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Medicare Part B Coding and Billing: For Therapy Services in Long-Term Care

Medicare Part B Coding and Billing: For Therapy Services in Long-Term Care
Kathleen D. Weissberg, OTD, OTR/L
June 2, 2018

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CPT Coding Guidance

Next, I will go through some of the commonly utilized CPT codes in physical therapy. I pulled from national coverage determinations from Medicare and local coverage determinations as well to get some of this information. You might be thinking, well wait, a second, I bill commercial insurance, I don't bill Medicare. Medicare is probably the most highly regulated venue or payer if you will, that we work with in therapy and oftentimes our commercial payers will follow the local coverage determinations or the national coverage determinations from Medicare so their oftentimes the most strict.  If we can follow those and we know that we're doing the right thing there, generally speaking, we're probably doing the right thing for our commercial payers as well.

CPT Coding Guidance: Modalities

These are direct, one-on-one contact with the patient by the providers so you need to have constant attendance. Coverage for these codes indicates the provider is performing the modality and cannot be performing another procedure at the same time. Only the actual time of the provider’s direct contact with the patient, providing services requiring the skills of a therapist is covered for these codes. Modalities that are chosen to treat the patient's symptoms or conditions should be selected based on what's most effective for the patient to achieve their goals.

Seldom will a patient require more than one or even two modalities to the same body part during the therapy session. The use of more than two modalities is pretty unusual and you'll need to justify that in your documentation. Additionally, Medicare says that the use of modalities as a stand-alone treatment is rarely therapeutic and usually not required as the sole treatment approach. Generally, speaking, a treatment plan won't consist solely of modalities. Of course, there are some exceptions there, such as wound care. Additionally, multiple heating modalities would not be used on the same day.  Exceptions again are rare and usually would involve musculoskeletal pathology or injuries where we're treating both superficial and deep structures. Documentation must support the use of multiple modalities as contributing to the patient’s progress and restoration of function. For example, it would not be medically necessary to perform both thermal ultrasound and thermal diathermy on the same area, in the same visit, as both are considered deep heat modalities.

When the symptoms that require the use of certain modalities begin to subside, and function improves, the medical record should reflect the discontinuation of those modalities so as to determine the patient’s ability to self-manage any residual symptoms. As the patient improves, the medical record should reflect a progression of the other procedures of the treatment program (therapeutic exercise, therapeutic activities, etc.). In all cases, the patient and/or caregiver should be taught aspects of self-management of his/her condition from the start of therapy.

Based on the CPT descriptors, these modalities apply to one or more areas treated (e.q. paraffin bath used for left and right hand is billed as one unit). With every modality that I will talk about as well as therapeutic procedures, you need to have in your documentation objective and/or subjective improvement. If there's no improvement whatsoever with the treatment, we need to change that treatment plan. Some alternative strategy needs to be utilized and if we don't change the treatment plan, then the documentation should strongly support why we're continuing to use that modality or that treatment procedure.

CPT 97010 Hot or Cold Packs.  Hot or cold packs (including ice massage) applied in the absence of any associated procedures or modalities or used alone to reduce discomfort are considered not to require the unique skills of a therapist. This particular code (97101) is bundled. It may be bundled with any therapy code. Whether you use this alone or in conjunction with something else that you're doing in therapy, this code is never paid separately. If you bill it on it's own, it will be denied. That said, if you're going to use hot packs or cold packs, you definitely want to have that in a clarification order or in your documentation. You need to include the area that's treated, the type of application, whether it's cold or hot, and the purpose of that application.

CPT 97012 Traction, Mechanical.  Mechanical traction is generally limited to the cervical or the lumbar spine with the expectation of relieving pain originating in those areas. So some specific indications include disk herniation, lumbago, sciatica, and cervical or lumbar radiculopathy. This modality would generally be used in conjunction with another therapeutic procedure and is not generally an isolated treatment. Equipment and tables using roller systems are not considered true mechanical traction and are not to be covered under this code. Coding Guidance for supportive documentation of code 97012 includes documenting the type of traction, the body part to which it is applied, and the etiology of the symptoms requiring the treatment. Your daily progress reports should include that information.  Only 1 unit of CPT code 97012 is generally covered per day of service.  

CPT 97024 Diathermy.  Diathermy, (CPT 97024) may be indicated when you have a large area of deep tissue requiring heat where it's not feasible to use ultrasound or some other modality. It's not reasonable and necessary to perform both thermal ultrasound and diathermy to the same region of the body in the same visit because both of these are considered to be deep heat modalities. Pulsed wave diathermy is covered for the same conditions and to the same extent as standard diathermy. For supportive documentation for this code, you need to include the area that is being treated, the objective clinical findings/measurements to support the need for a deep heat treatment as well as the subjective findings. Subjective finding includes pain ratings, pain location, activities which either increase or decrease the pain and any effect on function.

CPT 97032 Electrical Stimulation. CPT 97032 is manual electrical stimulation (e-stime) to one or more areas, each 15 minutes.  There is a lot of confusion between this code and the G-code, G0283. Most non-wound care electrical stimulation will be billed with G-code. G0283, as it's often provided in a supervised manner after the skilled application by a PT or PTA, without constant direct contact required during the treatment. CPT code 97032 is a constant attendance code, so what does that mean? It's manual contact by you, the therapist and because the use of a direct contact e-stim is less frequent, you're documentation again really needs to support why you're billing this code versus the G-code. So what might count as 97032? Well, an example that would require constant attendance is direct motor point stimulation that you would deliver via a probe or instructing a patient on the use of a tens unit. You need to be there constantly, changing and altering the parameters of that e-stim as you are directing it to that patient. Instructing the patient on the tens unit is billable under 97032. Typically speaking, most payers are only going to pay for a couple of visits to achieve a favorable response from the patient. After those couple of visits, generally speaking, they're going to ask you to carry that over to the patient or the caregiver.

If you are using functional electrical stimulation (FES), or neuromuscular electrical stimulation (NMES), while performing a therapeutic exercise, or functional activity at the same time, you can bill that as 97032, but what you don't want to do is bill the additional CPT codes of Therex, or Neuro R-ed at the same time. If you have a machine that combines ultrasound and e-stim, and they are being provided concurrently, you would bill that as ultrasound. Moving forward, if the patient requires supervision only for the fact that they have safety issues, you need to code G0283 and not 97032. Supervision needed for safety reasons only does not qualify as constant attendance. Finally, if you are providing any sort of continence improvement such as non-implantable pelvic floor electrical stimulators, (vaginal or anal probes) may be billed as 97032. If you're delivering traditional e-stim via the electrodes in the genital area, that would be billed as G0283.

Supportive documentation for code 97032 should include the specific type of electrical stimulation that you're using (elaborate more than manual or attended) Documentation also needs to include what area is being treated.  If you're using e-stim specifically for muscle weakness, the objective rating of strength and the functional deficits need to be included in your documentation.  Finally, if you're using it for pain, you need to document the pain rating, the location of the pain and the effect that your stim is having on function.

CPT 97033 Iontophoresis.  Iontophoresis is where we are introducing into the tissues through electrical current the ions of a chosen medication. Now the evidence from published, peer-reviewed literature is inconclusive to show that this is superior to any other type of treatment and for that reason, Iontophoresis is not covered by Medicare. It might be covered by a commercial insurance but for Medicare purposes, Iontophoresis is not covered.

CPT 97035 Ultrasound. CPT code 97035 is Ultrasound. Ultrasound can either be pulsed or continuous and again this should be used in conjunction with other therapeutic procedures, not as an isolated treatment. Indication for use includes limited joint movement, symptomatic soft tissue calcification, and neuromas. Phonophoresis is reimbursable by Medicare.  Phonophoresis is using Ultrasound to enhance the delivery of that topically applied drug. Separate payment is not made for the contact medium or for the drug that is being utilized but you can bill your phonophoresis as ultrasound and that is reimbursable by Medicare.  

If no objective and/or subjective improvement is noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of ultrasound. Documentation must clearly support the need for ultrasound more than 12 visits.

For proper supportive documentation for ultrasound treatment, you need to include the area(s) being treated, the frequency and the intensity of the ultrasound and the type of Ultrasound (pulsed or continuous). The objective clinical findings, such as the measurements of range of motion, the functional limitations, anything that you can put in there that supports the need for you to deliver this Ultrasound also should be included. Finally, documentation should include subjective findings such as pain ratings, pain location, and the effect on function. You'll note a common theme here and that is function which is what our payers are paying for. It's not that you're just doing a modality, it's that you're doing modality or therapeutic procedure that's carrying over to something that is functional for your patient.

CPT G0283 Electrical Stimulation (unattended). E-stim code, G0283 is unattended e-stim. As I said before, most non-wound care e-stim should be billed as G0283 because it is often provided in a supervised manner without constant direct contact required throughout the treatment.  Now while this is classified as a supervised modality, don't get confused. It's labeled unattended, but you still need to supervise your patient. You can't just leave the patient completely unsupervised. What this code means, though, is that it does not require direct, one-on-one contact. You're not in there consistently changing the parameters of that e-stim. Again, most e-stim that is conducted via the application of electrodes will be considered unattended e-stim. Examples of unattended electrical stimulation modalities include Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), and cyclical muscle stimulation (Russian stimulation)

For documentation purposes, you need to include again the type of e-stim that you're using (IFC, neuromuscular, Russian), the area being treated, and the parameters that you're utilizing. If you are using e-stim for pain documentation, you should include the pain rating scale, the location, and the effect of pain on function. 

CPT Coding Guidance: Therapeutic Procedures

Therapeutic procedures require direct one-on-one patient contact. Use of these procedures requires the qualified professional/auxiliary personnel to have direct (one-on-one) patient contact. Only the actual time of direct contact with the patient providing a service which requires the skills of a therapist is considered for coverage. Supervision of a previously taught exercise or exercise program, patients performing an exercise independently without direct contact by the qualified professional/auxiliary personnel, or use of different exercise equipment without requiring the intervention/skills of the qualified professional/ auxiliary personnel are not covered. The patient may be in the facility for a longer period of time, but only the time the qualified professional/auxiliary personnel is actually providing direct, one-on-one, patient contact which requires the skills of a therapist is considered covered time for these procedures, and only those minutes of treatment should be recorded. Under Medicare, time spent in the documentation of services (medical record production) is part of the coverage of the respective CPT code; there is no separate coverage for time spent on documentation (except for CPT Code 96125).

Now before we go on, I want to make a comment here because often times in our clinics, we are doing what we call point of care or point of service documentation, which of course would be covered. Point of care documentation occurs when you're sitting there with your patient and discussing this is how I thought you did today, for example. Let's talk about your goals and where do you want to go in therapy? How do you feel like you're progressing, et cetera? When you're involving your patient in goal setting and in the documentation that time would obviously be covered. Where your patient is not present or not participating obviously there's no coverage for those types of activities.

CPT 97110 Therapeutic Exercise. Therapeutic Exercises are used for the purpose of restoring strength, endurance, range of motion, flexibility, where loss or restrictions is a result of a specific disease or an injury and has resulted in a functional limitation. It is also a 15-minute code. Exercises may be active, active-assistive or passive.  Therapeutic Exercises require the unique skills of a therapist to evaluate the patient's abilities, design the Therex program, instruct the patient, and/or instruct the caregiver how to complete those exercises. However, after that teaching has been successfully completed, repetition of those exercises or monitoring for completion of the task in the absence of additional skill care would not be covered.

For example, a patient who has had a total knee arthroplasty starts the session on the exercise bike to begin some gentle range of motion. Initially, that patient requires skilled progression of that program from the pedal rocks to then building up to full revolutions and perhaps assessing and varying the seat height or the resistance along the way. That's all skilled treatment. Once the patient is able to safely exercise on the bike, no longer requiring any sort of frequent assessment or progression, even if set up is required, that bike now becomes an independent program and it's no longer covered by Medicare. So while you are still required to warm-up the patient on that bike, it's technically considered non-skilled, because the patient is performing that independently. You need to look at what requires your skills. Maybe it's not the set-up or the progression of the exercise, but maybe you're monitoring that patient's vital signs or you're teaching the patient how to monitor his or her own vital signs. In those cases again, it would still be skilled.

Exercise just to promote overall fitness, flexibility, or endurance, in absence of a complicated condition are not covered.  Maintenance exercises again, unless it requires the skills of a therapist are not going to be covered. And additionally, repetitive exercises that can be taught to the patient or to a caregiver as part of a self-management program would not be covered. Documentation must include measurable indicators such as the functional loss of joint motion or the muscle strength or whatever you're working on.  It's really important to also document how those limitations are impacting your patient's life and how improvement in one of those areas will impact function. Your documentation needs to describe new exercises that are added and any changes made to the exercise program which will help to justify that the services are skilled. Additionally, you need to show how you are transitioning those exercises over to a home exercise program. If Medicare reviews your documentation and sees that a home exercise program might have been indicated yet it was not initiated and the client is doing repetitive exercises, that treatment session(s) are generally going to be denied. A HEP is an integral part of the therapy plan of care and should be modified as the patient progresses during the course of treatment. It is appropriate to transition portions of the treatment to a HEP as the patient or caregiver master the techniques involved in the performance of the exercise.

If an exercise is taught to a patient and performed for the purpose of restoring functional strength, range of motion, endurance training, and flexibility, CPT code (97110) is the appropriate code. For example, a gym ball exercise used for the purpose of increasing the patient’s strength should be considered as therapeutic exercise when coding for billing. Also, the minutes spent taping, such as McConnell taping, to facilitate a strengthening intervention would be counted under 97110.

For many patients, passive range of motion should not be used more than 2-4 visits and is payable when performed to train the patient or train the caregiver on how to perform the movement. Documentation would be necessary to support services beyond the 2-4 visits (such as PROM where there is an unhealed, unstable fracture, or new rotator cuff repair, requiring the skills of a therapist to ensure that the extremity is maintained in proper position and alignment during the PROM).

Objective measurements of loss of strength and range of motion and their effect on function is very important to document. If 97110 is used to help with pain, include the pain rating scale again, the location of pain, and effect of pain on function.  Other key items to document for this code include the specific exercises performed, the purpose as they relate to function, the instructions, the assistance, and whatever you did to demonstrate that the skills of the therapist were required. When cardiopulmonary monitoring is required, include documentation of pulse oximetry, heart rate, blood pressure and perceived exertion.  

If you documentation states 10 reps with a two-pound weight for shoulder flexion or some sort of lower extremity marching with no other documentation, that does not show skilled need. Because again, you need to show what requires your skill and that the patient could not have done the treatment on their own or at a gym.  

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kathleen d weissberg

Kathleen D. Weissberg, OTD, OTR/L

Kathleen Weissberg, OTD, OTR/L, in her 25 years of practice, has worked in adult rehabilitation, primarily in long-term care as a clinician, manager, researcher, and most recently as Education Director with Select Rehabilitation where she oversees continued competency and education for close to 12,000 therapists. In her role, she conducts audits and provides denials management and quality improvement planning training for more than 700 LTC sites nationwide. She also conducts compliance, ethics, and jurisprudence training to therapists.  Kathleen has authored several publications that focus on patient wellness, fall prevention, dementia management, therapy documentation, and coding/billing compliance.  

 



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