97010 - Application of a modality to 1 or more areas; hot or cold packs - average fee amount - $10 - $20
97012 - Application of a modality to 1 or more areas; traction, mechanical
97016 - Application of a modality to 1 or more areas; vasopneumatic devices
97018 - Application of a modality to 1 or more areas; paraffin bath
97022 - Application of a modality to 1 or more areas; whirlpool
97024 - Application of a modality to 1 or more areas; diathermy (eg, microwave)
Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation, do not constitute (covered) therapy services for Medicare purposes. Services related to recreational activities such as golf, tennis, running, etc., are also not covered as therapy services.
To be considered reasonable and necessary, the services must meet Medicare guidelines. The guidelines for coverage of outpatient therapies have basic requirements in common.
In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
Improvement is evidenced by successive objective measurements whenever possible. If an individual’s expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.
Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities (CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 220.2(C)). For example, therapy may not be covered for a fully functional patient who developed temporary weakness from a brief period of bed rest following abdominal surgery. It is reasonably expected that as discomfort reduces and the patient gradually resumes daily activities, function will return without skilled therapy intervention.
In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.
A therapy plan of care is developed either by the physician/NPP, or by the physical therapist who will provide the physical therapy services, or the occupational therapist who will provide the occupational therapy services, (only a physician may develop the plan of care in a CORF). The plan must be certified by a physician/NPP.
If the goal of the plan of care is to improve functioning, the documentation must establish that the patient needs the unique skills of a therapist to improve functioning.
If the goal of the plan of care is to maintain, prevent or slow further deterioration of functional status function or prevent deterioration, the documentation must establish that the patient needs the unique skills of a therapist to maintain, prevent or slow further deterioration of functional status.
All services provided are to be specific and effective treatments for the patient’s condition according to accepted standards of medical practice; and the amount, frequency, and duration of the services must be reasonable.
The services that are provided must meet the description of skilled therapy below.
Billing Codes for Massage Therapists
CPT (Current Procedural Terminology) codes for massage therapy and related procedures - identifies the type of care or the procedure that is used in that care. The best way to know what codes the insurance company will accept is to call and ask them! You can not just bill whatever code that they accept. You have to bill what ever code you are trained in. Setting your fees for these codes are another issue. Just because you can get paid more for certain codes, you have to charge the same amount you charge cash clients (plus whatever additional billing fee there is) or else it is considered insurance fraud.
97010- modality; hot or cold packs- 15 minute increment
97124- massage treatment-15 minute increment
97140- myofascial release, manual therapy- 15 minute increment
97112- neuromuscular re-education- 15 minute increment
Diagnosis codes (ICD codes-International Classification of Disease)- Diagnosis codes are often needed when billing even though we are not able to diagnose. This information should come from the referring physician. If the physician does not write the code on the prescription, call them directly to get the code. I highly recommend that you do not try to select your own code from the online code finder or the information below as each physician may code things differently. I am providing this information because physicians often write the code but they don't say what it means.
Call the Physician to get the correct code.
Physical Medicine and Rehabilitation
The selection of appropriate physical medicine modalities and procedures should be based on the desired physiological response in correlation to the stages of healing. In most conditions or injuries, utilization of one carefully selected modality or procedure in combination with CMT is adequate to achieve a successful clinical outcome.
All decisions made by a chiropractor regarding the use of supportive physical medicine modalities and procedures shall be predicated upon a properly documented clinical rationale, which is consistent with current educational and practice standards. The details of all modalities or procedures provided shall be recorded when performed, including time for all constant attendance modalities and therapeutic procedures.
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 region4 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).
The physical medicine codes 97010-97028, 97032-97036, 97039 require a physician or therapist to be in constant attendance.
The codes 97110- 97124 should be used for physical therapy procedures.
Additional physical therapy codes 97140-97542 and 97597-97606 should be used as defined in CPT.
Physical therapists evaluation and re-evaluation services should be submitted using CPT codes 97001 and 97002. These codes may be reported separately if the patient’s condition requires significant separately identifiable services, above and beyond the usual pre-service and post-service work associated with the procedure performed. The modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service) is not valid with the physical therapy (PT) evaluations and re-evaluation codes 97001-97002. The evaluation or reevaluation codes will be allowed, as appropriate, when billed with other physical or occupational services on the same date. Because the modifier -25 is not valid with 97001-97002, if submitted, the service will be denied.
The CPT Manual defines a modality as “any physical agent applied to produce therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.” CPT codes within the code range of 97032-97036 are “Constant Attendance” codes that require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance.
The CPT Manual defines a therapeutic procedure as “a manner of affecting change through the application of clinical skills and/or services that attempt to improve function.”
CPT codes within the code ranges of 97110-97124, 97140, and 97530-97542 require direct (one-onone) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one-attendance.
Tests and Measurements:
CPT codes 97750 and 97755 require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance.
Orthotic Management and Prosthetic Management:
CPT codes 97760-97762 describe orthotic and prosthetic assessment, management, and training services. These codes also contain a 15 minute time component.
CPT Code 97140: Manual therapy techniques (e.g. mobilization, manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes. Description Code 97140 is used to report manual therapy (‘hands-on’) techniques that consist of , but are not limited to connective tissue massage, joint mobilization, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. Manual therapy techniques may be applied to one or more regions for 15-minute intervals. These services are not diagnosis or region specific.
CPT® code 97140 is to be reported for each 15 minutes of manual therapy techniques provided to one or more regions.
For example, if 30 minutes of manual therapy techniques were provided to one or more regions, code 97140 would be reported two times, one for each 15-minute interval.
It is important to recognize that 15 minutes must be spent in performing the pre-, intra, and post-service work in order to report code 97140.
Under certain circumstances, it may be appropriate to additionally report CMT/OMT codes in addition to code 97140. For example, a patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques as described by code 97140 to the neck region and CMT to the lumbar region. As separate body regions are addressed, it would be appropriate in this instance to report both codes 97140 and 98940. In this example, the modifier -59 should be appended to indicate that a distinct procedural
service was provided.
The application of coding modifiers is not a consideration when rendering UR determinations. This section is intended to provide a summary of the related Optum Reimbursement policy No. 0050 – Modifier-59. Under certain circumstances, it may be appropriate for chiropractors to report CPT code 97140 in addition to a CMT code. On these occasions it is appropriate to append the CPT procedural code 97140 with a modifier (-59).
A modifier provides the means by which the reporting health care practitioner can indicate that a CPT descriptor code (service or procedure), which has been performed, has been altered by a specific circumstance or in some way without changing the definition of the CPT code. Modifiers increase the specificity of certain CPT codes.
Modifier -59 indicates that the procedure (97140) represents a distinct service from others reported on the same date of service. This modifier was developed explicitly for the purpose of identifying services not typically performed together.
General Modality Guidelines
(CPT codes 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, G0281, G0283, and G0329)
CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.
CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another procedure at the same time. Only the actual time of the provider’s direct contact with the patient, providing services requiring the skills of a therapist, is covered for these codes.
Modalities chosen to treat the patient’s symptoms/conditions should be selected based on the most effective and efficient means of achieving the patient’s functional goals. Seldom should a patient require more than one (1) or two (2) modalities to the same body part during the therapy session. Use of more than two (2) modalities on each visit date is unusual and should be carefully justified in the documentation.
The use of modalities as stand-alone treatments is rarely therapeutic, and usually not required or indicated as the sole treatment approach to a patient’s condition. The use of exercise and activities has proven to be an essential part of a therapeutic program. Therefore, a treatment plan should not consist solely of modalities, but should also include therapeutic procedures. (There are exceptions, including wound care or when patient care is focused on modalities because the acute patient is unable to endure therapeutic procedures.) Use of only passive modalities that exceeds 4 visits should be very well supported in the documentation.
Multiple heating modalities should not be used on the same day. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation must support the use of multiple modalities as contributing to the patient’s progress and restoration of function. For example, it would not be medically necessary to perform both thermal ultrasound and thermal diathermy on the same area, in the same visit, as both are considered deep heat modalities.
When the symptoms that required the use of certain modalities begin to subside and function improves, the medical record should reflect the discontinuation of those modalities, so as to determine the patient’s ability to self-manage any residual symptoms. As the patient improves, the medical record should reflect a progression of the other procedures of the treatment program (therapeutic exercise, therapeutic activities, etc.). In all cases, the patient and/or caregiver should be taught aspects of self-management of his/her condition from the start of therapy.
Based on the CPT descriptors, these modalities apply to one or more areas treated (e.g., paraffin bath used for the left and right hand is billed as one unit).
CPT 97010 - hot or cold packs (to one or more areas)
Hot or cold packs (including ice massage) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a therapist.
Code 97010 is bundled. It may be bundled with any therapy code. Regardless of whether code 97010 is billed alone or in conjunction with another therapy code, this code is never paid separately. If billed alone, this code will be denied.
Applicable Outpatient Rehabilitation HCPCS Codes
The CMS identifies the following codes as therapy services, regardless of the presence of a financial limitation. Therapy services include only physical therapy, occupational therapy and speech-language pathology services. Therapist means only a physical therapist, occupational therapist or speech-language pathologist. Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology. Check the notes below the chart for details about each code.
When in effect, any financial limitation will also apply to services represented by the following codes, except as noted below.
NOTE: Listing of the following codes does not imply that services are covered or applicable to all provider settings.
96110+? 96111+? 96125 97001 97002 97003 97004 97010**** 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034
Billing - CPT Codes: Permitted
In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 - 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.
Supportive Documentation Requirements for 97010
The area(s) treated
The type of hot or cold application
CPT 97012 - Traction, Mechanical (to one or more areas)
Traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas.
Specific indications for the use of mechanical traction include cervical and/or lumbar radiculopathy and back disorders such as disc herniation, lumbago, and sciatica.
This modality is typically used in conjunction with therapeutic procedures, not as an isolated treatment.
Documentation should support the medical necessity of continued traction treatment in the clinic for greater than 12 visits. For cervical conditions, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home. The time devoted to patient education related to the use of home traction should be billed under 97012.
Only 1 unit of CPT code 97012 is generally covered per date of service.
Equipment and tables utilizing roller systems are not considered true mechanical traction. Services using this type of equipment are non-covered.
Non-Surgical Spinal Decompression Non-surgical spinal decompression is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, non-surgical spinal decompression is not covered by Medicare (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: Section 160.16). Examples of this type of non-covered procedure include, but are not limited to, VAX-D™, DRX-3000, DRX9000, Decompression Reduction Stabilization (DRS) System, IDD, MedX., Spina System, Accua-Spina System, SpineMED Decompression Table, Lordex Traction Unit, Triton DTS, and Z-Grav. If billed for purpose of receiving a denial, these services should be billed using CPT code 97039 and not with CPT 97012.
Supportive Documentation Requirements for 97012
Type of traction and part of the body to which it is applied, etiology of symptoms requiring treatment.
CPT 97014 – Electrical stimulation (unattended) (to one or more areas)
CPT 97014 is not a Medicare recognized code. See HCPCS code G0283 for electrical stimulation (unattended).
CPT 97016 - Vasopneumatic Devices (to one or more areas)
The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema or lymphedema.
Specific indications for the use of vasopneumatic devices include reduction of edema after acute injury or lymphedema of an extremity. Education on the use of a lymphedema pump for home use is covered when medically necessary and can typically be completed in three (3) or fewer visits once the patient has demonstrated measurable benefit in the clinic environment.
Note: Further treatment of lymphedema by a vasopneumatic device rendered by a clinician after the educational visits is generally not reasonable and necessary unless the patient presents with a condition or status requiring the skills and knowledge of a physical or occupational therapist.
The use of vasopneumatic devices is generally not covered as a temporary treatment while awaiting receipt of ordered compression stockings.
See NCD 280.6 in CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual for further coverage and use information on Pneumatic Compression Devices.
CPT codes 97010 describe Physical Medicine and Rehabilitation modalities that do not require direct (one-on-one) patient contact by the provider.
Consistent with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare Community Plan will not reimburse CPT codes 97010. Reimbursement for 97010 is included in the payment for other services.
Codes CPT code section
97010 Application of a modality to 1 or more areas; hot or cold packs
Supportive Documentation Requirements for 97016
Area of the body being treated, location of edema
Objective edema measurements (1+, 2+ pitting, girth, etc.), comparison with uninvolved side
Effects of edema on function
Type of device used
CPT 97018 – Paraffin Bath (to one or more areas)
Paraffin bath treatments typically do not require the unique skills of a
therapist. However, the skills, knowledge and judgment of a therapist might be required in the provision of such treatment or baths in a complicated case. Only in cases with complicated conditions will paraffin be covered, and then coverage is generally limited to educating the patient/caregiver in home use. Paraffin is contraindicated for open wounds or areas with documented desensitization.
CMS (the Centers for Medicare and Medicaid Services), the federal agency that administers the Medicare program, implemented a policy known as the Correct Coding Initiative (CCI). This policy is used to promote correct coding by physicians and to ensure that it makes appropriate payments for physician services. “This policy has been developed and applied by many third party payers across the country.” Correct coding emphasizes that procedures should be reported with the CPT codes that most comprehensively describe the services performed e.g., 98941 is a more comprehensive code than 98940. There are procedural codes that are not to be reported together because they are mutually exclusive to each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session. An example of mutually exclusive codes germane to this policy is 97140 – Manual therapy techniques (without the -59 modifier) vs. 98940, 98941, 98942, or 98943 – Chiropractic manipulative treatment.