Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)

For many patient situations however, a full patient evaluation is needed to develop the appropriate treatment plan in addition to wheelchair fitting and training. In these situations, it may be appropriate to bill the initial evaluation code (97161-97163 or 97165-97167), with the minutes spent for the evaluation/assessment assigned to either 97161-97163 or 97165-97167. On the day that the evaluation code is billed, the minutes assigned to 97542 should only be related to any wheelchair fitting and training provided, as 97542 is a timed code. For example, if a physical therapist spends 35 minutes gathering the patient history, prior functional status, current functional status, social considerations, range of motion, strength, sensation, balance, and transfers, this time would be assigned to the PT initial evaluation code 97162. As the session continues, the PT spends 45 minutes assessing the patient in a variety of wheelchair set ups, trying a variety of adaptations to best meet the patients comfort and functional needs, and initiates training with the patient and family, this 45 minutes would be assigned to code 97542.Supportive Documentation Requirements (at least every 4 visits) for 97542Documentation for a skilled wheelchair assessment should include the following:the recent event that prompted the need for a skilled wheelchair assessment;any previous wheelchair assessments have been completed, such as during a Part A SNF stay;most recent prior functional level;if applicable, any previous interventions that have been tried by nursing staff, caregivers or the patient that may have failed, prompting the initiation of skilled therapy intervention;functional deficits due to poor seating or positioning;objective assessments of applicable impairments such as range of motion (ROM), strength, sitting balance, skin integrity, sensation and tone;the response of the patient or caregiver to the fitting and training.When billing CPT code 97542 for wheelchair management/training, documentation must relate the training to expected functional goals that are attainable by the patient and /or caregiver.Describe the interventions to show that the skills of a therapist were required. For example, describe the various wheelchair adaptations trialed and the patients response to the intervention. If training is provided, describe the type of training, the amount of assistance required and the patient response to the training.CPT 97545 - Work hardening/conditioning; initial 2 hours; and CPT 97546 - each additional hourThese services are related solely to specific work skills and will be denied as not medically necessary for the diagnosis or treatment of an illness or injury.CPT codes 97597 and 97598: coverage criteria have been moved to the LCD for Debridement Services (L33614), effective 04/01/2016.CPT 97602Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per sessionDo not report 97602 in conjunction with 11042-11047Medicare coverage for wound care on a continuing basis for a particular wound requires documentation in the patient's record that the wound is improving in response to the wound care being provided. It is not medically reasonable or necessary to continue a given type of wound care if evidence of wound improvement cannot be shown. Evidence of improvement includes measurable changes (decreases) in at least some of the following:drainage;inflammation;swelling;pain;wound dimensions (diameter, depth);necrotic tissue/slough.Such evidence must be documented periodically (e.g. weekly.) A wound that shows no improvement after 30 days requires a new approach, which may include a physician/NPP reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.In rare instances, the goal of wound care provided in outpatient settings may be only to prevent progression of the wound, which, due to severe underlying debility or other factors such as inoperability, is not expected to improve. If this is the case, documentation should clearly indicate this rationale for continued skilled wound care.Examples of Non-Selective Debridement(without anesthesia) (CPT 97602) include the following items.Blunt debridementBlunt debridement involves the removal of necrotic tissue by cleansing or scraping (abrasion). It may also involve the cleaning and dressing of small or superficial lesions.Enzymatic debridementDebridement with topical proteolytic enzymes is used as an adjunctive therapy in treating chronic wounds. The manufacturers product insert contains indications, contraindications, precautions, dosage and administration guidelines; it is the clinicians responsibility to comply with those guidelines.Wet-to-moist dressingsWet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing.Autolytic and chemical debridementDocumentation for each treatment must include a detailed description of the procedure and the method (e.g., scalpel, scissors, 4x4 gauze, wet-to-dry, enzyme) used when billing 97602. Because the correct debridement code is dependent on type of debridement and wound size, documentation should include frequent wound measurements. The documentation should also include a description of the appearance of the wound (especially size, but also depth, stage, bed characteristics), as well as the type of tissue or material removed. The documentation must meet the criteria of the code billed.Additional guidance for debridement codes:Do not bill for more than one unit per session for CPT code 97602, regardless of the number or complexity of the wounds treated.Use the -59 modifier to indicate nonselective and selective debridement provided in a single encounter at different anatomical sites.Application and removal of dressings to the wound is included in the work and practice expenses of 97602 and should not be billed separately under a therapy plan of care. Charges for dressings, gauze, tape, sterile water for irrigation, tweezers, scissors, q-tips, and medications used in the wound care treatment will be denied even if the wound care service is found to be medically reasonable and necessary. Payment for dressings applied to the wound is included in HCPCS code 97602 and they are not to be billed separately.If a simple dressing change is performed without any active wound procedure as described by these codes, do not bill code 97602 to describe the service.For wound assessment it is not appropriate to bill therapy re-evaluation codes (97164, 97168) along with code 97602. The assessment, including measurements of the wound and a written report, is considered a part of code 97602.Patient and caregiver instructions are included in code 97602. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.This code represents sometimes therapy services and will be paid under the OPPS when (a) the service is not performed by a therapist, and (b) it is inappropriate to bill the service under a therapy plan of care. Nurses performing debridement (where allowed by state scope of practice acts) described by code 97602 may bill this code using revenue codes other than the therapy revenue codes 42x (PT) and 43x (OT).Payment for 97602, when performed by a qualified professional/auxiliary personnel under a therapy plan of care, is recognized as a bundled service under the Medicare Physician Fee Schedule (MPFS). Regardless of whether billed alone or in conjunction with another therapy code, separate payment is never made for 97602.Evaluation and management services should not be billed along with the debridement service unless a significant, separately identifiable evaluation and management service, correctly identified with modifier -25 on the claim, was also provided to the patient during the same encounter. (Therapists should not use the evaluation and management codes at any time.)Supportive Documentation Requirements (required at least every 10 visits) for 97602Etiology and duration of woundPrior treatment by a physician, non-physician practitioner, nurse and/or therapistStage of woundDescription of wound: length, width, depth, grid drawing and/or photographsAmount, frequency, color, odor, type of exudateEvidence of infection, undermining, or tunnelingNutritional statusComorbidities (e.g., diabetes mellitus, peripheral vascular disease)Pressure support surfaces in usePatients functional levelSkilled plan of treatment, including specific frequency, modalities and proceduresType of debridement performed, including instrument used, to support the debridement code billedChanging plan of treatment based on clinical judgment of the patients response or lack of response to treatmentFrequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.CPT 97605, 97606, 97607, 97608 Negative pressure wound therapy (eg,vacuum assisted drainage collection), utilizing durable medical equipment (dme), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.CPT 97606  surface area greater than 50 square centimetersCPT 97607- Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.CPT 97608- Total wound(s) surface area greater than 50 square centimeters.Negative pressure wound therapy (NPWT) involves negative pressure to the wound bed to manage wound exudates and promote wound healing. NPWT consists of a sterile sponge held in place with transparent film, a drainage tube inserted into the sponge, and a connection to a vacuum source. CPT Codes 97607 and 97608 are reported when a mechanically-powered device is used.Additional guidance for NPWT codes:These codes are not timed.Do not bill for more than one unit per session, regardless of the number or complexity of the wounds treated.Patient and caregiver instructions are included in codes 97605/97606 and 97607 and 97608. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.It is not appropriate to bill therapy re-evaluation codes (97164, 97168) along with 97605/97606 or 97607 and 97608. The assessment, including measurements of the wound and a written report, is considered a part of 97605/97606 or 97607 and 97608.Supportive Documentation Requirements (required at least every 10 visits) for 97605, 97606, 97607 and 97608Etiology and duration of woundPrior treatment by a physician, non-physician practitioner, nurse and/or therapistStage of woundDescription of wound: length, width, depth, grid drawing and/or photographsAmount, frequency, color, odor, type of exudateEvidence of infection, undermining, or tunnelingNutritional statusComorbidities (e.g., diabetes mellitus, peripheral vascular disease)Pressure support surfaces in usePatients functional levelSkilled plan of treatment, including specific frequency, modalities and proceduresChanging plan of treatment based on clinical judgment of the patients response or lack of response to treatmentFrequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.CPT 97750 - Physical Performance Test or Measurement (e.g., musculoskeletal, functional capacity) with written report, each 15 minutesThese tests and measurements are beyond the usual evaluation services performed. Examples of physical performance tests or measurements include isokinetic testing, Functional Capacity Evaluation (FCE) and Tinetti. This code may be used for the 6-minute walk test, with a computerized report of the patients oxygen saturation levels with increasing stress levels, performed under a PT or OT plan of care on pulmonary rehabilitation patients.The therapy evaluation and re-evaluation codes are for a comprehensive review of the patient including, but not limited to, history, systems review, current clinical findings, establishment of a therapy diagnosis, and estimation of the prognosis and determination and/or revision of further treatment. CPT 97750 is intended to focus on patient performance of a specific activity or group of activities (CPT Assistant, December 2003).There must be written evidence documenting the problem requiring the test, the specific test performed, and a separate measurement report. This report may include torque curves and other graphic reports with interpretation.97750 should not be used to bill for patient assessments/re-assessments such as ROM testing or manual muscle testing completed at the start of care (as this is typically part of the examination included in the initial evaluation) and/or as the patient progresses through the episode of treatment.CPT code 97750 is not covered on the same day as CPT codes 97161-97168 (due to CCI edits).Supportive Documentation Requirements (required at least every 10 visits) for 97750Problem requiring the test and the specific test performedSeparate measurement report, including any graphic reportsApplication to functional activityHow the test impacts the plan of care