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

Direct motor point stimulation delivered via a probeInstructing a patient in the use of a home TENS unitOnce a trial of TENS has been done in the clinic over 1-2 visits and the patient has had a favorable response, the patient can usually be taught to use a TENS unit for pain control in 1-2 visits. Consequently, it is inappropriate for a patient to continue treatment for pain with a TENS unit in the clinic settingNote that CPT code 64550 is for application of surface (transcutaneous) neurostimulator and is an operative/postoperative code. Use of this code would seldom fall under a therapy plan of treatment.Use for Walking in Patients with Spinal Cord Injury (SCI)The type of NMES that is used to enhance the ability to walk of SCI patients is commonly referred to as functional electrical stimulation (FES). See the section on CPT code 97116 for information on coverage for this use of NMES. (CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, section 160.12)Most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES) while performing a therapeutic exercise or functional activity may be billed as 97032. Do not bill for CPT codes 97110, 97112, 97116 or 97530 for the same time period.Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period.If providing an electrical stimulation modality that is typically considered supervised (G0283) to a patient requiring constant attendance for safety reasons due to cognitive deficits, do not bill as 97032. This type of monitoring may be done by non-skilled personnel.Non-Implantable Pelvic Floor Electrical Stimulation (CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,section 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 musculatureThe 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 pelvic muscle exercise (PME) training.Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283.Documentation must clearly support the medical necessity of electrical stimulation more than 12 visits as adjunctive therapy or for muscle retraining.Supportive Documentation Requirements (required at least every 10 visits) for 97032Type of electrical stimulation used (do not limit the description to manual or attended)Area(s) being treatedIf used for muscle weakness, objective rating of strength and functional deficitsIf used for pain include pain rating, location of pain, effect of pain on functionCPT 97033  Iontophoresis (to one or more areas)Iontophoresis is the introduction into the tissues, by means of an electric current, of the ions of a chosen medication.Iontophoresis will be allowed for treatment of intractable, disabling primary focal hyperhidrosis (ICD-10-CM codes L74.510-L74.513 or L74.519) that has not been responsive to recognized standard therapy. Good hygiene measures, extra-strength antiperspirants (for axillary hyperhidrosis), and topical aluminum chloride should initially be tried.CPT 97034 - Contrast Baths (to one or more areas)Contrast baths are a form of therapeutic heat and cold applied to distal extremities in an alternating pattern. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold.CPT Code 97034 is not covered when the services provided are hot and cold packs. This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment.This is a constant attendance code requiring direct, one-on-one patient contact by the provider. Only the actual time of the providers direct contact with the patient is to be billed.Supportive Documentation Requirements (required at least every 10 visits) for 97034Rationale requiring the unique skills of a therapist to apply, including the complicating factorsArea(s) being treatedSubjective findings to include pain ratings, pain location, effect on functionDocumentation must indicate the presence of these complicating factors for reimbursement of this code. If there are no complicating factors requiring the skills of a therapist, this modality is non-covered.CPT 97035  Ultrasound (to one or more areas)See list ofICD-10 Codes that DO NOT Support Medical NecessityPhonophoresis (the use of ultrasound to enhance the delivery of topically applied drugs) will be reimbursed as ultrasound, billable using CPT 97035. Separate payment will not be made for the contact medium or drugs.Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period.Supportive Documentation Requirements (required at least every 10 visits) for 97035Area(s) being treatedFrequency and intensity of ultrasoundObjective clinical findings such as measurements of range of motion and functional limitations to support the need for ultrasoundSubjective findings to include pain ratings, pain location, effect on functionIf no objective and/or subjective improvement is noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of ultrasound. Documentation must clearly support the need for ultrasound more than 12 visits.CPT 97036  Hubbard Tank (to one or more areas)This modality involves the patients immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.Hubbard tank treatments more than 12 visits require clear documentation supporting the medical necessity of continued use of this modality.Supportive Documentation Requirements for 97036Rationale requiring the unique skills of a therapist to apply, including the complicating factorsArea(s) being treatedCPT 97039 - Unlisted Modality(Specify type and time if constant attendance) 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.Note: Low level/cold laser light therapy (LLLT)is considered not reasonable and necessary under SSA 1862(a)(1)(A) and is not payable by Medicare. This procedure is considered non-covered billed under any HCPCS/CPT codes, including S8948 and 97039. Effective 7/1/2019, this service is reported with CPT code 0552T. Effective 1/1/2024, CPT 97037 (application of a modality to 1 or more areas; low-level laser therapy (ie, nonthermal and non-ablative) for post operative pain reduction.) has been added and is also non-covered by Medicare.Supportive Documentation Requirements for 97039Please see section Documentation Requirements for Unlisted Procedure Codes.CPT G0283 - Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of careSee 97032 for instructions in manual electrical stimulation.Most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.Code G0283 is classified as a supervised modality, even though it is labeled as unattended. A supervised modality does not require direct (one-on-one) patient contact by the provider. Most electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples of unattended electrical stimulation modalities include Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation).If unattended electrical stimulation is used for control of pain and swelling, there should be documented objective and/or subjective improvement in swelling and/or pain within 6 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.Documentation must clearly support the need for electrical stimulation more than 12 visits. Some patients can be trained in the use of a home TENS unit for pain control. Only 1-2 visits should be necessary to complete the training (which may be billed as 97032). Once training is completed, code G0283 should not be billed as a treatment modality in the clinic.Non-Implantable Pelvic Floor Electrical Stimulation(CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, section 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 delivered by vaginal or anal probes connected to an external pulse generator 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 treatments 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.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 pelvic muscle exercise (PME) training. Documentation should also include the method of delivery (e.g., probe or electrode).The charges for the electrodes are included in the practice expense portion of code G0283. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality. Do not bill Medicare for unattended electrical stimulation using code 97014.Supportive Documentation Requirements (required at least every 10 visits) for G0283Type of electrical stimulation used (e.g., TENS, IFC)Area(s) being treatedIf used for pain include pain rating, location of pain, effect of pain on function