Build Up Physical and Occupational Therapy Know-how

Build Up Physical and Occupational Therapy Know-how

Reaffirm your knowledge of ICD-10-CM codes and the more specific E/M PT/OT codes introduced in 2017.

Coding for physical and occupational therapy (PT and OT) requires an understanding of ICD-10-CM guidelines, and a firm knowledge on how to bill units of timed and untimed therapy CPT® codes.

ICD-10 Considerations

In therapy encounters, there is often more than one diagnosis in the treatment record or order. The primary diagnosis is the patient’s medical diagnosis such as a cerebrovascular accident (I63.9) or complete rotator cuff tear of the right shoulder (M75.121). The additional diagnoses, often referred to as the therapy diagnoses, are the conditions causing the patient to seek therapy. A therapy diagnosis may be an impairment, activity limitation, or disability such as dysphasia (R47.02) or difficulty walking (R26.2).
Always code to the greatest level of specificity based on the documentation provided. Claims can be denied for using unspecified or incorrect diagnosis codes.

Select an Appropriate Seventh Digit

Due to the nature of conditions and injuries that therapists treat, the seventh character definitions A (initial encounter), D (subsequent encounter), and S (sequela) frequently apply. The ICD-10 definition for initial encounter is not based on whether the provider is seeing the patient for the first time. When selecting the seventh character:
Use A while the patient receives active treatment for the condition. Examples of active treatment are: surgical treatment, an emergency department encounter, or evaluation and continuing treatment by the same or a different physician.
Use D for encounters after the patient has received active treatment for the condition and while receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an X-ray to check healing status of fracture, removal of an external or internal fixation device, medication adjustment, or other aftercare and follow-up visits following treatment of the injury or condition.
Use S for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using the seventh character S, include both the injury code that precipitated the sequela and the code for the sequela, itself. Add the S to the injury code, only — not the sequela code. The seventh character S identifies the injury responsible for the sequela. The specific type of sequela (e.g., scar) is sequenced first, followed by the injury code.
For example:
Susan is involved in a small kitchen fire while cooking at home and sustains a third-degree burn to her inner-left elbow. During healing, she develops a keloid scar.
L90.5     Scar conditions and fibrosis of skin
T22.322S          Burn of third degree of left elbow, sequela
X02.0XXS          Exposure to flames in controlled fire in building or structure, sequela
Jim tore his peripheral medial meniscus when he fell while paying basketball with his son. Following orthopedic treatment for his injury, Jim presents to PT for chronic residual instability in the joint.
M25.361          Other instability, right knee
S83.221S          Peripheral tear of medial meniscus, current injury, right knee, sequela
W01.0XXS        Fall on same level from slipping, tripping and stumbling without subsequent striking against object, sequela
Y93.67   Activity, basketball

Procedural Coding

CPT® coding for therapy consists of codes for evaluations, re-evaluations, and treatment. CPT® introduced new therapy evaluation and re-evaluation codes effective Jan. 1, 2017.
CPT® code descriptors for PT and OT evaluative procedures include specific components required for reporting, as well as the corresponding typical face-to-face times for each service. These evaluation codes require assigning a low-, moderate-, or high-complexity level to the therapy evaluation.
Each of the following components, noted in the code descriptors, must be documented to report the selected level of PT evaluation:

  • History
  • Examination
  • Clinical decision-making
  • Development of care plan

For PT re-evaluations based on an established and ongoing care plan, per CPT® use 97164 Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family. The American Physical Therapy Association (APTA) provides Table A for additional guidance when selecting an evaluation level.
Table A

Physical Therapy Evaluation Reference Table
CPT® Code 97161 97162 97163
Required Components (all are required in selecting evaluation level)
No personal factors and/or comorbidities X
1-2 personal factors and/or comorbidities X
3 or more personal factors and/or comorbidities X
Examination of body system(s) (elements include body structures and functions, activity limitations, and/or participation restrictions)
Addressing 1-2 elements X
Addressing a total of 3 or more elements X
Addressing a total of 4 or more elements X
Clinical Presentation
Stable X
Evolving X
Unstable X
Clinical Decision Making (complexity)
Low Moderate High
Development of Plan of Care
Additional Guiding Factors
Coordination, consultation, and collaboration of care with physicians, other qualified healthcare professional, or agencies is provided consistent with the nature of the problem(s) and the needs of the patient family, and/or other caregivers.
Typical Face-to-Face Time (minutes) 20 30 45
Table A copyright the American Physical Therapy Association

Each of the following components, noted in the code descriptors, must be documented to report the selected level of OT evaluation:

  • Occupational profile and client history (medical and therapy)
  • Assessments of occupational performance
  • Clinical decision-making
  • Development of plan of care

For OT re-evaluations based on an established and ongoing plan of care, per CPT® use 97168 Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.
Additional guidance on the components that must be done and documented during an occupational therapy evaluation is detailed in the February 2017 CPT® Assistant:
Occupational Profile
The occupational profile provides an understanding of the patient’s occupational history and experiences, and patterns of daily living, interests, values, and needs. The patient’s problems and concerns about performing occupational work (eg, activities of daily living [ADLs]) are identified as part of the profile. The patient’s presenting problem(s), the reason(s) for referral, and the patient’s goal(s) are also determined.
Assessments of Occupational Performance
The second component that must be considered in determining the level of the evaluation service is related to both the assessment and identification of occupational performance deficits. Performance deficits are defined as activity limitations and/or participation restrictions that result from skills deficits. In the code descriptor, “performance deficits” refer to occupations in which the client is experiencing problems. Occupations are defined in the OT Framework’s Table 1, Occupations [See]. This linkage between performance and skills deficits supports the emphasis of occupational therapy on occupational performance.
Clinical Decision-making
The third component that must be considered in determining the level of the evaluation service is clinical decision making. Although a separate component, clinical decision making occurs throughout the evaluation process. Table B outlines the three levels of complexity for clinical decision making based on the definitions of the CPT code descriptors.
Table B Levels of Complexity for Clinical Decision-making

CPT® Code/Level Clinical Decision-making
Low complexity (97165) Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.
Moderate complexity (97166) Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable completion of evaluation component.
High complexity (97167) Clinical decision making of high analytic complexity, which includes an analysis of the occupational profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient may present with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.

Regarding therapy treatments, there are procedure- or service-based codes and time-based codes. The procedure- or service-based codes are billed as one unit of service, regardless of the time spent on treatment. These codes do not require direct (one-on-one) patient contact. Examples include:
97010    Application of a modality to 1 or more areas; hot or cold packs
97012              mechanical traction
97014              electrical stimulation (unattended)
97022              whirlpool
Time-based therapy codes require the provider to have direct contact with the patient, and are reported once for each 15 minutes of service. One-on-one contact is defined as “the provider is required to maintain visual, verbal, and/or manual contact with the patient.”
The therapy treatment documentation must include the total number of minutes spent treating the patient for each modality or the beginning and end times of each treatment. At least eight minutes of therapy must be performed to charge for one unit of any of the time-based codes.
Per CPT® Assistant, multiple units can be reported per date of service for one or more procedures based on the summed total amount of time spent in direct contact with the patient while performing that therapy treatment.
Example: At 8 a.m. the therapist provides seven minutes of treatment described by code 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility; at 8:15 a.m. the therapist provides 23 minutes of treatment described by code 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities; and at 8:45 a.m. the therapist provides another eight minutes of treatment described by code 97110.
The total of time for 97110 was 15 minutes; therefore, one unit can be charged.
Per the Centers from Medicare & Medicaid Services (CMS), a provider cannot bill units totaling more time than the actual overall time spent treating the patient. If more than one CPT® code is billed during a day, the total number of units that can be billed are constrained by the total treatment time spent with the patient.
Example: If 24 minutes of code 97112 and 23 minutes of code 97110 were furnished, the total treatment time was 47 minutes; a maximum of three total units can be billed. The correct coding is two units of code 97112 and one unit of code 97110 (assign more units to the service that took the most time).
For more information on procedural coding in 2017, read the article “Track Therapy Care with New Evaluation Codes” on AAPC’s Knowledge Center:

Four Codes Represent Core Modalities

Four of the most common PT/OT treatment modalities are represented by CPT® codes 97110, 97112, 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes, and 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. These codes are sometimes referred to as therapy’s “Core Four:”
Examples of 97110 include treadmill (for endurance), isokinetic exercise (for range of motion), lumbar stabilization exercises (for flexibility), and gymnastic ball (for stretching or strengthening).
Examples of 97112 include proprioceptive neuromuscular facilitation, Feldenkreis, Bobath, BABS boards, and desensitization techniques.
Code 97140 reports the provision of manual (soft tissue and joint) therapy techniques for treatment of symptoms and impairments that might include limited range of motion, muscle spasm, pain, tissue adherence or contracted tissue and/or soft tissue swelling, inflammation, or other cause of soft tissue or joint restriction. As the code descriptor states, “manual” therapy requires providers to use their hands to provide these techniques. Manual therapy techniques may include soft tissue mobilization, joint mobilization and manipulation, manual lymphatic drainage, manual traction, craniosacral therapy, myofascial release, or neural gliding techniques.
Examples of 97530 include lifting stations, closed kinetic chain activity, hand assembly activity, transfers (chair to bed, lying to sitting, etc.), and throwing, catching, or swinging.
Review these examples, which include the Core Four:
Example 1: A breast cancer patient presents with lymphedema of the bilateral upper extremities. The physical therapist performs manual lymph drainage. The treatment starts centrally in the neck and trunk to clear out the main lymphatic pathways. Following this, the extremities are treated in segments: First, the proximal aspect of each extremity is decongested, followed by the distal aspect. The total treatment time is 45 minutes. Proper coding is 97140 x 3.
Example 2: Bob presents to PT status post right knee replacement. The therapist initiates a therapeutic exercise program using a stationary bike to increase right knee flexion. Direct one-on-one contact with the patient is required to instruct the patient in gentle range of motion exercises using pedal rocks. Pre-treatment right knee flexion is 55 degrees and post treatment is 60 degrees. The total treatment time is 30 minutes. Report 97110 x 2.
Example 3: John presents to OT status right CVA with subsequent left hemiparesis and decreased fine motor coordination. He is left hand dominant. John works full time as a line repair technician. This requires him to manipulate nuts and bolts and use various tools to repair machinery. The occupational therapist has him perform tasks to improve his fine motor coordination and in-hand manipulation consisting of: connecting and disconnecting nuts and bolts, sustained overhead reaching while performing nuts and bolts task (gross and fine motor coordination), in-hand manipulation with translation to tip pinch using marbles (for prehension improvement), and grooved pegboard task (timed to assess difference between left and right hands). The therapist works with John for 60 minutes. Report 97530 x 4.
Example 4: Janet presents to PT for dizziness due to vestibular dysfunction caused by a head injury. The physical therapist works with Janet for 20 minutes on vestibular ocular reflex exercises. The patient rests for five minutes. The therapist works with Janet for 25 minutes on single limb stance exercises and bird dip exercises. Report 97112 x 3.

CPT® Assistant February 2017 / Volume 27 Issue 2, New Occupational Therapy Evaluation Codes:

Jennifer Comstock
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About Has 2 Posts

Jennifer Comstock, CPC, began her medical billing career sorting payments and taking routing calls for a billing company. She went on to customer service, follow up and denials, accounts receivable, and finally coding. Comstock now works on claim edits and denials, and assists with audits. She is a member of the Allentown, Pa., local chapter.

No Responses to “Build Up Physical and Occupational Therapy Know-how”

  1. Menaka says:

    I have doubt regarding cast complication when a patient arrives hospital due to cast discomfort that created pain/ swelling/ in case too tight/loose after 2-3 days of closed reduction of radius fracture, what encounter do we use for the visit- initial or subsequent?
    Can we apply the below concept? . please help
    For complication codes, active treatment refers to treatment for thecondition described by the code, even though it may be related to an
    earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis,
    initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device,
    implant or graft that was placed at a previous encounter.7th character “A”, initial encounter is used for each encounter where the
    patient is receiving active treatment for the condition.

  2. shawn says:

    We’re getting denial of payment for CPT 97140, when billed with 97110. Is there anyway to avoid this?