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

Area(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.CPT 97150 - Therapeutic Procedure(s), Group (2 or more individuals)Group therapy procedures involve constant attendance of the physician, NPP, therapist, or assistant, but by definition do not require one-on-one patient contact.Supervision of a previously taught exercise program or supervising patients who are exercising independently is not a skilled service and is not covered as group therapy or as any other therapeutic procedure. Supervision of patients exercising on machines or exercise equipment, in the absence of the delivery of skilled care, is not a skilled service and is not covered as group therapy or as any other therapeutic procedure.Report 97150 for each member of the group.Group therapy consists of therapy treatment provided simultaneously to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, one unit of CPT code 97150 is appropriate per patient.Examples:In a 25-minute period, a therapist works with two patients, A and B, and divides his/her time between the two patients. The therapist moves back and forth between the two patients, spending a minute or two at a time, and provides occasional assistance and modifications to patient As exercise program and offers verbal cues for patient Bs gait training and balance activities on the parallel bars. The therapist does not track continuous identifiable episodes of direct one-on-one contact with either patient. The appropriate coverage is one (1) unit of CPT code 97150 for each patient.In a 45-minute period, a therapist works with 3 patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives 8 minutes, patient B receives 8 minutes and patient C received 8 minutes. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18 minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the therapist, they are each exercising independently. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise (CPT code 97110).If group therapy is billed on a given day, it must be listed in the Treatment Note. The minutes of this untimed code must be added to the Total Treatment Time for that day. Further documentation describing the skilled nature of the group session documented in the progress report or the treatment note may assist in supporting the medical necessity of the service.Supportive Documentation Requirements for 97150The purpose of the group and the number of participants in the groupDescription of the skilled activity provided in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual.CPT 97530 - Therapeutic Activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutesDocumentation must clearly support the need for continued therapeutic activity treatment beyond 10-12 visits.Supportive Documentation Requirements (required at least every 10 visits) for 97530Objective measurements of loss of ADLs, balance, strength, coordination, range of motion, mobility and effect on functionSpecific activities performed, and amount and type of assistance to demonstrate that the skills and expertise of the therapist were requiredCPT 97129 (code effective 01/01/2020)  Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (on-on-one) patient contact; initial 15 minutesCPT 97130 (code effective 01/01/2020) ;each additional 15 minutes (list separately in addition to code for primary procedure)This activity is designed to improve attention, memory, and problem-solving, including the use of compensatory techniques.Cognitive skills are an important component of many tasks, and the techniques used to improve cognitive functioning are integral to the broader impairment being addressed. Cognitive therapy techniques are most often covered as components of other therapeutic procedures, and, typically are better reported using other codes (such as 97535).Activities billed as cognitive skills development include only those that require the skills of a therapist and must be provided with direct (one-on-one) contact between the patient and the qualified professional/auxiliary personnel. These services are also reimbursable when billed by clinical psychologists.Claims for cognitive skills development should include diagnoses that reflect the underlying condition requiring therapy, as well as the symptoms or manifestations of the condition.Note: the restrictions placed upon this code do not apply to vision impairment rehabilitation services as defined in PM AB-02-078.Supportive Documentation Requirements (required at least every 10 visits) for 97129, 97130Objective assessment of the patients cognitive impairment and functional abilitiesPrognosis for recovery of the specific impaired cognitive abilities (remediation)A determination of a range of compensatory strategies that the individual can realistically utilize to improve daily functioning in a meaningful waySpecific cognitive activities performed, amount of assistance, and the patients response to the intervention, to demonstrate that the skills and expertise of the therapist were requiredThis service is payable to speech-language pathologists under certain conditions. More information on this coverage can be found in the Speech-Language Pathology LCD (L33580).CPT 97533  Sensory integrationUtilization of this service should be infrequent for Medicare patients.This service is payable to speech-language pathologists under certain conditions. More information on this coverage can be found in the Speech-Language Pathology LCD (L33580).Supportive Documentation Requirements (required at least every 10 visits) for 97533Objective assessments of the patients sensory integration impairments and functional limitationsDescribe the treatment techniques used that will improve sensory processing and promote adaptive responses to environmental demands, and the patients response to the intervention, to support that the skills of a therapist were requiredCPT 97535 Selfcare/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutesIADL means activities related to living independently in the community, including but not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.For example, as part of the initial occupational therapy program following a total hip arthroplasty (THA), a patient may need to learn adaptive lower extremity dressing techniques due to pain, limited ROM and hip precautions. The occupational therapist will need to evaluate the patient to determine the appropriate technique to be taught based on the patients unique assessment and will instruct the patient and/or caregiver in the special technique. Once the special dressing technique has been taught and monitored for safe completion, repetitious carrying out or practicing of the dressing technique would be considered non-skilled and would not be covered. Non-skilled interventions need not be recorded in the Treatment Notes as they are not billable. However, notation of non-skilled activities may be reported if the documentation indicates that the service was not billed (e.g., not included in the treatment minutes documented).As the patient progresses through an episode of care involving self care/home management training, documentation needs to clearly support that the skills of a therapist continue to be necessary. Documentation that demonstrates progression in the technique to more complex or less patient dependence will assist in demonstrating that the technique remains skilled. It is important that documentation demonstrates that the skills of a therapist are needed and that the patient is not merely practicing techniques that have already been taught.This code should be used for activities of daily living (ADL) and compensatory training for ADL, safety procedures, and instructions in the use of adaptive equipment and assistive technology for use in the home environment. See more specific codes for exercise training, orthotics, gait devices, etc.This code should not be used globally for all home instructions. When instructing the patient in a self management program, use the code that best describes the focus of the self management activity. For example, if the instruction given is for exercises to be done at home to improve ROM or strength use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if instructing the patient on using a sock aide for dressing, use 97535; if teaching the patient aquatic exercises to use as a independent program in the community pool, use 97113.Supportive Documentation Requirements (required at least every 10 visits) for 97535Objective measurements of the patients activity of daily living (ADL)/instrumental activity of daily living (IADL) impairment to be addressedThe specific ADL and/or compensatory training provided, specific safety procedures addressed, specific adaptive equipment/assistive technology utilized, instruction given and assist required (verbal or physical), and the patients response to the intervention, to support that the services provided required the skills and expertise of a therapistCPT 97537 - Community/Work Reintegration Training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis) direct one-on-one contact, each 15 minutesThis code should be utilized when a patient is trained in the use of assistive technology to assist with mobility, seating systems and environmental control systems for use in the community.For wheelchair management/propulsion training use 97542.Coverage greater than 4-6 visits for community training should be justified by documentation to show the medical necessity of the length of treatment.Supportive Documentation Requirements (required at least every 10 visits) for 97537Objective measurements of the patients community IADL impairment to be addressedSpecific training provided, amount of assist required (verbal or physical), and the patients response to the intervention, to support that the services rendered required the skills of a therapistCPT 97542 - Wheelchair Management (e.g., assessment, fitting, training), each 15 minutesThis code is used to reflect the skilled wheelchair management intervention clinicians provide related to the assessment, fitting and/or training for patients who must utilize a wheelchair for mobility. This service trains the patient, family and/or caregiver in functional activities that promote safe wheelchair mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications. Consider the following points when providing wheelchair management services.Typically up to 3-4 dates of service should be sufficient to train the patient/caregiver in wheelchair management. Coverage beyond this utilization should have supportive documentation.CPT Changes 2006  An Insiders View provides further clarification regarding the assessment portion of this code. A wheelchair assessment may include but is not limited to the patients strength, endurance, living situation, ability to transfer in and out of the chair, level of independence, weight, skin integrity, muscle tone, and sitting balance. Following verification of the patients need, patient measurements are taken of the patient prior to ordering the equipment to ensure accuracy of sizing wheelchair components. This measurement may also involve testing the patients abilities with various chair functions including propulsion, transferring from the chair to other surfaces (bed, toilet, car), and use of the chairs locking mechanism on various types of equipment for optimal determination of the appropriate equipment by the patient and caregiver. For example, 97542 would be used when assessing and fitting the patient with a wheelchair and custom seating system to provide stabilization, support, balance, and pressure management. To achieve functional goals related to independent wheelchair management, 97542 would also be used when training the patient in the safe operation and management of the wheelchair in the home and community environment. (This example is based upon the Clinical Example for 97542 in the CPT Changes 2006  an Insiders View.)There may be circumstances where a patient may be seen one time for a wheelchair assessment. If it is not necessary to complete a full patient evaluation, but only an assessment related to specific wheelchair needs, this one-time only session may be billed under 97542 with the appropriate units reflecting the time spent in the assessment.