary treatment while awaiting receipt of ordered compression stockings.
See NCD 280.6 in CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual for further coverage and use information on Pneumatic Compression Devices.
Vertebral Axial Decompression Therapy (i.e., VaxD, IDD, DR 5000, DR 9000, SpinaSystem, etc.)
• All claims for this service must be coded using S9090, with one unit of service per day.
• Based on the lack of scientific evidence (blinded studies, appropriate number of participants in studies already conducted, documented long-term results) S9090 will be allowed based on the 97012 allowance and unit limitation guidelines.
• This policy will remain in effect until such time that scientific studies performed within accepted standards are available.
• To ensure correct coding of this service there will be periodic audits performed at random.
• Those claims found to have been coded incorrectly will require appropriate refunds and patients' credits.
Policy Overview
CPT codes 97010 describe Physical Medicine and Rehabilitation modalities that do not require direct (one-on-one) patient contact by the provider.
Reimbursement Guidelines
Consistent with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare Community Plan will not reimburse CPT codes 97010. Reimbursement for 97010 is included in the payment for other services.
Codes CPT code section
97010 Application of a modality to 1 or more areas; hot or cold packs
Supportive Documentation Requirements for 97016
Area of the body being treated, location of edema
Objective edema measurements (1+, 2+ pitting, girth, etc.), comparison with uninvolved side
Effects of edema on function
Type of device used
CPT 97018 – Paraffin Bath (to one or more areas)
Paraffin bath treatments typically do not require the unique skills of a
therapist. However, the skills, knowledge and judgment of a therapist might be required in the provision of such treatment or baths in a complicated case. Only in cases with complicated conditions will paraffin be covered, and then coverage is generally limited to educating the patient/caregiver in home use. Paraffin is contraindicated for open wounds or areas with documented desensitization.
Coding Edits:
CMS (the Centers for Medicare and Medicaid Services), the federal agency that administers the Medicare program, implemented a policy known as the Correct Coding Initiative (CCI). This policy is used to promote correct coding by physicians and to ensure that it makes appropriate payments for physician services.[6] “This policy has been developed and applied by many third party payers across the country.”[7] Correct coding emphasizes that procedures should be reported with the CPT codes that most comprehensively describe the services performed e.g., 98941 is a more comprehensive code than 98940. There are procedural codes that are not to be reported together because they are mutually exclusive to each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session. An example of mutually exclusive codes germane to this policy is 97140 – Manual therapy techniques (without the -59 modifier) vs. 98940, 98941, 98942, or 98943 – Chiropractic manipulative treatment.
Aqua Massage Therapy
• This service should be coded using 97039 with a description of "aqua massage therapy" in the 2400 NTE segment or box 19. It should not be billed using 97124.
• It is considered experimental/investigational and is provider write-off unless a Limited Patient Waiver is signed before performance of the service.
• Use modifier "GA" to demonstrate waiver on file.
Massage
• This service must be coded as 97124, regardless of delivery.
• This will be denied content of service unless it is the only service provided on that date of service.
• Coverage Criteria BCBSKS will consider massage therapy for possible coverage if the following are met.
The massage must be:
** Medical in nature
** Medically necessary
** An integral part of the treatment plan
** Performed by a PT or OT
** Performed by a PTA or COTA under the direct supervision (on-site) of the physical or occupational therapist respectively.
• Limitation of Units of Massage Therapy per Date of Service
** Massage therapy 97124 is coded by 15-minute increments.
** One unit of service per date of service will be considered for coverage without medical records.
If more than one unit of massage is performed on any given date you must attach medical records to support the care. Processing of claims received without this information may be delayed until such information is provided.
** Refunds will be required if services were performed by someone other than the licensed eligible provider.
EXAMPLES OF RED FLAGS:
• Duplicative services
• Misuse of CPT codes
• Billing/use of 97124 and 97140 for the same body part on the same DOS
• # of units / treatment greater than BCBSKS policy allowable
• Billing/use of 97002 for DOS before Jan. 1, 2017 or 97164 for DOS after Jan. 1, 2017 on each DOS billed
• Upcoding (e.g. 97032 instead of 97014)
• Use of unlisted procedure and modality codes
• Billing/use of two or more superficial heating modalities to the same body part – Use of 97010, 97014, 97035 same body part, same session with no documented rationale and objective data to support necessity for each modality
• Continued use of modalities for periods greater than 10 treatment sessions with no documented rationale and objective data to support patient improvement and ongoing treatment.
Vertebral Axial Decompression Therapy (i.e., VaxD, IDD, DR 5000, DR 9000, SpinaSystem, etc.)
• All claims for this service must be coded using S9090, with one unit of service per day.
• Based on the lack of scientific evidence (blinded studies, appropriate number of
parti cipants in studies already conducted, documented long-term results) S9090 will be allowed based on the 97012 allowance and unit limitation guidelines.
• This policy will remain in effect until such time that scientific studies performed within accepted standards are available.
• To ensure correct coding of this service there will be periodic audits performed at random.
• Those claims found to have been coded incorrectly will require appropriate refunds and patients' credits
MOTION TESTING Procedure code
Performing routine muscle testing and range of motion or muscle testing (i.e., tests that are an integral part of the assessment performed each visit to determine the patient's status from one visit to the next and to determine the level of care required for the current visit) are considered content of the evaluation or therapy billed that particular day and should not be billed separately.
97010 CRYOTHERAPY Do not use procedure code 17340, as this is for direct application of chemicals to the skin. This code will deny content of service unless it is the only service provided on the date of service.
97010 HOT OR COLD PACKS Unattended One or more areas is one unit of service This code will deny content of service unless it is the only service provided on the date of service.
97012 TRACTION (MECHANICAL) Unattended One or more areas is one unit of service This code is one or more areas so the unit of service is limited to one regardless of the time spent or the number of areas treated. Sending in medical records will not change the units reimbursed on this code. Roller bed is not considered mechanical traction and is not medically necessary.
97014 ELECTRICAL STIMULATION , INTERFERENTIAL THERAPY,
CPT 97124 describes a service that is a separate and distinct service from Chiropractic Manual Therapy codes 98940-98943. CPT 97124 describes work including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) and is based on each 15 minutes of treatment per unit. When using this code on the same day as a CMT code service, it may be necessary to append a modifier-59 (Distinct Procedure). It should also be noted that this therapy procedure attempts to improve function by direct hands on and one-on-one patient-practitioner/therapist contact. All that is stated in this paragraph should be noted in the documentation.
The expected outcomes of massage are also more general in nature and may in fact be what patients can't tolerate at the more acute stage of their treatment plans. This would include such goals as to decrease pain, decrease muscle spasms, decrease muscle soreness, and increase circulation. Note: For purposes of secondary Medicare billing only, it is appropriate to bill CPT 97124 in conjunction with a CMT code codes 98940-98942 on the same date of service, provided the treatments are to separate body regions of the spine. In these instances Modifier-59 may be added to the 97124.
There is a lot of ambiguity in reference to this CPT code 97140. It is described as a mobilization/manipulation, manual lymphatic drainage, and manual traction of one or more regions. However, the ACA describes Manual Therapy Techniques as consisting of, but not limited to, connective tissue massage, joint mobilization and manipulation, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. It is also based on each 15 minutes of treatment per unit. When using this code on the same day as a CMT code service, it may be necessary to append a modifier-59 (Distinct Procedure). It should also be noted that this therapy procedure attempts to improve function by direct hands on and by one-on-one patient-practitioner/therapist contact. The goals of this particular procedure are to increase flexibility, to increase pain-free range of motion, and to get patients back to their normal daily activities.
This code 97140 continues to suffer from bad and inconsistent guidelines, edits, and laws. The CPT guidelines state that 97140 services are included in the CMT codes (9894-98942) when performed on the same spinal regions as a CMT codes. Also, Medicare NCCI edits categorized 97140 as a component of CMT, unless a modifier (e.g., -59) is used for a different region(s). However, Medicare law prohibits coverage and payment for non-CMT services. Thus, if 97140 is bundled with or into CMT, it would be a violation of Medicare law.
Furthermore, the Medicare relative value units (RVU) do not include any non-spinal services for (e.g., 97140, 97112, 97124 etc.)
When using a physical medicine procedure such as 97140, four things should be documented: technique, different anatomical area from the CMT, time component, and modifier-59.
This has been a humble attempt to try to clarify and define the differences of these therapeutic procedures. It represents one person’s reading of the ACA’s Chiropractic Coding Solutions Manual and the Manual of Chiropractic Code only. It is not legal advice and should not be considered as such.
97010 - Application of a modality to 1 or more areas; hot or cold packs - average fee amount - $10 - $20
97012 - Application of a modality to 1 or more areas; traction, mechanical
97016 - Application of a modality to 1 or more areas; vasopneumatic devices
97018 - Application of a modality to 1 or more areas; paraffin bath
97022 - Application of a modality to 1 or more areas; whirlpool
97024 - Application of a modality to 1 or more areas; diathermy (eg, microwave)
Medical Necessity
Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation, do not constitute (covered) therapy services for Medicare purposes. Services related to recreational activities such as golf, tennis, running, etc., are also not covered as therapy services.
To be considered reasonable and necessary, the services must meet Medicare guidelines. The guidelines for coverage of outpatient therapies have basic requirements in common.
In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
Improvement is evidenced by successive objective measurements whenever possible. If an individual’s expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.
Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities (CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 220.2(C)). For example, therapy may not be covered for a fully functional patient who developed temporary weakness from a brief period of bed rest following abdominal surgery. It is reasonably expected that as discomfort reduces and the patient gradually resumes daily activities, function will return without skilled therapy intervention.
In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.
A therapy plan of care is developed either by the physician/NPP, or by the physical therapist who will provide the physical therapy services, or the occupational therapist who will provide the occupational therapy services, (only a physician may develop the plan of care in a CORF). The plan must be certified by a physician/NPP.
If the goal of the plan of care is to improve functioning, the documentation must establish that the patient needs the unique skills of a therapist to improve functioning.
If the goal of the plan of care is to maintain, prevent or slow further deterioration of functional status function or prevent deterioration, the documentation must establish that the patient needs the unique skills of a therapist to maintain, prevent or slow further deterioration of functional status.
All services provided are to be specific and effective treatments for the patient’s condition according to accepted standards of medical practice; and the amount, frequency, and duration of the services must be reasonable.
The services that are provided must meet the description of skilled therapy below.
Billing Codes for Massage Therapists
CPT (Current Procedural Terminology) codes for massage therapy and related procedures - identifies the type of care or the procedure that is used in that care. The best way to know what codes the insurance company will accept is to call and ask them! You can not just bill whatever code that they accept. You have to bill what ever code you are trained in. Setting your fees for these codes are another issue. Just because you can get paid more for certain codes, you have to charge the same amount you charge cash clients (plus whatever additional billing fee there is) or else it is considered insurance fraud.
97010- modality; hot or cold packs- 15 minute increment
97124- massage treatment-15 minute increment
97140- myofascial release, manual therapy- 15 minute increment
97112- neuromuscular re-education- 15 minute increment
Diagnosis codes (ICD codes-International Classification of Disease)- Diagnosis codes are often needed when billing even though we are not able to diagnose. This information should come from the referring physician. If the physician does not write the code on the prescription, call them directly to get the code. I highly recommend that you do not try to select your own code from the online code finder or the information below as each physician may code things differently. I am providing this information because physicians often write the code but they don't say what it means.
Call the Physician to get the correct code.
33 minutes of therapeutic exercise (97110), 7 minutes of manual therapy (97140), 40 Total timed minutes
Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.
18 minutes of therapeutic exercise (97110),
13 minutes of manual therapy (97140),
10 minutes of gait training (97116),
8 minutes of ultrasound (97035),
49 Total timed minutes
Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed). You would still document the ultrasound in the treatment notes.
7 minutes of neuromuscular reeducation (97112)
7 minutes therapeutic exercise (97110)
7 minutes manual therapy (97140)
21 Total timed minutes
Appropriate billing is for one unit. The qualified professional (See definition in Pub. 100-02, chapter 15, section 220) shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only one unit is allowed.
NOTE: The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the eighth should be excluded from the total count. The total minutes of active treatment counted for all 15 minute timed codes includes all direct treatment time for the timed codes. Total treatment minutes - including minutes spent providing services represented by untimed codes - are also documented
General Modality Guidelines
(CPT 97010, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, G0281, G0283)
CPT 97016, 97018, 97022, 97024, and 97028 require supervision by the provider.
CPT 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another code at the same time. Only the actual time of the provider’s direct contact with the patient, providing services requiring the skills of a licensed therapist, is covered for these codes. These codes are designated for one or more areas.
The use of modalities as stand-alone treatments are rarely therapeutic, and usually not required or indicated as the sole treatment approach to a patient’s condition. The use of exercise and activities has proven to be an essential part of a therapeutic program. Therefore, a treatment plan should not consist solely of modalities, but include therapeutic procedures. Examples of exceptions are wound care or when a patient is unable to endure therapeutic procedures due to the acuteness of the condition. If a patient is unable to endure therapeutic procedures due to the acuteness of the condition, the number of visits for modalities should not exceed 2-4 visits.
Greater than two (2) modalities should not be used on each visit date.
A balance of supervised and constant attendance modalities should be used.
Multiple heating modalities should not be used on the same day. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation must support the medical necessity of multiple heating modalities. The documentation must support the use of multiple modalities as contributing to the patient’s progress and restoration of function.
These modalities apply to one or more areas treated per day (e.g. paraffin bath used for the left and right hand is billed as one unit).
CPT code 97010 - Application of a modality to one or more areas; hot or cold packs
Hot or cold packs (including Aquamed) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a licensed therapist. Regardless of whether CPT 97010 is billed alone or in conjunction with another therapy code, these modalities are considered non-skilled services and are not separately reimbursable. Hot and cold packs are a covered service; however not separately reimbursable. When CPT 97010 is billed there will be no separate payment (i.e. bundled).
Physical Medicine and Rehabilitation
The selection of appropriate physical medicine modalities and procedures should be based on the desired physiological response in correlation to the stages of healing. In most conditions or injuries, utilization of one carefully selected modality or procedure in combination with CMT is adequate to achieve a successful clinical outcome.
All decisions made by a chiropractor regarding the use of supportive physical medicine modalities and procedures shall be predicated upon a properly documented clinical rationale, which is consistent with current educational and practice standards. The details of all modalities or procedures provided shall be recorded when performed, including time for all constant attendance modalities and therapeutic procedures.
CPT 97140, manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction, one or more regions, each 15 minutes) cannot be reported or billed if the chiropractor also reports or bills for a chiropractic manipulative treatment (CMT) on the same anatomical region4 as the therapeutic procedure. If a chiropractor reports both a CPT 98940-series service and CPT 97140 on the same date of service, the chiropractor’s medical records must document the differences between the two procedures and that each was conducted on a different anatomical site. To document this, you may use Modifier 59 (Distinct procedural service) when billing for these procedures (i.e., CPT 97140-59).
It is not appropriate to bill CPT 97124, massage, for myofascial release. For myofascial release, CPT 97140 should be reported. When reporting or billing for CPT 97112 (neuromuscular re-education) and CPT 97124 (massage), as well as all other physical medicine modalities and therapeutic procedures, the details of the procedure shall be recorded in the medical record, including clinical rationale, anatomical site, description of service, and time (as required by the selected CPT code).
Payment Policy:
The physical medicine codes 97010-97028, 97032-97036, 97039 require a physician or therapist to be in constant attendance.
The codes 97110- 97124 should be used for physical therapy procedures.
Additional physical therapy codes 97140-97542 and 97597-97606 should be used as defined in CPT.
Physical therapists evaluation and re-evaluation services should be submitted using CPT codes 97001 and 97002. These codes may be reported separately if the patient’s condition requires significant separately identifiable services, above and beyond the usual pre-service and post-service work associated with the procedure performed. The modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service) is not valid with the physical therapy (PT) evaluations and re-evaluation codes 97001-97002. The evaluation or reevaluation codes will be allowed, as appropriate, when billed with other physical or occupational services on the same date. Because the modifier -25 is not valid with 97001-97002, if submitted, the service will be denied.
Modalities:
The CPT Manual defines a modality as “any physical agent applied to produce therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.” CPT codes within the code range of 97032-97036 are “Constant Attendance” codes that require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance.
Therapeutic Procedures:
The CPT Manual defines a therapeutic procedure as “a manner of affecting change through the application of clinical skills and/or services that attempt to improve function.”
CPT codes within the code ranges of 97110-97124, 97140, and 97530-97542 require direct (one-onone) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one-attendance.
Tests and Measurements:
CPT codes 97750 and 97755 require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance.
Orthotic Management and Prosthetic Management:
CPT codes 97760-97762 describe orthotic and prosthetic assessment, management, and training services. These codes also contain a 15 minute time component.
Definition
CPT Code 97140: Manual therapy techniques (e.g. mobilization, manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes.[1] Description Code 97140 is used to report manual therapy (‘hands-on’) techniques that consist of , but are not limited to connective tissue massage, joint mobilization, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. Manual therapy techniques may be applied to one or more regions for 15-minute intervals. These services are not diagnosis or region specific.
CPT® code 97140 is to be reported for each 15 minutes of manual therapy techniques provided to one or more regions.
For example, if 30 minutes of manual therapy techniques were provided to one or more regions, code 97140 would be reported two times, one for each 15-minute interval.
It is important to recognize that 15 minutes must be spent in performing the pre-, intra, and post-service work in order to report code 97140.
Under certain circumstances, it may be appropriate to additionally report CMT/OMT codes in addition to code 97140. For example, a patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques as described by code 97140 to the neck region and CMT to the lumbar region. As separate body regions are addressed, it would be appropriate in this instance to report both codes 97140 and 98940. In this example, the modifier -59 should be appended to indicate that a distinct procedural
service was provided.
Coding Modifiers:
The application of coding modifiers is not a consideration when rendering UR determinations. This section is intended to provide a summary of the related Optum Reimbursement policy No. 0050 – Modifier-59. Under certain circumstances, it may be appropriate for chiropractors to report CPT code 97140 in addition to a CMT code. On these occasions it is appropriate to append the CPT procedural code 97140 with a modifier (-59).
A modifier provides the means by which the reporting health care practitioner can indicate that a CPT descriptor code (service or procedure), which has been performed, has been altered by a specific circumstance or in some way without changing the definition of the CPT code. Modifiers increase the specificity of certain CPT codes.
Modifier -59 indicates that the procedure (97140) represents a distinct service from others reported on the same date of service. This modifier was developed explicitly for the purpose of identifying services not typically performed together.
General Modality Guidelines
(CPT codes 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, G0281, G0283, and G0329)
CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.
CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another procedure at the same time. Only the actual time of the provider’s direct contact with the patient, providing services requiring the skills of a therapist, is covered for these codes.
Modalities chosen to treat the patient’s symptoms/conditions should be selected based on the most effective and efficient means of achieving the patient’s functional goals. Seldom should a patient require more than one (1) or two (2) modalities to the same body part during the therapy session. Use of more than two (2) modalities on each visit date is unusual and should be carefully justified in the documentation.
The use of modalities as stand-alone treatments is rarely therapeutic, and usually not required or indicated as the sole treatment approach to a patient’s condition. The use of exercise and activities has proven to be an essential part of a therapeutic program. Therefore, a treatment plan should not consist solely of modalities, but should also include therapeutic procedures. (There are exceptions, including wound care or when patient care is focused on modalities because the acute patient is unable to endure therapeutic procedures.) Use of only passive modalities that exceeds 4 visits should be very well supported in the documentation.
Multiple heating modalities should not be used on the same day. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation must support the use of multiple modalities as contributing to the patient’s progress and restoration of function. For example, it would not be medically necessary to perform both thermal ultrasound and thermal diathermy on the same area, in the same visit, as both are considered deep heat modalities.
When the symptoms that required the use of certain modalities begin to subside and function improves, the medical record should reflect the discontinuation of those modalities, so as to determine the patient’s ability to self-manage any residual symptoms. As the patient improves, the medical record should reflect a progression of the other procedures of the treatment program (therapeutic exercise, therapeutic activities, etc.). In all cases, the patient and/or caregiver should be taught aspects of self-management of his/her condition from the start of therapy.
Based on the CPT descriptors, these modalities apply to one or more areas treated (e.g., paraffin bath used for the left and right hand is billed as one unit).
CPT 97010 - hot or cold packs (to one or more areas)
Hot or cold packs (including ice massage) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a therapist.
Code 97010 is bundled. It may be bundled with any therapy code. Regardless of whether code 97010 is billed alone or in conjunction with another therapy code, this code is never paid separately. If billed alone, this code will be denied.
Applicable Outpatient Rehabilitation HCPCS Codes
The CMS identifies the following codes as therapy services, regardless of the presence of a financial limitation. Therapy services include only physical therapy, occupational therapy and speech-language pathology services. Therapist means only a physical therapist, occupational therapist or speech-language pathologist. Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology. Check the notes below the chart for details about each code.
When in effect, any financial limitation will also apply to services represented by the following codes, except as noted below.
NOTE: Listing of the following codes does not imply that services are covered or applicable to all provider settings.
96110+? 96111+? 96125 97001 97002 97003 97004 97010**** 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034
Billing - CPT Codes: Permitted
In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 - 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.
Supportive Documentation Requirements for 97010
The area(s) treated
The type of hot or cold application
CPT 97012 - Traction, Mechanical (to one or more areas)
Traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas.
Specific indications for the use of mechanical traction include cervical and/or lumbar radiculopathy and back disorders such as disc herniation, lumbago, and sciatica.
This modality is typically used in conjunction with therapeutic procedures, not as an isolated treatment.
Documentation should support the medical necessity of continued traction treatment in the clinic for greater than 12 visits. For cervical conditions, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home. The time devoted to patient education related to the use of home traction should be billed under 97012.
Only 1 unit of CPT code 97012 is generally covered per date of service.
Equipment and tables utilizing roller systems are not considered true mechanical traction. Services using this type of equipment are non-covered.
Non-Surgical Spinal Decompression Non-surgical spinal decompression is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, non-surgical spinal decompression is not covered by Medicare (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: Section 160.16). Examples of this type of non-covered procedure include, but are not limited to, VAX-D™, DRX-3000, DRX9000, Decompression Reduction Stabilization (DRS) System, IDD, MedX., Spina System, Accua-Spina System, SpineMED Decompression Table, Lordex Traction Unit, Triton DTS, and Z-Grav. If billed for purpose of receiving a denial, these services should be billed using CPT code 97039 and not with CPT 97012.
Supportive Documentation Requirements for 97012
Type of traction and part of the body to which it is applied, etiology of symptoms requiring treatment.
CPT 97014 – Electrical stimulation (unattended) (to one or more areas)
CPT 97014 is not a Medicare recognized code. See HCPCS code G0283 for electrical stimulation (unattended).
CPT 97016 - Vasopneumatic Devices (to one or more areas)
The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema or lymphedema.
Specific indications for the use of vasopneumatic devices include reduction of edema after acute injury or lymphedema of an extremity. Education on the use of a lymphedema pump for home use is covered when medically necessary and can typically be completed in three (3) or fewer visits once the patient has demonstrated measurable benefit in the clinic environment.
Note: Further treatment of lymphedema by a vasopneumatic device rendered by a clinician after the educational visits is generally not reasonable and necessary unless the patient presents with a condition or status requiring the skills and knowledge of a physical or occupational therapist.
The use of vasopneumatic devices is generally not covered as a temporary treatment while awaiting receipt of ordered compression stockings.
See NCD 280.6 in CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual for further coverage and use information on Pneumatic Compression Devices.
Vertebral Axial Decompression Therapy (i.e., VaxD, IDD, DR 5000, DR 9000, SpinaSystem, etc.)
• All claims for this service must be coded using S9090, with one unit of service per day.
• Based on the lack of scientific evidence (blinded studies, appropriate number of participants in studies already conducted, documented long-term results) S9090 will be allowed based on the 97012 allowance and unit limitation guidelines.
• This policy will remain in effect until such time that scientific studies performed within accepted standards are available.
• To ensure correct coding of this service there will be periodic audits performed at random.
• Those claims found to have been coded incorrectly will require appropriate refunds and patients' credits.
Policy Overview
CPT codes 97010 describe Physical Medicine and Rehabilitation modalities that do not require direct (one-on-one) patient contact by the provider.
Reimbursement Guidelines
Consistent with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare Community Plan will not reimburse CPT codes 97010. Reimbursement for 97010 is included in the payment for other services.
Codes CPT code section
97010 Application of a modality to 1 or more areas; hot or cold packs
Supportive Documentation Requirements for 97016
Area of the body being treated, location of edema
Objective edema measurements (1+, 2+ pitting, girth, etc.), comparison with uninvolved side
Effects of edema on function
Type of device used
CPT 97018 – Paraffin Bath (to one or more areas)
Paraffin bath treatments typically do not require the unique skills of a
therapist. However, the skills, knowledge and judgment of a therapist might be required in the provision of such treatment or baths in a complicated case. Only in cases with complicated conditions will paraffin be covered, and then coverage is generally limited to educating the patient/caregiver in home use. Paraffin is contraindicated for open wounds or areas with documented desensitization.
Coding Edits:
CMS (the Centers for Medicare and Medicaid Services), the federal agency that administers the Medicare program, implemented a policy known as the Correct Coding Initiative (CCI). This policy is used to promote correct coding by physicians and to ensure that it makes appropriate payments for physician services.[6] “This policy has been developed and applied by many third party payers across the country.”[7] Correct coding emphasizes that procedures should be reported with the CPT codes that most comprehensively describe the services performed e.g., 98941 is a more comprehensive code than 98940. There are procedural codes that are not to be reported together because they are mutually exclusive to each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session. An example of mutually exclusive codes germane to this policy is 97140 – Manual therapy techniques (without the -59 modifier) vs. 98940, 98941, 98942, or 98943 – Chiropractic manipulative treatment.
Billing Guideline from BCBS
The BCBSVT policy on Autism Spectrum Disorders, Coverage of Services will remain in effect for members who have not renewed their group or individual coverage with us as of October 1, 2012.
The plan covers up to 30 outpatient sessions combined PT, ST, OT visits per plan year. This maximum applies to sessions provided in the home, an outpatient facility or professional office setting. The maximum number of visits included in covered benefits may vary for specific contracts or products. Please refer to the appropriate subscriber contract for the applicable benefit maximum. The modality codes (97032-97036) but excluding 97026, 97033, and 97034, (which are not covered under any circumstance) are generally considered to be an adjunct to a variety of therapies and when billed by an allopathic, osteopathic, or chiropractic physician, these services do not count against the defined benefit limit. However, if provided by a physical or occupational therapist as a standalone service these would count as a service against the defined benefit limit.
When physical therapy therapeutic procedures (CPT 97110-97535) are billed by any provider (including a chiropractic physician) these services will apply to the defined benefit limit for PT, ST, and OT combined. When billed by a chiropractor, this visit will also count against the initial 12 or subsequent approved chiropractic visits. Documentation for Constant Attendance Procedures/Modalities When documentation supports constant attendance therapeutic procedures or modalities (i.e. 97110, 97112) are being performed; time documentation is required.
The amounts of time versus the appropriate number of units to bill are as follows:
• If less than 8 minutes use modifier 52 for reduced services
• If 8-22 minutes bill 1 unit
• If 23-37 minutes bill 2 units, etc.
The following codes will be considered as medically necessary when applicable criteria have been met.
CPT 95992 Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day CPT 97001 – 97002 Initial PT evaluation & re-evaluation Physical medicine and rehabilitation modalities (constant attendance).
For this code range, services are measure in 15 minute time units. Units are required in addition to the code for billing with one unit equaling 15 minutes.
CPT 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
CPT 97035 Application of a modality to 1 or more areas; Ultrasound, each 15 minutes
CPT 97036 Application of a modality to 1 or more areas; Hubbard Tank, each 15 minutes
CPT 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
CPT 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/orproprioception for sitting and/or standing activities
CPT 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
Mechanical Traction:
CPT 97012 Mechanical traction is described as force used to create a degree of tension of soft tissues and/or to allow for a separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration of time, and angle of the pull (degrees) using mechanical means. Used in describing cervical and pelvic traction that are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body’s own weight to create the force). A common question is whether a roller table type of traction meets the above-noted requirements. According to the ACA’s interpretation, table type traction would normally meet the requirements of autotraction.
It should also be noted that manual traction, using one's hands or a towel to perform the traction, is identified under manual therapy CPT 97140 and, presumably, would not be recognized under mechanical traction. Massage:
CPT 97124 describes a service that is a separate and distinct service from Chiropractic Manual Therapy codes 98940-98943.
CPT 97124 describes work including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) and is based on each 15 minutes of treatment per unit. When using this code on the same day as a CMT code service, it may be necessary to append a modifier-59 (Distinct Procedure). It should also be noted that this therapy procedure attempts to improve function by direct hands on and one-on-one patient-practitioner/therapist contact. All that is stated in this paragraph should be noted in the documentation. The expected outcomes of massage are also more general in nature and may in fact be what patients can't tolerate at the more acute stage of their treatment plans. This would include such goals as to decrease pain, decrease muscle spasms, decrease muscle soreness, and increase circulation.
Note: For purposes of secondary Medicare billing only, it is appropriate to bill CPT 97124 in conjunction with a CMT code codes 98940-98942 on the same date of service, provided the treatments are to separate body regions of the spine. In these instances Modifier-59 may be added to the 97124.
Manual therapy techniques:
There is a lot of ambiguity in reference to this CPT code 97140. It is described as a mobilization/manipulation, manual lymphatic drainage, and manual traction of one or more regions. However, the ACA describes Manual Therapy Techniques as consisting of, but not limited to, connective tissue massage, joint mobilization and manipulation, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. It is also based on each 15 minutes of treatment per unit. When using this code on the same day as a CMT code service, it may be necessary to append a modifier-59 (Distinct Procedure). It should also be noted that this therapy procedure attempts to improve function by direct hands on and by one-on-one patient-practitioner/therapist contact.
The goals of this particular procedure are to increase flexibility, to increase pain-free range of motion, and to get patients back to their normal daily activities.
This code 97140 continues to suffer from bad and inconsistent guidelines, edits, and laws. The CPT guidelines state that 97140 services are included in the CMT codes (9894-98942) when performed on the same spinal regions as a CMT codes. Also, Medicare NCCI edits categorized 97140 as a component of CMT, unless a modifier (e.g., -59) is used for a different region(s). However, Medicare law prohibits coverage and payment for non-CMT services. Thus, if 97140 is bundled with or into CMT, it would be a violation of Medicare law. Furthermore, the Medicare relative value units (RVU) do not include any non-spinal services for (e.g., 97140, 97112, 97124 etc.)
When using a physical medicine procedure such as 97140, four things should be documented: technique, different anatomical area from the CMT, time component, and modifier-59. This has been a humble attempt to try to clarify and define the differences of these therapeutic procedures. It represents one person’s reading of the ACA’s Chiropractic Coding Solutions Manual and the Manual of Chiropractic Code only. It is not legal advice and should not be considered as such.
The BCBSVT policy on Autism Spectrum Disorders, Coverage of Services will remain in effect for members who have not renewed their group or individual coverage with us as of October 1, 2012.
The plan covers up to 30 outpatient sessions combined PT, ST, OT visits per plan year. This maximum applies to sessions provided in the home, an outpatient facility or professional office setting. The maximum number of visits included in covered benefits may vary for specific contracts or products. Please refer to the appropriate subscriber contract for the applicable benefit maximum. The modality codes (97032-97036) but excluding 97026, 97033, and 97034, (which are not covered under any circumstance) are generally considered to be an adjunct to a variety of therapies and when billed by an allopathic, osteopathic, or chiropractic physician, these services do not count against the defined benefit limit. However, if provided by a physical or occupational therapist as a standalone service these would count as a service against the defined benefit limit.
When physical therapy therapeutic procedures (CPT 97110-97535) are billed by any provider (including a chiropractic physician) these services will apply to the defined benefit limit for PT, ST, and OT combined. When billed by a chiropractor, this visit will also count against the initial 12 or subsequent approved chiropractic visits. Documentation for Constant Attendance Procedures/Modalities When documentation supports constant attendance therapeutic procedures or modalities (i.e. 97110, 97112) are being performed; time documentation is required.
The amounts of time versus the appropriate number of units to bill are as follows:
• If less than 8 minutes use modifier 52 for reduced services
• If 8-22 minutes bill 1 unit
• If 23-37 minutes bill 2 units, etc.
The following codes will be considered as medically necessary when applicable criteria have been met.
CPT 95992 Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day CPT 97001 – 97002 Initial PT evaluation & re-evaluation Physical medicine and rehabilitation modalities (constant attendance).
For this code range, services are measure in 15 minute time units. Units are required in addition to the code for billing with one unit equaling 15 minutes.
CPT 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
CPT 97035 Application of a modality to 1 or more areas; Ultrasound, each 15 minutes
CPT 97036 Application of a modality to 1 or more areas; Hubbard Tank, each 15 minutes
CPT 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
CPT 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/orproprioception for sitting and/or standing activities
CPT 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
Mechanical Traction:
CPT 97012 Mechanical traction is described as force used to create a degree of tension of soft tissues and/or to allow for a separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration of time, and angle of the pull (degrees) using mechanical means. Used in describing cervical and pelvic traction that are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body’s own weight to create the force). A common question is whether a roller table type of traction meets the above-noted requirements. According to the ACA’s interpretation, table type traction would normally meet the requirements of autotraction.
It should also be noted that manual traction, using one's hands or a towel to perform the traction, is identified under manual therapy CPT 97140 and, presumably, would not be recognized under mechanical traction. Massage:
CPT 97124 describes a service that is a separate and distinct service from Chiropractic Manual Therapy codes 98940-98943.
CPT 97124 describes work including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) and is based on each 15 minutes of treatment per unit. When using this code on the same day as a CMT code service, it may be necessary to append a modifier-59 (Distinct Procedure). It should also be noted that this therapy procedure attempts to improve function by direct hands on and one-on-one patient-practitioner/therapist contact. All that is stated in this paragraph should be noted in the documentation. The expected outcomes of massage are also more general in nature and may in fact be what patients can't tolerate at the more acute stage of their treatment plans. This would include such goals as to decrease pain, decrease muscle spasms, decrease muscle soreness, and increase circulation.
Note: For purposes of secondary Medicare billing only, it is appropriate to bill CPT 97124 in conjunction with a CMT code codes 98940-98942 on the same date of service, provided the treatments are to separate body regions of the spine. In these instances Modifier-59 may be added to the 97124.
Manual therapy techniques:
There is a lot of ambiguity in reference to this CPT code 97140. It is described as a mobilization/manipulation, manual lymphatic drainage, and manual traction of one or more regions. However, the ACA describes Manual Therapy Techniques as consisting of, but not limited to, connective tissue massage, joint mobilization and manipulation, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. It is also based on each 15 minutes of treatment per unit. When using this code on the same day as a CMT code service, it may be necessary to append a modifier-59 (Distinct Procedure). It should also be noted that this therapy procedure attempts to improve function by direct hands on and by one-on-one patient-practitioner/therapist contact.
The goals of this particular procedure are to increase flexibility, to increase pain-free range of motion, and to get patients back to their normal daily activities.
This code 97140 continues to suffer from bad and inconsistent guidelines, edits, and laws. The CPT guidelines state that 97140 services are included in the CMT codes (9894-98942) when performed on the same spinal regions as a CMT codes. Also, Medicare NCCI edits categorized 97140 as a component of CMT, unless a modifier (e.g., -59) is used for a different region(s). However, Medicare law prohibits coverage and payment for non-CMT services. Thus, if 97140 is bundled with or into CMT, it would be a violation of Medicare law. Furthermore, the Medicare relative value units (RVU) do not include any non-spinal services for (e.g., 97140, 97112, 97124 etc.)
When using a physical medicine procedure such as 97140, four things should be documented: technique, different anatomical area from the CMT, time component, and modifier-59. This has been a humble attempt to try to clarify and define the differences of these therapeutic procedures. It represents one person’s reading of the ACA’s Chiropractic Coding Solutions Manual and the Manual of Chiropractic Code only. It is not legal advice and should not be considered as such.
Aqua Massage Therapy
• This service should be coded using 97039 with a description of "aqua massage therapy" in the 2400 NTE segment or box 19. It should not be billed using 97124.
• It is considered experimental/investigational and is provider write-off unless a Limited Patient Waiver is signed before performance of the service.
• Use modifier "GA" to demonstrate waiver on file.
Massage
• This service must be coded as 97124, regardless of delivery.
• This will be denied content of service unless it is the only service provided on that date of service.
• Coverage Criteria BCBSKS will consider massage therapy for possible coverage if the following are met.
The massage must be:
** Medical in nature
** Medically necessary
** An integral part of the treatment plan
** Performed by a PT or OT
** Performed by a PTA or COTA under the direct supervision (on-site) of the physical or occupational therapist respectively.
• Limitation of Units of Massage Therapy per Date of Service
** Massage therapy 97124 is coded by 15-minute increments.
** One unit of service per date of service will be considered for coverage without medical records.
If more than one unit of massage is performed on any given date you must attach medical records to support the care. Processing of claims received without this information may be delayed until such information is provided.
** Refunds will be required if services were performed by someone other than the licensed eligible provider.
EXAMPLES OF RED FLAGS:
• Duplicative services
• Misuse of CPT codes
• Billing/use of 97124 and 97140 for the same body part on the same DOS
• # of units / treatment greater than BCBSKS policy allowable
• Billing/use of 97002 for DOS before Jan. 1, 2017 or 97164 for DOS after Jan. 1, 2017 on each DOS billed
• Upcoding (e.g. 97032 instead of 97014)
• Use of unlisted procedure and modality codes
• Billing/use of two or more superficial heating modalities to the same body part – Use of 97010, 97014, 97035 same body part, same session with no documented rationale and objective data to support necessity for each modality
• Continued use of modalities for periods greater than 10 treatment sessions with no documented rationale and objective data to support patient improvement and ongoing treatment.
Vertebral Axial Decompression Therapy (i.e., VaxD, IDD, DR 5000, DR 9000, SpinaSystem, etc.)
• All claims for this service must be coded using S9090, with one unit of service per day.
• Based on the lack of scientific evidence (blinded studies, appropriate number of
parti cipants in studies already conducted, documented long-term results) S9090 will be allowed based on the 97012 allowance and unit limitation guidelines.
• This policy will remain in effect until such time that scientific studies performed within accepted standards are available.
• To ensure correct coding of this service there will be periodic audits performed at random.
• Those claims found to have been coded incorrectly will require appropriate refunds and patients' credits
MOTION TESTING Procedure code
Performing routine muscle testing and range of motion or muscle testing (i.e., tests that are an integral part of the assessment performed each visit to determine the patient's status from one visit to the next and to determine the level of care required for the current visit) are considered content of the evaluation or therapy billed that particular day and should not be billed separately.
97010 CRYOTHERAPY Do not use procedure code 17340, as this is for direct application of chemicals to the skin. This code will deny content of service unless it is the only service provided on the date of service.
97010 HOT OR COLD PACKS Unattended One or more areas is one unit of service This code will deny content of service unless it is the only service provided on the date of service.
97012 TRACTION (MECHANICAL) Unattended One or more areas is one unit of service This code is one or more areas so the unit of service is limited to one regardless of the time spent or the number of areas treated. Sending in medical records will not change the units reimbursed on this code. Roller bed is not considered mechanical traction and is not medically necessary.
97014 ELECTRICAL STIMULATION , INTERFERENTIAL THERAPY,
CPT 97124 describes a service that is a separate and distinct service from Chiropractic Manual Therapy codes 98940-98943. CPT 97124 describes work including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) and is based on each 15 minutes of treatment per unit. When using this code on the same day as a CMT code service, it may be necessary to append a modifier-59 (Distinct Procedure). It should also be noted that this therapy procedure attempts to improve function by direct hands on and one-on-one patient-practitioner/therapist contact. All that is stated in this paragraph should be noted in the documentation.
The expected outcomes of massage are also more general in nature and may in fact be what patients can't tolerate at the more acute stage of their treatment plans. This would include such goals as to decrease pain, decrease muscle spasms, decrease muscle soreness, and increase circulation. Note: For purposes of secondary Medicare billing only, it is appropriate to bill CPT 97124 in conjunction with a CMT code codes 98940-98942 on the same date of service, provided the treatments are to separate body regions of the spine. In these instances Modifier-59 may be added to the 97124.
There is a lot of ambiguity in reference to this CPT code 97140. It is described as a mobilization/manipulation, manual lymphatic drainage, and manual traction of one or more regions. However, the ACA describes Manual Therapy Techniques as consisting of, but not limited to, connective tissue massage, joint mobilization and manipulation, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. It is also based on each 15 minutes of treatment per unit. When using this code on the same day as a CMT code service, it may be necessary to append a modifier-59 (Distinct Procedure). It should also be noted that this therapy procedure attempts to improve function by direct hands on and by one-on-one patient-practitioner/therapist contact. The goals of this particular procedure are to increase flexibility, to increase pain-free range of motion, and to get patients back to their normal daily activities.
This code 97140 continues to suffer from bad and inconsistent guidelines, edits, and laws. The CPT guidelines state that 97140 services are included in the CMT codes (9894-98942) when performed on the same spinal regions as a CMT codes. Also, Medicare NCCI edits categorized 97140 as a component of CMT, unless a modifier (e.g., -59) is used for a different region(s). However, Medicare law prohibits coverage and payment for non-CMT services. Thus, if 97140 is bundled with or into CMT, it would be a violation of Medicare law.
Furthermore, the Medicare relative value units (RVU) do not include any non-spinal services for (e.g., 97140, 97112, 97124 etc.)
When using a physical medicine procedure such as 97140, four things should be documented: technique, different anatomical area from the CMT, time component, and modifier-59.
This has been a humble attempt to try to clarify and define the differences of these therapeutic procedures. It represents one person’s reading of the ACA’s Chiropractic Coding Solutions Manual and the Manual of Chiropractic Code only. It is not legal advice and should not be considered as such.
Subscribe to:
Posts (Atom)
Top Medicare billing tips
-
Patient Discharge Status Code - Definition A patient discharge status code is a two-digit code that identifies where the patient is at th...
-
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr... -
REIMBURSEMENT GUIDELINES Global Obstetrical (OB) Care As defined by the American Medical Association (AMA), "the total obstetric pa...
-
procedure code and description 93922 LIMITED BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, (EG, FOR LOW...
-
CPT CODE J3301 - Kenalog-40 Injection Kenalog-40 Injection (triamcinolone acetonide injectable suspension, USP) is a synthetic glucocortic...
-
Procedure code and description 95806 - Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory air...
-
Procedure code and Description 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the...
-
Frequency Limitations: Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonabl...
-
procedure code and description 11042 -Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square cm ...
-
Procedure Code Changes and Description • Deleted Codes * 49080 - Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic...