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

Appropriate 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 minutesThe clinician shall select which CPT code to bill since each service was performed for the same amount of time and only one unit is allowed. The correct coding is1 unit 97112OR1 unit 97110OR1 unit 97140For treatment sessions with both timed and untimed services, the units and time documented for any untimed CPT codes should not be included in the counting of units and time for the timed CPT codes for a calendar day. The minutes for the timed codes are reflected in the Timed Code Treatment Minutes, with the units allocated as described above. The untimed minutes are reflected in the Total Treatment Time, which is a combination of the timed code minutes and the untimed code minutes. Per CMS, it is important that the total number of timed treatment minutes support the billing of units on the claim, and that the total treatment time reflects services billed as untimed codes. For example:35 minutes OT evaluation (CPT 97162-untimed code)25 minutes therapeutic exercise (CPT 97110)8 minutes therapeutic activities (CPT 97530)_____________________________________Total Timed Code Treatment minutes = 33 minutesTotal Treatment Time = 68 minutesThe evaluation, being an untimed code, is billable as 1 unit. Do not include the evaluation minutes in the total timed code treatment minutes when determining the appropriate number of units to bill for the timed codes. 33 total minutes of timed codes is billable as 2 units. To allocate the 2 timed code units, break out the 15-minute blocks first25 minutes 97110 = one 15-minute block + 10 remaining minutes8 minutes 97530 = zero 15-minute blocks + 8 remaining minutesSince code 97110 has one 15-minute block, at least 1 unit of 97110 shall be billed. To determine which code shall be billed with the second unit,compare the remaining minutes. Since code 97110 has more remaining minutes, the second timed code unit shall be applied to this code. Correct coding for this session is1 unit 97162 + 2 units 97110The medical record documentation will note that the therapeutic activities wereperformed.40 minutes PT evaluation (CPT97163-untimed)20 minutes unattended electrical stimulation (CPT G0283-untimed)10 minute therapeutic exercise for home exercise program (CPT 97110)Total Timed Code Treatment Minutes = 10 minutesTotal Treatment Time = 70 minutesThe untimed services are billable as 1 unit each. 10 minutes for the timed code is billable as 1 unit. The correct coding for this session is1 unit 97163 + 1 unit G0283 + 1 unit 97110Payment for therapy services is based on the qualified professional/auxiliary personnel's time spent in treating the individual patient. For this reason, in the same time period (such as from 1:00 to 1:15) a clinician cannot bill any of the following pairs of CPT codes for therapy services provided to the same, or to different patients.Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97762)Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032-97039)Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) or (b) above - (CPT codes 97032-977622), for example, any CPT code for a therapeutic procedure (e.g., 97116 - gait training) with any attended modality CPT code (e.g., 97035 - ultrasound)Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110-97762) with the group therapy CPT code (97150) requiring constant attendance, for example, group therapy (97150) with neuromuscular reeducation (97112)Any CPT code for modalities requiring constant attendance (CPT codes 97032-97039) with the group therapy CPT code (97150) for example, group therapy (97150) with ultrasound (97035)Any untimed evaluation or reevaluation code (CPT codes 97161-97168) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032-97039), therapeutic procedures (CPT 97110-97762) and group therapy (CPT code 97150)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 CPT code 96125). 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.Utilization Guidelines and Maximum Billable Units per Date of ServiceRarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed.The following interventions should be reported no more than one unit per code per day per discipline; additional units will be denied:97012, 97016, 97018, 97022, 97024, 97028, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97597, 97598, 97605, 97606, G0281, G0283, G0329.The following timed interventions should be reported no more than 2 (two) units per code per day per discipline; additional units will be denied: 97033, 97034, 97035, 97036.The following interventions should be reported no more than 4 (four) units per code per day per discipline; additional units will be denied:97032, 97110, 97112, 97113, 97116, 97124, 97530,97533, 97535, 97537, 97542, 97760, 97761, 97763, 97129, 97130.Denials due to the limits described in this section of the LCD may be appealed.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/auxilliary personnel, the time spent by the qualified professional/auxilliary 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.Other Comments:For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.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.