evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
42 CFR, Sections 424.4, 482.56, 484 and 485.705 define therapy personnel qualification requirements.42 CFR, Section 486 describes coverage for services rendered by physical therapists in independent practice.Federal RegisterFederal Register, Vol. 72, No. 227, November 27, 2007, pages 66328-66333 and 66397-66408, and the correction notice for this rule, published in the Federal Register on January 15, 2008, pages 2431-2433, addresses personnel qualification standards for therapy services and certification requirements.Federal Register, July 22, 2002, Decision Memo for Neuromuscular Electrical Stimulation (NMES) for Spinal Cord Injury (CAG 00153R), at:http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=55&CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15:220 through 230 Coverage and documentation requirements for physical and occupational therapy services.CMS Publication 100-03,Medicare National Coverage Decisions (NCD) Manual, (multiple sections):provides coverage information on several specific types of therapy services. See body of LCD for individual references.CMS Publication 100-04,Claims Processing Manual, Chapter 5:10.2 Financial limitation for therapy services (therapy cap).CMS Publication 100-04,Claims Processing Manual, Chapter 5:20-100 HCPCS coding and therapy billing requirements.CMS Publication 100-04,Claims Processing Manual, Chapter 20:1-10 Orthotics billing.CMS, 11 Part B Billing Scenarios for PTs and OTs, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp#TopOfPage
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CMS, 11 Part B Billing Scenarios for PTs and OTs, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp#TopOfPageCommunication from CMS that the Contractor LCD is not required to include the V57.1-V57.89 ICD-9-CM codes.CMS Transmittal No. 4149, Publication 100-04,Medicare Claims Processing Manual, October 23, 2018, removes Functional Reporting requirements and edits for outpatient therapy services.CMS Transmittal No. 179, Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius, Change request #8458, January 14, 2014, provides clarification that coverage of skilled nursing and skilled therapy services does not turn on the presence or absence of a beneficiarys potential for improvement, but rather on the beneficiarys need for skilled care.Article TextThis article contains coding guidelines that complement the Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L33631).Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.The diagnosis code(s) must best describe the patient's condition for which the service was performed.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Unless otherwise specified, italicized text within this article represents quotation from CMS sources.CMS National Coverage provisions:Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation, do not constitute (covered) therapy services for Medicare purposes.MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.In the case of rehabilitative therapy, improvement is evidenced by successive objective measurements whenever possible. If an individuals expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities (CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 220.2(C)).In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patients functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.Skilled TherapyA service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Skilled therapy services may be necessary to improve a patients current condition, to maintain the patients current condition, or to prevent or slow further deterioration of the patients condition.Rehabilitative therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in each state) are necessary to safely and effectively furnish a recognized therapy service, whose goal is improvement of an impairment or functional limitation.Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiarys need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.While a beneficiarys particular medical condition is a valid factor in deciding if skilled (rehabilitative or maintenance)therapy services are needed, a beneficiarys diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the service(s) can be carried out by non-skilled personnelTherapy StudentsQualified professionals may serve as clinical instructors for therapy students within their scope of practice. Physical therapist assistants and occupational therapy assistants may only serve as clinical instructors for physical therapist assistant students and occupational therapy assistant students, respectively, when performed under the direction and supervision of the licensed physical or occupational therapist (in states where licensure applies). Services performed by a student (therapy student or therapy assistant student) are not reimbursed, even if provided under line of sight supervision of the therapist. However, the services of a qualified professional are covered, even when a student is participating in the care. To be covered when the student is participating, the qualified professional must be present in the room and must:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
direct the service, making the skilled judgment and assessment, and assume responsibility for the treatment;not be engaged in treating another patient or doing other tasks at the same time (such as documentation); AND mustsign all documentation appropriately. A student may also sign the documentation, but it is not necessary since the Part B payment is for the qualified professionals service, not for the students services.Supervision LevelsSupervision levels for outpatient therapy services depend on the setting where they are provided. Direct supervision (in the office suite) by a physician/NPP is required for therapists and qualified auxiliary personnel when therapy services are provided incident to the services of a physician/NPP. Also, direct supervision by a physical therapist (for PTAs) or occupational therapist (for OTAs) is required when assistants provide therapy services in the private practice setting or in the office of a physician/NPP. General supervision (the supervising therapist is available but not necessarily on the premises) is required by a physical therapist (for PTAs) or occupational therapist (for OTAs) when therapy services are provided in any other setting.Private Practice Therapy ServicesTo qualify as a private practice, each individual must be enrolled as a private practitioner and employed in one of the following practice types:unincorporated solo practice, partnership, or group practice;physician/NPP group or groups that are not professional corporations, if allowed by state and local law;physical or occupational therapist employed by physician/NPP group practices (PTPP, OTPP), if state and local law permits this employee relationship.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Private practice also includes therapists who are practicing therapy as employees of another supplier, of a professional corporation or other incorporated therapy practice. Private practice does not include individuals when they are working as employees of an institutional provider.Services should be furnished in the therapists or groups office or in the patients home. The office is defined as the location(s) where the practice is operated during the hours that the therapist engages in the practice at that location. If the services are furnished in a private practice office space, that space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.Therapy Provided by Physicians and Physician EmployeesThe services of PTAs and OTAs also may not be billed incident to a physicians/NPPs service. However, if a PT and PTA (or an OT and OTA) are both employed in a physicians office, the services of the PTA, when directly supervised by the PT or the services of the OTA, when directly supervised by the OT may be billed by the physician group as PT or OT services using the PIN/NPI of the enrolled PT (or OT). (See Section 230.4 for private practice rules on billing services performed in a physicians office.) If the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA billed incident to the physicians service, because they do not meet the qualification standards in 42CFR484.4.Coding Information and Documentation Requirements for Specific Services:CPT 97161-97163  Physical therapy evaluation CPT 97165-97167  Occupational therapy evaluation
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Coding Information and Documentation Requirements for Specific Services:CPT 97161-97163  Physical therapy evaluation CPT 97165-97167  Occupational therapy evaluationWhen an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP. The goal, frequency, and duration of treatment are implied in the diagnosis and one-time service. The referral/order of a physician/NPP is the certification that the evaluation is needed and the patient is under the care of a physician. Therefore, when evaluation is the only service, a referral/order and evaluation are the only required documentation. If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient.For initial evaluations, PTs shall use codes 97161-97163 and OTs shall use codes 97165-97167. Physicians and other qualified non-physician providers should use the evaluation and management codes 99201-99350 for evaluations.Consider the following points when billing for an evaluation.
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.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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)
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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 used
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Area 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 treated