Billing and Coding: Outpatient Physical Therapy

Title XVIII of the Social Security Act, §1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, §30 Rules for Provision of Services and §30.1 Rules for Payment of CORF Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.1 Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Rehabilitation Therapy, or Speech-Language Pathology Services, §220.2 Reasonable and Necessary Outpatient Rehabilitation Therapy Services, §220.4 Functional Reporting, §230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology, §230.1 Practice of Physical Therapy, §230.4 Services Furnished by a Therapist in Private Practice (TPP)

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §160.2 Treatment of Motor Function Disorders with Electrical Nerve Stimulation, §160.12 Neuromuscular Electrical Stimulator (NMES), §160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell's Palsy)

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §230.8 Non-Implantable Pelvic Floor Electrical Stimulator, §270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for the Outpatient Physical Therapy L34428 LCD.

Electrical Stimulation (CPT^® code 97032 and HCPCS codes G0281 and G0283) and Electromagnetic Therapy (HCPCS code G0329)

NOTE: The coverage/non-coverage indications for Electrical Stimulation Therapy and Electromagnetic Therapy and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.1.

Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes (CPT^® code 97032)

Attended electrical stimulation requires direct (1-on-1) contact with the patient by the qualified professional/qualified personnel in providing electrical stimulation manually through the use of probes or other devices.

Types of electrical stimulation that may require constant attendance and direct 1-on-1 contact by the qualified professional/qualified personnel include but are not limited to:

• Direct motor point stimulation
• Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES)- if performed with therapeutic exercise, neuromuscular reeducation or functional activities, 97032 may be billed for the time the qualified professional/qualified personnel spends applying/instructing and adjusting the FES application, but 97110, 97112, or 97530 should not be billed during the same time period
• FES used for facilitating gait in patients with spinal cord injury (SCI)- Refer to CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §160.12
• Ultrasound with electrical stimulation provided concurrently should be billed as ultrasound (97035)- do not bill for both ultrasound and electrical stimulation for the same time period
• Determining trigger points associated with application of a transcutaneous electrical nerve stimulation (TENS) unit using a handheld probe, would be reported by 97032

The actual application of a TENS unit including the instruction in use and appropriate settings would be described by reporting 97032.

TENS is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under §1862(a)(1)(A) of the Social Security Act.

Non-Implantable Pelvic Floor Electrical Stimulators - CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §230.8 - provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Stimulation is generally delivered by vaginal or anal probes connected to an external pulse generator and may be billed as 97032.

Stimulation delivered via electrodes should be billed as G0283.

The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.

Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.

A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.

The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of PME training.

Utilization of electrical stimulation may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement. Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring).

Documentation must clearly support the medical necessity of electrical stimulation for more than 12 visits as adjunctive therapy or for muscle retraining. Typically, patients can be trained in the use of a home muscle stimulator for retraining weak muscles. Up to 2 visits should be necessary to complete the training. Once training is successfully completed, this procedure should not be billed as a treatment modality in the clinic, as the patient would be independent in application and use of the modality.

Non-covered Indications

• Electrical Stimulation (CPT^® code 97032) used in the treatment of facial nerve paralysis, commonly known as Bell’s palsy (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §160.15)
• Electrical Stimulation (CPT^® code 97032) used to treat motor function disorders such as multiple sclerosis (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §160.2)
• Electrical Stimulation (CPT^® code 97032) for the treatment of strokes when it is determined there is no potential for restoration of function
• Electrical Stimulation when it is an isolated intervention utilized purely for strengthening of a muscle with at least fair graded strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activities.

Supportive Documentation Recommendations for 97032

• Type of electrical stimulation used (in addition to the description specifying “manual” and “attended”)
• Area(s) being treated
• If used for muscle weakness, objective rating of strength and functional deficits
• If used for pain include pain rating, location of pain, effect of pain on function

Electrical stimulation (unattended), to 1 or more areas for indication(s) other than wound care, as part of a therapy plan of care. (HCPCS G0283) See 97032 for instructions in manual electrical stimulation.

Most non-wound care electrical stimulation treatment provided as part of a therapy plan of care should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/assistive personnel) without constant, direct contact required throughout the treatment. Code G0283 is classified as a “supervised” modality. A supervised modality does not require direct (1-on-1) patient contact by the provider. Typically, electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation.

Examples of unattended electrical stimulation modalities include, but are not limited to, Interferential Current (IFC), TENS, and cyclical muscle stimulation (Russian stimulation).

Utilization of electrical stimulation may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement.

Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring).

Documentation must clearly support the medical necessity of unattended electrical stimulation used for control of pain and swelling, with objective and/or subjective changes noted in swelling and/or pain within 12 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality. Typically, patients can be trained in the use of a TENS unit for self-management of their pain. Up to 2 visits should be necessary to complete the training. Once training is successfully completed, this procedure should not be billed as a treatment modality in the clinic, as the patient would be independent in application and use of the modality.

The cost of electrodes used with unattended electrical stimulation is included in the practice expense portion of G0283. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality.

Supportive Documentation Recommendations for G0283

• Type of electrical stimulation used (e.g., TENS, IFC)
• Area(s) being treated
• Objective/subjective measures of how treatment is impacting pain (intensity, location, impact on function) and/or swelling

Electromagnetic therapy, to 1 or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. (HCPCS G0329)

Electrical stimulation, (unattended), to 1 or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. (HCPCS Code G0281)

Note: CPT^® code 97014 is an invalid code on the Medicare fee schedule and should not be reported in the claim form. G0281 replaces code 97014, only where it applies to treatment of wounds, as defined in the code narrative.

Supportive Documentation Recommendations for G0281 and G0329

• Etiology and duration of wound
• Type of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatment
• Stage of wound
• Description of wound: length, width, depth, grid drawing and/or photographs
• Amount, frequency, color, odor, type of exudate
• Evidence of infection, undermining, or tunneling
• Nutritional status
• Co-morbidities (e.g., diabetes mellitus, peripheral vascular disease)
• Pressure support surfaces in use
• Patient’s functional level
• Skilled plan of treatment, including specific frequency of the modality
• Changing plan of treatment based on clinical judgment of the patient’s response or lack of response to treatment
• Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session)

Note: HCPCS G0282 - Electrical stimulation, (unattended), to 1 or more areas, for wound care other than described in G0281. This code is not covered by Medicare.

Self-Care/Home Management Training (CPT^® code 97535)

When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity. For example, if the instruction given is for exercises to be done at home to improve range of motion (ROM) or strength, use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if instructing the patient's spouse or caregiver how to assist the patient up/down steps using an assistive device to get into and out of the home, use 97116; if teaching the patient aquatic exercises to use as an independent program in the community pool, use 97113.

Hot/Cold Packs (CPT^® code 97010)

The payment for hot or cold packs is bundled into the payment for other covered services and is not reimbursable. Ice massage should be reported using CPT^® code 97010.

Direct 1-on-1 Contact

Regardless of the procedure or modality being performed, if the patient is not receiving direct 1-on-1 contact but is being supervised by the therapist, the group therapy code should be used.

Orthotic Management and Training and Prosthetic Training (CPT^® code 97760)

For entities subject to the related LCD, assessment of the patient regarding the orthotic, measurement and/or fitting, supplies to fabricate or modify the orthotic, and time associated with making the orthotic should not be reported with CPT^® code 97760, unless the entities are certain that duplicate payments will not be made to Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) suppliers using the "L" code.

Community/Work Reintegration (CPT^® code 97537)

Should be utilized when a patient is trained in the use of assistive technology to assist with mobility, seating systems, and environmental control systems for use in the community.