Divide PT and OT Services into Two Categories
By Kim Cohee, PT, MS, MBA, DPT, OCS
Physical therapy (PT) and occupational therapy (OT) service modalities are divided into two categories: “supervised” and “constant attendance.” Modalities are typically defined as physical agents intended to effect therapeutic changes (using thermal, acoustic, mechanical, or electric energy). To report these services properly, you must understand the difference between the two types of modalities, as well as the specific requirements for each applicable CPT® code.
Supervised modalities may be billed one unit per date of service. Supervised modalities require neither direct, one-on-one provider-to-patient contact, nor constant supervision. Several of the most familiar supervised modalities include:
97010 Application of a modality to 1 or more areas; hot or cold packs
A hot or cold pack often is used in the beginning or end of a therapy treatment to address pain related to a surgery, injury, or overuse condition. Be sure to document the reason for treatment, the treatment location, and the treatment time in minutes. Medicare designates 97010 as a Status B code, meaning it is always bundled to other provided services. Medicare does not reimburse this code, but other insurers might.
97012 Application of a modality to 1 or more areas; traction, mechanical
Mechanical traction includes cervical and lumbo-pelvic traction. The patient is typically harnessed into a device that applies a distracting force intended to unload a patient’s spinal column. Common diagnoses for traction include cervical and lumbar radiculopathies or disc pathologies. The length of treatment in minutes, the location of treatment, and the traction parameters used must be documented.
97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
Electrical stimulation (unattended) includes Russian, high-volt pulsed galvanic (HVPG), and transcutaneous electrical nerve stimulation (TENS). Therapists use unattended electrical stimulation to alleviate pain as well as to re-train muscles inhibited due to swelling, pain, and immobilization. Common diagnoses would be post surgical conditions such as anterior cruciate ligament (ACL) reconstruction and rotator cuff repair.
Code 97014 is a Status I code; meaning, it is not valid for Medicare. Rather, the Medicare code for unattended electrical stimulation without wound care is G0283 Electrical stimulation (unattended), to one or more areas, for indication(s) other than wound care as part of a therapy plan of care. Documentation is the same as for manual electrical stimulation (see below in the Constant Attendance section); electrode placement also should be outlined in the unattended treatment.
97016 Application of a modality to 1 or more areas; vasopneumatic devices
Vasopneumatic device describes a sleeve placed over a swollen limb, such as an ankle, knee, or an upper extremity. The sleeve intermittently fills with air, creating a brief compressive force, with the goal to reduce effusion or edema related to injury or surgery when appropriate. This modality is also useful in treating lymphedema when using a lymphedema-specific pump. Documentation should include the parameters with which the device was set to compress and release pressure and the total treatment time. One example of this type of pump is the Jobst pump, but other manufacturers make similar devices.
97018 Application of a modality to 1 or more areas; paraffin bath
Paraffin bath is typically for pain relief in the hands and feet, and uses superficial heat to reduce discomfort in conditions such as arthritis. This service is often provided initially for patient training for use of home devices. It is important to provide documentation regarding medical necessity of this intervention, and why it requires the unique skills of an occupational or physical therapist.
97022 Application of a modality to 1 or more areas; whirlpool
This code includes both wet and dry whirlpools. The modality is intended to decrease pain and muscle spasm, to increase circulation to an injured area (such as the hand, ankle, or wrist), or to clean a wound. Documentation should include the water temperature, the area being treated and time in the water, the type of dressing applied, and any chemicals added to the water.
97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes
Larger whirlpools, called Hubbard tanks, can be used for the full body, when necessary. This service is reported using 97036. Note that this service requires constant attendance.
Coding for Supervised Services
Clinical Example 1: Patient presents with a diagnosis of right ankle sprain. The therapist chooses to use a Jobst pump for 10 minutes, followed by manual therapy (15 minutes) and therapeutic exercise (15 minutes) for range of motion while in a cold whirlpool. Total treatment time is 40 minutes. Total timed treatment, however, is 30 minutes because only one unit per session can be charged for an unattended modality (and does not include the untimed code time, which is constant attendance, explained below). You should still record the time for the treatment, however. Thirty minutes equals two units of timed treatment, within the time frame of ≥23 minutes to ≤38 minutes.
The therapist cannot bill both the whirlpool and the therapeutic exercise because they are being performed at the same time. One unit of vasopneumatic device, one unit of therapeutic exercise, and one unit of manual therapy are billable, according to the Centers for Medicare & Medicaid Services (CMS) “eight-minute rule.”
Documentation should include the patient’s position (patient is supine with ankle elevated on bolster), Jobst sleeve placement, compression on and off times (compression for 30 seconds, release for 30 seconds), and total time (10 minutes). Manual therapy should include descriptions of the treatment type (such as grade III joint mobilization), location (right talocrural joint), and for how long.
The constant attendance modality is billed in 15-minute increments and requires direct, one-on-one provider-to-patient contact. Such treatments may be billed in multiple units. Examples include:
97032 Application of modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
Electrical stimulation (manual) may involve treatment using a handheld unit for a condition such as Bell’s palsy, which affects nerves in the face (note that per National Coverage Determination (NCD) 100-03, section 160.15, Medicare does not cover electrical stimulation for Bell’s palsy). TENS placement for the purpose of showing a patient how to use the unit also may be billed with 97032. Documentation should include specifically where the therapist applies the stimulation on the body, treatment time, on and off time if intermittent, intensity/frequency, and patient instructions.
97033 Application of modality to 1 or more areas; iontophoresis, each 15 minutes
Iontophoresis is the use of an electric current to introduce medication into the tissues to reduce pain and edema. The most common medication is dexamethasone—a controlled substance. A physician must write the prescription because therapists are not licensed to distribute controlled substances. The patient gets the medication at the pharmacy and brings it to the therapy visit. The therapist may use the medication as prescribed by the doctor.
Common diagnoses for which iontophoresis is prescribed may include tendonitis, tendonopathies, and bursitis. This is also a constant-attendance modality, but you can’t bill for the unit’s run time because only one-on-one time with the patient may be billed, and the therapist does not supervise the patient throughout the entire treatment. The total billable time includes only the time spent educating patients about the treatment, prepping them for the treatment, set-up time, and skin check before and after the running of the unit.
97035 Application of modality to 1 or more areas; ultrasound, each 15 minutes
Ultrasound uses high-frequency sound waves to decrease pain, muscle spasm, and joint stiffness with the intention of increasing flexibility. The scientific evidence supporting the efficacy of ultrasound for this purpose is in question, according to the medical evidence using randomized controlled trials. Documentation for ultrasound ideally includes the size of the used ultrasound head, length of treatment time, continuous versus pulsed, intensity, depth of penetration (1 or 3 MHz), and the medication name if doing phonophoresis.
Coding for Constant Attendance Services
Clinical Example 2: A patient is being treated for biceps tendonitis and is experiencing shoulder pain, swelling, and stiffness. The therapist chooses to treat the patient initially with iontophoresis with passive range of motion and postural re-education. A possible billing scenario may be 15 minutes of passive shoulder range of motion, followed by 12 minutes of postural training with exercise instruction, and ending with iontophoresis consisting of five minutes of setup and explanation to the patient, as well as 12 minutes of run time.
The total treatment time is 44 minutes, but based on Medicare’s eight-minute rule, only 32 minutes are billable. The therapist should bill for one unit of therapeutic exercise (97110) and one unit of neuromuscular re-education (97112). Per Medicare rules, the iontophoresis is not billable because the setup time is not equal to or greater than eight minutes (even though the run time is).
If the therapist spends 20 minutes on posture re-education, you may bill for two units of neuromuscular re-education and one unit of therapeutic exercise. Because the total timed treatment exceeds 38 minutes, the therapist can bill Medicare three units for 40 minutes (including the five minutes of iontophoresis setup) of total timed treatment.
Documentation for this example needs to include the names of any exercises performed, number of sets and reps, amount of resistance used, position of the patient during each exercise, goal of each exercise, caregiver training and education, and time spent doing the exercises. The iontophoresis documentation should include the name of the medication used, total dose used and the time period, where the electrodes were placed, and the length of the treatment.
Remember: The above example is based on the CMS’ eight-minute rule, which may not apply in all cases. Coders should be aware of individual insurance practices regarding therapy billing (iontophoresis is a Status A code for Medicare, and may be paid depending on your payer’s local coverage determination (LCD)).
Reimbursement for all of the services mentioned here can vary greatly from payer to payer, and from state to state. Knowing your local policies is critical to getting paid for the care given by providers. On a final note, all modalities should include documentation regarding patient response to treatment.
Kim Cohee, PT, MS, MBA, DPT, OCS, is the manager of the University of Utah Orthopaedic Center Therapy Services. She graduated from the University of Utah with undergraduate and doctorate degrees in physical therapy and a Master of Science in Exercise Physiology. She received her Master of Business Administration from Western Governors University in 2009, and achieved Orthopedic Clinical Specialist (OCS) designation in 2006.