CPT CODE, DESCRIPTION AND FEE amount
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 - Average Fee amount -$40
97761 - Prosthetic training, upper and/or lower extremity(s), each 15 minutes - Average Fee amount - $35
97762 - Checkout for orthotic/prosthetic use, established patient, each 15 minutes - Average Fee amount - $48
Some of the policies implemented in this notification were 1) discussed in the CY 2006 OPPS final rule, or 2) discussed in the CY 2006 MPFS final rule or reflected in its Addendum B. Other policies contained in this notification correct or clarify our previous policy noted in Transmittal 515, CR 3647, issued April 1, 2005 in Pub. 100-04. This CR updates the therapy code list and associated policies for CY 2006, as follows:
1) “Orthotic Management and Prosthetic Management” Services.
In order to create a new category under the section for physical medicine and rehabilitation services, HCPCS/CPT modified the descriptor of one of these codes, CPT 97504 (2005), and renumbered it as well as two other HCPCS/CPT codes. The new therapy code list removes the CY 2005 CPT codes, 97504, 97520 and 97703 and replaces them with CPT codes 97760, 97761 and 97762, respectively, for use in CY 2006.
Constant Attendance Modalities (97010-97039), Therapeutic Procedures (97110-97542), Orthotic Management (97760, 97762), and the unlisted Physical Medicine code (97799) will be limited to a maximum 4 therapeutic modalities per treatment session, not to exceed one hour (4 units) for the combinations of codes submitted.
Generally, CPT code 97116 should not be reported with 97760. However, if a service represented by code 97760 was performed on an upper extremity and a service represented by code 97116© (gait training) was also performed, both codes may be billed with modifier 59 to denote separate anatomic sites.
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
The “Rule of Eight” reporting requirements described in the policy section below apply to all of the 15 minute time-based codes listed above under Modalities, Therapeutic Procedures, Tests and
Measurements, and Orthotic Management and Prosthetic Management. However, this policy focuses
on Constant Attendance Modalities and Therapeutic Procedures
I. “Rule of Eight”
The Health Plan has adopted The Centers for Medicare & Medicaid Services (CMS) reporting guidelines for determining the appropriate number of units to report with respect to physical medicine CPT codes that are subject to a 15-minute time component. The Health Plan refers to this guideline as the “Rule of Eight.”
The “Rule of Eight” addresses the relationship between the direct (one-on-one) time spent with the patient, and the billing and reimbursement of a unit of service. According to the “Rule of Eight”, the provider must spend more than one-half (8 minutes or more) of a given 15-minute time component with the patient in order to properly submit that unit to the Health Plan for reimbursement
II. Reporting Guidelines
The Health Plan requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the performance of procedures that are reported to Health Plan as direct treatment services.
• The time reported should be the time actually spent in the delivery of the modality and/or therapeutic procedure. This means that pre and post-delivery services should not be counted in determining the treatment time.
• The time that the patient spends not being treated, due to resting periods or waiting for a piece of equipment to become available, is not considered treatment time.
• All treatment time, including the beginning and ending time of the direct treatment, must be recorded in the patient’s medical record, along with the note describing the specific modality or procedure.
III. Determining Units
A. A provider should not report a direct treatment service if only one attended modality or therapeutic procedure is provided in a day, and the procedure is performed for less than 8 minutes.
B. A single 15-minute unit of direct treatment service may be billed when the duration of direct treatment is equal to or greater than 8 minutes, and less than 23 minutes. If the duration of a single modality or procedure is between 23 minutes but less than 38 minutes, then two 15-minute units of direct treatment service may be billed.
The following table indicates the appropriate protocol for reporting each additional unit:
Number of units billed: Number of minutes provided in treatment:
1 unit 8 minutes to < 23 minutes
2 units 23 minutes to < 38 minutes
3 units 38 minutes to < 53 minutes
4 units 53 minutes to < 68 minutes
5 units 68 minutes to < 83 minutes
6 units 83 minutes to < 98 minutes
7 units 98 minutes to < 113 minutes
8 units 113 minutes to < 128 minutes*
TMJ Orthotic Adjustments
Adjustments for TMJ orthotics are normally billed under CPT codes 97760 or 97762. These services are not separately covered with a TMJ diagnosis. These adjustments are considered an integral part of the splint therapy and as such will be denied regardless if billed alone or with another service.
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