physical and occupational therapists must use the appropriate CPT® and HCPCS codes 64550, 95831-95852, 95992, 97001-97799 and G0283, with the exceptions noted later in the Noncovered and Bundled Codes section. They must bill the appropriate covered HCPCS codes for miscellaneous materials and supplies. For information on surgical dressings dispensed for home use, refer to the Supplies, Materials and Bundled Services section, page 136. If more than 1 patient is treated at the same time use CPT® code 97150. Refer to the Physical Medicine CPT® Codes Billing Guidance section, page 70 for additional information.
Electrical Stimulation Therapy (CPT codes 64550 and 97032, HCPCS code G0283)
CPT code 97032 requires "visual, verbal and/or manual contact "(i.e. constant attendance). A separate CPT code 64550 is available for "initial application of a TENS unit in which electrodes are placed on the skin" for patients that will be operating the TENS unit at home.
Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity.
Daily Maximum for Services
The daily maximum allowable fee for physical and occupational therapy services
(see WAC 296-23-220and WAC 296-23-230 ......................................................... $ 118.07
The daily maximum applies to CPT® codes 64550, 95831-95852 and 97001-97799 and HCPCS code G0283 when performed for the same claim for the same date of service. If physical, occupational, and massage therapy services are provided on the same day, the daily maximum applies once for each provider type.
If the worker is treated for 2 separate claims with different allowed conditions on the same date, the daily maximum will apply for each claim.
If part of the visit is for a condition unrelated to an accepted claim and part is for the accepted condition, therapists must apportion their usual and customary charges equally between the insurer and the other payer based on the level of service provided during the visit. In this case, separate chart notes for the accepted condition should be sent to the insurer since the employer doesn‘t have the right to see information about an unrelated condition.
The daily maximum allowable fee doesn‘t apply to:
* Performance based physical capacities examinations (PCEs),
* Work hardening services,
* Work evaluations or
* Job modification/prejob accommodation consultation services.
Billing and Coding Guidelines
Comment: Several commenters suggested that CPT code 64550 (application of surface neurostimulator) is not an operative/postoperative code and that it may be used for the initial instruction and issuing of a TENS unit for
Response: CPT 64550 is in the surgery section of the CPT manual. The LCD advises that when one-to-one patient teaching is provided, to ensure safe, effective use of a home TENS unit, the timed code 97032 better reflects the 1:1 nature when providing this skilled service.
CPT Codes 64550, 90901, 92520, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 95992, 96105, 96110, 96111, 97532, 97597, 97598, 97602, 97605, 97606 and HCPCS Codes 0019T, 0183T
These codes sometimes represent therapy services, as described below:
* They always represent therapy services (limited when limits are in effect) and require therapy modifiers when the service is: • Performed by or, where allowed, under the supervision of therapists; or • Furnished by other qualified personnel and the service provided is integral to an outpatient rehabilitation therapy POC; and * They do not represent therapy services, and therapy limits (when in effect) will not apply when: • It is not appropriate to bill the services under a therapy POC; and • They are billed by practitioners (physicians, clinical nurse specialists, nurse practitioners, and psychologists) who are not therapists; or • They are billed to A/MACs by hospitals for outpatient services furnished by non-therapists.
Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.
1. Heat Treatment, Including the Use of Diathermy (CPT code 97024) and Ultra-Sound (CPT code 97035) for Pulmonary Conditions
2. There is no physiological rationale or valid scientific documentation of effectiveness of diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition and for such purpose this treatment cannot be considered reasonable and necessary within the meaning of §1862(a)(1) of the Act.
3. Electrical stimulation (HCPCS code G0283; CPT code 97032) is considered not reasonable and necessary and is excluded from Medicare coverage for the following:
a. motor nerve disorders such as Bell’s Palsy. (ICD-9 code 351.0)
b. TENS treatments and related services (i.e. CPT code 64550), furnished in physicians/NPP or therapist’s office. (See CMS Pub.100-2 Ch.16 §180, CMS Pub.100-3 §160.3)
c. Electrical Stimulation is not medically necessary for the treatment of strokes when there is no potential for restoration of function.
Improper Coding of Claims
We identified inappropriate claims for TENS services submitted by Totalcare with CPT code 64550. We referred these claims to United for review by its medical policy staff. Based on this review, United officials concluded that TotalCare performed regular, recurrent physical therapy services in an office setting. However, claims for these services were often submitted under code 64550 (the code normally used for TENS services). United further determined that TotalCare should have submitted such claims with a CPT code for physical therapy procedures, which generally correspond to payment rates that are considerably lower than the rates for TENS services (code 64550). This is consistent with information provided by the American Academy of Physical Medicine and Rehabilitation, which concluded that recurrent therapy, provided in an offi ce setting, should not be billed with the CPT code for TENS (code 64550).
As noted previously, CPT code 64550 is intended for the initial application of the TENS unit, and therefore, it generally should not be billed multiple times for the same patient. However, we found many instances where TotalCare billed code 64550 multiple times for individual patients without explanation of the need for the additional TENS sessions. In one instance, TotalCare billed that code 98 times for a patient within one year, with the payments totaling $4,880. In addition, we determined that United paid these claims because it did not have sufficient claims processing controls (for example, claims payment system edits) to limit the number of times code 64550 is allowed per patient.
As a non-participating provider in United’s Empire Plan provider network, TotalCare’s claims for physical therapy services are subject to considerable benefi t rate reductions. However, United did not apply these rate reductions because code 64550 does not correspond to physical therapy. If TotalCare billed appropriately for physical therapy services, United would have paid TotalCare up to $8 for each service claimed. Instead, United paid up to $100 for each service. As a result, United overpaid TotalCare $248,202 for 4,633 inappropriate claims for TENS services during our audit period.
United officials agreed with our audit findings, and they indicated that they have initiated actions to recover the overpayments made to TotalCare. In addition, United has taken steps to prevent such overpayments from occurring in the future. We also discussed our findings with the Departmentof Civil of Service (Department). Department officials likewise agreed with our findings and stated that United should have procedures to identify and deny multiple claims for TENS services (code 64550).