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

Do not bill for a therapy initial evaluation for each therapy discipline on more than one date of service. If an evaluation spans more than one day, the evaluation should only be billed as one unit for the entire evaluation service (typically billed on the day that the evaluation is completed). Do not count as therapy treatment the additional minutes needed to complete the evaluation during the subsequent session(s).Do not bill test and measurement, range of motion (ROM) or manual muscle testing (MMT) codes (CPT95851-95852, 97750, 97755) on the same day as the initial evaluation. The procedures performed are included in the initial evaluation codes and are not allowed by the Correct Coding Initiative(CCI) edits.CPT codes 95831-95834 are deleted for 2020. To report manual muscle testing, please refer toevaluation codes 97161-97168.Do not bill therapy screenings utilizing the evaluation codes. Screenings are not billable services.If treatment is given on the same day as the initial evaluation, the treatment is billed using the appropriate CPT codes. The documentation must clearly describe the treatment that was provided in addition to the evaluation.CPT 97164  Physical therapy reevaluation CPT 97168  Occupational therapy reevaluationThe reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services.Continuous assessment of the patients progress is a component of the ongoing therapy services, and is not payable as a reevaluation.Consider the following points when billing for a reevaluation.Indications for a reevaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care.When reevaluations are done for a significant change in condition, documentation must show a significant improvement, decline or change in the patients diagnosis, condition or functional status that was not anticipated in the current plan of care. When a patient exhibits a demonstrable change in functional ability, a reevaluation may be necessary to revise long term goals and interventions. The plan of care may need to be revised and recertified if significant changes are made, such as a change in the long-term goals.Therapy reevaluations should contain all the applicable components of an initial evaluation and must be completed by a clinician. (See the Reevaluation section of Documentation Requirements for information regarding therapy assistant participation in the reevaluation process.)A reevaluation is not a routine, recurring service. Do not bill for routine reevaluations, including those done for the purpose of completing an updated plan of care, a recertification report, a progress report, or a physician progress report. Although some state regulations and practice acts require reevaluations at specific intervals, for Medicare payment, reevaluations must meet Medicare coverage guidelines.These reevaluation codes are untimed, billable as one unit.Do not bill for reevaluations as unlisted codes (97039, 97139, 97799) or test and measurement, ROM, MMT codes (95831-95834, 95851-95852, 97750, 97755).Supportive Documentation Requirements for 97161-97163, 97164, and 97165-97167, 97168Refer to theDocumentation RequirementsSection of this Articlefor further information.General Modality Guidelines (CPT codes 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, G0281, G0283, and G0329)Based on the CPT descriptors, these modalities apply to one or more areas treated (e.g., paraffin bath used for the left and right hand is billed as one unit).CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another procedure at the same time. Only the actual time of the providers direct contact with the patient, providing services requiring the skills of a therapist, is covered for these codes.Code 97010is bundled. It may be bundled with any therapy code. Regardless of whether code 97010 is billed alone or in conjunction with another therapy code, this code is never paid separately. If billed alone, this code will be denied.Supportive Documentation Requirements for 97010The area(s) treatedThe type of hot or cold applicationCPT 97012- Traction, Mechanical (to one or more areas)Documentation should support the medical necessity of continued traction treatment in the clinic for greater than 12 visits. For cervical conditions, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home. The time devoted to patient education related to the use of home traction should be billed under 97012. Only 1 unit of CPT code 97012 is generally covered per date of service.Non-Surgical Spinal DecompressionNon-surgical spinal decompressionis performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, non-surgical spinal decompression is not covered by Medicare(CMS Publication 100-03,Medicare National Coverage Determinations (NCD)Manual: Section 160.16).Examples of this type of non-covered procedure include, but are not limited to, VAX-D, DRX-3000, DRX9000, Decompression Reduction Stabilization (DRS) System, IDD, MedX., Spina System, Accua-Spina System, SpineMED Decompression Table, Lordex Traction Unit, Triton DTS, and Z-Grav.If billed for purpose of receiving a denial, these services should be billed using CPT code 97039 and not with CPT 97012.Supportive Documentation Requirements for 97012Type of traction and part of the body to which it is applied, etiology of symptoms requiring treatment.CPT 97014  Electrical stimulation(unattended) (to one or more areas) CPT 97014 is not a Medicare recognized code. See HCPCS code G0283 for electrical stimulation (unattended).CPT 97016 - Vasopneumatic Devices(to one or more areas)See NCD 280.6 in CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manualfor further coverage and use information on Pneumatic Compression Devices.Supportive Documentation Requirements for 97016Area of the body being treated, location of edemaObjective edema measurements (1+, 2+ pitting, girth, etc.), comparison with uninvolved sideEffects of edema on functionType of device usedCPT 97018 Paraffin Bath (to one or more areas)Once a trial of monitored paraffin treatment 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 paraffin unit in 1-2 visits. Consequently, it is inappropriate for a patient to continue paraffin treatment in the clinic setting.Only 1 unit of CPT code 97018 is generally covered per date of service.Supportive Documentation Requirements for 97018Documentation needs to support more than 2 visits to educate patient and/or caregiver in home use once effectiveness has been determined.Rationale for requiring the unique skills of a therapist to apply and train the patient/caregiver, including the complicating factorsArea of body treatedCPT 97022  Whirlpool (to one or more areas)If greater than 8 visits are needed for whirlpools that require the skills of a therapist, the documentation should support the medical necessity of the continued treatment.Whirlpool should not be separately billed when provided on the same date of service as debridement (97597-97598) for the same body part.Fluidotherapy is a superficial dry heat modality consisting of a whirlpool of finely divided solid particles suspended in a heated air stream, the mixture having the properties of a liquid.Use of fluidized therapy dry heat is covered as an acceptable alternative to other heat therapy modalities in the treatment of acute or sub-acute traumatic or non-traumatic musculoskeletal disorders of the extremities.(CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Section 150.8)Supportive Documentation Requirements for 97022Rationale for requiring the unique skills of a therapist to apply, including the complicating factorsArea(s) being treatedOnly 1 unit of CPT code 97022 should be billed per date of service.CPT 97024  Diathermy (i.e., microwave)Only 1 unit of CPT code 97024 is covered per date of service.(CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Section 150.5) If no objective and/or subjective improvement is noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented, or documentation should include the therapists rationale for continued diathermy. Documentation must clearly support the need for diathermy more than 12 visits.Supportive Documentation Requirements (required at least every 10 visits) for 97024Area(s) being treatedObjective clinical findings/measurements to support the need for a deep heat treatmentSubjective findings to include pain ratings, pain location, activities which increase or decrease pain, effect on function, etc.CPT 97026  Infrared (to one or more areas) -including AnodyneNot covered:The Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary. The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. SeeCMS Publication 100-03Medicare National Coverage Determinations NCD) Manual, section 270.6 and Publication 100-04, Medicare Claims Processing Manual,Chapter 5, section 20.4.CPT 97028 - Ultraviolet (to one or more areas)Only 1 unit of CPT code 97028 should be billed per date of service.Supportive Documentation Requirements (required at least every 10 visits) for 97028Area(s) being treatedObjective clinical findings/measurements to support the need for ultravioletMinimal erythema dosageOnly 1 unit of CPT code 97028 should be billed per date of service.CPT 97032  electrical stimulation (manual) (to one or more areas), each 15 minutesSee codes G0281-G0283 for instructions regarding supervised electrical stimulation.97032 is a constant attendance electrical stimulation modality that requires direct (one-on-one) manual patient contact by the qualified professional/auxiliary personnel. Because the use of a constant, direct contact electrical stimulation modality is less frequent, documentation should clearly describe the type of electrical stimulation provided, as well as the medical necessity of the constant contact to justify billing 97032 versus G0283. Devices delivering high voltage stimulation may require one-on-one patient contact (e.g., MicroVas, when applied in a high voltage mode).Types of electrical stimulation that may require constant attendance and should be billed as 97032 when continuous presence by the qualified professional/auxiliary personnel is required include the following examples.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)