evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
A description of the patient's condition (including applicable impairments and functional limitations) that necessitates an orthoticAny complicating factorsThe specific orthotic provided and the date issuedA description of the skilled training providedResponse of the patient to the orthoticCPT 97761 - Prosthetic training, upper and/or lower extremity(s), initial prosthetic(s) encounter, each 15 minutesProsthetic training is the professional instruction necessary for a patient to properly use an artificial device that has been developed to replace a missing body part.Prosthetic training includes preparation of the stump, skin care, modification of prosthetic fit (revisions to socket liner or stump socks), and initial mobility and functional activity training. Once a patient begins gait training with the prosthesis, use code 97116.Supportive Documentation Requirements for 97761Type of prosthesis, extremity involvedSpecific training provided and amount of assistance neededAny complicating factors and specific description of these (with objective measurements), such as pain, joint restrictions/contractures, strength deficits, etc.CPT 97763 - Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutesPer CPT Changes 2018, these assessments are intended for established patients who have already received their orthotic or prosthetic device, to check for skin integrity, wound changes, abnormalities of fit or a loss of function directly related to the device (e.g., pain, skin breakdown, and falls of devices or other problems related to the orthotic or prosthetic.If the checkout assessment resulted in the need for further training in the use of the orthotic/prosthetic, code 97763 would be appropriate for the training.Documentation must clearly support the need for more than 2 visits for the checkout assessment.Supportive Documentation Requirements for 97763Reason for assessmentFindings from the assessmentSpecific device, modifications made, instruction given
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Reason for assessmentFindings from the assessmentSpecific device, modifications made, instruction givenCPT 97799 - Unlisted physical medicine/rehabilitation service or procedure, not timed-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 Requirements for 97799Please see Documentation Requirements for Unlisted Procedure codes. This is an untimed code, billable as "1" unit.CPT G0281  Electrical stimulation, (unattended),to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of careCPT G0329 - Electromagnetic therapy,to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of careDo not bill a re-evaluation code for the wound assessment).If ES or electromagnetic therapy is being used, wounds must be evaluated at least monthly by the treating physician.Per NCD 270.1, electrical stimulation (G0281) and electromagnetic therapy (G0329) are NOT COVERED for the treatment of:stage I or stage II wounds;electrical stimulation or electromagnetic therapy when used as an initial treatment modality;continued treatment with ES or electromagnetic therapy if measurable signs of healing have not been demonstrated within any 30-day period of treatment;wounds that demonstrate a 100% epithelialized wound bed;a patient in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
G0281 code replaces code 97014, only where it applies to treatment of wounds, as defined in the code narrative.Nationally Covered Indications(CMS Publication 100-03,Medicare National Coverage Determinations(NCD) Manual, section 270.1):Electrical stimulation (ES) and electromagnetic therapy for the treatment of wounds are considered adjunctive therapies, and will only be covered for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers. Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence. ES or electromagnetic therapy will be covered only after appropriate standard wound therapy has been provided for at least 30 days and there are no measurable signs of healing. This 30-day period may begin while the wound is acute. Standard wound care includes optimization of nutritional status, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, and necessary treatment to resolve any infection that may be present. Standard wound care based on the specific type of wound includes frequent repositioning of a patient with pressure ulcers (usually every 2 hours), off-loading of pressure and good glucose control for diabetic ulcers, establishment of adequate circulation for arterial ulcers, and the use of a compression system for patients with venous ulcers. Measurable signs of healing include a decrease in wound size (either surface area or volume), decrease in amount of exudates, and decrease in amount of necrotic tissue. ES or electromagnetic therapy must be discontinued when the wound demonstrates a 100% epithelialized wound bed.Supportive Documentation Requirements (required at least every 10 visits) for G0281 and G0329
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Etiology and duration of woundType of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatmentStage of woundDescription of wound: length, width, depth, grid drawing and/or photographsAmount, frequency, color, odor, type of exudateEvidence of infection, undermining, or tunnelingNutritional statusComorbidities (e.g., diabetes mellitus, peripheral vascular disease)Pressure support surfaces in usePatients functional levelSkilled plan of treatment, including specific frequency of the modalityChanging plan of treatment based on clinical judgment of the patients response or lack of response to treatmentFrequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session)CPT G0282 - Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281This code is not covered by Medicare.Other Available Therapy Codes CPT Codes95851, and 95852 - Muscle and Range of Motion Testing
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
For the typical patient, the evaluation (97161-97163, 97165-97167) and reevaluation codes (97164, 97168) include all the necessary evaluation tools, including range of motion and manual muscle testing. Baseline measurements may be done with an initial evaluation, but are not separately billable in addition to the evaluation. In addition, assessments, which are separate from evaluations and reevaluations, are included in the therapy treatment services and procedures and should be coded consistent with the intervention for which the assessment is necessary.Every muscle or joint in the affected extremity or trunk section, as described in the code descriptor, must be tested when coding these procedures. For example:CPT codes 95831-95834 are deleted for 2020. To report manual muscle testing, please refer to evaluation codes 97161-97168.Code 95851 is Range of motion measurements and report; each extremity (excluding hand) or trunk section (spine). To use this code for extremity ROM testing, every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted. It would not be appropriate to bill code 95851 if only shoulder ROM needed to be tested.These codes are not covered on the same visit date as CPT codes 97161-97168 (due to CCI edits).Supportive Documentation RequirementsThese codes are typically consultative. It is expected that the administration of these tests will generate material that will be formulated into a report. That report should clearly indicate the purpose and rationale for the test, the test performed with results and how the information affects the treatment plan.Application of Casts and Strapping Codes(29065, 29075, 29085, 29086, 29345, 29355, 29365, 29405, 29425, and 29445, 29200-29280, 28520-29590, 29799)More than 8-10 visits for evaluation, treatment, modification and caregiver education would not be considered reasonable and necessary without significant documentation.These are untimed codes.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
More than 8-10 visits for evaluation, treatment, modification and caregiver education would not be considered reasonable and necessary without significant documentation.These are untimed codes.General Guidelines for Strapping (CPT codes 29200-29280, 28520-29590, 29799. For dates of service prior to 2010, CPT code 29220 is used to report low back strapping, and for dates of service between 01/01/2010 and 09/30/2010, CPT code 29799 is used to report the service.)A physician who applies the initial cast, strap or splint and also assumes all of the subsequent fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes. A temporary cast/splint/strap is not considered to be part of the preoperative care.Strapping is not always synonymous with taping (such as McConnell taping or kinesiotaping). See additional information on taping under codes 97110 and 97112. See code 97140 for wrapping techniques for manual lymphatic drainage.For dates of service on and after 10/1/2010, low back strapping (regardless of CPT code billed) will be considered a non-reimbursable service under Medicare, as the service has been removed from CPT as an obsolete procedure [CPT Changes 2010  An Insiders View, page 91].Special instructions for code 29580  Strapping; Unna bootBilateral unna boots should be billed with a modifier -50 (bilateral procedure).CPT 29799 - Unlisted procedure, casting or strapping
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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 medical record and claim 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. As of 10/01/2010, low back strapping (formerly CPT code 29220) should not be billed with CPT code 29799.Supportive Documentation Requirements for 29799This is an untimed code, billable as "1" unit. Please see section Documentation Requirements for Unlisted Procedure Codes.General Guidelines for Splinting (Codes 29105-29131, 29505-29515)See codes 97760 and 97762 for further information on orthotics.According to CPT Assistant-February 2007, orthosis application differs from the purpose of an application of a cast or strapping device. Casting and strapping codes should not be reported for orthotics fitting and training.This example is based upon a clinical vignette in CPT Assistant-April 2002.Patient C is a 70-year-old female who presents to the outpatient orthopaedic clinic following a left ankle injury when her foot became twisted in her dog's run chain. After the orthopaedist evaluates the patient, radiologic views were obtained that substantiated the diagnosis of a sprained ankle ligament. A short-leg plaster posterior molded splint is applied by the physical therapist due to the degree of swelling (billable as CPT 29515). Upon return to the orthopaedic clinic, the splint is removed, x-rays repeated, and based on those findings, a short-leg fiberglass nonwalking cast is applied.These are untimed codes.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CPT 90901  Biofeedback training by any modalityCPT 90912  Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient90913; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (list separately in addition to code for primary procedure)Biofeedback therapy differs from electromyography which is a diagnostic procedure used to record and study the electrical properties of skeletal muscle. An electromyography device may be used to provide feedback with certain types of biofeedback. Biofeedback therapy is covered under Medicare only when it is reasonable and necessary for the individual patient for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments (heat, cold, massage, exercise, support) have not been successful. This therapy is not covered for treatment of ordinary muscle tension states or for psychosomatic conditions.(CMS Publication 100-03, Medicare National Coverage Determinations (NCD)Manual, Section 30.1)Biofeedback for incontinence
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Biofeedback is covered for the treatment of stress and/or urge incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. Biofeedback is not a treatment, per se, but a tool to help patients learn how to perform PME. Biofeedback-assisted PME incorporates the use of an electronic or mechanical device to relay visual and/or auditory evidence of pelvic floor muscle tone, in order to improve awareness of pelvic floor musculature and to assist patients in the performance of PME.A failed trial of PME training is defined as no clinically significant improvement in urinary incontinence after completing four weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength.When providing biofeedback procedures for urinary incontinence, use CPT 90901 when EMG and/or manometry are not performed. CPT 90912 and 90913 describe biofeedback that is more involved than conventional biofeedback measures (code 90901) and includes evaluations of the EMG activity of the pelvic muscles, urinary sphincter and/or anal sphincter by using sensors. This procedure can use manometry (measure of pressure of gases or liquids by use of a manometer) or EMG (electromyography - the recording of electrical activity initiated in the muscle tissue for testing purposes) to measure activity. The EMG activity is evaluated and provides objective information regarding the muscle activity and provides a basis for pelvic muscle rehabilitation utilizing biofeedback.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Additional documentation is necessary to justify biofeedback services beyond 5-6 visits. The descriptor for codes 90901 does not include a time element; therefore, this code should be billed as one (1) unit.Supportive Documentation Requirements (required at least every 10 visits) for 90901 and 90912/90913As noted in the NCD descriptions above, biofeedback is covered only when more conventional treatments such as heat, cold, massage, exercise (such as PME), and/or support have not been successful. Therefore, documentation must provide a clear history of the conventional treatments unsuccessfully tried before initiating biofeedback. Since biofeedback is only covered when there is a lack of response to other therapies, the lack of response to or contraindication to, other therapies must be noted in the patient's record.Additionally for the treatment of incontinence, include:identification of the type and degree of incontinence, expectations from the treatment and the time frame in which an improvement is anticipated;clear documentation of the formal instruction, monitoring and follow-up of a prescribed course of PME;evidence of behavioral modification training including, but not limited to, bladder retraining and fluid intake modification;the use of a patient record-keeping system, such as a personal voiding diary, in evaluating and monitoring progress.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CPT 95992  Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per dayCoverage for 95992 is limited to the following condition:H81.11-H81.13 BENIGN PAROXYSMAL VERTIGOCPT 96125  Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professionals time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.For psychological and neuropsychological testing by physician or psychologist, see 96101-96103, 96118-96120Code 96125 has been established to report these test procedures when performed by qualified health care professionals, such as SLPs and OTs. Code 96125 is a time-based code intended to be reported per hour, including the time administering the tests to the patient, interpreting the results, and preparing the report. Note that this code includes both face-to-face time and non-face-to-face time.Clinical example: A 36 year old male with TBI from a MVA is referred to the health care professional for standardized cognitive performance testing following a recent discharge. The qualified health care professional selects and completes face-to-face administration of the appropriate standardized test(s) to examine the patients current level of functional cognitive performance. Raw and standardized scores are derived and analyzed. A written report is prepared by the qualified health care professional and sent to the referring physician.Miscellaneous Services (Non-covered)The following are non-covered as skilled therapy services. This is not an all inclusive list.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Miscellaneous Services (Non-covered)The following are non-covered as skilled therapy services. This is not an all inclusive list.Iontophoresis, except as indicated for primary focal hyperhidrosisAnodyneLow level laser treatment (LLLT)/cold laser therapy(report CPT 0552T, effective 7/1/2019, and additionally, 97037 effective 1/1/2024)Dry hydrotherapy massage (e.g., aquamassage, hydromassage, or water massage)Massage chairs or roller bedsInteractive metronome therapyLoop reflex trainingVestibular ocular reflex trainingContinuous passive motion (CPM) device setup and adjustmentsCraniosacral therapyElectro-magnetic therapy, except as indicated for chronic woundsConstraint Induced Movement Therapy (CIMT)Work-hardening programsPelvic Floor Dysfunction (not including incontinence)pelvic floor congestionpelvic floor pain not of spinal originhypersensitive clitorisprostatitiscystourethroceleenterocelerectocelevulvodyniavulvar vestibulitis syndrome (VVS)Due to the lack of peer reviewed evidence concerning the effect on patient health outcomes, skilled therapy interventions (e.g., ultrasound, electrical stimulation, soft tissue mobilization, and therapeutic exercise) for the treatment of the following conditions is considered investigational and thus non-covered.Frequency Specific Microcurrent: non-covered due to lack of medical literature supporting the effectiveness of this therapyWhole body periodic acceleration: does not meet the benefit requirement that it requires the services of a skilled professionalLight beam Generator therapy: non-covered due to lack of medical literature supporting the effectiveness of this therapyFunctional Electrical Stimulating (FES) devices other than those that assist in walking are not covered under Medicare [NCD 160.12]. Consequently, any services related to the evaluation for or training of patients to use such a device is not covered. Such devices may include, but are not limited, to the Ergys system.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
General Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, the time of any assessment is included and billed within the appropriate treatment intervention CPT code. Therapy services shall be payable when the medical record and the information on the claim consistently and accurately report covered therapy services. Documentation must be legible, relevant and sufficient to justify the medical necessity of the services billed.Medicare requires a legible identifier of the person(s) who provided the service. The method used shall be a hand written or an electronic signature to sign an order or other medical documentation for medical review purposes. Electronic or hand written signatures that have been communicated through facsimile are also acceptable. Effective April 28, 2008, stamp signatures were no longer acceptable. The document guidelines in CMS Pub 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 220 and 230 identify the minimal expectations of documentation by providers or suppliers or beneficiaries submitting claims for payment of therapy services to the Medicare program. It is encouraged, in order to support the medical necessity and the skilled nature of the treatment, to document more thoroughly and frequently. Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:Paint a picture of the patients impairments and functional limitations requiring skilled intervention;Describe the prior functional level to assist in establishing the patients potential and prognosis;Describe the skilled nature of the therapy treatment provided;Justify that the type, frequency and duration of therapy is medically necessary for the individual patients condition;Clearly document both Timed Code Treatment Minutes and Total Treatment Time in order to justify the units billed;Identify each specific skilled intervention/modality provided to justify coding.