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

Problem requiring the test and the specific test performedSeparate measurement report, including any graphic reportsApplication to functional activityHow the test impacts the plan of careCPT 97755 - Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutesThis is an assessment code, per each 15 minutes, and must be accompanied by a written report explaining the nature and complexity of the assistive technology needed by the patient. This can include testing multiple components/systems to determine optimal interface between client and technology applications, and determining the appropriateness of commercial (off the shelf) or customized components/systems. This assessment may require more than one patient visit due to the complexity of the patients condition and his/her decreased tolerance for activity at one session.Training for use in assistive technology in the home environment is coded as 97535 and for use in the community as 97537.CPT code 97755 is not covered on the same day as CPT codes 97161-97168 (due to CCI edits). Utilization of this service should be infrequent.Supportive Documentation Requirements for 97755The goal of the assessmentThe technology/component/system involvedA description of the process involved in assessing the patients responseThe outcome of the assessmentDocumentation of how this information affects the treatment planCPT 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 minutesOutpatient hospital therapy departments, comprehensive outpatient rehabilitation facilities (CORFs), outpatient rehabilitation facilities, nursing homes (limited to patients covered under a Medicare Part B stay), and home health agencies (limited to patients not under a HH plan of care) bill the Part A MAC for the orthotic utilizing the relevant HCPCS Level II L code and revenue code 274 on the claim form. These settings do not require a DME supplier billing enrollment to bill and be reimbursed for the L codes.A physical or occupational therapist in private practice or a physician/NPP is considered by Medicare to be a "supplier" and must bill the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for orthotics. Any supplier that issues orthotics must be enrolled as a supplier of Durable Medical Equipment, Prosthetics, Orthotics, or Supplies (DMEPOS) prior to billing the DME MAC. Follow the directions from the DME MAC when billing for orthotics (utilizing an L code). Note: Therapists in private practice and physicians/NPPs should follow the guidance below for billing CPT 97760 to the Medicare carrier/Part B MAC.Ongoing visits by the qualified professional/auxiliary personnel to apply the device would be considered monitoring. Once the initial fit is established, any further visits should be used for specific documented problems and modifications that require skilled therapy; these are billed with CPT 97763. It is reasonable and necessary to require 1-3 visits to fit and educate the patient or caregiver. The medical necessity of any further visits must be supported by documentation in the medical record.Coverage under CPT code 97760 is not for prefabricated/commercial (i.e., off the shelf) components such as, but not limited to a lumbar roll, non-customized foam supports/wedges (e.g., heel cushions), or multi-podus boots. Such components do not require the skills of a therapist and are non-covered. Minor modifications to prefabricated orthotics do not constitute a customized orthotic.Code 97760 should not be reported with 97116 for the same extremity.Payment for prosthetics and orthotics is made on the basis of a fee schedule whether it is billed to the DME MAC or the Part A MAC.The L codes for orthotics provide a brief description of the device and describe whether the device needs to be molded to a patient model, custom fabricated, custom fitted, or have no fitting specifications. Select the appropriate L code based on the description of the brace provided.The Medicare payment for the L codes includes the following items.Assessment of the patient regarding the orthoticMeasurement and/or fittingSupplies to fabricate or modify the orthoticTime associated with making the orthoticCPT 97760 should be used to report the initial encounter for orthotic "training" completed by qualified professionals/auxiliary personnel. CPT 97760 may be used in conjunction with the L code only for the time spent training the patient in the use of the orthotic. Orthotic training may include teaching the patient regarding a wearing schedule, placing and removing the orthosis, skin care and performing tasks while wearing the device.To avoid duplicate billing, the time spent assessing, measuring and/or fitting, fabricating or modifying, or making the orthotic may not be included in calculating the number of units to bill for CPT 97760 when also billing the appropriate L code. CPT 97760 is a "timed" code and only minutes actually spent in the training of the patient should be counted when determining units to bill when an L code is also billed.There may be circumstances where a patient is only going to be seen for a brief therapy episode for issuance of an orthotic. If it is not necessary to complete a full, comprehensive patient evaluation, but only an assessment related to determining the specific orthotic, do not bill an initial therapy evaluation code in addition to the L code.For other patient situations however, a full patient initial evaluation is needed to develop the appropriate treatment plan in addition to an assessment related to determining the specific orthotic. 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 assigned to either 97161-97163 or 97165-97167. For example, a patient is referred to occupational therapy for a wrist-hand orthotic with possible continued therapy. The OT spends 35 minutes evaluating the patient which includes the history, subjective complaints, prior and current functional levels, ROM, strength, sensation, skin integrity, and ADL assessment. This time would be assigned to the OT evaluation code 97165. The OT then begins the assessment of the patient for the orthotic which includes determining the need for the orthotic and the type of orthotic, subsequently fabricating the appropriate device and fitting it to the patient. This time, which takes 45 minutes, would be reimbursed under the L code. The OT spends an additional 20 minutes training the patient in the wearing schedule of the orthotic, skin care and exercises to be performed while the orthotic is in place. These 20 minutes would be assigned to code 97760, billable as 1 unit for the training component.Per CPT Assistant, 2017, Code 97760 includes orthotic management and training provided at the initial encounter. Subsequent encounters, reported with code 97763 (effective 2018) include exercises performed in the orthotic, instruction in skin care and orthotic wearing time, and time associated with modification of the orthotic due to healing of tissues, change in edema, or interruption in skin integrity.For an orthotic to be billed, it must be medically necessary for the patient's condition. To bill for training the patient to use the orthotic (CPT 97760) the documentation must justify the need for a skilled qualified professional/auxiliary personnel to train the patient in the use and care of the orthotic. When the management of the orthotic can be turned over to the patient, the caregiver or nursing staff, the services of the therapist will no longer be covered.An orthotic provided for positioning and/or increasing range of motion in a non-functional extremity must include documentation that the unique skills of a therapist are required to fit and manage the orthotic and that the orthotic is medically necessary for the patient's condition.It is not appropriate to bill CPT 97760 for measurements taken to obtain custom fitted burn or pressure garments. These garments do not fit the definition of an orthotic.Supportive Documentation Requirements for 97760A description of the patient's condition (including applicable impairments and functional limitations) that necessitates an orthoticAny complicating factorsThe specific orthotic provided and the date issuedA description of the skilled training providedResponse of the patient to the orthoticCPT 97761 - Prosthetic training, upper and/or lower extremity(s), initial prosthetic(s) encounter, each 15 minutesProsthetic training is the professional instruction necessary for a patient to properly use an artificial device that has been developed to replace a missing body part.Prosthetic training includes preparation of the stump, skin care, modification of prosthetic fit (revisions to socket liner or stump socks), and initial mobility and functional activity training. Once a patient begins gait training with the prosthesis, use code 97116.Supportive Documentation Requirements for 97761Type of prosthesis, extremity involvedSpecific training provided and amount of assistance neededAny complicating factors and specific description of these (with objective measurements), such as pain, joint restrictions/contractures, strength deficits, etc.CPT 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 minutesPer CPT Changes 2018, these assessments are intended for established patients who have already received their orthotic or prosthetic device, to check for skin integrity, wound changes, abnormalities of fit or a loss of function directly related to the device (e.g., pain, skin breakdown, and falls of devices or other problems related to the orthotic or prosthetic.If the checkout assessment resulted in the need for further training in the use of the orthotic/prosthetic, code 97763 would be appropriate for the training.Documentation must clearly support the need for more than 2 visits for the checkout assessment.Supportive Documentation Requirements for 97763Reason for assessmentFindings from the assessmentSpecific device, modifications made, instruction givenCPT 97799 - Unlisted physical medicine/rehabilitation service or procedure, not timed-If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the claim and medical record must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information.Supportive Documentation Requirements for 97799Please see Documentation Requirements for Unlisted Procedure codes. This is an untimed code, billable as "1" unit.CPT G0281  Electrical stimulation, (unattended),to one 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 careCPT G0329 - Electromagnetic therapy,to one 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 careDo not bill a re-evaluation code for the wound assessment).If ES or electromagnetic therapy is being used, wounds must be evaluated at least monthly by the treating physician.Per NCD 270.1, electrical stimulation (G0281) and electromagnetic therapy (G0329) are NOT COVERED for the treatment of:stage I or stage II wounds;electrical stimulation or electromagnetic therapy when used as an initial treatment modality;continued treatment with ES or electromagnetic therapy if measurable signs of healing have not been demonstrated within any 30-day period of treatment;wounds that demonstrate a 100% epithelialized wound bed;a patient in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary.G0281 code replaces code 97014, only where it applies to treatment of wounds, as defined in the code narrative.Nationally Covered Indications(CMS Publication 100-03,Medicare National Coverage Determinations(NCD) Manual, section 270.1):Electrical stimulation (ES) and electromagnetic therapy for the treatment of wounds are considered adjunctive therapies, and will only be covered for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers. Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence. ES or electromagnetic therapy will be covered only after appropriate standard wound therapy has been provided for at least 30 days and there are no measurable signs of healing. This 30-day period may begin while the wound is acute. Standard wound care includes optimization of nutritional status, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, and necessary treatment to resolve any infection that may be present. Standard wound care based on the specific type of wound includes frequent repositioning of a patient with pressure ulcers (usually every 2 hours), off-loading of pressure and good glucose control for diabetic ulcers, establishment of adequate circulation for arterial ulcers, and the use of a compression system for patients with venous ulcers. Measurable signs of healing include a decrease in wound size (either surface area or volume), decrease in amount of exudates, and decrease in amount of necrotic tissue. ES or electromagnetic therapy must be discontinued when the wound demonstrates a 100% epithelialized wound bed.Supportive Documentation Requirements (required at least every 10 visits) for G0281 and G0329