evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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.Utilization GuidelinesThe Medicare Physician Fee Schedule (MPFS) is the method of payment for outpatient therapy services, except critical access hospitals (CAH), which are paid on a reasonable cost basis. Although CAHs are not paid via the MPFS, all outpatient coverage, coding and documentation guidelines, as noted in the Medicare manuals and this LCD, apply.Untimed CPT CodesWhen a therapy treatment modality or procedure is not defined in the AMA CPT Manual by a specific time frame (such as each 15 minutes), the modality or procedure is considered an untimed service. Untimed services are billedbased on the number of times the procedure is performed, often once per day.Untimed services billed as more than 1 unit will require significant documentation to justify treatment greater than one session per day per therapy discipline. See the section CPT 97161-97163 and 97165-97167 for additional guidance on billing for evaluations that span more than 1 day. The minutes spent providing untimed services are reflected in the documentation under Total Treatment Time(and are not included in the minutes for timed CPT codes when determining the number of timed-based units that may be billed).
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Timed CPT CodesMany CPT codes for therapy modalities and procedures specify that direct (one-on-one) time spent in patient contact is 15 minutes.The time counted is the time the patient is treatedusing skilled therapy modalities and procedures, and is recorded in the documentation as Timed Code Treatment Minutes. Pre- and post-delivery services are not to be counted when recording the treatment time. The time counted is the intra-service care that begins when the qualified professional/auxiliary personnel is directly working with the patient to deliver the service. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment. The intra-service care includes assessment. The time the patient spends not being treated because of a need for toileting or resting should not be counted. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. Time spent supervising a patient performing an activity that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the Timed Code Treatment Minutes. Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.The first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise (CPT 97110) and 20 minutes self-care/home management training (CPT 97535). The total Timed Code Treatment Minutes documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in Timed Code Treatment Minutes will determine the number of units billed. Once the minutes have been summed, use the chart below to determine the total allowable units, based on the total Timed Code Treatment minutes.1 unit > 8 minutes through 22 minutes2 units > 23 minutes through 37 minutes
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
1 unit > 8 minutes through 22 minutes2 units > 23 minutes through 37 minutes3 units > 38 minutes through 52 minutes4 units > 53 minutes through 67 minutes5 units > 68 minutes through 82 minutes6 units > 83 minutes through 97 minutes7 units > 98 minutes through 112 minutes8 units > 113 minutes through 127 minutesWhen the total Timed Code Treatment minutes for the day is less than 8 minutes, the service(s) should not be billed. It is important to allocate the total billable units for timed services to the appropriate CPT codes based upon the number of minutes spent providing each individual service. Any timed service provided for at least 15 minutes, must be billed one unit. Any timed service provided for at least 30 minutes, must be billed two units, and so on. When determining the allocation of units, it is easiest to separate out each service first into 15-minute time blocks. For example: 20 minutes of Therapeutic Exercise (CPT 97110) = one 15-minute block + 5 remaining minutesAt least 1 unit must be allocated to this code38 minutes of Self-care/Home Management Training (97535) = two 15-minute blocks + 8 remaining minutesAt least 2 units must be allocated to this codeIf 38 minutes of CPT 97535 is the only treatment provided, then 3 units would be billed. However, as demonstrated in the examples below, there may be treatment sessions in which the correct billing would only allow 2 units, based on the remaining minutes.The remaining minutes (those minutes remaining after the 15-minute blocks have been allocated) are considered when the total billable units for the day allow for an additional unit to be billed. See the following examples:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
24 minutes of neuromuscular reeducation (CPT 97112)23 minutes of therapeutic exercise (CPT 97110)____________________________________________47 total Timed Code Treatment minutesUtilizing the chart above, 47 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first24 minutes 97112 = one 15-minute block + 9 remaining minutes23 minutes 97110 = one 15-minute block + 8 remaining minutesEach code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most remaining minutes (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is2 units 97112 + 1 unit 9711020 minutes of neuromuscular reeducation (CPT 97112)20 minutes therapeutic exercise (CPT 97110)________________________________________40 total Timed Code Treatment minutesUtilizing the chart above, 40 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first20 minutes 97112 = one 15-minute block + 5 remaining minutes20 minutes 97110 = one 15-minute block + 5 remaining minutesEach code contains one 15-minute block, therefore, each code shall be billed for at least 1 one unit. As 3 units is allowed, a review of the remaining minutes is required to determine which code should be billed the additional unit. Since the remaining minutes for each service are the same in this example, either of the codes may be billed for the additional unit. The correct coding is either one of the following
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
2 units 97112 + 1 unit 97110OR1 unit 97112 + 2 units 971104 minutes assessing shoulder strength prior to initiating and progressing therapeutic exercise (CPT 97110)32 minutes therapeutic exercise (CPT 97110)7 minutes manual therapy (CPT 97140)_______________________________________43 total Timed Code Treatment minutesUtilizing the chart above, 43 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
36 minutes 97110 = two 15-minute blocks + 6 remaining minutes7 minutes 97140 = zero 15-minute blocks + 7 remaining minutesCode 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the remaining minutes, and apply the additional unit to the service with the most remaining minutes. The correct coding is2 units 97110 + 1 unit 9714018 minutes of therapeutic exercise (CPT 97110)13 minutes of manual therapy (CPT 97140)10 minutes of gait training (CPT 97116)8 minutes of ultrasound (CPT 97035)_______________________________________49 total Timed Code Treatment minutesAppropriate 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 is
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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 97165)25 minutes therapeutic exercise (CPT 97110)8 minutes therapeutic activities (CPT 97530)_____________________________________Total Timed Code Treatment minutes = 33 minutesTotal Treatment Time = 68 minutes
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
The 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 97165 + 2 units 97110The medical record documentation will note that the therapeutic activities were performed.40 minutes PT evaluation (CPT 97163)20 minutes unattended electrical stimulation (CPT G0283-untimed)10 minute therapeutic exercise for home exercise program (CPT 97110)
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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 97110-97763)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 97032-97763), 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 97110-97763) 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 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 97110-97763) and group therapy (CPT code 97150)
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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, 97129, 97150, 97161-97168, 97605, 97606, G0281, G0283, G0329.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
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, 97130, 97530, 97533, 97535, 97537, 97542, 97760, 97761, 97763.Canalith repositioning (95992) should generally be limited to five or fewer encounters. Sessions in excess of this parameter must be documented as to their need and why these exercises cannot be performed by the beneficiary without the supervision of trained professionals. Denials due to the limits described in this section of thearticle may be appealed.
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (A56572)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF).Provisions in this article and the LCD only address Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary procedures for other conditions not included in this article/LCD.Coding GuidelinesProcedure 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.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Specific Coding GuidelinesNo separate payment for venography performed during the operative session may be allowed and it should not be separately billed.This LCD will not affect the use of this treatment for cancer related diagnoses.Exclusion for total number of levels involved will not apply for a diagnosis of multiple myeloma.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related 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.
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (A56573)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF).Provisions in this article and the LCD only address Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary procedures for other conditions not included in this article/LCD.Coding GuidelinesProcedure 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.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Specific Coding GuidelinesNo separate payment for venography performed during the operative session may be allowed and it should not be separately billed.This LCD will not affect the use of this treatment for cancer related diagnoses.Exclusion for total number of levels involved will not apply for a diagnosis of multiple myeloma.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related 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.
Article - Billing and Coding: Computerized Axial Tomography (CT), Thorax (A56580)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim that lacks the necessary information to process that claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Computerized Axial Tomography (CT), Thorax L33459.Reordering Identical Type of Imaging Examination:No imaging examination (pertaining to an identical CPTcode only) should be ordered more frequently than 6 times per calendar year. Furthermore, this frequency limit shall only apply to the following outpatient Places of Service (POS): office (11), outpatient hospital (22), independent clinic (49), rural health clinic (72) and independent diagnostic testing facility (IDTF).
Article - Billing and Coding: Surface Electrical Stimulation in the Treatment of Dysphagia (A56584)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Surface Electrical Stimulation in the Treatment of Dysphagia L34578.