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

Type 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 functionTHERAPEUTIC PROCEDURESGeneral Guidelines for Therapeutic Procedures (CPT codes 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97530,97533, 97535, 97537, 97542, 97602, 97605, 97606, 97607, 97608, 97750, 97755, 97760, 97761, 97763 and 97799)Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code; there is no separate coverage for time spent on documentation (except for CPT Code 96125).CPT codes 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97140, 97530,97533, 97535, 97537, 97542, 97760, 97761, and 97763 describe different types of therapeutic interventions. The expected goals documented in the treatment plan, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of these procedures may be used in a treatment plan, documentation must support the use of each procedure as it relates to a specific therapeutic goal.CPT 97110 - Therapeutic Exercises to develop strength and endurance, range of motion and flexibility (one or more areas, each 15 minutes)For many patients a passive-only exercise program should not be used more than 2-4 visits to develop and train the patient or caregiver in performing PROM. Documentation would be necessary to support services beyond this level (such as PROM where these is an unhealed, unstable fracture, or new rotator cuff repair, requiring the skills of a therapist to ensure that the extremity is maintained in proper position and alignment during the PROM).Documentation should include not only measurable indicators such as functional loss of joint motion or muscle strength, but also information on the impact of these limitations on the patients life and how improvement in one or more of these measures leads to improved function.Documentation of progress should show the condition is responsive to the therapy chosen and that the response is (or is expected to be) clinically meaningful. Metrics of progress that are functionally meaningful (or obviously related to clinical functional improvement) should be documented wherever possible. For example, long courses of therapy resulting in small changes in range of motion might not represent meaningful clinical progress benefiting the patients function.Documentation should describe new exercises added, or changes made to the exercise program to help justify that the services are skilled. Documentation must also show that exercises are being transitioned as clinically indicated to an independent or caregiver-assisted exercise program (home exercise program (HEP)). An HEP is an integral part of the therapy plan of care and should be modified as the patient progresses during the course of treatment. It is appropriate to transition portions of the treatment to an HEP as the patient or caregiver master the techniques involved in the performance of the exercise.If an exercise is taught to a patient and performed for the purpose of restoring functional strength, range of motion, endurance training, and flexibility, CPT code (97110) is the appropriate code. For example, a gym ball exercise used for the purpose of increasing the patients strength should be considered as therapeutic exercise when coding for billing. Also, the minutes spent taping, such as McConnell taping, to facilitate a strengthening intervention would be counted under 97110.Documentation must clearly support the need for continued therapeutic exercise greater than 12-18 visits.Supportive Documentation Requirements (required at least every 10 visits) for 97110Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on functionIf used for pain include pain rating, location of pain, effect of pain on functionSpecific exercises performed, purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills of a therapist were requiredWhen skilled cardiopulmonary monitoring is required, include documentation of pulse oximetry, heart rate, blood pressure, perceived exertion, etc.CPT 97112 - Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (one or more areas, each 15 minutes)This therapeutic procedure is provided for the purpose of restoring balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation (PNF), BAPs boards, vestibular rehabilitation, desensitization techniques, balance and posture training).If an exercise/activity is taught to the patient and performed for the purpose of restoring functional balance, motor coordination, kinesthetic sense, posture, or proprioception for sitting or standing activities, CPT (97112) is the appropriate code. For example, a gym ball exercise used for the purpose of improving balance should be considered as neuromuscular reeducation when coding for billing. The minutes spent taping, such as McConnell taping or kinesiotaping techniques, to enhance proprioception would be counted under CPT code 97112.When therapy is instituted because there is a history of falls or a falls screening has identified a significant fall risk, documentation should indicate:specific fall dates and/or hospitalization(s) and reason for the fall(s), if known;most recent prior functional level of mobility, including assistive device, level of assist, frequency of falls or near-falls;cognitive status;prior therapy intervention;functional loss due to the recent change in condition;balance assessments (preferably standardized), lower extremity ROM and muscle strength testing;patient and caregiver training;carry-over of therapy techniques to objectively document progress.Documentation must clearly support the need for continued neuromuscular reeducation greater than 12-18 visits.Supportive Documentation Requirements (required at least every 10 visits) for 97112Objective loss of activities of daily living (ADLs), mobility, balance, coordination deficits, hypo- and hypertonicity, posture and effect on function. ADL means basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring.Specific exercises/activities performed (including progression of the activity), purpose of the exercises as related to function, instruction given, and/or assistance needed, to support that the skills of a therapist were required.CPT 97113 - Aquatic Therapy with Therapeutic Exercises (one or more areas, each 15 minutes)Aquatic therapy refers to any therapeutic exercise, therapeutic activity, neuromuscular re-education, or gait activity that is performed in a water environment including whirlpools, hubbard tanks, underwater treadmills and pools.See CPT 97150 Group Therapy for guidelines when treating more than one patient at the same time in the aquatic environment.This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).Documentation must clearly support the need for aquatic therapy greater than 8 visits.The aquatic therapy treatment minutes counted toward the total timed code treatment minutes should only include actual skilled exercise time that required direct one-on-one patient contact by the qualified professional/auxiliary personnel. Do not include minutes for the patient to dress/undress, get into and out of the pool, etc.Do not bill for the water modality used to provide the aquatic environment, such as whirlpool (97022), in addition to 97113.Supportive Documentation Requirements (required at least every 10 visits) for 97113Justification for use of a water environmentObjective loss of ADLs, mobility, ROM, strength, balance, coordination, posture and effect on functionIf used for pain include pain rating, location of pain, effect of pain on functionSpecific exercises/activities performed (including progression of the activity), purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills and of a therapist were required.CPT 97116 - Gait Training (includes stair climbing) (one or more areas, each 15 minutes)Documentation must clearly support the need for continued gait training beyond 12-18 visits within a 4-6 week period.Neuromuscular Electrostimulation - Use for Walking in Patients with Spinal Cord Injury (SCI) (CPT code 97116)- 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). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Coverage for the use of NMES/FES is limited to SCI patients, for walking, who have completed a training program, which consists of at least 32 physical therapy sessions with the device over a period of 3 months. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices frequently and for the long term. Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program. The goal of physical therapy must be to train SCI patients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy.(Italicized information about NMES for walking in SCI patients is from CMS Publication 100-03,Medicare National Coverage Determinations (NCD)Manual, section 160.12)ICD-10-CM diagnosis code G82.20 must be present for payment to be made. However, while paraplegia of lower limbs is a necessary condition for coverage, the nine criteria above are also required. 97116 is the only code to be billed. It must be used for one-on-one face-to-face service provided by the physician or therapist.Supportive Documentation Requirements (required at least every 10 visits) for 97116Objective measurements of balance and gait distance, assistive device used, amount of assistance required, gait deviations and limitations being addressed, use of orthotic or prosthesis, need for and description of verbal cueingPresence of complicating factors (pain, balance deficits, gait deficits, stairs, architectural or safety concerns)Specific gait training techniques used, instructions given, and/or assistance needed, and the patients response to the intervention, to demonstrate that the skills of a therapist were requiredCPT 97124  Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) (one or more areas, each 15 minutes)Documentation must clearly support the need for continued massage beyond 6-8 visits, including instruction, as appropriate, to the patient and caregiver for continued treatment.This code is not covered on the same visit date as CPT code 97140 (manual therapy techniques).Massage chairs, aquamassage tables and roller beds are not considered massage. These services are non-covered.Do not bill 97124 for percussion for postural drainage.Supportive Documentation Requirements (required at least every 10 visits) for 97124Area(s) being treatedObjective clinical findings such as measurements of range of motion, description of muscle spasms and effect on functionSubjective findings including pain ratings, pain location, effect on functionCPT 97139 - Unlisted Therapeutic Procedure(specify) 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 Requirementsfor 97139 Please see section Documentation Requirements for Unlisted Procedure Codes.CPT 97140 - Manual Therapy Techniques (e.g.,mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutesThe goal of treatment is to reduce lymphedema of an extremity by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain such reduction of the extremity after therapy is complete. This therapy involves intensive treatment to reduce the volume by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program. Ultimately the plan must be to transfer the responsibility of care from the therapist to management by the patient, patients family, or patients caregiver.The therapeutic exercise component for MLD / CDT is covered under CPT code 97110.Documentation must clearly support the need for continued manual therapy treatment beyond 12-18 visits. When the patient and/or caregiver has been instructed in the performance of specific techniques, the performance of these same techniques should not be continued in the clinic setting and counted as minutes of skilled therapy.CPT code 97124 (massage) is not covered on the same visit as this code.Supportive Documentation Requirements (required at least every 10 visits) for 97140Area(s) being treatedSoft tissue or joint mobilization technique usedObjective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on functionFor MLD/CDP, supportive documentation should include:medical history related to onset, exacerbation and etiology of the lymphedemacomorbiditiesprior treatmentcognitive and physical ability of patient and/or caregiver to follow self-management techniques;pain/discomfort descriptions and ratings;limitation of function related to self-care, mobility, ADLs and/or safety;prior level of function;limb measurements of affected and unaffected limbs at start of care and periodically throughout treatment;description of skin condition, wounds, infected sites, scars.