CPT CODE - 97001, 97110, 97140, 97124, 97002 - Therapy Procedure

CPT CODE and Description

97001 - Physical therapy evaluation Average fee payment $70 - $80

97002 - Physical therapy re-evaluation Average fee payment $35 - $50

97003 - Occupational therapy evaluation Average fee payment $80 - $95

97004 - Occupational therapy re-evaluation 

97110 Phys. Med, Tx, 1 area, 30 Min, Ea. Vist; ther. Exerc Therapeutic exercises (15 minutes)


97140 Manual therapy (eg. Mobililzation/manipulation, manual lymphatic drainage, manual traction) Manual therapy techniques


Coverage Indications, Limitations, and/or Medical Necessity
  

    ACTIVE PARTICIPATION of the clinician in treatment means that the clinician personally furnishes in its entirety at least one billable service on at least one day of treatment.

    ASSESSMENT is separate from evaluation and is included in services or procedures (it is not separately reimbursable).

    CERTIFICATION is the physicianns/nonphysician practitionerrs (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.

    INTERVAL of certified treatment (certification interval) consists of 90 calendar days or less, based on an individualls need. A physician/NPP may certify a plan of care for an interval length that is less than 90 days. There may be more than one certification interval in an episode of care. The certification interval is not the same as a Progress Report period.

    TREATMENT DAY means a single calendar day on which treatment, evaluation and/or re-evaluation is provided. There could be multiple visits, treatment sessions/encounters on a treatment day.

    General Therapy Guidelines

    For requirements on furnishing therapy service in a pool, please refer to Pub 100-02, Chapter 15, Section 220C for a complete discussion on renting/leasing pool space, use of the rented/leased space, and documentation required to support these requirements.

    Therapy services must relate directly and specifically to a written treatment plan. The plan (also known as a plan of care or plan of treatment), must be established before treatment is begun. The plan is established when it is developed (e.g., written or dictated).

    The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded with the plan. Establishing the plan, which is described below, is not the same as certifying the plan, which is described in §220.1.1 through 220.1.3.

    Outpatient therapy services shall be furnished under a plan established by:

        A physician/NPP (consultation with the treating physical therapist, occupational therapist, or speech-language pathologist is recommended. Only a physician may establish a plan of care in a CORF);

        The physical therapist who will provide the physical therapy services;

        The occupational therapist who will provide the occupational therapy services; or

        The speech-language pathologist who will provide the speech-language pathology services.

    It is acceptable to treat under two separate plans of care when different physicianns/NPPs refer a patient for different conditions. It is also acceptable to combine the plans of care into one plan covering both conditions if one or the other referring physician/NPP is willing to certify the plan for both conditions. The Treatment Notes continue to require timed code treatment minutes and total treatment time and need not be separated by plan. Progress Reports should be combined if it is possible to make clear that the goals for each plan are addressed. Separate Progress reports referencing each plan of care may also be written, at the discretion of the treating clinician, or at the request of the certifying physician/NPP, but shall not be required by contractors.

    Covered therapy services must:

        Qualify as skilled therapy services;

        Be considered under accepted standards of medical practice to be a specific and effective treatment for the patientts condition;

        Be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a qualified therapist; and

        The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.

    Therefore, therapy services are covered when they are rendered:

        under a written treatment plan developed by the individualls physician, non-physician practitioners, optometrist, and/or therapist;
        to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration; and
        the patientts functional limitations are documented in terms that are objective and measurable.


    Rehabilitative Therapy

    Rehabilitative therapy includes services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, decrease in severity or rationalization for an optimistic outlook to justify continued treatment. Improvement is evidenced by successive objective measurements whenever possible (see objective measurement and other instruments for evaluation in the 220.3.C of this chapter). If an individualls 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.

    Rehabilitative therapy requires the skills of a therapist to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation. (See definition of therapist in section 220.A of this chapter.) Services that can be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without the supervision of therapists are not rehabilitative therapy services.

    Rehabilitative therapy may be needed, and improvement in a patientts condition may occur, even when a chronic, progressive, degenerative, or terminal condition exists. For example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety dependence requiring skilled therapy services. The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patientts condition or to maximize his/her functional abilities. The deciding factors are always whether the services are considered reasonable, effective treatments for the patientts condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel.

    Maintenance Programs

    Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.

    Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following circumstances:

        Establishment or design of maintenance programs. If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patientts current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered. If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered. If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.

        Delivery of maintenance programs. Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiaryys need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patientts clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program. Such skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the therapy procedures required to maintain the patientts current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patientts special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patientts current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures. Unlike coverage for rehabilitation therapy, coverage of therapy services to carry out a maintenance program does not depend on the presence or absence of the patientts potential for improvement from the therapy.

        The deciding factors are always whether the services are considered reasonable, effective treatments for the patientts condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel or caregivers.

        Periodic evaluations of the patientts condition and response to treatment may be covered when medically necessary if the judgment and skills of a professional provider are required.

            The design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease may be considered medically necessary.

            Limited services may be considered medically necessary to establish and assist the patient and/or his caregiver with the implementation of a rehabilitation maintenance program.*

            Training of a nursing home staff to implement specific physical care needs of a patient may be covered on a very limited basis when the needs of the patient are above and beyond what would be considered normal nursing care.
            The infrequent reevaluations required to assess the patientts condition and adjust the program may be considered medically necessary.

        *Note: Additional sessions at the end of a course of physical therapy designed to teach the patient or caregiver a home program or to transition the patient to home therapy are not considered to be medically necessary. It is expected that this type of training is carried out during the normal course of therapy.

        It is not medically necessary for a therapist to perform or supervise maintenance programs that do not require the professional skills of a therapist. These situations include:
            services related to activities for the general good and welfare of patients (i.e., general exercises to promote overall fitness and flexibility;
            repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking, such as that provided in support for feeble and unstable patients; and
            range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities that can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel.

        The above referenced indications do not apply to Cardiac Rehabilitation. This program requires individual plans of care and involves procedures and modalities which target a different set of clinical conditions than does physical therapy.

        General Physical Therapy Guidelines (Pub. 100-02, Chapter 15, Section 230.1)

        Physical therapy services are those services provided within the scope of practice of physical therapists and necessary for the diagnosis and treatment of impairments, functional limitations, disabilities or changes in physical function and health status. For descriptions of aquatic therapy in a community pool see Pub. 100-02, Chapter 15, Section 220C.

        The new personnel qualifications for physical therapists and Physical Therapist Assistants (PTAs) were discussed in the 2008 Physician Fee Schedule. See the Federal Register of November 27, 2007, for the full text. See also the correction notice for this rule, published in the Federal Register on January 15, 2008.

   
        General Occupational Therapy Guidelines

        Occupational therapy services are those services provided within the scope of practice of occupational therapists and necessary for the diagnosis and treatment of impairments, functional disabilities or changes in physical function and health status.

        Occupational therapy is medically prescribed treatment concerned with improving or restoring functions which have been impaired by illness or injury or, where function has been permanently lost or reduced by illness or injury, to improve the individualls ability to perform those tasks required for independent functioning. Such therapy may involve:

        - The evaluation and reevaluation as required, of a patientts level of function by administering diagnostic and prognostic tests;

        - The selection and teaching of task-oriented therapeutic activities designed to restore physical function;

        - The planning, implementing and supervising of individualized therapeutic activity programs as part of an over all active treatmentt program for a patient with a diagnosed psychiatric illness;

        - The planning and implementing of therapeutic tasks and activities to increase sensory input and improve response for a stroke patient with functional loss resulting in a distorted body image;

        - The teaching of compensatory technique to improve the level of independence in the activities of daily living or adapt to an evolving deterioration in health and function, for example:
            - teaching a patient who has lost the use of an arm how to pare potatoes and chop vegetables with one hand;
            - teaching an upper extremity amputee how to functionally utilize a prosthesis;
            - teaching a stroke patient new techniques to enable the patient to perform feeding, dressing, and other activities as independently as possible; or
            - Teaching a patient with a hip fracture/hip replacement techniques of standing tolerance and balance to enable the patient to perform such functional activities as dressing and homemaking tasks.
        - The designing, fabricating and fitting of orthotics and self-help devices; e.g., making a hand splint for a patient with rheumatoid arthritis to maintain the hand in a functional position or constructing a device which would enable an individual to hold a utensil and feed independently; or
        - Vocational and prevocational assessment and training, subject to the limitations specified in section 230.1B of Pub 100-02, Chapter 15.

        Only a qualified occupational therapist has the knowledge, training and experience required to evaluate and, as necessary, reevaluate a patientts level of function, determine whether an occupational therapy program could reasonably be expected to improve, restore, or compensate for lost function and where appropriate, recommend to the physician/NPP a plan of treatment where appropriate.

        The new personnel qualifications for occupational therapists and Occupational Therapist Assistants (OTAs) were discussed in the 2008 Physician Fee Schedule. See the Federal Register of November 27, 2007, for the full text. See also the correction notice for this rule, published in the Federal Register on January 15, 2008.


        Occupational therapy may be required for a patient with a specific diagnosed psychiatric illness where such services are required and may be covered if coverage criteria are met.

        Occupational therapy may include vocational and prevocational assessment and training.

        Occupational therapy may include treatment of functional limitations that would include those therapies which restore the patientts ability to perform activities of daily living, e.g., eating, drinking, dressing, bathing, grooming, toileting, and performing personal hygiene.

        General Speech-language Therapy Guidelines

        Speech-language pathology services are those services provided within the scope of practice of speech-language pathologists and necessary for the diagnosis and treatment of speech and language disorders which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability. (See Pub. 100-03, Chapter 1, Section 170.3, for additional information).

        See Pub 100-02, Chapter 15, Section 230.3B for requirements and definition for a qualified speech-language pathologist for Medicare coverage.

        Services of speech-language pathology assistants are not recognized for Medicare coverage. Services provided by speech-language pathology assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services. Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although and aide may help a therapist by providing unskilled services, those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

        Evaluation Services for speech-language pathology

        Speech-language pathology evaluation services are covered if they are reasonable and necessary and not excluded as routine screening by section 1862 (a)(7) of the Act. The speech-language pathologist employs a variety of formal and informal speech, language and dysphagia assessment tests to ascertain the type, causal factor(s), and severity of the speech and language or swallowing disorders. Reevaluation of patients for whom speech, language and swallowing were previously contraindicated is covered only if the patient exhibits a change in medical condition. However, monthly reevaluations; e.g., a Western Aphasia Battery, for a patient undergoing a rehabilitative speech-language pathology program, are considered a part of the treatment session and shall not be covered as a separate evaluation for billing purposes. Although hearing screening by the speech-language pathologist may be part of an evaluation, it is not billable as separate service.

        Therapeutic Services

        The following are examples of common medical disorders and resulting communication deficits, which may necessitate active rehabilitative therapy. This list is not all-inclusive:

        - Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia dysphasia, apraxia, and dysarthria;
        - Neurological disease such as Parkinsonism or Multiple Sclerosis with dysarthria, dysphagia, inadequate respiratory volume control, or voice disorder; or
        - Laryngeal carcinoma requiring laryngectomy resulting in aphonia.

        Impairments of the Auditory System

        The terms aural rehabilitation, auditory rehabilitation, auditory processing, lipreading and speechreading are among the terms used to describe covered services related to perception and comprehension of sound through the auditory system. See Pub 100-04, chapter 12, section 30.3 for billing instructions. For example:
            - Auditory processing evaluation and treatment may be covered and medically necessary. Examples include but are not limited to services for certain neurological impairments or the absence of natural auditory stimulation that results in impaired ability to process sound. Certain auditory processing disorders require diagnostic audiological tests in addition to speech-language pathology evaluation and treatment.

            - Evaluation and treatment for disorders of the auditory system may be covered and medically necessary, for example, when it has been determined by a speech language pathologist in collaboration with an audiologist that the hearing impaired beneficiaryys current amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patientts functional communications needs. Audiologists and speech-language pathologists both evaluate beneficiaries for disorders of the auditory system using different skills and techniques, but only speech-language pathologist may provide treatment.Assessment for the need for rehabilitation of the auditory system (but not the vestibular system) may be done by a speech language pathologist. Examples include but are not limited to: evaluation of comprehension and production of language in oral, signed or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family.

        Examples of rehabilitation include but are not limited to treatment that focuses on comprehension, and production of language in oral, signed or written modalities: speech and voice production, auditory training, speech reading, multimodal (e.g., visual, auditory-visual, and tactile) training, communication strategies, education and counseling. In determining the necessity for treatment, the beneficiaryys performance in both clinical and natural environment should be considered.

        Dysphagia

        Dysphagia, or difficulty in swallowing, can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia and death. It is most often due to complex neurological and/or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies. For these reasons, it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment.

        The speech-language pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques. The equipment that is used in the examination may be fixed, mobile or portable. Professional guidelines recommend that the service be provided in a team setting with a physician/NPP who provides supervision of the radiological examination and interpretation of medical conditions revealed in it.


        Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it related to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques.

 Evaluation Codes (CPT Codes 97001 and 97002 for physical therapy and (CPT Codes 97003 and 97004 for occupational therapy)


The initial evaluation identifies the problem or difficulty the patient is having which helps determine the appropriate therapy necessary to treat the patient. An evaluation is a comprehensive service requiring professional skills to make clinical judgments about conditions for which services are indicated. If a new diagnosis/problem is encountered, then an additional evaluation may be appropriate to determine what course of treatment is necessary for the separate identifiable diagnosis/problem.

        Re-evaluations are indicated periodically when the professional assessment indicates a significant improvement or decline in the patientts condition or functional status. The re-evaluation focuses on the patientts progress toward current goals. Professional judgment is used to determine continued care, modifying goals and/or treatment or terminating services.

For evaluations/re-evaluations, physical therapists should use codes 97001 and 97002, and occupational therapists should use codes 97003 and 97004. 

1. When physical medicine and rehabilitation services are performed for beneficiaries who have suffered musculoskeletal or neurological complications secondary to some other disease, use the ICD-9-CM code for the sign/symptom/complication diagnosis. The underlying condition may also be coded, but is not required. However, the underlying, causal pathological condition alone will not be sufficient for coverage. 

For example, when a patient suffers a Colles’ fracture (813.41), the appropriate diagnosis code for physical therapy is stiffness of joint-forearm (719.53). Submitting ICD-9-CM 813.41 alone without submitting ICD-9-CM code 719.53 will result in claim denial.

2. Intervention with PM&R modalities and procedures is indicated when an assessment and diagnosis by the physician and/or therapist supports utilization of the intervention; there is documentation of objective physical and functional limitations. PM&R services in providers’ offices and patients’ homes are covered when reasonable and medically necessary for the treatment of the patient’s condition (signs and symptoms). The type, frequency and duration of services must be medically necessary for the patient’s condition under accepted medical, physical therapy, and occupational therapy practice standards, and relate directly to a written treatment plan. There must be an expectation that the condition or the level of function will improve significantly within a reasonable and generally predictable period of time.

3. For all PM&R modalities and therapeutic procedures on a given day, it is usually not medically necessary to have more than one treatment session per discipline. Depending on the severity of the patient’s condition, the usual treatment session provided in the home or office setting is from 30 to 60 minutes. The medical necessity of services for a longer length of time must be documented in the treatment plan. Therapy directed at maintenance of current function is not a Medicare benefit.

4. For incident to claims submitted by a physician:

* Services performed by individuals who are not employees, not contracted, or not under a physician/nonphysician practitioner’s (based upon the individual State’s scope of practice) direct supervision, are not covered.

* Services not relating to a written treatment plan that was established by the therapist or by the physician before treatment began are not covered.

* Services that do not require the professional skills of a physician/nonphysician practitioner to perform or supervise are not medically necessary.

5. For claims submitted by a physical or occupational therapist in private practice:

* Claims submitted by anyone other than a Medicare-certified therapist are not covered.

* Medicare-certified therapists include qualified therapists and qualified therapy assistants, but do not include aides. 

* Services provided by aides or physical therapy students, regardless of the level of supervision, are not paid for by Medicare Part B.

* Services not performed by or under the direct supervision of the therapist are not covered.

* Services performed by persons who are not employees of the therapist are not covered.

* Services not relating to a written treatment plan that was established by the therapist or by the physician before treatment began are not covered.

* Services furnished to a patient who has not been seen by a physician once in 30 days from the initial treatment day and every subsequent 30 days after are not covered.

* Services not furnished in the therapist’s office or in the patient’s home are not covered.

* Physical or occupational therapy services that do not require the professional skills of a qualified physical or occupational therapist to perform or supervise and therefore are not covered.

6. Services provided concurrently by a physician and/or physical therapist and/or occupational therapist may be covered if separate and distinct goals are documented in the treatment plans.

7. "Because dementia is a diagnostic term with broad clinical implications, it does not support the medical necessity of a Medicare covered benefit when used alone...When a beneficiary with dementia experiences an illness or injury unrelated to the dementia, the provider should submit a claim with the primary diagnosis that most accurately reflects the need for the provided service. For example, following a hip replacement in a patient with Alzheimer's Disease, a physical therapy provider should submit a clean claim using ICD-9 Code V43.64 (Hip joint replacement by artificial or mechanical device or prosthesis) as the primary diagnosis, not ICD-9 code 331.0 (Alzheimer's Disease)." (CMS Transmittal AB-01-135) If the patient’s dementia is so severe that they would not benefit from the therapy, it would be inappropriate to bill for these services.


8. Certifications are required for each 30 day interval of treatment and are timely when the certification occurs before or during the interval. Certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay. Certifications are acceptable without justification for 30 days after they are due. Delayed certification should include one or more certifications or recertifications on a single signed and dated document. 


Each Complex Decongestive Physiotherapy (CDP) treatment session normally consists of five phases:

  • Skin care, including cleansing, lubrication, debriding and the administration of antimicrobial therapy.
  • Manual lymph drainage involving a gentle massage technique that is carried out in a predetermined manner aimed at redirecting lymph and edema fluid toward adjacent, functioning lymph systems.
  • Multi-layered compression wrapping (bandages) to prevent any reaccumulation of excavated edema fluid and to prevent the ultrafiltration of additional fluid into the interstitial space.
  • Individualized exercises with the bandage in place to enhance lymphatic flow from peripheral to central drainage components. These exercises are aimed at augmenting muscular contraction, enhancing joint mobility, strengthening the limb and reducing the muscle atrophy that frequently occurs secondary to lymphedema.
  • Patient and/or caregiver instruction for continuous self-treatment.


CDP therapy is covered by Medicare when all of the following conditions are met:
  • The treating practitioner, within his scope of practice, documents a diagnosis of lymphedema and specifically orders CDP therapy.
  • The patient or caregiver has the ability to understand and provide home-based CDP following instruction/education.
  • The CDP services must be provided by those trained specifically in physical therapy, occupational therapy or speech-language therapy. Services of athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low-vision specialists or any other profession may not be billed as therapy services.
  • The frequency and duration of the services must be reasonable and necessary, as defined in this policy.
  • The lymphedema causes a limitation of function related to the patient’s self-care, mobility and/or safety.
  • The lymphedema is not reversible by exercises or elevation of the affected limb alone.

The goal of CDP therapy is not to achieve maximum volume reduction, but to ultimately transfer the responsibility for the care from the provider to the patient, the patient’s family or the patient’s caregiver. Unless the patient is able to continue an ongoing self-continuation program at home, there is only temporary benefit from the treatment. The endpoint of treatment is not when the edema resolves or stabilizes, but when the patient and/or his caregiver are able to continue the treatments at home. Patients who do not have the capacity or support system to accomplish these skills in a one- to three-week period of time are not good candidates for CDP.

CDP services should not exceed 60 minutes per treatment, three to five times per week for one to three weeks. The therapy services billed as CDP are subject to all national and local policies for physical therapy. Other services such as skin care and the supplies associated with the compression wrapping are included in the services and are not paid separately. As described earlier in the policy, patient education is an integral part of each CDP treatment session and is not separately billable.

A CDP course of treatment is generally expected no more than once per lifetime. Additional courses of treatment will require documentation to demonstrate reasonableness and necessity. In the absence of such documentation, these services will be considered maintenance physical therapy, which is not a covered benefit.
Medicare also covers pneumatic compression devices for the treatment of lymphedema (through the DMERCs). However, their use is not considered to be a part of CDP. A patient requiring both modes of treatment should be rare. In such a case, documentation supporting the clear medical necessity for both forms of treatment must be maintained in the medical records and be made available to Medicare on request.
Physical therapy and occupational therapy services performed concurrently for the therapeutic exercise portion of the session are duplicative, and not medically necessary. Only one service type is allowed.
CDP services performed “incident to” a physician’s services (physician will bill for services) require direct supervision by the physician. (Part B)
The efficacy of CDP treatment is not well-established for patients who have other underlying conditions, e.g., congestive heart failure, chronic venous insufficiency, acute infection(s), etc. Medicare would, therefore, expect to see a selective approach to treatment of patients with these chronic or acute conditions. Documentation should indicate any recent change in the patient’s condition; this documentation should be in the referral summary from the referring provider. The documentation should indicate that other routine therapies (diuresis, elevation, bandaging, etc.) were attempted but failed to produce satisfactory results, and that true lymphedema was present, not just simple tissue edema.
Allowed unit limitations (once per provider, per discipline, per date of service, per patient) by discipline for CPT codes 97001, 97002, 97003 and 97004 are described in the Utilization Guidelines section below.

 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, which 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:
    • 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.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.


Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 74X, 75X

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
97001©
Pt evaluation
97002©
Pt re-evaluation
97003©
Ot evaluation
97004©
Ot re-evaluation
97110©
Therapeutic exercises
97124©
Massage therapy
97140©
Manual therapy

Billing and Coding Guidelines


Optum will allow up to one evaluation unit, 97001 and 97003 performed by a licensed physical therapist and occupational
therapist respectively, per member, per episode of care.

*An evaluation is supported if:

• It is provided by a licensed PT or OT practicing within their scope of their license.

• There is a documented new occurrence or a documented separate and distinct condition

• There is a documented new surgical procedure, related to a previously treated/concurrently treated condition.

• The clinical record is consistent with Optum’s Guideline for Recordkeeping policy.

An episode may include treatment related to multiple conditions.

A documented flare-up or exacerbation does not usually require a new evaluation but may require a re-evaluation.


The Physical Therapy evaluation and Occupational Therapy evaluation CPT codes were established in 1998. Prior to this, the
Evaluation and Management (E/M) codes were utilized to represent a physical or occupational therapy evaluation.

The Current Procedural Terminology (CPT) manual defines physical and occupational therapy evaluation as follows:


97001 Physical Therapy evaluation

1. Exceptions for Evaluation Services

Evaluation. The CMS will except therapy evaluations from caps after the therapy caps are reached when evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services. For example, the following CPT codes for evaluation procedures may be appropriate:


92521, 92522 , 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004


Background Information

The Physical Therapy evaluation and Occupational Therapy evaluation CPT codes were established in 1998. Prior to this, the
Evaluation and Management (E/M) codes were utilized to represent a physical or occupational therapy evaluation.

The Current Procedural Terminology (CPT) manual defines physical and occupational therapy evaluation as follows:

97001 Physical Therapy evaluation

97003 Occupational Therapy evaluation

Unlike the E/M CPT codes**, the Physical Therapy evaluation and Occupational Therapy evaluation CPT codes lack specificity in regards to any such classification or descriptor. While CPT does not list guidelines associated with use of the Physical Therapy  and Occupational Therapy evaluation codes, CMS guidelines support use of these codes solely by a licensed physical or occupational therapist and at a maximum frequency of once per day. Additionally, CMS clearly defines the required components which must be documented in the provider record, to include the definition of “episode of care”.

**The Current Procedural Terminology (CPT) manual defines Evaluation/Management (E/M) “new patient” as one who has not
received any professional services from the physician or another physician of the same specialty and subspecialty who belongs to the same group practice, within the past three years.

**An established patient is one who has received professional services from the physician or another physician of the same
specialty and subspecialty who belongs to the same group practice, within the past three year. The Current Procedural Terminology (CPT) manual defines physical and occupational therapy re-evaluation as follows:

97002 Physical Therapy re-evaluation


97004 Occupational Therapy re-evaluation


Definitions:

 PT is a branch of rehabilitative health to help patients regain or  improve their physical abilities, such as mobility, strength, gait, endurance, coordination and balance. PT services are reported under CPT codes 97001-97799.


Policy:

 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


97003 Occupational Therapy evaluation

* These assessments may be medically necessary when a device is newly issued or there is a modification or re-issue of the device.
* These assessments may be medically necessary when patients experience loss of function directly related to the orthotic or prosthetic device (e.g., pain, skin breakdown, or falls.
* Requires direct one-on-one patient contact 
* Note: The following items are included in the Durable Medical Equipment Regional Contractor (DMERC) reimbursement for a prosthesis/orthosis within 90 days of delivery of the prosthesis/orthosis and, therefore, are not separately billable to Medicare:
a. Evaluation of the residual limb and/or gait
b. Fitting of the prosthesis/orthosis
c. Cost of base component parts and labor contained in HCPCS base codes
d. Repairs due to normal wear or tear

e. Adjustments of the prosthesis/orthosis or the prosthetic component/orthotic component made when fitting the prosthesis/orthosis or component when the adjustments are not necessitated by changes in the residual limb or the patient’s functional abilities


Unlike the E/M CPT codes**, the Physical Therapy evaluation and Occupational Therapy evaluation CPT codes lack specificity in regards to any such classification or descriptor. While CPT does not list guidelines associated with use of the Physical Therapy and Occupational Therapy evaluation codes, CMS guidelines support use of these codes solely by a licensed physical or occupational therapist and at a maximum frequency of once per day. Additionally, CMS clearly defines the required components which must be documented in the provider record, to include the definition of “episode of care”.


The contractor shall return to the provider (RTP) institutional outpatient claims reporting HCPCS codes 97003 or 97004, if modifier GO is not present. X X

1. Exceptions for Evaluation Services

Evaluation. The CMS will except therapy evaluations from caps after the therapy caps are reached when evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services. For example, the following CPT codes for evaluation procedures may be appropriate: 

92521, 92522 , 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004.


 Physicians/NPPs, independent physical therapists, and independent occupational therapists may bill for physical therapy services using the CPT physical medicine and rehabilitation codes. For evaluations/re-evaluations, physical therapists should use CPT code 97001 and CPT code 97002, and occupational therapists should use CPT code 97003 and CPT code 97004. For evaluation/reevaluations physician/NPP should report the appropriate E&M code.  

Calculating time units for CPT 97110

Treatment Notes, indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units for the total therapy minutes provided. 

Example 1 –

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

See the chart above. 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. 


Example 2 – 
20 minutes of neuromuscular reeducation (97112) 
20 minutes therapeutic exercise (97110), 
40 Total timed code minutes. Appropriate billing for 40 minutes is 3 units. 

Each service was done at least 15 minutes and should be billed for at least one unit, but the total allows 3 units. Since the time for each service is the same, choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes

Billing - CPT Codes: Not Permitted

In the same 15-minute (or other) time period, a therapist cannot bill any of the following pairs of CPT codes for outpatient therapy services provided to the same, or to different patients.

Examples include:
a. Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97542);


b. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032 - 97039);

c. Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) and (b) above -- (CPT codes 97032- 97542). For example:any CPT code for a therapeutic procedure (eg. 97116-gait training) with any attended modality CPT code (eg. 97035-ultrasound);

d. Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110 - 97542) with the group therapy CPT code (97150) requiring constant attendance. For example: group therapy (97150) with neuromuscular reeducation (97112);

e. Any CPT code for modalities requiring constant attendance (CPT codes 97032 - 97039) with the group therapy CPT code (97150). For example: group therapy (97150) with ultrasound (97035);


f. Any untimed evaluation or reevaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 - 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150).

Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110 - 97542) with the group therapy CPT code (97150) requiring constant attendance. For example: group therapy (97150) with neuromuscular reeducation (97112);

Any untimed evaluation or reevaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 - 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150


One-on-One Example: 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 receives 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 (97110) corresponding to the time of the skilled intervention with each patient.

b. Group Example: In a 25-minute period, a therapist works with two patients, A and B, and divides his/her time between 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 A’s exercise program and offers verbal cues for patient B’s gait training and balance activities in the parallel bars. The therapist does not track continuous or notable, identifiable episodes of direct one-on-one contact with either patient and would bill each patient one unit of group therapy (97150) corresponding to the time of the skilled intervention with each patient.

Overview

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 typically 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; 



Appropriate billing for 40 minutes is 3 units. Each service was done at least 15 minutes and should be billed for at least one unit, but the total allows 3 units. Since the time for each service is the same, choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes.


ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is not establishing limited coverage for CPT codes 97001, 97002, 97003 and 97004 at this time.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 97110, 97124 and 97140:
Covered for:
457.0
Post-mastectomy lymphedema syndrome
457.1
Other lymphedema
757.0
Hereditary edema of legs
Note: Limited coverage denials will be based on the “Outpatient Physical Medicine and Rehabilitation” (4Y-22) LCD.

Documentation Requirements

  • The use of pneumatic compression devices for the treatment of lymphedema is not considered a part of CDP. A patient who requires both modes of treatment, i.e., CDP and the use of a pneumatic compression device, should be rare. In such a case, documentation supporting the clear medical necessity for both forms of treatment must be maintained in the medical records and be made available to Medicare on request.
  • A CDP course of treatment is generally expected to occur no more than once per lifetime. Additional courses of treatment will require documentation to demonstrate reasonableness and necessity. In the absence of such documentation, these services will be considered maintenance physical therapy, which is not a covered benefit.
  • The efficacy of CDP treatment is not well-established for patients who have other underlying conditions, e.g., congestive heart failure, chronic venous insufficiency, acute infection(s), etc. Medicare would, therefore, expect to see a selective approach to treatment of patients with these chronic or acute conditions. Documentation should indicate any recent change in the patient’s condition; this documentation should be in the referral summary from the referring provider. The documentation should indicate that other routine therapies (diuresis, elevation, bandaging, etc.) had been attempted but failed to produce satisfactory results, and that true lymphedema was present, not just simple tissue edema.
  • Documentation supporting the medical necessity of each of the CDP services should be legible, maintained in the patient’s medical record and made available to Medicare upon request. For all patients, documentation in the progress notes should indicate clear objective evidence of improvement in the first week or 10 days of therapy. This evidence should be documented by changes in weight, limb circumference or other objective measurements (measurements such as limb circumference are useful only if carried out in a standardized fashion that lends itself to reproduction).

Utilization Guidelines
Allowed units outlined in the table below may be billed no more than once per provider, per discipline, per date of service, per patient. The codes allowed zero units in the column for “Allowed Units” may not be billed under a plan of care indicated by the discipline in that column. Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP). (See CMS Change Request 5253 for additional detail.)

Allowed Units
Physician/NPP Not Under a Therapy POC
CPT Code
Code Description
Timed/
Untimed
PT
OT
SLP
97001©
Pt evaluation
Untimed
1
0
0
N/A
97002©
Pt re-evaluation
Untimed
1
0
0
N/A
97003©
Ot evaluation
Untimed
0
1
0
N/A
97004©
Ot re-evaluation
Untimed
0
1
0
N/A


Specific Complex Decongestive Physiotherapy Guidelines:

    Complex decongestive physiotherapy (CDP) consists of skin care, manual lymph drainage, compression wrapping, and exercises. Although there is no means to allow payment of the total treatment via one treatment code, payment will be allowed for the therapy services associated with the treatment (ie, 97001, 97002, 97003, 97004, 97110, 97140 and 97535). Other services such as skin care and the supplies associated with the compression wrapping are included in the therapy services performed during each session.

    The goal of this therapy is not to achieve maximum volume reduction, but to ultimately transfer the responsibility of the care from the clinic, hospital, or doctor, to home care by the patient, patientts family or patientts caregiver. Unless the patient is able to continue therapy at home, there is only temporary benefit from the treatment. The endpoint of treatment is not when the edema resolves or stabilizes, but when the patient and/or their cohort are able to continue the treatments at home. Patients who do not have the capacity or support system to accomplish these skills in a reasonable time are not good candidates for CDP.

    It is expected that therapy education sessions would usually last for 1 to 2 weeks, with the patient attending 3-5 times per week, depending on the progress of the therapy. After that time, there should have been enough teaching and instruction that the care could be continued by the patient or patient caregiver in the home setting. The maximum benefits of treatment are not expected unless the patient continues treatment at home.

    The therapy billed in conjunction with the manual lymph drainage therapy will be subject to all national and local policies for therapy services.

1 comment:

Urooj Shah said...

This was a good suggestion that you put up here...dude…..hope that it benefits all the ones who land up here. 
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