evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services (A53296)
Dressing ChangeA dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602). Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. These services are reimbursed as part of a billable E/M or procedure code that, commonly but not necessarily, occurs on the same date of service as the dressing change. If not included in another service, the costs associated with dressing changes may be reported as not separately payable. All topical applications (e.g. medications, ointments, and dressings) are included in the payment for the procedure codes. It is only appropriate to provide an Advance Beneficiary Notice of Noncoverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. An ABN for a dressing change is NOT appropriate since the costs of the dressing change are packaged into other procedures billed.Evaluation/Re-assessmentIn general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable.
Article - Billing and Coding: Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services (A53296)
Evaluation/Re-assessmentIn general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable. Initial wound assessments that are medically necessary may be reimbursable as a separately identifiable Evaluation and Management (E/M) service or i.e., physical therapy initial evaluation CPT codes 97161-97163.Note that CPT codes 97160-97163 are "always" therapy codes and the therapy modifier must be applied. Re-assessment/re-evaluation of a wound (which may be completed with a dressing change) is generally considered to be a non-covered routine service. An exception would require documentation clearly supporting that there had been a significant improvement, decline, or change in the patients condition or functional status that wasnot anticipated in the plan of careand required further evaluation. The evaluation must be provided by a physician/NPP or therapist or other qualified incident-to hospital staff. Patients may be evaluated by the physician/NPP and the follow-up care may then be provided by qualified hospital incident-to staff working under the physicians plan of care. When a physical therapist provides these incident-to follow-up services and provides an initial therapy evaluation (CPT 97161-97163), the documentation must clearly indicate the medical necessity for these additional evaluative services (as compared to the previously completed physician evaluation of the patients condition) in order to be separately reimbursable. An ABN may be given when medical necessity is not supported for the initial therapy evaluation. However, an ABN may not be given when medical necessity is not supported for a follow-up visit since there is no billable therapy code for a routine re-assessment (i.e. routine wound assessment with/without a dressing change). While a physician/NPP may not bill a new patient E/M with modifier 25 for any global service, the hospital may bill the E/M. See the IOMMedicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.3.DebridementSelective Debridement (CPTs 97597 and 97598)- Documentation to support selective debridement should include the following:
Article - Billing and Coding: Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services (A53296)
DebridementSelective Debridement (CPTs 97597 and 97598)- Documentation to support selective debridement should include the following: Clear description of instruments used for debridement (i.e. high-pressure waterjet, scissors, scalpel, forceps). Thorough objective assessment of the wound including drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to be targeted for debridementNon-Selective Debridement (CPT 97602)- Documentation to support non-selective debridement should include: Type of technique utilized i.e., wet-to-moist, enzymatic, abrasion. Thorough objective assessment of the wound as described in Selective Debridement above.Whirlpool If the patient uses whirlpool for treatment of a wound prior to receiving selective debridement services for the woundduring the same visit, then the whirlpool isnotseparately reimbursable and should not be billed with modifier 59 unless two separate wounds are treated with the different modalities. If the patient uses whirlpool for treatment of a wound prior to receiving non-selective debridement services for the woundduring the same visit, then the whirlpoolisseparately reimbursable and may be billed with modifier 59. Whirlpool can also be completedduring the same visitfor non-wound care related purposes. It is appropriate to separately bill CPT 97022 when the whirlpool is used for other purposes not involving wound care i.e., facilitation of range of motion activitiesUnna Boot ApplicationAll supply items related to the Unna boot are inclusive in the reimbursement for CPT 29580.High Compression Multi-Layered Bandage Systems
Article - Billing and Coding: Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services (A53296)
Unna Boot ApplicationAll supply items related to the Unna boot are inclusive in the reimbursement for CPT 29580.High Compression Multi-Layered Bandage SystemsThe application of the high compression bandage systems (i.e., Profore, Dyna-Flex, Surepress, Setopress, and other similar product systems) are used to primarily treat lymphedema and venous or stasis ulcers. Providers should note that the treatment of lymphedema with the application of high compression bandage systems continues to be non-covered by Medicare. However, a brief period of patient and/or caregiver education may be medically necessary and reimbursable. Noridian will cover and separately reimburse for the application training when Medicare coverage requirements are met. Further information may be found in the Noridian article titledBilling and Coding: High Compression Bandage System Clarification.Sources:Current Procedural Terminology Assistant- May 2002 Active Wound Care Management;Current Procedural Terminology Manual;IOMMedicare Benefit Policy ManualPublication 100-02, Chapter 15, Sections 100 and 220-230;IOMMedicare Claims Processing ManualPublication 100-04, Chapter 5, Sections 20 and 100.7 andChapter 12, Sections 30.6 and 40.3;National Corrective Coding Initiatives(NCCI);Change Request9782.
Article - Billing and Coding: Medical Necessity of Therapy Services (A53304)
CMS National Coverage PolicyN/AArticle TextMedical records must support medical necessity of therapy services provided e.g., Are the services appropriate for the patients condition and do the services require the skills and knowledge of a qualified clinician? For detailed guidance, view the CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220-230. The requirements in these sections describe a standard of care that is anticipated throughout the therapy plan of care for each discipline. To meet Medicares standard of coverage all of the following requirements must be met.Qualified ClinicianTherapy services must be provided by a qualified clinician i.e., physician, non-physician practitioner (NPP), therapist, or speech-language pathologist (SLP). Treatment services may also be provided by an appropriately supervised physical therapy (PT) or occupational therapy (OT) assistant. Services provided by a therapy aide with or without qualified clinician supervision are not reimbursable in any therapy setting. For additional information, see the attachedBilling and Coding:Therapy Students and Aidesarticle in the Related Local Coverage Documents link below.Skilled Level of CareSkill is a level of expertise acquired through specialized training not attained by the general population. While a patient's medical condition is a valid factor in deciding if skilled therapy services are needed, a patient's diagnosis or prognosis is never the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by non-skilled personnel after sufficient training.To demonstrate that services are at a skilled level of care, the medical record must support that the expertise and knowledge of a qualified clinician was necessary and was provided. Documentation needs to clearly indicate the clinicians unique professional contribution to the therapy services e.g., Why did the patient require professional treatment, education or training? What specialized treatment, education or training did the clinician actually provide? How did the patient benefit from the specialized knowledge applied by the clinician?
Article - Billing and Coding: Medical Necessity of Therapy Services (A53304)
Skilled land and water-based therapy programs require that the patient have direct one-on-one contact with the qualified clinician throughout the procedure. The services of a qualified clinician cannot be billed for supervising a patient that is independently completing an exercise program. Additionally, ongoing repetitive exercises that do not demonstrate the need for continued hands-on involvement and/or teaching by the qualified clinician would not be considered to be at a skilled level of care. Documentation must support that the therapy sessions are at a level of complexity that requires ongoing qualified clinician input.Medical Necessity - RehabilitationServices must be under accepted standards of medical practice and considered to be specific and effective treatment for the patients condition. The amount, frequency, and duration of the services planned and provided must be reasonable. Services must be necessary for treatment of the patients condition: The medical record must clearly describe the patients condition before, during, and after the therapy episode to support that the patient significantly benefited from ongoing therapy services and that the progress was sustainable and of practical value when measured against the patients condition at the start of treatment. Documentation of comparable objective/functional measures plays a key role in demonstrating medical necessity.Example of acceptable and unacceptable comparative measures:Acceptablecomparative measure: At the time of the initial evaluation it was documented that the patient had an objective manual muscle test (MMT) of 3/5 for right knee extension. Documentation in the 10 day progress report supported that the patient had achieved 4/5 for right knee extension which demonstrated significant benefit for the patient.Unacceptablecomparative measure: At the time of the 10 day progress report the documentation supported that the patient had an objective MMT of 4/5 for right biceps flexion. At the time of the 20 day progress report documentation supported that the patient was able to complete 3 sets of 10 repetitions for right biceps flexion during each therapy visit. Since the MMT information is not directly comparable to the therapeutic exercise sets and repetitions this comparison does not clearly demonstrate ongoing significant benefit for the patient and may result in denial.These objective/functional measures must minimally be established for the patients prior level of function (PLOF), status at the initial evaluation, and status at each progress reporting interval. Qualified clinicians must complete the progress reports a minimum of every ten treatment days throughout the episode of care. The progress reporting interval does not match the interval for physician certification of therapy services which may extend up to 90 calendar days.
Article - Billing and Coding: Medical Necessity of Therapy Services (A53304)
Successful rehabilitation therapy requires the attainment of significant progress for a reasonable period of time beyond the immediate intervention. Services should not be repetitive, palliative, or simply reinforcing previously learned skills or maintaining function. In most instances, the goal of therapy is to maximize patient/caregiver abilities within the patients home environment. It is expected that the patients treatment goals and achievements during the therapy episode will reflect significant and timely progress toward this end. As a result, during the therapy episode, the emphasis of therapy will generally shift from traditional, patient-centered therapeutic services to patient/caregiver education in order to prepare the patient for a safe transition to an effective maintenance program. The expectation is that the patient/caregiver will be compliant in performing the established maintenance program to help prevent relapse. If therapeutic gains from prior therapy services are tenuous, such that additional concentrated therapy is needed for non-skilled maintenance of the patient in their usual living environment (that includes caregivers), then the goals of additional therapy would be considered to be unrealistic.Medical Necessity - MaintenanceMedicare reimburses for the development of a medically necessary individualized maintenance program to:Maximize and retain the patient's functional status achieved with therapy services;Assure patient safety within their home environment;Train the patient and/or caregiver in the maintenance activities;Prevent further decline in the patient's condition.Medicare does not reimburse for carrying out maintenance activities when:The activities do not require the skills of a qualified clinician i.e., the level of complexity and sophistication of the activities do not require the performance and/or supervision of a therapist.The condition of the patient is such that the services do not require the performance and/or supervision of a therapist.The activities can reasonably be provided by non-skilled personnel after training is completed by the qualified clinician.
Article - Billing and Coding: Medical Necessity of Therapy Services (A53304)
It is anticipated that once the maintenance program is established, updates to the program will be necessary on an infrequent basis.When additional medical necessary services are required for the same medical condition, a thorough initial evaluation should be completed for the patient who was previously discharged. Documentation for maintenance program revisions must support that any additional therapy services require the performance and/or supervision of a qualified therapist due to the complexity/sophistication of the required procedures and/or the condition of the patient. The documentation must clearly indicate why a revision of the maintenance program is necessary and what specific revision(s) are needed. Key documentation components include:Was the patient/caregiver compliant with their previously established maintenance program?Was the patient unable to complete the maintenance program? Why?Are there anynewsignificant medical and/or functional issues noted since discharge from prior therapy that necessitate revision of the maintenance program?For additional information, see the attachedBilling and Coding: Therapy Evaluation, Re-Evaluation and Formal Testingarticle in the Related Local Coverage Documents link below.SourcesCenters for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Manual (RAI) Version 3, Section OCMS Inpatient Rehabilitation Facility (IRF) Training Q&A Series 4 Section V, #33IOM,Medicare Benefit Policy Manual, Publication 100-02, Chapter 1, Section 110IOM,Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220-230.
Article - Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing (A53309)
CMS National Coverage PolicyN/AArticle TextTherapy evaluation and formal testing services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants. These services can only be provided by qualified clinicians i.e., a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP).Therapy evaluation, re-evaluation, and formal testing codes can only be billed when the medical record supports the completion of a medically necessary comprehensive evaluation or formal test. Documentation must support that the service was needed based on the patients current clinical status or condition. Medicare does not reimburse for services related solely to workplace skills and activities. Additional evaluative services may be necessary when an episode of care is interrupted by a short-stay inpatient hospitalization or outpatient surgery that could reasonably impact the patients therapy progression. Note that routine continuous assessment of the patient's expected progress in accordance with the plan of care is not separately reimbursable as a re-evaluation or formal testing service.Initial Evaluations- (i.e., CPT97161-97163,97165-97167)Providers may simultaneously receive multiple physician referrals for multiple medical conditions for one patient. When this occurs, it is expected that one qualified clinician from each appropriate discipline i.e., physical therapist (PT), and/or occupational therapist (OT), and/or SLP, will complete a thorough initial evaluation that encompasses each of the identified medical conditions. Following completion of the initial evaluation, other staff therapists specializing in specific medical conditions may treat the patient as needed. When medical necessity is supported, an initial evaluation is appropriate for: A new patient who has not received prior therapy services. A patient who has returned for additional therapy after having been discharged from prior therapy services for the same or for a different condition. Time spent evaluating this returning patient should not be coded as a re-evaluation. Prior discharge may have been due to one of the following:Patient no longer significantly benefited from ongoing therapy services or;Patient no longer required therapy services for an extended period of time or;Patient experienced a significant change in medical status that necessitated discharge.
Article - Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing (A53309)
Patient no longer significantly benefited from ongoing therapy services or;Patient no longer required therapy services for an extended period of time or;Patient experienced a significant change in medical status that necessitated discharge. A patient who is currently receiving therapy services and develops a newly diagnosed unrelated condition. Example: A patient is currently receiving treatment following a total knee arthroplasty (TKA). During the therapy episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines that the rotator cuff injury is not related to the TKA. Therefore, it is reasonable for the clinician to provide and code for a new evaluation of the rotator cuff injury since it is a newly identified diagnosis for an unrelated condition.For additional information, see the attachedMedical Necessity of Therapy Servicesarticle in the Related Coverage Documents link below.Re-Evaluations- (i.e., CPT97164, 97168)Re-evaluations are separately reimbursable when the medical record supports that the patient's clinical status or condition required the additional evaluative service. When medical necessity is supported, a re-evaluation is appropriate and is separately billable for:
Article - Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing (A53309)
 A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition. A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patients rehabilitation potential.Note that routine continuous assessment ofthe patient's expected progress in accordance with the plan of care is not considered to be a medically necessary service and is not separately reimbursable as a re-evaluation. Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services an is included in services and procedures.Formal Testing(i.e., CPT97750, 95851-95852)Formal testing services are considered inclusive (not separately reimbursable) when they are provided on the same day as an initial evaluation or re-evaluation service. Formal testing services are separately reimbursable when the medical record supports that the patient's clinical status or condition required the additional testing service. Formal testing services should not be billed using therapy service or procedure codes. When medical necessity is supported a formal test is appropriate and is separately reimbursable when documentation supports the completion of a formal, date signed, distinctly identifiable findings report which includes: Testing and/or measurement results with comparative values for specific standardized grading scales. Providers interpretation of results. Support of how the findings were incorporated into the therapy plan of care, when applicable.Note that routine continuous assessment of the patient's expected progress in accordance with the plan of care is not considered to be a medically necessary service and is not separately reimbursable as a formal test. Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services and is included in services and procedures.
Article - Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing (A53309)
Sources:Current Procedural Terminology (CPT) Manual CMS Internet Only Manual (IOM),Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220(A), 220.3.5(A), 230.1. IOM,Medicare Benefit Policy Manual,, Publication 100-02, Chapter 16, Section 150