Physical and Occupational Therapy: Extend Coding Know-how to Full Capacity

Note: This is part one of a two part series

By Shannon Sullivan, CPC, CMBS, William Pena, PT, DPT, CHCC, and Carl Petitto, OTR/L, CHCC

The Office of the Inspector General (OIG) announced in its 2009 Work Plan it will pay close attention to outpatient physical therapy services provided by independent therapists. For reimbursement, the OIG says all outpatient physical therapy services must be “reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member” A recommended reference for therapy services documentation requirements is Medicare Benefit Policy Manual, 100-2, chapter 15, sections 220 and 230.

To be considered reasonable and necessary, the services must meet Medicare guidelines. The guidelines for outpatient therapies coverage have the following basic requirements:

  • There must be an expectation that the patient’s condition will improve significantly in a reasonable (and generally predictable) time period.
  • If an individual’s expected rehabilitation potential would be insignificant compared to the extent and duration of therapy services required to achieve such potential, therapy would not be covered, as it is not considered rehabilitative or reasonable and necessary.
  • When there is limited restorative functioning potential, a safe and effective maintenance program requires skilled treatment—the unique skills of a therapist.
  • A therapy care plan is developed either by the physician or a non-physician practitioner (NPP), or by the physical therapist (PT) providing the physical therapy services. The plan must then be certified by a physician or NPP.
  • All provided services should be specific and effective treatments for the patient’s condition according to accepted medical practice standards; and the amount, frequency, and duration of the services must be reasonable.
  •  The provided services must meet the description of skilled therapy that follows.

Services not requiring a therapist’s professional skills are not medically necessary. The skills of a therapist may also be furnished by a trained and experienced physician, NPP, physical therapy assistant (PTA), or occupational therapy assistant (OTA) when appropriately supervised by a therapist. If a patient’s therapy can proceed safely and effectively through a home exercise program, self management program, restorative nursing program, or caregiver assisted program, payment cannot be made for therapy services.

Consider the following points when determining if a service is skilled.

  • Rehabilitative therapy occurs when a therapist’s skills (as defined by each state’s scope of practice for therapists) are necessary to safely and effectively furnish a recognized therapy service, whose goal is improving impairment or functional limitation.
  • The services should be at a level of complexity and sophistication, or the patient’s condition should be such, that a qualified clinician or a therapist’s supervising assistant is required. Services not requiring a therapist’s skills are not considered reasonable or necessary therapy services, even if they are performed or supervised by a therapist, a physician, or an NPP.
  • While a beneficiary’s medical condition is a valid factor when deciding if skilled therapy services are necessary, a beneficiary’s diagnosis or prognosis should never be the sole factor determining if a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the service(s) can be carried out by non-skilled personnel.
  • For therapy coverage, the patient must require a therapist’s skills to realize improved function. For example, therapy may not be covered for a fully functional patient who developed temporary weakness from a brief bed rest period following abdominal surgery. As discomfort reduces and the patient gradually resumes daily activities, function will return without skilled therapy intervention.
  • If at any point the treatment is determined as not rehabilitative, or becomes repetitive and does not require a therapist’s skills, the services are non-covered.
  • There may be circumstances where the patient – with or without the assistance of an aide or other caregiver – does activities planned by a clinician. Although these activities may support the patient’s treatment, if they can be done by the patient, aides, or other caregivers without qualified personnel’s active participation, they are considered unskilled.
  • If a patient’s ability to comprehend instructions, follow directions, or remember skills that are necessary to achieve an increase in function is so limited that functional improvement is very unlikely, rehabilitative therapy is not required and not covered. Limited services in these circumstances may be covered with supportive documentation, however, if a therapist’s skills are required to establish and teach a caregiver a safety or maintenance program.
    •  This does not apply to limited situations where rehabilitative therapy is reasonable and achieving meaningful goals is appropriate even when a patient does not have the ability to comprehend instructions, follow directions or remember skills. Examples include sitting and standing balance activities that help a patient sit upright in a seat or wheelchair or safely transferring from the wheelchair to a toilet.
    • This also does not apply to patients who can potentially recover the abilities to remember or follow directions. Treatment may be aimed at rehabilitating these abilities, such as following a traumatic brain injury.

Coding Accuracy

Examine many factors to ensure coding accuracy. For example, when looking at physical therapy documentation, glean specific information such as the primary medical diagnosis closest to the current therapy care plan, clinical findings, extent of function loss, and the patient’s overall health status. Check to see if the provider enters the diagnosis representing the most intensive services—over 50 percent of the rehabilitation effort for the revenue code billed. Don’t forget a second diagnosis—the treatment diagnosis, which indicates why rehabilitative services were furnished. For example, cerebrovascular accident (CVA) may be the primary diagnosis while hemiplegia might be the treatment diagnosis.

These CMS assumptions were used to construct billing scenarios regarding Part B therapy services. The requirements are necessary pre-conditions to the following information and are part of the service delivery framework that CMS assumes is in place when Part B therapy services are delivered:

  • PTs and OTs and their therapy assistants—PTAs and OTAs—meet Medicare personnel qualifications.
  • All provided therapy services are skilled and medically necessary and are appropriate to each patient’s care plan.
  • Therapists can enroll in Medicare as PT or OT service providers, but therapy assistants cannot. The therapy assistant’s services are billed through the enrolled therapist or other therapy provider.
  • The therapist should report the time the therapy assistant provides care, whether it is one-on-one care or delivered via the untimed codes, such as supervised modalities or group therapy.
  • All Medicare rules are met with respect to supervision requirements for therapy assistants in their respective settings. For example: (1) direct “in the office suite” supervision in private practice PT or OT therapy settings; and (2) general supervision in the following settings: outpatient prospective system (OPPS), skilled nurse facility (SNF), comprehensive outpatient rehabilitation facilities (CORF), rehab agency and the home health agency (HHA).
  • Each therapist’s supervision of therapy assistant(s) is in compliance with all state laws and regulations and with local medical review policies.

Untimed CPT® Codes

When a therapy treatment modality or procedure is not defined in the American Medical Association’s (AMA’s) CPT® manual by a specific time frame, such as “each 15 minutes,” the modality or procedure is considered an untimed service. Untimed services are billed based on the number of times the procedure is performed, per day. Untimed services billed as more than one unit will require significant documentation to justify treatment greater than one session per day per therapy discipline. See the CPT® section including 97001 and 97003 for additional guidance on billing for evaluations spanning more than one day. The minutes spent providing untimed services are reflected in the documentation under “Total Treatment Time” and are not included in the minutes for timed CPT® codes when determining the number of timed-based units that may be billed.

Timed CPT® Codes

Many CPT® codes for therapy modalities and procedures specify that direct (one-on-one) time spent in patient contact is 15 minutes. The time counted is the time the patient is treated using skilled therapy modalities and procedures, and is recorded in the documentation as “timed code treatment minutes.” Pre- and post-delivery services are not counted when recording the treatment time. The time counted is the “intra-service” care beginning when the personnel are directly working with the patient to deliver the service. The patient should already be in the treatment area (eg, on the treatment table, or in the gym) and prepared to begin treatment. The intra-service care includes assessment. The time the patient spends not being treated due to toileting or resting should not be counted. The time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. Time spent supervising a patient performing an activity defined as a timed code or for the patient to perform an independent activity, even if a therapist is providing the equipment, isn’t considered billable time and these minutes should not be counted in the timed code treatment minutes. Therapy timed services require direct, one-on-one patient qualified personnel contact, and by definition cannot be billed when performed in a supervised manner.

The first step when billing timed CPT® codes is to total the minutes for all timed modalities and procedures provided to the patient on a single service date for a single discipline. For example, a patient under an OT care plan receives skilled treatment consisting of 20 minutes of therapeutic exercise (97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) and 20 minutes of self-care/home management training (97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes). The total timed code treatment minutes documented will be 40 minutes. The combined time of 40 minutes will determine the total number of timed code OT units that should be billed for the day. Whether a single timed code service or multiple timed code services is provided, the skilled minutes documented in timed code treatment minutes will determine units billed.

After the minutes are summed, use the chart that follows to determine the total allowable units, based on the total timed code treatment minutes.

1 unit > 8 minutes through 22 minutes

2 units > 23 minutes through 37 minutes

3 units > 38 minutes through 52 minutes

4 units > 53 minutes through 67 minutes

5 units > 68 minutes through 82 minutes

6 units > 83 minutes through 97 minutes

7 units > 98 minutes through 112 minutes

8 units > 113 minutes through 127 minutes

When the total timed code treatment minutes for the day is less than 8 minutes, the service(s) should not be billed. Allocate the timed services’ total billable units to the appropriate CPT® codes based on the minutes spent providing each individual service.

Example 1: A CVA patient receives skilled treatment consisting of 15 minutes of therapeutic exercise (97110) and 15 minutes of gait training (97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)). The total timed code treatment minutes documented will be 30 minutes. One unit of 97110 and one unit of 97116 should be billed.

Example 2: A patient suffering from rotator cuff tendinitis receives 15 minutes of electrical stimulation, 15 minutes of manual therapy. The timed code treatment minutes documented will be 15 minutes and total treatment time for this session is 30 minutes. One unit of electrical stimulation (97014 Application of a modality to one or more areas; electrical stimulation (unattended) or G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care—depending on insurance) and one unit of  97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes should be billed.

As a professional coder, you must examine many factors to ensure coding accuracy. For example, when looking at physical therapy documentation, glean specific information, such as the primary medical diagnosis that relates the closest to the current therapy care plan, clinical findings, extent of function loss, and the patient’s overall health status.

Individual Treatment

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 a therapist’s presence (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. Any time the therapist attends one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist. Therapy services payment is based on the qualified professional/auxiliary personnel’s time spent in treating the individual patient. For this reason, in the same time period (such as from 1 to 1:15) a clinician cannot bill any of the following CPT® codes for therapy services provided to the same, or to different, patients:

  • Any two CPT® codes for therapeutic procedures requiring direct one-on-one patient contact (97110-97762).
  • Any two CPT® codes for modalities requiring constant attendance and direct one-on-one patient contact (97032-97039).
  • Any two CPT® codes requiring either constant attendance or direct one-on-one patient contact as described in (a) or (b) above (97032-977622): for example, any code for a therapeutic procedure (eg, 97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)) with any attended modality code (eg, 97035 Application of a modality to one or more areas; ultrasound, each 15 minutes).
  • Any CPT® code for therapeutic procedures requiring direct one-on-one patient contact (97110-97762) with the group therapy code (97150 Therapeutic procedure(s), group (2 or more individuals)) requiring constant attendance; for example, group therapy (97150) with neuromuscular reeducation (97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities).
  • Any CPT® code for modalities requiring constant attendance (97032-97039) with the group therapy code (97150); for example, group therapy (97150) with ultrasound (97035).
  • Any untimed evaluation or reevaluation code (97001-97004) with any other timed or untimed CPT® codes, including constant attendance modalities (97032-97039), therapeutic procedures (97110-97762) and group therapy (97150).

There is more to come on physical and occupational therapy. In a future article, we’ll discuss coding differences in group therapy and individual therapy, documentation guidelines, and what constitutes as unauthorized personnel providing outpatient therapy services.

Shannon Sullivan, CPC, CMBS, holds a Bachelor’s degree in business management and is a managing owner of Atlantic Billing and Coding, LLC. She is also a member of the Medicare Outreach and Education Board and is the local chapter education coordinator for the Northern New York Region.

William Pena, PT, DPT, CHCC, holds a Doctorate in physical therapy and is an owner of a private practice, continuing patient treatment in a variety of settings. He is also an owner and manager of Atlantic Billing and Coding, LLC, and is a certified health care compliance consultant.

Carl Petitto, OTR/L, CHCC, holds a Bachelor’s degree in occupational therapy, health and human services. Carl is an owner of a private practice, continuing patient treatment in a variety of settings. He is also an owner and manager of Atlantic Billing and Coding, LLC, and is a certified health care compliance consultant. He earned a commission in the U.S. Army Reserve as an occupational therapist. After serving 13 years of combined active duty and reserve Navy and Army service, Carl has been honorably discharged from military service.

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