Billing and Coding: Outpatient Physical Therapy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for the Outpatient
Physical Therapy L34428 LCD.

**Electrical Stimulation (CPT  code 97032 and 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
Manual, Chapter 1, Part 4, 270.1.  
  
 **Application of a modality to 1 or more areas; electrical stimulation
(manual), each 15 minutes ( CPT code 97032)**  
  
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  
 FES used for facilitating gait in patients with spinal cord injury (SCI)-
Refer to CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage
Determinations Manual, Chapter 1, Part 2, 160.12  
 Ultrasound with electrical stimulation provided concurrently should be
billed as ultrasound (97035)- do not bill for both ultrasound 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 Stimulators - CMS Internet-Only
Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter
1, Part 4, 230.8 - 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 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 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

**Electrical stimulation (unattended), to 1 or more areas for indication(s)
other than wound care, as part of a therapy plan of care. ( HCPCS G0283) See
97032 for instructions in manual electrical stimulation. **  
  
Most non-wound care electrical stimulation treatment provided as part of a
therapy plan of care 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

**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 plan of care. ( HCPCS G0329)** **  
  
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 plan of care. ( HCPCS Code G0281)**  
  
 **Note: CPT  code 97014 is an invalid code on the Medicare fee schedule and
should not be reported in 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**.  
  
**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 instructing the patient's
spouse or caregiver how to assist the patient up/down steps using an assistive
device to get into and out of the home, use 97116; if teaching the patient
aquatic exercises to use as an independent program in the community pool, use
97113.

**Hot/Cold Packs (CPT** **** **code 97010)**

The payment for hot or cold packs is bundled into the payment for other
covered services and is not reimbursable. Ice massage should be reported using
CPT code 97010.

**Direct 1-on-1 Contact**

Regardless of the procedure or modality being performed, if the patient is not
receiving direct 1-on-1 contact but is being supervised by the therapist, the
group therapy code should be used.

**Orthotic Management and Training and Prosthetic 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.

**Community/Work Reintegration (CPT  code 97537)**

Should be utilized when a patient is trained in the use of assistive
technology to assist with mobility, seating systems, and environmental control
systems for use in the community.