evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Rationale 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 dosage
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Area(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)
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES) while performing a therapeutic exercise or functional activity may be billed as 97032. Do not bill for CPT codes 97110, 97112, 97116 or 97530 for the same time period.Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period.If providing an electrical stimulation modality that is typically considered supervised (G0283) to a patient requiring constant attendance for safety reasons due to cognitive deficits, do not bill as 97032. This type of monitoring may be done by non-skilled personnel.Non-Implantable Pelvic Floor Electrical Stimulation (CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,section 230.8.)Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculatureThe methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training.Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283.Documentation must clearly support the medical necessity of electrical stimulation more than 12 visits as adjunctive therapy or for muscle retraining.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Supportive Documentation Requirements (required at least every 10 visits) for 97032Type of electrical stimulation used (do not limit the description to manual or attended)Area(s) being treatedIf used for muscle weakness, objective rating of strength and functional deficitsIf used for pain include pain rating, location of pain, effect of pain on functionCPT 97033  Iontophoresis (to one or more areas)Iontophoresis is the introduction into the tissues, by means of an electric current, of the ions of a chosen medication.Iontophoresis will be allowed for treatment of intractable, disabling primary focal hyperhidrosis (ICD-10-CM codes L74.510-L74.513 or L74.519) that has not been responsive to recognized standard therapy. Good hygiene measures, extra-strength antiperspirants (for axillary hyperhidrosis), and topical aluminum chloride should initially be tried.CPT 97034 - Contrast Baths (to one or more areas)Contrast baths are a form of therapeutic heat and cold applied to distal extremities in an alternating pattern. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold.CPT Code 97034 is not covered when the services provided are hot and cold packs. This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment.This is a constant attendance code requiring direct, one-on-one patient contact by the provider. Only the actual time of the providers direct contact with the patient is to be billed.Supportive Documentation Requirements (required at least every 10 visits) for 97034Rationale requiring the unique skills of a therapist to apply, including the complicating factorsArea(s) being treatedSubjective findings to include pain ratings, pain location, effect on function
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Rationale requiring the unique skills of a therapist to apply, including the complicating factorsArea(s) being treatedSubjective findings to include pain ratings, pain location, effect on functionDocumentation must indicate the presence of these complicating factors for reimbursement of this code. If there are no complicating factors requiring the skills of a therapist, this modality is non-covered.CPT 97035  Ultrasound (to one or more areas)See list ofICD-10 Codes that DO NOT Support Medical NecessityPhonophoresis (the use of ultrasound to enhance the delivery of topically applied drugs) will be reimbursed as ultrasound, billable using CPT 97035. Separate payment will not be made for the contact medium or drugs.Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period.Supportive Documentation Requirements (required at least every 10 visits) for 97035Area(s) being treatedFrequency and intensity of ultrasoundObjective clinical findings such as measurements of range of motion and functional limitations to support the need for ultrasoundSubjective findings to include pain ratings, pain location, effect on functionIf no objective and/or subjective improvement is noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of ultrasound. Documentation must clearly support the need for ultrasound more than 12 visits.CPT 97036  Hubbard Tank (to one or more areas)This modality involves the patients immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.Hubbard tank treatments more than 12 visits require clear documentation supporting the medical necessity of continued use of this modality.Supportive Documentation Requirements for 97036Rationale requiring the unique skills of a therapist to apply, including the complicating factorsArea(s) being treated
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CPT 97039 - Unlisted Modality(Specify type and time if constant attendance) 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.Note: Low level/cold laser light therapy (LLLT)is considered not reasonable and necessary under SSA 1862(a)(1)(A) and is not payable by Medicare. This procedure is considered non-covered billed under any HCPCS/CPT codes, including S8948 and 97039. Effective 7/1/2019, this service is reported with CPT code 0552T. Effective 1/1/2024, CPT 97037 (application of a modality to 1 or more areas; low-level laser therapy (ie, nonthermal and non-ablative) for post operative pain reduction.) has been added and is also non-covered by Medicare.Supportive Documentation Requirements for 97039Please see section Documentation Requirements for Unlisted Procedure Codes.CPT G0283 - Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of careSee 97032 for instructions in manual electrical stimulation.Most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.Code G0283 is classified as a supervised modality, even though it is labeled as unattended. A supervised modality does not require direct (one-on-one) patient contact by the provider. Most electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples of unattended electrical stimulation modalities include Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation).
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
If unattended electrical stimulation is used for control of pain and swelling, there should be documented objective and/or subjective improvement in swelling and/or pain within 6 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality.Documentation must clearly support the need for electrical stimulation more than 12 visits. Some patients can be trained in the use of a home TENS unit for pain control. Only 1-2 visits should be necessary to complete the training (which may be billed as 97032). Once training is completed, code G0283 should not be billed as a treatment modality in the clinic.Non-Implantable Pelvic Floor Electrical Stimulation(CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, section 230.8.) Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283.The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatments days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training. Documentation should also include the method of delivery (e.g., probe or electrode).The charges for the electrodes are included in the practice expense portion of code G0283. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality. Do not bill Medicare for unattended electrical stimulation using code 97014.Supportive Documentation Requirements (required at least every 10 visits) for G0283
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 function
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
THERAPEUTIC 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.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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 97110
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Objective 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.