Procedure CODE AND Description


97140 – Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

97530 – Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

97112 – Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities average fee amount-$30 – $40

97760 – Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes

97110 – Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112 – Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

97113 – Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises

97116 – Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)

97124 – Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

97139 – Unlisted therapeutic procedure (specify)

Myofascial Release/Soft Tissue Mobilization codes (97110, 97112, 97530, 97140,97150, 97530, 97532, 97533, 97537,97542, 97545, 97750, 97755, 97760, 97799)

This procedure may be medically necessary for the treatment of restricted motion of soft tissues involving the extremities, neck and/or trunk. Skilled manual techniques (active and/or passive) are applied to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples include:

•    Facilitation of fluid exchange.
•    Restoration of movement in acutely edematous; muscles.
•    Stretching of shortened connective tissue.

This procedure may be medically necessary as an adjunct to other therapeutic procedures such as codes 97110 (therapeutic exercises), 97112 (neuromuscular re-education) or 97530 (therapeutic activities).

Neuromuscular Reeducation (CPT code 97112)

1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, motor planning, body awareness, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkreis, and Bobath).

2. Neuromuscular Reeducation may be considered reasonable and necessary for impairments, which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, desensitization, proprioception, hypo/hypersensitivity, hypo/hypertonicity, and neglect).

Massage Therapy (CPT code 97124)

1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment as well as a treatment tool.

2. Massage Therapy, including effleurage, pétrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least one of the following conditions is present and documented:

a. The patient having paralyzed musculature contributing to impaired circulation
b. The patient having sensitivity of tissues to pressure
c. The patient having tight muscles resulting in shortening and/or spasticity of affective muscles
d. The patient having abnormal adherence of tissue to surrounding tissue
e. The patient having relaxation in preparation for neuromuscular reeducation or therapeutic exercise
f. The patient having contractures and decreased range of motion

Manual Therapy Techniques (CPT code 97140)

1. Joint Mobilization (Peripheral or Spinal)

This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

2. Soft Tissue Mobilization

This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue.

Myofascial release/soft tissue mobilization can be considered reasonable and necessary if at least one of the following conditions is present and documented:

a. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk

b. Treatment being a necessary adjunct to other occupational therapy interventions such as 97110, 97112 or 97530

3. Manual Lymphatic Drainage/Complex Decongestive Physiotherapy

The goal of this type of therapy is to reduce lymphedema by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain the reduction after therapy is complete. This therapy involves intensive treatment to reduce the size of the extremity by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program.

a. It is expected that during these sessions, education is being provided to the patient and/or caregiver on the correct application of the compression bandage.

b. It is also expected that after the completion of the therapy, the patient and/or caregiver can perform these activities without supervision.

97140 Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

* This procedure may be medically necessary as an adjunctive therapeutic procedure to another therapeutic procedure on the same day, e.g., massage or gait training.

* The above description of 97140 includes different forms of manual therapy. This is not an all inclusive list and not intended to exclude other forms of manual therapy.

*  “Manual” entails the use of hands. Thus, 97140 is for hands-on therapy only.


Manual therapy includes the following:

Manual traction may be considered reasonable and necessary for cervical radiculopathy.

Joint Mobilization (peripheral or spinal) may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

Myofascial release/soft tissue mobilization, one or more regions, may be reasonable and necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems. This procedure may be reasonable and necessary as an adjunct to other therapeutic procedures such as CPT 97110, 97112, or 97530.

Manipulation may be reasonable and necessary for treatment of painful spasm or restricted motion of soft tissues. This procedure may be reasonable and necessary as an adjunct to therapeutic procedures such as CPT 97110, 97112, or 97530.

Manual lymphatic drainage/complete decongestive therapy (MLD) may be reasonable and necessary for documented lymphedema. The therapist should be trained in MLD. The 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 the reduction of the extremity after therapy is complete. This therapy involves intensive treatment to reduce the size of the extremity by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program.

During these sessions, education should be provided to the patient and/or caregiver on the correct application of the compression bandage.

In moderate-severe lymphedema, daily visits may be required for the initial visits.

After the completion of the therapy the patient and/or caregiver could perform these activities without supervision.

Generally no more than 3-4 units per visit are covered.

The exercise component for MLD is covered under CPT 97110.

The bandaging component of MLD is covered under 97140 and should not be billed utilizing the ‘Splinting and Strapping’ CPT codes.

This code is generally not covered for greater than 12-18 visits within a 4-6 week period. Documentation must support the need for continued treatment beyond this frequency and duration. When the patient and/or caregiver have been instructed in the performance of specific techniques, the performance of these techniques should not be continued in the clinic setting. No more than 1-2 services/units of this code are generally covered on each visit date. Documentation must support the number of services/units for visit date.

Manipulation 

CPT description for code 97140 (manual therapy) includes manual therapy and techniques such as manipulation, soft tissue mobilization or joint mobilization. Individual techniques should not be separately coded or billed since it is a time-based code. All techniques applied on the same date of service should be totaled into the time calculated for the code. This procedure may be medically necessary as an adjunct to other therapeutic procedures such as those represented by code 97110 (therapeutic exercises), 97112 (neuromuscular re-education) or 97530 (therapeutic activities).

Joint Mobilization

This procedure may be medically necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure. CPT description for code 97140 (manual therapy) includes manual therapy and techniques such as manipulation, soft tissue mobilization or joint mobilization. Individual techniques should not be separately coded or billed since it is a time-based code. All techniques applied on the same date of service should be totaled into the time calculated for the code.

Documentation supporting the medical necessity for continued treatment must be made available to Medicare upon request.

Billing and Coding Guidelines

CPT 97140, manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction, one or more regions, each 15 minutes) cannot be reported or billed if the chiropractor also reports or bills for a chiropractic manipulative treatment (CMT) on the same anatomical region as the therapeutic procedure. If a chiropractor reports both a CPT 98940-series service and CPT 97140 on the same date of service, the chiropractor’s medical records must document the differences between the two procedures and that each was conducted on a different anatomical site. To document this, you may use Modifier 59 (Distinct procedural service) when billing for these procedures (i.e., CPT 97140-59).

It is not appropriate to bill CPT 97124, massage, for myofascial release. For myofascial release, CPT 97140 should be reported. When reporting or billing for CPT 97112 (neuromuscular re-education) and CPT 97124 (massage), as well as all other physical medicine modalities and therapeutic procedures, the details of the procedure shall be recorded in the medical record, including clinical rationale, anatomical site, description of service, and time (as required by the selected CPT code).

Modifier 52 should not be used for therapy services less than 15 minutes. At least eight minutes of a physical therapy timed service must be provided in order to use a therapy procedure code (i.e. 97140 – manual therapy techniques, one or more regions, each 15 minutes). If the therapy service is less than eight minutes, it is not billable as those codes require a minimum of eight minutes. Procedure code 97140 can be submitted with one unit for services that span 8-22 minutes. An additional 8 minutes must be provided beyond the 15-minute increment to submit a second unit. If 12 minutes of 97140 is provided, it is not appropriate to append modifier 52

CPT® code 97140 is reported for each 15 minutes of manual therapy technique provided to one or more regions. Manual therapy is not a mutually exclusive procedure when it is billed for different body regions separate from CMT codes 98940 – 98943. Medical documentation may be requested to review appropriateness. When manual therapy is performed to the same region as the CMT with similar outcomes, it will not be reimbursed separately.

When manual therapy is performed on the same date of service as CMT and is separate from the CMT procedure, a separate diagnosis related to the treatment must be identified by a specific ICD-10-CM diagnosis code; CPT® code 97140 must be billed with modifier 59


Example

A 40-year old male complaining of severe low back pain and neck pain was examined and treated

Code 97140 Manual therapy techniques (eg, obilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.
97002 Physical therapy evaluation

Billing Guide

97140-59
97002

Example  Unit calculation

33 minutes of therapeutic exercise (97110),
7 minutes of manual therapy (97140),
40 Total timed minutes

Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.

1. Restricted to one procedure per date of service (cannot bill two together for the same date of service.)

2. 97014 cannot be billed on same date of service as procedure code 20974, 20975 or 20982.

3. When a physical therapist and an occupational therapist perform the same procedure for the same recipient for the same day of  service, the maximum units reimbursed by Medicaid will be the daily limit allowed for procedure, not the maximum units allowed for both providers.

4. 97760 should not be reported with 97116 for the same extremity.

5. Procedures 97010, 97012, 97016, 97018, 97024, 97026 (therapy procedures) must be billed with one of the following codes: 97014, 97020, 97110, 97112, 97113, 97116, 97124, 97140, 97150,  97530, 97535, or 97542 (therapeutic treatment).

Timing calculation

33 minutes of therapeutic exercise (97110), 7 minutes of manual therapy (97140), 40 Total timed minutes

Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.

18 minutes of therapeutic exercise (97110),
13 minutes of manual therapy (97140),
10 minutes of gait training (97116),
8 minutes of ultrasound (97035),
49 Total timed minutes

Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed). You would still document the ultrasound in the treatment notes.

CPT code 97530 (therapeutic activities) – This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance in a progressive manner.

The activities are usually directed at a loss or restriction of mobility, strength, balance or coordination. They require the professional skills of a qualified professional and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.

97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes:

*  This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance in a progressive manner.

* The activities are usually directed at a loss or restriction of mobility, strength, balance or coordination. They require the professional skills of a provider and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.

* The Epley maneuver (also known as Canalith Repositioning Maneuver) is used for the treatment of benign paroxysmal positional vertigo (BPPV). Use code 97530 when performing the Epley maneuver. “There is no provision for direct payment to audiologists for therapeutic services.” Quote from Program Memorandum, Transmittal No. AB-02-080, June 7, 2002, CR 2073. An audiologist can perform the Epley maneuver when the diagnostic criteria are met and the service is performed incident to a physician or qualified non-physician practitioner.

Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involves movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, transfers, and overhead activities) to restore functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of the therapist to design the activities to address a specific functional need of the patient and to instruct the patient in performance of these activities. These dynamic activities must be part of an active treatment plan and be directed at a specific outcome.

In order for therapeutic activities to be covered, the following requirements must be met:

The patient has a documented condition for which therapeutic activities can reasonably be expected to restore or improve functioning;

There is a clear correlation between the type of exercise performed and the patient’s underlying medical condition for which the therapeutic activities were prescribed;

The patient’s condition is such that he/she is unable to perform the therapeutic activities without the skilled intervention of the therapist.
This code is generally not covered for greater than 10-12 visits. Documentation must support the need for continued treatment beyond 12 visits. No greater than 1-2 services/units of this code is generally covered on each visit date; if this code is utilitized in conjunction with CPT 97110 or 97112 on any given visit date only 1-2 services/units of CPT 97530 are generally covered.

Additional Documentation Requirements
Objective measurements of balance, strength, coordination, mobility, etc.

Specific activities performed, amount of assistance required.

Documentation to support that the skills and expertise of the therapist were needed.

Functional limitations addressed.

Functional progress at reassessment and discharge. If no progress, the reason for lack of progress documented and/or alternative treatment strategy.

97750 Physical Performance Test or Measurement

The clinician performs a test of physical performance evaluating function of one or more body areas and evaluates functional capacity. A written report is included. This is in addition to a routine evaluation or re-evaluation (97001-97004). CPT code 97750 is not covered on the same day as CPT codes 97001-97004 (due to CCI edits). This code can be billed in 15-minute increments.


97755 Assistive Technology Assessment Each 15 minutes

The provider performs an assessment of the suitability & benefits of acquiring any assistive technology device or equipment that will help restore, augment, or compensate for existing functional ability in the pt (e.g., provision of large amounts of rehab engineering). Coverage is specifically for assessment of mobility, seating & environmental control systems that require high-level adaptations, not for routine seating & mobility systems (e.g., manual/power wheelchair evaluations). This is an assessment code, per each 15 minutes, & must be accompanied by a written report explaining the nature & complexity of the assistive technology needed by the patient. This can include testing multiple components/systems to determine optimal interface between client & technology applications, & determining the appropriateness of commercial (off the shelf) or customized components/systems. This assessment may require more than one pt visit due to the complexity of the pt’s condition & his/her decreased tolerance for activity at one session. Training for use in assistive technology in the home environment is coded as 97535 and for use in the community as 97537. CPT 97755 is not covered on the same day as CPT codes 97001-97004 (due to CCI edits)

Billing and Coding Guideline





A beneficiary received occupational therapy (HCPCS 97530 timed‖ code 97530 which
is defined in 15 minute units) for a total of 60 minutes. The provider would then report revenue
code 043X and 4 units.

Blue Cross as the result of a coding edit. Edit denials are designed to ensure appropriate coding and to assist in processing claims accurately and consistently. The code combinations and outcomes are listed below.

CODE DENIAL TO CODES

97124 Incidental 97110, 97112-97113, 97116, 97139- 97140, 97150, 97530, 97532-97533,97535, 97537, 97542, 97545-97546,98925-98929, 98940-98943

97140 Incidental 97139, 97150, 97545-97546

97140 Mutually  Exclusive 97530, 97532-97533

97140 Incidental 98925-98929, 98940-98943

97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

Example: Column 1 Code / Column 2 Code – 97140/97530

Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy. Alternatively, the therapy time blocks may be split. For example, manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.

Modifier 59 is used appropriately when two timed procedures are performed in different blocks of time on the same day.

This policy describes Optum’s documentation requirements for reimbursement of the Physical Medicine and Rehabilitation  (PM&R) CPT codes which make up the timed, skilled, direct one-on-one component of treatment. Specifically CPT codes, 97110- 97140, 97530-97542, 97750-97762.

The CPT section devoted to “therapeutic procedures” contains many of the CPT codes utilized by rehabilitation providers to describe the skilled, direct one-on-one component of treatment. These codes describe the bulk of hands-on, skilled care 0 provided by rehabilitation providers.

CPT defines Therapeutic Procedures 97110-97140, 97530-97542, 97750-97762 as follows:

• A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.

• Physician or therapist required to have direct (one-on-one) patient contact.

• Therapeutic procedure, one or more areas, each 15 minutes;

Additionally, the definition of CPT codes 97750-97755, Therapeutic Procedures, Tests and Measurement includes, “with written report, each 15 minutes.”

In the case of the timed therapeutic CPT codes, documentation should reflect the thought process and skilled decision making of the licensed therapy provider. As such, documentation of patient/client care needs to be more than a litany of procedures related to a date of service. Documentation must include evidence of knowledge and skill related to the procedures performed. It also should provide verification of professional judgment. This concept of clinical decision making can be incorporated  into clinical documentation.






97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

* This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkreis, Bobath, BAP’s boards and desensitization techniques). The procedure may be medically reasonable and necessary for impairments which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity) or which cause loss of proprioception.

This therapeutic procedure is provided for the purpose of restoring balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation (PNF), Feldenkreis, Bobath, BAP’s boards, and desensitization techniques).

This procedure may be reasonable and necessary for impairments which affect the body’s neuromuscular system such as:

documented loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs, and/or fingers;

documented nerve palsy, such as peroneal nerve injury causing foot drop;

documented muscular weakness or flaccidity as result of a cerebral dysfunction, a nerve injury or disease or having had a spinal cord disease or trauma;

documented poor static or dynamic sitting/standing balance;

documented loss of gross and fine motor coordination;

documented hypo/hypertonicity.

Documentation for neuromuscular reeducation must show impairments which affect the neuromuscular system as listed above. Documentation must contain objective measurements/ratings of loss of motion, strength, balance, coordination, and/or mobility, e.g., degrees of motion, strength grades, assist for balance and mobility, specific tests for balance and coordination.

When neuromuscular re-education incorporates ‘Body Weight Supported Treadmill Training with Robotics’, CPT 97112 should be used. The documentation should clearly define goals and progress to reflect medical necessity.

If an exercise is instructed to the patient and performed for the purpose of restoring functional balance, motor coordination, kinesthetic sense, posture, or proprioception for sitting or standing activities, CPT 97112 is the appropriate code. For example, a gym ball exercise used for the purpose of improving balance should be considered as neuromuscular reeducation when coding for billing.

This code is generally not covered for greater than 12-18 visits within a 4-6 week period. Documentation must support the need for continued treatment beyond this frequency and duration. No greater than 1-2 services/units of this code should be used on each visit date. If this code is used in conjunction with CPT 97110 or CPT 97530 on any given visit date, only 1-2 services/units of CPT 97112 are generally covered. Documentation must support the number of services/units for each visit date.

Additional Documentation Requirements
Objective measurements of strength and range of motion (with comparison to the uninvolved side) and mobility, balance, and coordination deficits to support the use of this code.

Specific exercises performed, purpose of exercises as related to function, instruction given, and/or assistance needed.

Documentation to support that the skills and expertise of the therapist were required.

Functional limitations/deficits as result of the neuromuscular impairment.

Response of patient to treatment.

Functional progress at reassessment and discharge. If no progress, the reason for the lack of progress and/or alternative treatment strategy.

Example 1 – 

24 minutes of neuromuscular reeducation, code 97112,
23 minutes of therapeutic exercise, code 97110,
Total timed code treatment time was 47 minutes.

The 47 minutes falls within the range for 3 units = 38 to 52 minutes. Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more
than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.

For myofascial release, CPT 97140 should be reported. When reporting or billing for CPT 97112 (neuromuscular re-education) and CPT 97124 (massage), as well as all other physical medicine modalities and therapeutic procedures, the details of the procedure shall be recorded in the medical record, including clinical rationale, anatomical  site, description of service, and time (as required by the selected CPT code).

Question: There is a new code for repositioning, CPT code 95992. My understanding is that Change Request 6397 states that CPT code 95992 is bundled with E/M codes, which therapists were not allowed to file. The direction was for therapy providers to continue to use submit CPT code 97112 so that we could get paid. Has something changed on that?


Answer: Providers should continue to use CPT code 97112 as directed in Change Request (CR) 6397

The Use of the Rehabilitation CPT Codes (97110, 97112 and 97530) by Optometrists in the Rehabilitative Setting


Definition:

The CPT Codes 97112, 97110 and 97530 fall within the 97000 series of codes considered “Physical Medicine and Rehabilitation”. Originally OT and PT providers had exclusively used the codes. And many third party payors still call the 97000 series “OT and PT codes”. Since 2002 CMS has defined qualified vision rehabilitation specialists as – Optometrist, Ophthalmologist, and Occupational Therapist when under the direct supervision of OD or OMD. State and National legislations have shown that these codes are not exclusive to any particular group of providers as long as the provider is licensed to provide the services they are performing under their state laws. Some state Boards of Optometry specifically provide guidance for optometrists on this and some state boards do not. You should check your local state board for their position. Currently, the 97000 series CPT codes are used by MD, DO, OD, DC, DPM, OT, PT, & SLP providers.

Unfortunately, CPT framework encourages payers to think of services in silos. In other words, payers expect professionals of each specialty group to bill the majority of their services within their specialty code set. They often are surprised when optometrists bill outside the 92000 series, and they erroneously try to recode the procedure into the 92000 series. We are experiencing this change of coding in regard to the 97110, 97112 and 97530 codes.

The CPT Code 97530 is for “Therapeutic Activities; Utilized to restore a patient’s functional performance with  dynamic activities, such as training in specific functional movements or activities performed during daily living routines.

CODE DENIAL TO CODES

97124 Incidental 97110, 97112-97113, 97116, 97139- 97140, 97150, 97530, 97532-97533, 97535, 97537, 97542, 97545-97546, 98925-98929, 98940-98943

97140 Mutually Exclusive 97530, 97532-97533

 Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

•    Safe and effective.
•    Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).
•    Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
o    Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
o    Furnished in a setting appropriate to the patient’s medical needs and condition.
o    Ordered and furnished by qualified personnel.
o    One that meets, but does not exceed, the patient’s medical needs.
o    At least as beneficial as an existing and available medically appropriate alternative.

Group 1 Codes


95992    Canalith repositioning proc
97001    Pt evaluation
97002    Pt re-evaluation
97003    Ot evaluation
97004    Ot re-evaluation
97012    Mechanical traction therapy
97016    Vasopneumatic device therapy
97018    Paraffin bath therapy
97022    Whirlpool therapy
97024    Diathermy eg microwave
97028    Ultraviolet therapy
97032    Electrical stimulation
97034    Contrast bath therapy
97035    Ultrasound therapy
97036    Hydrotherapy
97039    Physical therapy treatment
97110    Therapeutic exercises
97112    Neuromuscular reeducation
97113    Aquatic therapy/exercises
97116    Gait training therapy
97124    Massage therapy
97139    Physical medicine procedure
97140    Manual therapy 1/> regions
97150    Group therapeutic procedures
97530    Therapeutic activities
97532    Cognitive skills development
97533    Sensory integration
97535    Self care mngment training
97537    Community/work reintegration
97542    Wheelchair mngment training
97545    Work hardening
97546    Work hardening add-on
97750    Physical performance test
97755    Assistive technology assess
97760    Orthotic mgmt and training
97761    Prosthetic training
97762    C/o for orthotic/prosth use
97799    Physical medicine procedure
G0283    Elec stim other than wound

Team Therapy:

Therapists, or therapy assistants, working together as a “team” to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.

CPT codes are used for billing the services of one therapist or therapy assistant. The therapist cannot bill for his/her services and those of another therapist or a therapy assistant, when both provide the same or different services, at the same time, to the same patient(s). Where a physical and occupational therapist both provide services to one patient at the same time, only one therapist can bill for the entire service or the PT and OT can divide the service units. For example, a PT and an OT work together for 30 minutes with one patient on transfer activities. The PT and OT could each bill one unit of 97530. Alternatively, the 2 units of 97530 could be  Reviewed 9/2009 billed by either the PT or the OT, but not both. Similarly, if two therapy assistants provide services to the same patient at the same time, only the service of one therapy assistant can be billed by the supervising therapist or the service units can be split between the two therapy assistants and billed by the supervising therapist(s).

Procedure Code Modifier Short Description PT OT SLP Comments

97035* GP Ultrasound therapy X Timed 15 min units
97036* GP Hydrotherapy X Timed 15 min units
97039* GP Physical therapy treatment X
97110* GP, GO Therapeutic exercises X X Timed 15 min units
97112* GP, GO Neuromuscular reeducation X X Timed 15 min units
97113* GP, GO Aquatic therapy/exercises X X Timed 15 min units
97116* GP Gait training therapy X Timed 15 min units
97124* GP, GO Massage therapy X X Timed 15 min units
97139* GP Physical medicine procedure X
97140* GP, GO Manual therapy X X Timed 15 min units
97150* GP, GO Group therapeutic procedures X X
97165 GO DSHS OT eval (bed rail assessment) X
EPA required.

One per client, unless change of residence or condition OT Eval for bedrails is a DSHS program. Use EPA# 870001326 with billing code 0434- 97165.

97166 GO DSHS OT eval (personal care for children) X EPA required.

One per client, unless change of residence or condition OT eval for personal care is a DSHS program. Use EPA# 870001343 with billing code 0434- 97166.

97161 GP PT eval low complex 20 X Only one of these

Documentation Requirements:

The following criteria must be documented to support the clinical necessity of manual therapy services:

• The clinical indication and appropriateness of the selected MTT including the need for skilled care services for treating a musculoskeletal condition

• The clinical rationale for a separate and identifiable service must be documented when both CPT code 97140 and a CMT procedural code are reported on the same date

• Description of the manual therapy technique e.g., joint manipulation, myofascial release, mobilization, etc.

• Location e.g., spinal region(s), shoulder, thigh, etc.

• Time (This applies only to CPT code 97140, which includes a timed-therapy services requirement)

There are general coverage criteria, which must be met when conducting utilization review determinations, in addition to those documentation requirements (above) associated with the different types of manual therapies. These criteria are found in the member’s Summary Plan Description (SPD) or Certificate of Coverage (COC), and health plan medical policies to determine whether coverage is provided, if there are any exclusions or benefit limitations applicable to this policy

Prior Authorization Requests (PARs)

Independent Physical and Occupational Therapists and hospital based therapy clinics providing outpatient therapy services must submit PARs for medically necessary services when:

* The member is a child (age 20 and under) and has exceeded 48 units of PT/OT service per 12 month period, or

* When Habilitative PT/OT is being sought. PARs are approved for up to a twelve (12) month period (depending on medical necessity determined by the reviewer).

* Retroactive PAR request forms will not be accepted.Overlapping PAR request dates for same provider types will not be accepted, with the exception of Early Intervention PAR requests which may have overlapping dates of service and multiple provider types. All Early Intervention PT/OT PARs must additionally indicate that the member has an Individual Family Service Plan (IFSP) and that it is current and approved.

* Incomplete, incorrect or insufficient member information on a PAR request form will not be accepted. Submit PARs for the number of units for each specific procedure code requested, not for the number of services. Modifier codes must be included. The same modifiers used on the PAR must be used on the claim, in the same order.

* When submitting Rehabilitative Therapy PARs, and subsequent claims, CPT codes for PT services must have the GP modifier (e.g. 97001+GP). CPT codes for OT services must have the GO modifier (e.g. 97003+GO).

* When submitting Habilitative Therapy PARs, and subsequent claims, CPT codes for PT services must have the GP modifier and HB modifier (e.g. 97001+GP+HB). CPT codes for OT services must have the GO modifier and HB modifier (e.g. 97003+GO+HB).

* Early Intervention PARs, and subsequent claims, must have the GP or GO modifier plus the TL modifier (e.g. 97110+GP+TL).

Procedure Code Short Description Provider Type Max Daily Units Prior Authorization Required

92526 Treatment of swallowing dysfunction and/or oral function for feeding

OT 1 Sometimes 97010 Application of modality; hot or cold packs

PT, OT 1 Sometimes 97012 Application of modality; mechanical traction

PT, OT 1 Sometimes 97014 Application of modality; electrical stimulation

PT, OT 1 Sometimes 97016 Application of modality; vasopneumatic devices

PT, OT 1 Sometimes 97018 Application of modality; paraffin bath

PT, OT 1 Sometimes
97022 Application of modality; whirlpool PT, OT 1 Sometimes
97024 Application of modality; diathermy (microwave)

PT, OT 1 Sometimes
97026 Application of modality: infrared PT, OT 1 Sometimes
97028 Application of modality; ultraviolet PT, OT 1 Sometimes
97032 Application of modality; electrical stimulation, each unit 15 mins

PT, OT 2 Sometimes 97033 Application of modality; iontophoresis, each unit 15 mins

PT, OT 4 Sometimes 97034 Application of modality; contrast baths, each unit 15 mins

PT, OT 4 Sometimes 97035 Application of modality; ultrasound, each unit 15 mins

PT, OT 4 Sometimes 97036 Application of modality; hubbard tank, each unit 15 mins

PT, OT 4 Sometimes 97110 Therapeutic exercises, each unit 15 mins

PT, OT 4 Sometimes 97112 Neuromuscular reeducation, each unit 15 mins

PT, OT 4 Sometimes 97113 Aquatic therapy with therapeutic exercises, each unit 15 mins

PT, OT 2 Sometimes 97116 Gait training, each unit 15 mins PT, OT 3 Sometimes 97124 Massage (effleurage, petrissage, tapotement), each unit 15 mins

PT, OT 4 Sometimes 97140 Manual therapy, each unit 15 mins

PT, OT 2 Sometimes 97150 Therapeutic procedures, group (two or more individuals)

PT, OT 1 Sometimes  97161 Evaluation of physical therapy, typically 20 minutes

PT 1 No 97162 Evaluation of physical therapy, typically 30 minutes

PT 1 No 97163 Evaluation of physical therapy, typically 45 minutes

PT 1 No 97164 Re-evaluation of physical therapy, typically 20 minutes

PT 1 No 97165 Evaluation of occupational therapy, typically 30 minutes

OT 1 No 97166 Evaluation of occupational therapy, typically 45 minutes

OT 1 No 97167 Evaluation of occupational therapy established plan of care, typically 60 minutes

OT 1 No 97168 Re-evaluation of occupational therapy established plan of care, typically 30 minutes

OT 1 No 97530 Therapeutic activities, direct oneon-one contact, each unit 15 mins

PT, OT 3 Sometimes 97532 Cognitive skills development, each unit 15 mins

PT, OT 3 Sometimes 97533 Sensory integration, each unit 15 mins

PT, OT 4 Sometimes 97535 Self care / home management training (activities of daily living, including instruction on the use of assistive technology devices), each unit 15 mins

PT, OT 4 Sometimes 97537 Community/work reintegration training, each unit 15 mins

PT, OT 4 Sometimes 97542 Wheelchair management training and fitting, each unit 15 mins

PT, OT 4 Sometimes 97545 Work hardening/conditioning, each unit initial 2 hours

PT, OT 1 Sometimes 97546 Work hardening, additional 1 hour PT, OT 1 Sometimes 97597 Debridement, open wound, and wound assessment, first 20 square centimeters or less of wound surface area, per session

PT, OT 1 No 97598 Debridement, open wound, and wound assessment, each additional 20 square centimeters of wound surface area, per sessions

PT, OT 1 No 97602 Wound(s) care including nonselective debridement, and instruction, per sessions

PT, OT 1 No 97750 Physical performance test or measurement, each unit 15 mins

PT, OT 2 No 97755 Assistive technology assessment, each unit 15 mins

PT, OT 20 Always 97760 Orthotic management and training, each unit 15 mins

PT, OT 4 Sometimes 97761 Prosthetic training, each unit 15 mins

PT, OT 4 Sometimes 97762 Checkout for orthotic/prosthetic use, each unit 15 mins PT, OT 4 Sometimes 97799 Unlisted physical medicine/rehab (specify) PT, OT 1 Sometimes

L1902 Ankle foot orthotic, gauntlet, prefabricated, OTS PT, OT 2 No

L1960 Ankle foot orthotic, posterior solid ankle, plastic, CF PT, OT 2 No

L3730 Elbow orthotic, double upright with forearm/arm cuffs, extension/ flexion assist, CF PT, OT 2 No