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

Due to the lack of peer reviewed evidence concerning the effect on patient health outcomes, skilled therapy interventions (e.g., ultrasound, electrical stimulation, soft tissue mobilization, and therapeutic exercise) for the treatment of the following conditions is considered investigational and thus non-covered.Frequency Specific Microcurrent: non-covered due to lack of medical literature supporting the effectiveness of this therapyWhole body periodic acceleration: does not meet the benefit requirement that it requires the services of a skilled professionalLight beam Generator therapy: non-covered due to lack of medical literature supporting the effectiveness of this therapyFunctional Electrical Stimulating (FES) devices other than those that assist in walking are not covered under Medicare [NCD 160.12]. Consequently, any services related to the evaluation for or training of patients to use such a device is not covered. Such devices may include, but are not limited, to the Ergys system.General Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, the time of any assessment is included and billed within the appropriate treatment intervention CPT code. Therapy services shall be payable when the medical record and the information on the claim consistently and accurately report covered therapy services. Documentation must be legible, relevant and sufficient to justify the medical necessity of the services billed.Medicare requires a legible identifier of the person(s) who provided the service. The method used shall be a hand written or an electronic signature to sign an order or other medical documentation for medical review purposes. Electronic or hand written signatures that have been communicated through facsimile are also acceptable. Effective April 28, 2008, stamp signatures were no longer acceptable. The document guidelines in CMS Pub 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 220 and 230 identify the minimal expectations of documentation by providers or suppliers or beneficiaries submitting claims for payment of therapy services to the Medicare program. It is encouraged, in order to support the medical necessity and the skilled nature of the treatment, to document more thoroughly and frequently. Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:Paint a picture of the patients impairments and functional limitations requiring skilled intervention;Describe the prior functional level to assist in establishing the patients potential and prognosis;Describe the skilled nature of the therapy treatment provided;Justify that the type, frequency and duration of therapy is medically necessary for the individual patients condition;Clearly document both Timed Code Treatment Minutes and Total Treatment Time in order to justify the units billed;Identify each specific skilled intervention/modality provided to justify coding.Documentation may be submitted in any format as long as all the necessary information is captured. Forms 700 & 701 are not required documents. The documentation must establish that the patient needs the unique skills of a therapist to improve functioning. This is accomplished through a description of the patients condition, and any complexities that impact that condition. Not only should documentation describe the needs of the patient that require the unique skills of a therapist, but should also describe the services provided that required the expertise, knowledge, clinical judgment, decision making and abilities of a clinician that assistants, qualified auxiliary personnel, caretakers or the patient cannot provide independently. A therapists skills may be documented, for example, by the descriptions of the skilled treatment, the changes made to the treatment due to an assessment of the patients needs on a particular treatment day, or due to progress judged sufficient to modify the treatment toward the next more complex or difficult task. Documentation should establish the variables that influence the patients condition, especially those factors that influence the therapists (or clinician's) decision to provide more services than are typical for the individuals condition. Documentation should establish through objective measurements that the patient is making progress toward goals.When regression or plateaus occur, the reasons for the lack of progress should be noted to justify continued treatment.Only a clinician may perform an initial examination, evaluation, reevaluation and assessment or establish a diagnosis or a plan of care. The clinician may include as part of the evaluation or reevaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or reevaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.Refer to CMS guidance on billing by PTAs and OTAs under https://www.cms.gov/Medicare/Billing/TherapyServices/Billing Examples Using CQ/CO Modifiers for Services Furnished In Whole or In Part by PTAs and OTAs.Initial Evaluation (CPT codes 97161-97163, 97165-97167)The initial evaluation, which must be performed by a clinician, should document the medical necessity of a course of therapy through objective findings and subjective patient self-reporting. Documentation of the initial evaluation should list the conditions being treated and any complexities that make treatment more lengthy or difficult. Where it is not obvious, describe the impact of the conditions and complexities so that it is clear to the medical reviewer that the services planned are appropriate for the individual.The initial evaluation establishes the baseline data necessary for assessing expected rehabilitation potential, setting realistic goals and measuring progress. Initial evaluations need to provide objective, measurable documentation of the patients impairments and how any noted deficits affect ADLs/IADLs and result in functional limitations. Functional limitations refer to the inability to perform actions, tasks and activities that constitute the usual activities for the patient. Functional limitations must be meaningful to the patient and caregiver, and must have potential for improvement. In addition, the remediation of such limitations must be recognized as medically necessary.To support medical necessity, the evaluation should include the following items.Presenting condition or complaint...."What brings the patient to therapy at this time?Patients should exhibit a significant change from their usual physical or functional ability to warrant an evaluation.Provide an objective description of the changes in function that now necessitate skilled therapy. Simply stating decline in function does not adequately justify the initiation of therapy services.Diagnosis and description of specific problem(s) to be evaluatedInclude area of the body, and conditions and complexities that could impact treatmentSubjective complaints and date of onsetRelevant medical historyApplicable medical history, medications, comorbidities (factors that make therapy more complicated or require extra precautions)Prior diagnostic imaging/testing resultsPrior therapy history for the same diagnosis, illness or injuryIf recent therapy was provided, documentation must clearly establish that additional therapy is reasonable and necessarySocial support/environmentWhat level of support is available, and what level of independence is required for the patient to be safe in the home environment?Does the patient live alone, with a caregiver, in a group home, in a residential care facility, in a skilled nursing facility (SNF), etc.?Does the home situation have obstacles that the patient must overcome (e.g., stairs without handrails)?What are the patients usual responsibilities in the home environment?Prior level of functionKey piece of information used for establishing potential, prognosis and realistic functional goalsFunctional status just prior to the onset of the treating condition requiring therapyRecord in objective, measurable and functional termsFunctional testingmobility status (transfers, bed mobility, gait, etc.);self-care dependence (toileting, dressing, grooming, etc.);meaningful ADLs/IADLs;pain, and how it limits function; andfunctional balance.Objectively measure and/or describe the patients current level of functioning. Examples, based on the patients need, may include:Objective impairment testingTesting done to determine the source or cause of the functional limitation(s), such as ROM, manual muscle testing, coordination, tone assessment, balance etc.Use concise, objective measurements. Avoid minimal/moderate/severe types of descriptions when more specific definitions or measurements are available. For example, when measuring shoulder flexion AROM, document degrees of motion, rather than documenting, Shoulder flexion: minimal loss of motion.AssessmentSummary of the therapists analysis of the condition being evaluated based on the examination of the patient. Clinical reasoning for treatment should be evident when further therapy is recommended.Prognosis for return to prior functional status, or the maximum expected conditionPlan of care (see paragraph below)Signature and credentials of the therapist or physician/NPP completing the initial evaluation and plan of care. Each therapy discipline must have a separate plan of care. The plan of care (POC) must contain ALL of the following information.Required POC ElementAdditional PointsDiagnosisThe diagnosis should be specific and as relevant to the problem being treated as possible. In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.Bill the most relevant diagnosis.As always, when billing for therapy services, the ICD-10 code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason. For example, when a patient with diabetes is being treated for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible in accordance with State and local laws and the contractors Local Coverage Determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position.Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.Long Term Goals (LTGs)LTGs should:pertain to the functional impairment findings documented in the evaluation;reflect the final level the patient is expected to achieve as a result of therapy in the current setting;be realistic, and should have a positive effect on the quality of the patients everyday functions;befunction-basedand written in objective, measurable terms with a predicted date for achieving the goals.Type of TreatmentThe type of treatment includes the type of therapy discipline operating under this POC (PT or OT) and should describe the types of treatment modalities, procedures or interventions to be provided.Amount of TreatmentRefers to the number of times in a day the type of treatment will be provided. Where not specified, one treatment session a day is assumed.Treatment provided more than one session per day per discipline will require additional documentation to support this amount of therapy.Frequency of TreatmentRefers to the number of times in a week that the type of treatment is provided.Treatment more than two or three times a week is expected to be a rare occurrence. Treatment frequency of greater than three times per week requires documentation to support this intensity.Duration of TreatmentRefers to the number of weeks, or the number of treatment sessions, for this plan of care.Clinicians could also estimate the duration of the entire episode of care in this setting.