Billing and Coding: Outpatient Occupational Therapy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Outpatient
Occupational Therapy L34427.

**Electrical Stimulation (CPT  code 97032, HCPCS codes G0281 and G0283), and
Electromagnetic Therapy (HCPCS code G0329)**

**NOTE:** The coverage/non-coverage indications for Electrical Stimulation
Therapy and Electromagnetic Therapy and definition are found in the CMS
Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations
(NCD) Manual, Chapter 1, Part 4, 270.1.  
  
 **CPT  code 97032- Application of a modality to 1 or more areas; electrical
stimulation (manual), each 15 minutes**  
  
Attended electrical stimulation requires direct (1-on-1) contact with the
patient by the qualified professional/qualified personnel in providing
electrical stimulation manually through the use of probes or other devices.  
  
Types of electrical stimulation that may require constant attendance and
direct 1-on-1 contact by the qualified professional/qualified personnel
include but are not limited to:

 Direct motor point stimulation  
 Functional Electrical Stimulation (FES) or Neuromuscular Electrical
Stimulation (NMES)-if performed with therapeutic exercise, neuromuscular
reeducation or functional activities, 97032 may be billed for the time the
qualified professional/qualified personnel spends applying/instructing and
adjusting the FES application, but 97110, 97112, or 97530 should not be billed
during the same time period  
 Ultrasound (US) with electrical stimulation provided concurrently should be
billed as US (97035)-do not bill for both US and electrical stimulation for
the same time period  
 Determining trigger points associated with application of a transcutaneous
electrical nerve stimulation (TENS) unit using a handheld probe, would be
reported by 97032

The actual application of a TENS unit including the instruction in use and
appropriate settings would be described by reporting 97032.  
  
TENS is not reasonable and necessary for the treatment of Chronic Low Back
Pain (CLBP) under 1862(a)(1)(A) of the Social Security Act.  
  
Non-Implantable Pelvic Floor Electrical Stimulator (CMS Internet-Only Manual,
Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter
1, Part 4, 230.8). Non-implantable pelvic floor electrical stimulators
provide neuromuscular electrical stimulation through the pelvic floor with the
intent of strengthening and exercising pelvic floor musculature. Stimulation
is generally delivered by vaginal or anal probes connected to an external
pulse generator and may be billed as 97032.  
  
Stimulation delivered via electrodes should be billed as G0283.  
  
__ The methods of pelvic floor electrical stimulation vary in location,
stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration
(duty cycle), treatments per day, number of treatment days per week, length of
time for each treatment session, overall time period for device use and
between clinic and home settings. In general, the stimulus frequency and other
parameters are chosen based on the patient's clinical diagnosis.  
  
Pelvic floor electrical stimulation with a non-implantable stimulator is
covered for the treatment of stress and/or urge urinary incontinence in
cognitively intact patients who have failed a documented trial of pelvic
muscle exercise (PME) training.  
  
A failed trial of PME training is defined as no clinically significant
improvement in urinary continence after completing 4 weeks of an ordered plan
of pelvic muscle exercises designed to increase periurethral muscle strength.
__  
  
The patient's medical record must indicate that the patient receiving a non-
implantable pelvic floor electrical stimulator was cognitively intact,
motivated, and had failed a documented trial of PME training.  
  
Utilization of electrical stimulation may be necessary during the initial
phase of treatment, but there must be an improvement in function. These
modalities should be utilized with appropriate therapeutic procedures to
effect continued improvement. **Note:** Coverage for this indication is
limited to those patients where the nerve supply to the muscle is intact,
including brain, spinal cord, and peripheral nerves, and other non-
neurological reasons for disuse are causing the atrophy (e.g., post-casting or
splinting of a limb, and contracture due to soft tissue scarring).  
  
Documentation must clearly support the medical necessity of electrical
stimulation for more than 12 visits as adjunctive therapy or for muscle
retraining. Typically, patients can be trained in the use of a home muscle
stimulator for retraining weak muscles. Up to 2 visits should be necessary to
complete the training. Once training is successfully completed, this procedure
should not be billed as a treatment modality in the clinic, as the patient
would be independent in application and use of the modality.  
  
__**Non-covered Indications**

 Electrical Stimulation (CPT **** code 97032) used in the treatment of
facial nerve paralysis, commonly known as Bell's palsy (CMS Internet-Only
Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual,
Chapter 1, Part 2, 160.15)  
 Electrical Stimulation (CPT **** code 97032) used to treat motor function
disorders, such as multiple sclerosis (CMS Internet-Only Manual, Pub. 100-03,
Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2,
160.2)  
 Electrical Stimulation (CPT ** **code 97032) for the treatment of strokes
when it is determined there is no potential for restoration of function  
 Electrical Stimulation when it is an isolated intervention utilized purely
for strengthening of a muscle with at least fair graded strength. Most muscle
strengthening is more efficiently accomplished through a treatment program
that includes active procedures such as therapeutic exercises and therapeutic
activities.

**Supportive Documentation Recommendations for 97032**

 Type of electrical stimulation used (in addition to the description
specifying "manual" and "attended")  
 Area(s) being treated  
 If used for muscle weakness, objective rating of strength and functional
deficits  
 If used for pain include pain rating, location of pain, effect of pain on
function

**HCPCS G0283 - Electrical stimulation (unattended), to 1 or more areas for
indication(s) other than wound care, as part of a therapy plan of care. See
97032 for instructions in manual electrical stimulation**.  
  
Most non-wound care electrical stimulation treatment provided as part of a
therapy plan of care (POC) should be billed as G0283, as it is often provided
in a supervised manner (after skilled application by the qualified
professional/assistive personnel) without constant, direct contact required
throughout the treatment. Code G0283 is classified as a "supervised" modality.
A supervised modality does not require direct (1-on-1) patient contact by the
provider. Typically, electrical stimulation conducted via the application of
electrodes is considered unattended electrical stimulation.  
  
Examples of unattended electrical stimulation modalities include, but are not
limited to, Interferential Current (IFC), TENS, and cyclical muscle
stimulation (Russian stimulation).  
  
Utilization of electrical stimulation may be necessary during the initial
phase of treatment, but there must be an improvement in function. These
modalities should be utilized with appropriate therapeutic procedures to
effect continued improvement.  
  
**Note** : Coverage for this indication is limited to those patients where the
nerve supply to the muscle is intact, including brain, spinal cord, and
peripheral nerves, and other non-neurological reasons for disuse are causing
the atrophy (e.g., post-casting or splinting of a limb, and contracture due to
soft tissue scarring).  
  
Documentation must clearly support the medical necessity of unattended
electrical stimulation used for control of pain and swelling, with objective
and/or subjective changes noted in swelling and/or pain within 12 visits. If
no improvement is noted, a change in treatment plan (alternative strategies)
should be implemented or documentation should support the need for continued
use of this modality. Typically, patients can be trained in the use of a TENS
unit for self-management of their pain. Up to 2 visits should be necessary to
complete the training. Once training is successfully completed, this procedure
should not be billed as a treatment modality in the clinic, as the patient
would be independent in application and use of the modality.  
  
The cost of electrodes used with unattended electrical stimulation is included
in the practice expense portion of G0283. Do not bill the Medicare contractor
or the patient for electrodes used to provide electrical stimulation as a
clinic modality.  
  
**Supportive Documentation Recommendations for G0283**

 Type of electrical stimulation used (e.g., TENS, IFC)  
 Area(s) being treated  
 Objective/subjective measures of how treatment is impacting pain (intensity,
location, impact on function) and/or swelling

**HCPCS G0329 - Electromagnetic therapy, to 1 or more areas for chronic stage
III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous
stasis ulcers not demonstrating measurable signs of healing after 30 days of
conventional care as part of a therapy POC.**  
  
 **HCPCS Code- G0281 Electrical stimulation, (unattended), to 1 or more areas,
for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic
ulcers, and venous stasis ulcers not demonstrating measurable signs of healing
after 30 days of conventional care, as part of a therapy POC.**  
  
 **Note: CPT  code 97014 is an invalid code on the Medicare fee schedule and
should not be reported on the claim form. G0281 replaces code 97014, only
where it applies to treatment of wounds, as defined in the code narrative**.  
  
 **Supportive Documentation Recommendations for G0281 and G0329**

 Etiology and duration of wound  
 Type of prior treatments by a physician, non-physician practitioner, nurse
and/or therapist that failed, including the duration of the failed treatment  
 Stage of wound  
 Description of wound: length, width, depth, grid drawing and/or photographs  
 Amount, frequency, color, odor, type of exudate  
 Evidence of infection, undermining, or tunneling  
 Nutritional status  
 Co-morbidities (e.g., diabetes mellitus, peripheral vascular disease)  
 Pressure support surfaces in use  
 Patient's functional level  
 Skilled plan of treatment, including specific frequency of the modality  
 Changing plan of treatment based on clinical judgment of the patient's
response or lack of response to treatment  
 Frequent skilled observation and assessment of wound healing (at least
weekly, but preferably with each treatment session)

**Note: HCPCS G0282-Electrical stimulation, (unattended), to 1 or more areas,
for wound care other than described in G0281. This code is not covered by
Medicare**.

**Hot or Cold Packs Therapy (CPT  code 97010)**

  1. The payment for hot or cold packs is bundled into the payment for other covered services and is not reimbursable. 
  2. Ice massage should be reported using this code.

**Self-Care Home Management Training (CPT  code 97535)**  
  
When instructing the patient in a self-management program, use the code that
best describes the focus of the self-management activity. For example, if the
instruction given is for exercises to be done at home to improve range of
motion (ROM) or strength, use 97110; if instructing the patient in balance or
coordination activities at home, use 97112; if teaching the patient aquatic
exercises to use as an independent program in the community pool, use 97113.
This code should not be used globally for all home instructions.

**Note: When identifying orthotics fitting and training see CPT code 97760.**

**Orthotics Training (CPT  code 97760)** For entities subject to the related
LCD, assessment of the patient regarding the orthotic, measurement and/or
fitting, supplies to fabricate or modify the orthotic, and time associated
with making the orthotic should not be reported with CPT **** code 97760,
unless the entities are certain that duplicate payments will not be made to
Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS)
suppliers using the "L" code.

**Aquatic Therapy with Therapeutic Exercises**

**Note:** Aquatic therapy with therapeutic exercise should not be billed in
situations where no exercise is being performed in the water environment
(e.g., debridement of ulcers).