Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)

Documentation Requirements for Unlisted Procedure CodesUnlisted modality- 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/auxilliary personnel, the time spent by the qualified professional/auxilliary personnel, one-on-one with the beneficiary.Unlisted therapeutic procedure- 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.Unlisted physical medicine/rehabilitation service or procedure- 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.Unlisted procedure, casting or strapping- 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.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 billed based 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. 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).Time Based Codes (if applicable)When billing time-based codes the CPT time rule appliesExact times MUST be documented in the medical recordThe code reported should be selected based on the time closest to that indicated in the code descriptorMany 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 treated using 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.When determining the allocation of units, it is easiest to separate out each service first into 15-minute time blocks. For example:24 minutes 97112 = one 15-minute block + 9 remaining minutes23 minutes 97110 = one 15-minute block + 8 remaining minutesEach code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most remaining minutes (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is 2 units 97112 + 1 unit 97110.The first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise and 20 minutes self-care/home management training. The total Timed Code Treatment Minutes documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in Timed Code Treatment Minutes will determine the number of units billed.Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.Do not bill for documentation time separately(except for standardized cognitive performance testing). This is incorporated in the HCPCS/CPT fee reimbursed for each individual service provided.Do not code higher than what the procedure requires. Coding in this manner may allow the provider to collect inappropriate revenues without incurring additional costs.Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.Do not unbundle services/procedures. Unbundling refers to the practice of splitting a single payment code into two or more codes. This may lead to inappropriate multiple payments.Do not bill separately for supplies used to provide therapy services, such as electrodes, theraband, theraputty, etc.Therapists, or therapy assistants, working together as a team to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient. For example, if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.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 (97162), followed by 20 minutes fluidotherapy (97022).Time documentation in the treatment noteTimed Code Treatment Minutes: 0 minutesTotal Treatment Time: 50 minutesThe first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise (CPT 97110) and 20 minutes self-care/home management training (CPT 97535). The total Timed Code Treatment Minutes documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in Timed Code Treatment Minutes will determine the number of units billed.Once the minutes have been summed, use the chart below to determine the total allowable units, based on the total Timed Code Treatment minutes.1 unit>8 minutes through 22 minutes2 units>23 minutes through 37 minutes3 units>38 minutes through 52 minutes4 units>53 minutes through 67 minutes5 units>68 minutes through 82 minutes6 units>83 minutes through 97 minutes7 units>98 minutes through 112 minutes8 units>113 minutes through 127 minutesWhen the total Timed Code Treatment minutes for the day is less than 8 minutes, the service(s) should not be billed.It is important to allocate the total billable units for timed services to the appropriate CPT codes based upon the number of minutes spent providing each individual service. Any timed service provided for at least 15 minutes, must be billed one unit. Any timed service provided for at least 30 minutes, must be billed two units, and so on. When determining the allocation of units, it is easiest to separate out each service first into 15-minute time blocks. For example:20 minutes of Therapeutic Exercise (CPT 97110) = one 15-minute block + 5 remaining minutesAt least 1 unit must be allocated to this code38 minutes of Self-care/Home Management Training (97535) = two 15-minute blocks + 8 remaining minutesAt least 2 units must be allocated to this codeIf 38 minutes of CPT 97535 is the only treatment provided, then 3 units would be billed. However, as demonstrated in the examples below, there may be treatment sessions in which the correct billing would only allow 2 units, based on the remaining minutes.The remaining minutes (those minutes remaining after the 15-minute blocks have been allocated) are considered when the total billable units for the day allow for an additional unit to be billed. See the following examples:24 minutes of neuromuscular reeducation (CPT 97112)23 minutes of therapeutic exercise (CPT 97110)____________________________________________47 total Timed Code Treatment minutesUtilizing the chart above, 47 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first24 minutes 97112 = one 15-minute block + 9 remaining minutes23 minutes 97110 = one 15-minute block + 8 remaining minutesEach code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most remaining minutes (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is2 units 97112 + 1 unit 9711020 minutes of neuromuscular reeducation (CPT 97112)20 minutes therapeutic exercise (CPT 97110)________________________________________40 total Timed Code Treatment minutesUtilizing the chart above, 40 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first20 minutes 97112 = one 15-minute block + 5 remaining minutes20 minutes 97110 = one 15-minute block + 5 remaining minutesEach code contains one 15-minute block, therefore, each code shall be billed for at least 1 one unit. As 3 units is allowed, a review of the remaining minutes is required to determine which code should be billed the additional unit. Since the remaining minutes for each service are the same in this example, either of the codes may be billed for the additional unit. The correct coding is either one of the following2 units 97112 + 1 unit 97110OR1 unit 97112 + 2 units 971104 minutes assessing shoulder strength prior to initiating and progressing therapeutic exercise (CPT 97110)32 minutes therapeutic exercise (CPT 97110)7 minutes manual therapy (CPT 97140)_______________________________________43 total Timed Code Treatment minutesUtilizing the chart above, 43 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first36 minutes 97110 = two 15-minute blocks + 6 remaining minutes7 minutes 97140 = zero 15-minute blocks + 7 remaining minutesCode 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the remaining minutes, and apply the additional unit to the service with the most remaining minutes. The correct coding is2 units 97110 + 1 unit 9714018 minutes of therapeutic exercise (CPT 97110)13 minutes of manual therapy (CPT 97140)10 minutes of gait training (CPT 97116)8 minutes of ultrasound (CPT 97035)_______________________________________49 total Timed Code Treatment minutesAppropriate billing for a total of 49 minutes is 3 units. To allocate those 3 units, determine the 15-minute blocks first18 minutes 97110 = one 15-minute block + 3 remaining minutes13 minutes 97140 = zero 15-minute blocks + 13 remaining minutes10 minutes 97116 = zero 15-minute blocks + 10 remaining minutes8 minutes 97035 = zero 15-minute blocks + 8 remaining minutesCode 97110 shall be billed for at least one unit as it contains one 15-minute block. The additional 2 units billable (for a total of 3 units for the day), must be applied to the services with the greatest remaining minutes. The correct coding is1 unit 97110 + 1 unit 97140 + 1 unit 97116There are not enough total minutes for the day to allow billing for the ultrasound. However, the ultrasound will still be documented in the treatment notes.7 minutes of neuromuscular reeducation (CPT 97112)7 minutes of therapeutic exercise (97110)7 minutes of manual therapy (97140)___________________________________________21 total Timed Code Treatment minutes