Eli's Rehab Report

Published on Mon Jan 16, 2006 PDF

Question: Our physician provided therapeutic exercises including recumbent bike for 18 minutes and stabilization, stretch and strengthening exercises with physioball for 33 minutes.  She also did neuromuscular re-education and proprioceptive work for whole-body balance on round board for eight minutes. We billed codes 97150 and CPT 97112 for separate services rendered, but the insurance company is only paying for 97150, stating that 97150 includes 97112. Is this true?


Missouri Subscriber


Answer: Yes, this is correct. The National Correct Coding Initiative (NCCI) considers 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) mutually exclusive to 97150 (Therapeutic procedure[s], group [2 or more individuals]). 

This edit does allow you to use a modifier to bypass it because 97150 is for group therapy and 97112 is for direct one-on-one therapy. To the payer, this code combination appears that the provider is potentially reporting the same services twice -- once in a group and once in direct care.

You aren't clear about whether your physiatrist performed the therapeutic exercises in a group setting or not. If your documentation shows that the two services were separate and distinct services -- the therapeutic exercises in a group setting and at a different session from when the therapist performed direct face-to-face neuromuscular re-education with the patient -- then you should apply a modifier 59 (Distinct procedural service) to 97112. This tells the payer that the two services were separate and distinct.

If the physiatrist performs these two services in a direct one-on-one setting with the patient, then you should report the therapeutic exercises using 97110 (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) rather than 97150. These two codes (97110 and 97112) do not carry any National Correct Coding Initiative (NCCI) edits.

FYI: Mutually exclusive codes represent those services that your physiatrist cannot reasonably perform during the same session. CMS bases mutually exclusive edits either on the CPT definition or the medical impossibility/improbability that the physician could perform the procedures at the same session.