Billing and Coding: Outpatient Physical and Occupational Therapy Services

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners.

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(20) excludes payment for PT or OT services furnished incident to the physician by personnel that do not meet the qualifications that apply to therapists, except licensing.

Code of Federal Regulations
42 CFR, Sections 410.59 and 410.61 describe outpatient occupational therapy services and the plan of treatment for outpatient rehabilitation services, respectively.

42 CFR, Sections 410.60 and 410.61 describe outpatient physical therapy services and the plan of treatment for outpatient rehabilitation services, respectively.

42 CFR, Sections 410.74, 410.75, 410.76, and 419.22 define the services of non-physician practitioners.

42 CFR, Sections 424.24 and 424.27 describe therapy certification and plan requirements.

42 CFR, Sections 424.4, 482.56, 484 and 485.705 define therapy personnel qualification requirements.

42 CFR, Section 486 describes coverage for services rendered by physical therapists in independent practice.

Federal Register
Federal Register, Vol. 72, No. 227, November 27, 2007, pages 66328-66333 and 66397-66408, revises personnel qualification standards for therapy services and certification requirements.

Federal Register, July 22, 2002, Decision Memo for Neuromuscular Electrical Stimulation (NMES) for Spinal Cord Injury (CAG 00153R), at:
http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=55&

CMS Publications:
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

220 through 230 Coverage and documentation requirements for physical and occupational therapy services.

CMS Publication 100-03, Medicare National Coverage Decisions Manual, (multiple sections):

provides coverage information on several specific types of therapy services. See body of LCD for individual references.

CMS Publication 100-04, Claims Processing Manual, Chapter 5:

10.2 Financial limitation for therapy services (therapy cap).

CMS Publication 100-04, Claims Processing Manual, Chapter 5:

20-100 HCPCS coding and therapy billing requirements.

CMS Publication 100-04, Claims Processing Manual, Chapter 20:

1-10 Orthotics billing.

CMS, “11 Part B Billing Scenarios for PTs and OTs”, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp#TopOfPage

Communication from CMS that the Contractor LCD is not required to include the Z51.89 ICD-10-CM code.

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Outpatient Physical and Occupational Therapy Services L34049.

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

• The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
• Relevant medical history
• Results of pertinent tests/procedures
• Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Therapy services shall be payable when the medical record and the information on the claim consistently and accurately report covered therapy services. Documentation must be legible, relevant and sufficient to justify the medical necessity of the services billed.

Medicare requires a legible identifier of the person(s) who provided the service. The method used shall be a hand written or an electronic signature to sign an order or other medical documentation for medical review purposes. Electronic or hand written signatures that have been communicated through facsimile are also acceptable.

Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:

• Paint a picture of the patient’s impairments and functional limitations requiring skilled intervention;
• Describe the prior functional level to assist in establishing the patient’s potential and prognosis;
• Describe the skilled nature of the therapy treatment provided;
• Justify that the type, frequency and duration of therapy is medically necessary for the individual patient’s condition;
• Clearly document both Timed Code Treatment Minutes and Total Treatment Time in order to justify the units billed;
• Identify each specific skilled intervention/modality provided to justify coding;
• Provide outcome measures or results f other assessment tools or measurement instruments, as appropriate, to demonstrate the clinical progress being attained by the patient in regards to the patient’s identified functional limitations.

Documentation may be submitted in any format as long as all the necessary information is captured. Forms 700 & 701 are not required documents. The documentation must establish that the patient needs the unique skills of a therapist to improve functioning. This is accomplished through a description of the patient’s condition, and any complexities that impact that condition. Not only should documentation describe the needs of the patient that require the unique skills of a therapist, but should also describe the services provided that required the expertise, knowledge, clinical judgment, decision making and abilities of a clinician that assistants, qualified auxiliary personnel, caretakers or the patient cannot provide independently. A therapist’s skills may be documented, for example, by the descriptions of the skilled treatment, the changes made to the treatment due to an assessment of the patient’s needs on a particular treatment day, or due to progress judged sufficient to modify the treatment toward the next more complex or difficult task.

Documentation should establish the variables that influence the patient’s condition, especially those factors that influence the therapist’s (or clinician's) decision to provide more services than are typical for the individual’s condition. Documentation should establish through objective measurements that the patient is making progress toward goals. When regression or plateaus occur, the reasons for the lack of progress should be noted to justify continued treatment.

Only a clinician may perform an initial examination, evaluation, reevaluation and assessment or establish a diagnosis or a plan of care. The clinician may include as part of the evaluation or reevaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or reevaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.

Initial Evaluation

The initial evaluation, which must be performed by a clinician, should document the medical necessity of a course of therapy through objective findings and subjective patient self-reporting. Documentation of the initial evaluation should list the conditions being treated and any complexities that make treatment more lengthy or difficult.

Where it is not obvious, describe the impact of the conditions and complexities so that it is clear to the medical reviewer that the services planned are appropriate for the individual.

The initial evaluation establishes the baseline data necessary for assessing expected rehabilitation potential through functional testing using standardized scales appropriate to the patient's diagnosis, the setting of realistic goals and the objective measurement of progress using these same scales. Initial evaluations need to provide objective, measurable documentation of the patient’s impairments and how any noted deficits affect ADLs/IADLs and result in functional limitations. Functional limitations refer to the inability to perform actions, tasks and activities that constitute the “usual activities” for the patient. Functional limitations must be meaningful to the patient and caregiver, and must have potential for improvement. In addition, the remediation of such limitations must be recognized as medically necessary.

To support medical necessity, the evaluation should include the following items.

• Presenting condition or complaint...."What brings the patient to therapy at this time?”
• Patients should exhibit a significant change from their “usual” physical or functional ability to warrant an evaluation.
• Provide an objective description of the changes in function that now necessitate skilled therapy. Simply stating “decline in function” does not adequately justify the initiation of therapy services.
• Diagnosis and description of specific problem(s) to be evaluated
• Include area of the body, and conditions and complexities that could impact treatment
• Subjective complaints and date of onset
• Relevant medical history
• Applicable medical history, medications, comorbidities (factors that make therapy more complicated or require extra precautions)
• Prior diagnostic imaging/testing results
• Prior therapy history for the same diagnosis, illness or injury
• If recent therapy was provided, documentation must clearly establish that additional therapy is reasonable and necessary
•  Social support/environment ?Does the patient live alone, with a caregiver, in a group home, in a residential care facility, in a skilled nursing facility (SNF), etc? ?What level of support is available, and what level of independence is required for the patient to be safe in the home environment?
• Does the home situation have obstacles that the patient must overcome (e.g., stairs without handrails)?
• What are the patient’s usual responsibilities in the home environment?
• Prior level of function
• Key piece of information used for establishing potential, prognosis and realistic functional goals
• Functional status just prior to the onset of the treating condition requiring therapy
• Record in objective, measurable and functional terms
• Functional testing ?Objectively measure and/or describe the patient’s current level of functioning.

Examples, based on the patient’s need, may include:

• mobility status (transfers, bed mobility, gait, etc);
• self-care dependence (toileting, dressing, grooming, etc);
• meaningful ADLs/IADLs;
• pain, and how it limits function; and
• balance.

 Objective impairment testing

• Testing done to determine the source or cause of the functional limitation(s), such as ROM, manual muscle testing, coordination, tone assessment, balance etc.
• Use concise, objective measurements. Avoid minimal/moderate/severe types of descriptions when more specific definitions or measurements are available. For example, when measuring shoulder flexion AROM, document degrees of motion, rather than documenting, “Shoulder flexion: minimal loss of motion.”

  Assessment

• Summary of the therapist’s analysis of the condition being evaluated based on the examination of the patient. Clinical reasoning for treatment should be evident when further therapy is recommended.
• Prognosis for return to prior functional status, or the maximum expected conditio
• Plan of care (see paragraph below)
• Signature and credentials of the therapist or physician/NPP completing the initial evaluation and plan of care.

Each therapy discipline must have a separate plan of care. The plan of care (POC) must contain ALL of the following information.

•  Required POC Element
•  Additional Points
•  Diagnosis

The diagnosis should be specific and as relevant to the problem being treated as possible. In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.

Bill the most relevant diagnosis. As always, when billing for therapy services, the ICD-10 code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason. For example, when a patient with diabetes is being treated for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible in accordance with State and local laws and the contractors Local Coverage Determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position.

Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.

Long Term Goals (LTGs)

 LTGs should:

•  pertain to the functional impairment findings documented in the evaluation;
•  reflect the final level the patient is expected to achieve as a result of therapy in the current setting;
•  be realistic, and should have a positive effect on the quality of the patient’s everyday functions;
•  be function-based and written in objective, measurable terms with a predicted date for achieving the goals.

 Type of Treatment

The type of treatment includes the type of therapy discipline operating under this POC (PT or OT) and should describe the types of treatment modalities, procedures or interventions to be provided.

 Amount of Treatment

 Refers to the number of times in a day the type of treatment will be provided. Where not specified, one treatment session a day is assumed.

 Treatment provided more than one session per day per discipline will require additional documentation to support this amount of therapy.

Frequency of Treatment

 Refers to the number of times in a week that the type of treatment is provided.

 Treatment more than two or three times a week is expected to be a rare occurrence. Treatment frequency of greater than three times per week requires documentation to support this intensity.

Duration of Treatment

Refers to the number of weeks, or the number of treatment sessions, for this plan of care.

Clinicians could also estimate the duration of the entire episode of care in this setting.

Re-evaluations

Re-evaluation documentation must include clear justification for the need for further tests and measurements after the initial evaluation, such as new clinical findings, a significant, unanticipated change in the patient’s condition, or failure to respond to the interventions in the plan of care. It is expected that clinicians continually assess the patient’s progress as part of the ongoing therapy services. This assessment is not considered a formal re-evaluation; the time of any assessment is included and billed within the appropriate treatment intervention CPT code.

Re-evaluations must be performed by clinicians and contain all applicable components of the initial evaluation. Resolved problems do not need to be re-evaluated; new or ongoing problems may need to be re-evaluated, especially if there is an anticipated change to the long term goals.

Progress Reports

Progress reports provide justification for the medical necessity of treatment. Progress reports shall be written by a clinician at least once every 10 treatment days or at least once every 30 calendar days, whichever is less. Writing progress notes more frequently than the minimum is encouraged to support the medical necessity of treatment. A progress report is not a separately billable service.

In CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, sections 220-230, Medicare defines the minimum REQUIRED elements of a progress report. It is essential that clinicians include all required elements in their documentation (either in a progress report or treatment note).

Progress note elements include(CMS required elements are italicized): ? Date of the beginning and end of the reporting period that this report refers to;

•  Date that the report was written by the clinician, or if dictated, the date on which it was dictated;
•  Objective reports of the patient’s subjective statements, if they are relevant;
•  Objective measurements (impairment/function testing) to quantify progress and support justification for continued treatment;
•  Description of changes in status relative to each goal currently being addressed in treatment. Descriptions shall make identifiable reference to the goals in the current plan of care;
•  Assessment of improvement, extent of progress (or lack thereof) toward each goal;
•  Plans for continuing treatment, including documentation of treatment plan revisions as appropriate;
•  Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment;
•  Signature with credentials of the clinician who wrote the report.

No specific format is required to demonstrate patient progress as long as all information noted in the bullets above are included at least once in the medical record for each progress report period (10 treatment days or 30 calendar days, whichever is less). Progress report information may be included in the treatment notes, progress reports and/or formal re-evaluations (when re-evaluation guidelines are met).

During each progress report period, the clinician must personally furnish in its entirety at least one billable service on at least one day of treatment. Verification of the clinician’s treatment shall be documented by the clinician’s signature on the treatment note and/or progress report.

Treatment Notes

Medical record documentation is required for every treatment day, and every therapy service to justify the use of codes and units on the claim.

The treatment note must include the following required information:

• date of treatment;
• identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;
• record of the total time spent in services represented by timed codes under timed code treatment minutes;
• record of the total treatment time in minutes, which is a sum of the timed and untimed services;
• signature and credentials of each individual(s) that provided skilled interventions.

In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:

• patient comments regarding pain, function, completion of self management/home exercise program (HEP), etc;
• significant improvement or adverse reaction to treatment;
• significant, unusual or unexpected changes in clinical status;
• parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;
• description of the skilled components of the specific exercises, training, or activities;
• instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;
• communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);
• communication with patient, family, caregiver;
• equipment provided
• any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.

If grid or checklist forms are used for daily notes or exercise/activity logs, include the signature and credentials of the qualified professional/auxiliary personnel providing the service each day. Listing of exercise names (e.g., pulleys, UBE, TKE, SLR) does not alone imply that skilled treatment has been provided, especially if the exercises have been performed over multiple sessions. Be sure to occasionally document the skilled components of the exercises so they do not appear repetitive and therefore, unskilled. Documenting functional activities performed (e.g., “ambulated 35 feet with min assist”, “upper body dressing with set up and supervision”) also does not alone imply that skilled treatment was provided. The skilled components/techniques of the qualified professional/auxiliary personnel used to improve the functional activity should be occasionally documented to support medical necessity.

When documenting treatment time, consistently use the CMS language of total “Timed Code Treatment Minutes” and “Total Treatment Time”. Do not use other language or abbreviations when referring to treatment minutes as it may be difficult for medical review to determine the type of minutes documented. The amount of time for each specific intervention/modality provided may also be recorded voluntarily.

Do not record treatment time as “Time in / Time out” for the entire session as this does not accurately reflect the actual treatment time. Do not “round” all treatments to 15-minute increments, but rather record the actual treatment time. Also do not record as “units” of treatment, instead of minutes.

Only “intra-service care” of skilled therapy services should be reflected in the time documentation. Do not include unbillable time, such as time for:

• changing;
• waiting for treatment to begin;
• waiting for equipment;
• resting;
• toileting; or
• performing unskilled or independent exercises or activities.

Discharge Notes

A discharge note is required for each episode of treatment and must be written by the clinician. The discharge note is a progress report covering the time from the last progress report up to the date of discharge, and includes all required components of a progress report. The discharge note may be considered the last opportunity to justify the medical necessity of the entire treatment episode. Therefore, if a discharge summary has been completed, it may be prudent to submit it with any request of records for medical review, even if the claim under review is for a treatment period prior to the date of discharge.

In the case of an unanticipated discharge, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified auxiliary personnel. In the case of a discharge anticipated within 3 treatment days of the progress report, the clinician may provide objective goals which, when met, will authorize the assistant or qualified auxiliary personnel to discharge the patient. In that case, the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist. There must be indication that the clinician has reviewed the treatment notes and agrees to the discharge.

Certifications and Recertifications

Medicare beneficiaries receiving outpatient therapy services must be under the care of a physician/NPP. Orders (sometimes called referrals) and certifications are common means of demonstrating such evidence of physician involvement.

Certification, which is a coverage condition for therapy payment, requires a dated physician/NPP signature on the therapy plan of care or some other document that indicates approval of the plan of care. A certification often differs from an order or referral in that it must contain all required elements of a plan of care. To assist medical review in determining that the certification requirements are met, certifications/recertifications should include the following elements(CMS required elements are italicized):

• The date from which the plan of care being sent for certification becomes effective (for initial certifications, the initial evaluation date will be assumed to be the start date of the certified plan of care);
• Diagnoses;
• Long term treatment goals;
• Type, amount, duration and frequency of therapy services;
• Signature, date and professional identity of the therapist who established the plan; and
• Dated physician/NPP signature indicating that the therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan. (Note: The CORF benefit does not recognize an NPP for certification.)

Effective January 1, 2008, the interval length shall be determined by the patient’s needs, not to exceed 90 days. Certifications which include all the required plan of care elements will be considered valid for the longest duration in the plan (such as 3x/wk for 6 weeks which will be considered as a total of 18 treatments). If treatment continues past the longest duration specified, a recertification will be required.

Documentation Requirements for Unlisted Procedure Codes

Unlisted modality - In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxilliary personnel, the time spent by the qualified professional/auxilliary personnel, one-on-one with the beneficiary.

Unlisted therapeutic procedure - Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.

Unlisted physical medicine/rehabilitation service or procedure - Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.

Unlisted procedure, casting or strapping - Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.

Untimed CPT Codes

When a therapy treatment modality or procedure is not defined in the AMA 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, often once per day. Untimed services billed as more than “1” unit will require significant documentation to justify treatment greater than one session per day per therapy discipline. 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).

Time Based Codes (if applicable)

• When billing time-based codes the CPT time rule applies
• Exact times MUST be documented in the medical record
  • The code reported should be selected based on the time closest to that indicated in the code descriptor
• 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 to be counted when recording the treatment time. The time counted is the “intra-service” care that begins when the qualified professional/auxiliary personnel is directly working with the patient to deliver the service. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment. The intra-service care includes assessment. The time the patient spends not being treated because of a need for toileting or resting should not be counted. In addition, 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 that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the “Timed Code Treatment Minutes.” Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.
  • When determining the allocation of units, it is easiest to separate out each service first into “15-minute time blocks”. For example:
    • 24 minutes 97112 = one 15-minute block + 9 remaining minutes
    • 23 minutes 97110 = one 15-minute block + 8 remaining minutes

• Each code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most “remaining minutes” (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is 2 units 97112 + 1 unit 97110.

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 date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise and 20 minutes self-care/home management training. The total “Timed Code Treatment Minutes” documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in “Timed Code Treatment Minutes’ will determine the number of units billed.

Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.

• Do not bill for documentation time separately(except for standardized cognitive performance testing). This is incorporated in the HCPCS/CPT fee reimbursed for each individual service provided.
• Do not code higher than what the procedure requires. Coding in this manner may allow the provider to collect inappropriate revenues without incurring additional costs.
• Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.
• Do not “unbundle” services/procedures. Unbundling refers to the practice of splitting a single payment code into two or more codes. This may lead to inappropriate multiple payments.
• Do not bill separately for supplies used to provide therapy services, such as electrodes, theraband, theraputty, etc.
• Therapists, or therapy assistants, working together as a “team” to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient. For example, if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.

Examples of treatment time documentation

A treatment session includes 20 minutes therapeutic exercise (97110), 15 minutes therapeutic activities (97530) and 20 minutes unattended electrical stimulation (G0283).
Time documentation in the treatment note

Timed Code Treatment Minutes: 35 minutes

Total Treatment Time: 55 minutes

A 30 minute OT initial evaluation is completed (97162), followed by 20 minutes fluidotherapy (97022).
Time documentation in the treatment note

Timed Code Treatment Minutes: 0 minutes

Total Treatment Time: 50 minutes

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 date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise (CPT 97110) and 20 minutes self-care/home management training (CPT 97535). The total “Timed Code Treatment Minutes” documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in “Timed Code Treatment Minutes’ will determine the number of units billed.

Once the minutes have been summed, use the chart below to determine the total allowable units, based on the total Timed Code Treatment minutes.

When the total Timed Code Treatment minutes for the day is less than 8 minutes, the service(s) should not be billed.

It is important to allocate the total billable units for timed services to the appropriate CPT codes based upon the number of minutes spent providing each individual service. Any timed service provided for at least 15 minutes, must be billed one unit. Any timed service provided for at least 30 minutes, must be billed two units, and so on. When determining the allocation of units, it is easiest to separate out each service first into “15-minute time blocks”. For example:

20 minutes of Therapeutic Exercise (CPT 97110) = one 15-minute block + 5 remaining minutes

• At least 1 unit must be allocated to this code

38 minutes of Self-care/Home Management Training (97535) = two 15-minute blocks + 8 remaining minutes

• At least 2 units must be allocated to this code
• If 38 minutes of CPT 97535 is the only treatment provided, then 3 units would be billed. However, as demonstrated in the examples below, there may be treatment sessions in which the correct billing would only allow 2 units, based on the “remaining minutes”.

The “remaining minutes” (those minutes remaining after the “15-minute blocks” have been allocated) are considered when the total billable units for the day allow for an additional unit to be billed. See the following examples:

For treatment sessions with both timed and untimed services, the units and time documented for any untimed CPT codes should not be included in the counting of units and time for the timed CPT codes for a calendar day. The minutes for the timed codes are reflected in the Timed Code Treatment Minutes, with the units allocated as described above. The untimed minutes are reflected in the Total Treatment Time, which is a combination of the timed code minutes and the untimed code minutes. Per CMS, it is important that the total number of timed treatment minutes support the billing of units on the claim, and that the total treatment time reflects services billed as untimed codes. For example:

Payment for therapy services 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 1:00 to 1:15) a clinician cannot bill any of the following pairs of CPT codes for therapy services provided to the same, or to different patients.

1. Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97762)
   
2. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032-97039)
   
3. Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) or (b) above - (CPT codes 97032-977622), for example, any CPT code for a therapeutic procedure (e.g., 97116 - gait training) with any attended modality CPT code (e.g., 97035 - ultrasound)
   
4. Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110-97762) with the group therapy CPT code (97150) requiring constant attendance, for example, group therapy (97150) with neuromuscular reeducation (97112)
   
5. Any CPT code for modalities requiring constant attendance (CPT codes 97032-97039) with the group therapy CPT code (97150) for example, group therapy (97150) with ultrasound (97035)
   
6. Any untimed evaluation or reevaluation code (CPT codes 97161-97168) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032-97039), therapeutic procedures (CPT 97110-97762) and group therapy (CPT code 97150)

Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.

• Do not bill for documentation time separately(except for CPT code 96125). This is incorporated in the HCPCS/CPT fee reimbursed for each individual service provided.
• Do not code higher than what the procedure requires. Coding in this manner may allow the provider to collect inappropriate revenues without incurring additional costs.
• Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.
• Do not “unbundle” services/procedures. Unbundling refers to the practice of splitting a single payment code into two or more codes. This may lead to inappropriate multiple payments.
• Do not bill separately for supplies used to provide therapy services, such as electrodes, theraband, theraputty, etc.
• Therapists, or therapy assistants, working together as a “team” to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient. For example, if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.

Utilization Guidelines and Maximum Billable Units per Date of Service
Rarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed.

The following interventions should be reported no more than one unit per code per day per discipline; additional units will be denied:
97012, 97016, 97018, 97022, 97024, 97028, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97597, 97598, 97605, 97606, G0281, G0283, G0329.

The following timed interventions should be reported no more than 2 (two) units per code per day per discipline; additional units will be denied: 97033, 97034, 97035, 97036.

The following interventions should be reported no more than 4 (four) units per code per day per discipline; additional units will be denied:
97032, 97110, 97112, 97113, 97116, 97124, 97530, 97533, 97535, 97537, 97542, 97760, 97761, 97763, 97129, 97130.

Denials due to the limits described in this section of the LCD may be appealed.

Documentation Requirements for Unlisted Procedure Codes (97039, 97139, 97799, 29799)
97039 - In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxilliary personnel, the time spent by the qualified professional/auxilliary personnel, one-on-one with the beneficiary.

97139 - Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.

97799 - Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.

29799 - Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.

Other Comments:
For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.
In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxiliary personnel, the time spent by the qualified professional/auxiliary personnel, one-on-one with the beneficiary.