evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Documentation must clearly support the need for continued neuromuscular reeducation greater than 12-18 visits.Supportive Documentation Requirements (required at least every 10 visits) for 97112Objective loss of activities of daily living (ADLs), mobility, balance, coordination deficits, hypo- and hypertonicity, posture and effect on function. ADL means basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring.Specific exercises/activities performed (including progression of the activity), purpose of the exercises as related to function, instruction given, and/or assistance needed, to support that the skills of a therapist were required.CPT 97113 - Aquatic Therapy with Therapeutic Exercises (one or more areas, each 15 minutes)Aquatic therapy refers to any therapeutic exercise, therapeutic activity, neuromuscular re-education, or gait activity that is performed in a water environment including whirlpools, hubbard tanks, underwater treadmills and pools.See CPT 97150 Group Therapy for guidelines when treating more than one patient at the same time in the aquatic environment.This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).Documentation must clearly support the need for aquatic therapy greater than 8 visits.The aquatic therapy treatment minutes counted toward the total timed code treatment minutes should only include actual skilled exercise time that required direct one-on-one patient contact by the qualified professional/auxiliary personnel. Do not include minutes for the patient to dress/undress, get into and out of the pool, etc.Do not bill for the water modality used to provide the aquatic environment, such as whirlpool (97022), in addition to 97113.Supportive Documentation Requirements (required at least every 10 visits) for 97113Justification for use of a water environmentObjective loss of ADLs, mobility, ROM, strength, balance, coordination, posture and effect on functionIf used for pain include pain rating, location of pain, effect of pain on functionSpecific exercises/activities performed (including progression of the activity), purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills and of a therapist were required.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CPT 97116 - Gait Training (includes stair climbing) (one or more areas, each 15 minutes)Documentation must clearly support the need for continued gait training beyond 12-18 visits within a 4-6 week period.Neuromuscular Electrostimulation - Use for Walking in Patients with Spinal Cord Injury (SCI) (CPT code 97116)- 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). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Coverage for the use of NMES/FES is limited to SCI patients, for walking, who have completed a training program, which consists of at least 32 physical therapy sessions with the device over a period of 3 months. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices frequently and for the long term. Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program. The goal of physical therapy must be to train SCI patients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy.(Italicized information about NMES for walking in SCI patients is from CMS Publication 100-03,Medicare National Coverage Determinations (NCD)Manual, section 160.12)ICD-10-CM diagnosis code G82.20 must be present for payment to be made. However, while paraplegia of lower limbs is a necessary condition for coverage, the nine criteria above are also required. 97116 is the only code to be billed. It must be used for one-on-one face-to-face service provided by the physician or therapist.Supportive Documentation Requirements (required at least every 10 visits) for 97116
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Objective measurements of balance and gait distance, assistive device used, amount of assistance required, gait deviations and limitations being addressed, use of orthotic or prosthesis, need for and description of verbal cueingPresence of complicating factors (pain, balance deficits, gait deficits, stairs, architectural or safety concerns)Specific gait training techniques used, instructions given, and/or assistance needed, and the patients response to the intervention, to demonstrate that the skills of a therapist were requiredCPT 97124  Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) (one or more areas, each 15 minutes)Documentation must clearly support the need for continued massage beyond 6-8 visits, including instruction, as appropriate, to the patient and caregiver for continued treatment.This code is not covered on the same visit date as CPT code 97140 (manual therapy techniques).Massage chairs, aquamassage tables and roller beds are not considered massage. These services are non-covered.Do not bill 97124 for percussion for postural drainage.Supportive Documentation Requirements (required at least every 10 visits) for 97124Area(s) being treatedObjective clinical findings such as measurements of range of motion, description of muscle spasms and effect on functionSubjective findings including pain ratings, pain location, effect on function
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Area(s) being treatedObjective clinical findings such as measurements of range of motion, description of muscle spasms and effect on functionSubjective findings including pain ratings, pain location, effect on functionCPT 97139 - Unlisted Therapeutic Procedure(specify) 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 Requirementsfor 97139 Please see section Documentation Requirements for Unlisted Procedure Codes.CPT 97140 - Manual Therapy Techniques (e.g.,mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutesThe goal of treatment is to reduce lymphedema of an extremity by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain such reduction of the extremity after therapy is complete. This therapy involves intensive treatment to reduce the volume by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program. Ultimately the plan must be to transfer the responsibility of care from the therapist to management by the patient, patients family, or patients caregiver.The therapeutic exercise component for MLD / CDT is covered under CPT code 97110.Documentation must clearly support the need for continued manual therapy treatment beyond 12-18 visits. When the patient and/or caregiver has been instructed in the performance of specific techniques, the performance of these same techniques should not be continued in the clinic setting and counted as minutes of skilled therapy.CPT code 97124 (massage) is not covered on the same visit as this code.Supportive Documentation Requirements (required at least every 10 visits) for 97140
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Area(s) being treatedSoft tissue or joint mobilization technique usedObjective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on functionFor MLD/CDP, supportive documentation should include:medical history related to onset, exacerbation and etiology of the lymphedemacomorbiditiesprior treatmentcognitive and physical ability of patient and/or caregiver to follow self-management techniques;pain/discomfort descriptions and ratings;limitation of function related to self-care, mobility, ADLs and/or safety;prior level of function;limb measurements of affected and unaffected limbs at start of care and periodically throughout treatment;description of skin condition, wounds, infected sites, scars.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CPT 97150 - Therapeutic Procedure(s), Group (2 or more individuals)Group therapy procedures involve constant attendance of the physician, NPP, therapist, or assistant, but by definition do not require one-on-one patient contact.Supervision of a previously taught exercise program or supervising patients who are exercising independently is not a skilled service and is not covered as group therapy or as any other therapeutic procedure. Supervision of patients exercising on machines or exercise equipment, in the absence of the delivery of skilled care, is not a skilled service and is not covered as group therapy or as any other therapeutic procedure.Report 97150 for each member of the group.Group therapy consists of therapy treatment provided simultaneously to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, one unit of CPT code 97150 is appropriate per patient.Examples:In a 25-minute period, a therapist works with two patients, A and B, and divides his/her time between the two patients. The therapist moves back and forth between the two patients, spending a minute or two at a time, and provides occasional assistance and modifications to patient As exercise program and offers verbal cues for patient Bs gait training and balance activities on the parallel bars. The therapist does not track continuous identifiable episodes of direct one-on-one contact with either patient. The appropriate coverage is one (1) unit of CPT code 97150 for each patient.In a 45-minute period, a therapist works with 3 patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives 8 minutes, patient B receives 8 minutes and patient C received 8 minutes. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18 minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the therapist, they are each exercising independently. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise (CPT code 97110).
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
If group therapy is billed on a given day, it must be listed in the Treatment Note. The minutes of this untimed code must be added to the Total Treatment Time for that day. Further documentation describing the skilled nature of the group session documented in the progress report or the treatment note may assist in supporting the medical necessity of the service.Supportive Documentation Requirements for 97150
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
The purpose of the group and the number of participants in the groupDescription of the skilled activity provided in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual.CPT 97530 - Therapeutic Activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutesDocumentation must clearly support the need for continued therapeutic activity treatment beyond 10-12 visits.Supportive Documentation Requirements (required at least every 10 visits) for 97530Objective measurements of loss of ADLs, balance, strength, coordination, range of motion, mobility and effect on functionSpecific activities performed, and amount and type of assistance to demonstrate that the skills and expertise of the therapist were requiredCPT 97129 (code effective 01/01/2020)  Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (on-on-one) patient contact; initial 15 minutesCPT 97130 (code effective 01/01/2020) ;each additional 15 minutes (list separately in addition to code for primary procedure)This activity is designed to improve attention, memory, and problem-solving, including the use of compensatory techniques.Cognitive skills are an important component of many tasks, and the techniques used to improve cognitive functioning are integral to the broader impairment being addressed. Cognitive therapy techniques are most often covered as components of other therapeutic procedures, and, typically are better reported using other codes (such as 97535).Activities billed as cognitive skills development include only those that require the skills of a therapist and must be provided with direct (one-on-one) contact between the patient and the qualified professional/auxiliary personnel. These services are also reimbursable when billed by clinical psychologists.Claims for cognitive skills development should include diagnoses that reflect the underlying condition requiring therapy, as well as the symptoms or manifestations of the condition.Note: the restrictions placed upon this code do not apply to vision impairment rehabilitation services as defined in PM AB-02-078.Supportive Documentation Requirements (required at least every 10 visits) for 97129, 97130
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Objective assessment of the patients cognitive impairment and functional abilitiesPrognosis for recovery of the specific impaired cognitive abilities (remediation)A determination of a range of compensatory strategies that the individual can realistically utilize to improve daily functioning in a meaningful waySpecific cognitive activities performed, amount of assistance, and the patients response to the intervention, to demonstrate that the skills and expertise of the therapist were requiredThis service is payable to speech-language pathologists under certain conditions. More information on this coverage can be found in the Speech-Language Pathology LCD (L33580).CPT 97533  Sensory integrationUtilization of this service should be infrequent for Medicare patients.This service is payable to speech-language pathologists under certain conditions. More information on this coverage can be found in the Speech-Language Pathology LCD (L33580).Supportive Documentation Requirements (required at least every 10 visits) for 97533Objective assessments of the patients sensory integration impairments and functional limitationsDescribe the treatment techniques used that will improve sensory processing and promote adaptive responses to environmental demands, and the patients response to the intervention, to support that the skills of a therapist were required
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CPT 97535 Selfcare/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutesIADL means activities related to living independently in the community, including but not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.For example, as part of the initial occupational therapy program following a total hip arthroplasty (THA), a patient may need to learn adaptive lower extremity dressing techniques due to pain, limited ROM and hip precautions. The occupational therapist will need to evaluate the patient to determine the appropriate technique to be taught based on the patients unique assessment and will instruct the patient and/or caregiver in the special technique. Once the special dressing technique has been taught and monitored for safe completion, repetitious carrying out or practicing of the dressing technique would be considered non-skilled and would not be covered. Non-skilled interventions need not be recorded in the Treatment Notes as they are not billable. However, notation of non-skilled activities may be reported if the documentation indicates that the service was not billed (e.g., not included in the treatment minutes documented).As the patient progresses through an episode of care involving self care/home management training, documentation needs to clearly support that the skills of a therapist continue to be necessary. Documentation that demonstrates progression in the technique to more complex or less patient dependence will assist in demonstrating that the technique remains skilled. It is important that documentation demonstrates that the skills of a therapist are needed and that the patient is not merely practicing techniques that have already been taught.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
This code should be used for activities of daily living (ADL) and compensatory training for ADL, safety procedures, and instructions in the use of adaptive equipment and assistive technology for use in the home environment. See more specific codes for exercise training, orthotics, gait devices, etc.This code should not be used globally for all home instructions. When instructing the patient in a self management program, use the code that best describes the focus of the self management activity. For example, if the instruction given is for exercises to be done at home to improve ROM or strength use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if instructing the patient on using a sock aide for dressing, use 97535; if teaching the patient aquatic exercises to use as a independent program in the community pool, use 97113.Supportive Documentation Requirements (required at least every 10 visits) for 97535Objective measurements of the patients activity of daily living (ADL)/instrumental activity of daily living (IADL) impairment to be addressedThe specific ADL and/or compensatory training provided, specific safety procedures addressed, specific adaptive equipment/assistive technology utilized, instruction given and assist required (verbal or physical), and the patients response to the intervention, to support that the services provided required the skills and expertise of a therapistCPT 97537 - Community/Work Reintegration Training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis) direct one-on-one contact, each 15 minutesThis code should be utilized when a patient is trained in the use of assistive technology to assist with mobility, seating systems and environmental control systems for use in the community.For wheelchair management/propulsion training use 97542.Coverage greater than 4-6 visits for community training should be justified by documentation to show the medical necessity of the length of treatment.Supportive Documentation Requirements (required at least every 10 visits) for 97537Objective measurements of the patients community IADL impairment to be addressedSpecific training provided, amount of assist required (verbal or physical), and the patients response to the intervention, to support that the services rendered required the skills of a therapist
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
Objective measurements of the patients community IADL impairment to be addressedSpecific training provided, amount of assist required (verbal or physical), and the patients response to the intervention, to support that the services rendered required the skills of a therapistCPT 97542 - Wheelchair Management (e.g., assessment, fitting, training), each 15 minutesThis code is used to reflect the skilled wheelchair management intervention clinicians provide related to the assessment, fitting and/or training for patients who must utilize a wheelchair for mobility. This service trains the patient, family and/or caregiver in functional activities that promote safe wheelchair mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications. Consider the following points when providing wheelchair management services.Typically up to 3-4 dates of service should be sufficient to train the patient/caregiver in wheelchair management. Coverage beyond this utilization should have supportive documentation.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CPT Changes 2006  An Insiders View provides further clarification regarding the assessment portion of this code. A wheelchair assessment may include but is not limited to the patients strength, endurance, living situation, ability to transfer in and out of the chair, level of independence, weight, skin integrity, muscle tone, and sitting balance. Following verification of the patients need, patient measurements are taken of the patient prior to ordering the equipment to ensure accuracy of sizing wheelchair components. This measurement may also involve testing the patients abilities with various chair functions including propulsion, transferring from the chair to other surfaces (bed, toilet, car), and use of the chairs locking mechanism on various types of equipment for optimal determination of the appropriate equipment by the patient and caregiver. For example, 97542 would be used when assessing and fitting the patient with a wheelchair and custom seating system to provide stabilization, support, balance, and pressure management. To achieve functional goals related to independent wheelchair management, 97542 would also be used when training the patient in the safe operation and management of the wheelchair in the home and community environment. (This example is based upon the Clinical Example for 97542 in the CPT Changes 2006  an Insiders View.)There may be circumstances where a patient may be seen one time for a wheelchair assessment. If it is not necessary to complete a full patient evaluation, but only an assessment related to specific wheelchair needs, this one-time only session may be billed under 97542 with the appropriate units reflecting the time spent in the assessment.