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

Re-evaluations (CPT codes 97164, 97168)See CPT 97164 and 97168 for coverage guidelines for therapy re-evaluations.Re-evaluation documentation must include clear justification for the need for further tests and measurements after the initial evaluation, such as new clinical findings, a significant, unanticipated change in the patients condition, or failure to respond to the interventions in the plan of care. It is expected that clinicians continually assess the patients progress as part of the ongoing therapy services. This assessment is not considered a formal re-evaluation; the time of any assessment is included and billed within the appropriate treatment intervention CPT code.Re-evaluations must be performed by clinicians and contain all applicable components of the initial evaluation. Resolved problems do not need to be re-evaluated; new or ongoing problems may need to be re-evaluated, especially if there is an anticipated change to the long term goals.Progress ReportsProgress reports provide justification for the medical necessity of treatment. Progress reports shall be written by a clinician at least once every 10 treatment days. Writing progress notes more frequently than the minimum is encouraged to support the medical necessity of treatment. A progress report is not a separately billable service. In CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Sections 220-230, Medicare defines the minimum REQUIRED elements of a progress report. It is essential that clinicians include all required elements in their documentation (either in a progress report or treatment note). Progress note elements include (CMS required elements are italicized):Date of the beginning and end of the reporting period that this report refers to;Date that the report was written by the clinician, or if dictated, the date on which it was dictated;Objective reports of the patients subjective statements, if they are relevant;Objective measurements(impairment/function testing) to quantify progress and support justification for continued treatment;Description of changes in status relative to each goal currently being addressed in treatment. Descriptions shall make identifiable reference to the goals in the current plan of care;Assessment of improvement, extent of progress (or lack thereof) toward each goal;Plans for continuing treatment, including documentation of treatment plan revisions as appropriate;Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment;Signaturewith credentials of the clinician who wrote the report.No specific format is required to demonstrate patient progress as long as all information noted in the bullets above are included at least once in the medical record for each progress report period (10 treatment days). Progress report information may be included in the treatment notes, progress reports and/or formal re-evaluations (when re-evaluation guidelines are met). During each progress report period, the clinician must personally furnish in its entirety at least one billable service on at least one day of treatment. Verification of the clinicians treatment shall be documented by the clinicians signature on the treatment note and/or progress report.Treatment NotesMedical record documentationis required for every treatment day, and every therapy serviceto justify the use of codes and units on the claim. The treatment note must include the following required information:date of treatment;identification of each specific treatment, intervention or activity providedin language that can be compared with the CPT codes to verify correct coding;record of the total time spent in services represented by timed codes under timed code treatment minutes;record of the total treatment time in minutes, which is a sum of the timed and untimed services;signature and credentials of each individual(s) that provided skilled interventions.In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:patient comments regarding pain, function, completion of self management/home exercise program (HEP), etc.;significant improvement or adverse reaction to treatment;significant, unusual or unexpected changes in clinical status;parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;description of the skilled components of the specific exercises, training, or activities;instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);communication with patient, family, caregiver;equipment providedany additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patients functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.If grid or checklist forms are used for daily notes or exercise/activity logs, include the signature and credentials of the qualified professional/auxiliary personnel providing the service each day. Listing of exercise names (e.g., pulleys, UBE, TKE, SLR) does not alone imply that skilled treatment has been provided, especially if the exercises have been performed over multiple sessions. Be sure to occasionally document the skilled components of the exercises so they do not appear repetitive and therefore, unskilled. Documenting functional activities performed (e.g., ambulated 35 feet with min assist, upper body dressing with set up and supervision) also does not alone imply that skilled treatment was provided. The skilled components/techniques of the qualified professional/auxiliary personnel used to improve the functional activity should be occasionally documented to support medical necessity.When documenting treatment time, consistently use the CMS language of total Timed Code Treatment Minutes and Total Treatment Time. Do not use other language or abbreviations when referring to treatment minutes as it may be difficult for medical review to determine the type of minutes documented.The amount of time for each specific intervention/modality provided may also be recorded voluntarily.Do not record treatment time as Time in / Time out for the entire session as this does not accurately reflect the actual treatment time. Do not round all treatments to 15-minute increments, but rather record the actual treatment time. Also do not record as units of treatment, instead of minutes. Only intra-service care of skilled therapy services should be reflected in the time documentation. Do not include unbillable time, such as time for:changing;waiting for treatment to begin;waiting for equipment;resting;toileting; orperforming unskilled or independent exercises or activities.Examples of treatment time documentationA treatment session includes 20 minutes therapeutic exercise (97110), 15 minutes therapeutic activities (97530) and 20 minutes unattended electrical stimulation (G0283). Time documentation in the treatment noteTimed Code Treatment Minutes: 35 minutesTotal Treatment Time: 55 minutesA 30 minute OT initial evaluation is completed (97165), followed by 20 minutes fluidotherapy (97022). Time documentation in the treatment noteTimed Code Treatment Minutes: 0 minutesTotal Treatment Time: 50 minutesCanalith Repositioning:Documentation should include:- Results of physiologic testing (if performed)- A plan for the continuing care,- The progress demonstrated,- The number of anticipated additional services,- Explanation of why the patient would be unable to performing the exercises at home without the immediate supervision of a trained professional.Discharge NotesA discharge note is required for each episode of treatment and must be written by the clinician. The discharge note is a progress report covering the time from the last progress report up to the date of discharge, and includes all required components of a progress report. The discharge note may be considered the last opportunity to justify the medical necessity of the entire treatment episode. Therefore, if a discharge summary has been completed, it may be prudent to submit it with any request of records for medical review, even if the claim under review is for a treatment period prior to the date of discharge.In the case of an unanticipated discharge, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified auxiliary personnel. In the case of a discharge anticipated within 3 treatment days of the progress report, the clinician may provide objective goals which, when met, will authorize the assistant or qualified auxiliary personnel to discharge the patient. In that case, the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist. There must be indication that the clinician has reviewed the treatment notes and agrees to the discharge.Certifications and RecertificationsMedicare beneficiaries receiving outpatient therapy services must be under the care of a physician/NPP. Orders (sometimes called referrals) and certifications are common means of demonstrating such evidence of physician involvement. Certification, which is a coverage condition for therapy payment, requires a dated physician/NPP signature on the therapy plan of care or some other document that indicates approval of the plan of care. A certification often differs from an order or referral in that it must contain all required elements of a plan of care. To assist medical review in determining that the certification requirements are met, certifications/recertifications should include the following elements(CMS required elements are italicized):The date from which the plan of care being sent for certification becomes effective (for initial certifications, the initial evaluation date will be assumed to be the start date of the certified plan of care);Diagnoses;Long term treatment goals;Type, amount, duration and frequency of therapy services;Signature, date and professional identity of the therapist who established the plan; andDated physician/NPPsignature indicating that the therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan. (Note: The CORF benefit does not recognize an NPP for certification.)Effective January 1, 2008, the interval length shall be determined bythe patients needs, not to exceed 90 days.Certifications which include all the required plan of care elements will be considered valid for the longest duration in the plan (such as 3x/wk for 6 weeks which will be considered as a total of 18 treatments). If treatment continues past the longest duration specified, a recertification will be required.Documentation Requirements for Unlisted Procedure Codes (97039, 97139, 97799, 29799)97039 - In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxiliary personnel, the time spent by the qualified professional/auxiliary personnel, one-on-one with the beneficiary.97139 - Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.97799 - Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.29799 - Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.Utilization GuidelinesThe Medicare Physician Fee Schedule (MPFS) is the method of payment for outpatient therapy services, except critical access hospitals (CAH), which are paid on a reasonable cost basis. Although CAHs are not paid via the MPFS, all outpatient coverage, coding and documentation guidelines, as noted in the Medicare manuals and this LCD, apply.Untimed CPT CodesWhen a therapy treatment modality or procedure is not defined in the AMA CPT Manual by a specific time frame (such as each 15 minutes), the modality or procedure is considered an untimed service. Untimed services are billedbased on the number of times the procedure is performed, often once per day.Untimed services billed as more than 1 unit will require significant documentation to justify treatment greater than one session per day per therapy discipline. See the section CPT 97161-97163 and 97165-97167 for additional guidance on billing for evaluations that span more than 1 day. The minutes spent providing untimed services are reflected in the documentation under Total Treatment Time(and are not included in the minutes for timed CPT codes when determining the number of timed-based units that may be billed).Timed CPT CodesMany CPT codes for therapy modalities and procedures specify that direct (one-on-one) time spent in patient contact is 15 minutes.The time counted is the time the patient is treatedusing skilled therapy modalities and procedures, and is recorded in the documentation as Timed Code Treatment Minutes. Pre- and post-delivery services are not to be counted when recording the treatment time. The time counted is the intra-service care that begins when the qualified professional/auxiliary personnel is directly working with the patient to deliver the service. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment. The intra-service care includes assessment. The time the patient spends not being treated because of a need for toileting or resting should not be counted. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. Time spent supervising a patient performing an activity that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the Timed Code Treatment Minutes. Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.