Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97112, 97116, 97161, 97165, and 
97535 billed for August 18, 2022, to August 31, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 97110, 97112, 97116, 97161, 97165, and 97535 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The 
definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular 
reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting 
and/or standing activities. The definition of code 97116 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities. The definition of code 97161 is physical therapy 
evaluation: low complexity, requiring these components: A history with no personal factors and/or 
comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and 
measures addressing 1-2 elements from any of the following: body structures and functions, activity 
limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated 
characteristics; and Clinical decision making of low complexity using standardized patient assessment 
instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face 
with the patient and/or family. The definition of code 97165 is occupational therapy evaluation, low 
complexity, requiring these components: An occupational profile and medical and therapy history, which 
includes a brief history including review of medical and/or therapy records relating to the presenting problem; 
An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial 
skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low 
complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused 
assessment(s), and consideration of a limited number of treatment options. Patient presents with no 
comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) 
with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are 
spent face-to-face with the patient and/or family. The definition of code 97535 is self-care/home management 
training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, 
and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 
minutes. 
 
We find that CPT codes 97110, 97112, 97116, 97161, 97165, and 97535 are not supported in the medical 
record. Specifically, there are no physical therapy records submitted for the dates of service at issue. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 97110, 97112, 97116, 97161, 97165, and 
97535 billed for August 18, 2022, to August 31, 2022.