Billing CPT 97530 AND 97542

CPT CODE AND DESCRIPTION

97530 - Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes


97542 - Wheelchair management (eg, assessment, fitting, training), each 15 minutes



Wheelchair Management Training (CPT 97542)

97542 Wheelchair management/propulsion training, each 15 minutes:

* This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific goal.

* The patient must have the capacity to learn from instructions.

* Documentation of medical necessity must be available on request for an unusual frequency or duration of training sessions. Typically no more than 4 total sessions are sufficient.

* When billing 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient.

The draft LCD suggests that “three (3) to four (4) sessions should be sufficient to teach the patient and/or caregiver these skills unless the patient is severely impaired or presents with another condition requiring additional treatment sessions.” AOTA is concerned that the extent of wheelchair management training may not be fully understood. Patients whose only means of independent mobility is a wheelchair need to learn how to manipulate the wheelchair parts, propel and maneuver a wheelchair on different types of surfaces including ramps and uneven terrain, curbs and stairs. The training in wheelchair management is often much more extensive, especially in a healthier wheelchair dependent person who needs to become independent in navigating all types of situations. This code was intended only to be used where a person has the capability to learn to maneuver a wheelchair independently. For these reasons and the general concerns regarding “rules of thumb” limitations, AOTA requests that this limiting language be removed.


This procedure describes the skilled intervention therapists provided related to wheelchair activities for patients who are wheelchair bound. According to CPT Changes 2006 – An Insider’s View, a wheelchair assessment may include but is not limited to the patient’s strength, endurance, living situation, and ability to transfer in and out of the chair, level of independence, weight, skin integrity, muscle tone, and sitting balance.

Following verification of the patient’s need, measurements are taken prior to ordering the equipment. This measurement ccasionally involves testing the patient’s abilities with various chair functions including propulsion, transferring from the chair to other situations (bed, toilet, car), and use of the chair’s locking mechanism on various types of equipment for optimal determination of the appropriate equipment by the patient and caregiver.

Common treatment Dx for wheelchair management (97542):

781.2 abnormality of gait

781.92 abnormal posture

719.7 difficulty walking

728.87 weakness

781.3 lack of coordination


Additional Documentation Requirements for 97542:

** Documentation for a skilled wheelchair assessment should include the following:

o What recent event prompted the need for a skilled  wheelchair assessment; o What previous wheelchair assessments have been completed, such as during a Part A SNF stay;

o Most recent prior functional level;

o What intervention was tried by nursing staff, caregivers or the patient themselves;

o Functional deficit due to poor seating or positioning;

o Objective assessments of applicable impairments such as range of motion (ROM), strength, sitting balance, skin integrity, sensation and tone.

** When billing CPT code 97542 for wheelchair management/training, documentation must relate the training to expected functional goals that are attainable by the patient and/or caregiver.

** The response of the patient to the instruction or fitting


** Documentation must clearly support that the services rendered required the skills and expertise of the therapists.


Optum Policy Overview

This policy describes Optum’s documentation requirements for reimbursement of the Physical Medicine and Rehabilitation (PM&R) CPT codes which make up the timed, skilled, direct one-on-one component of treatment. Specifically CPT codes, 97110-
97140, 97530-97542, 97750-97762.



The CPT section devoted to “therapeutic procedures” contains many of the CPT codes utilized by rehabilitation providers to describe the skilled, direct one-on-one component of treatment. These codes describe the bulk of hands-on, skilled care typically provided by rehabilitation providers.

CPT defines Therapeutic Procedures 97110-97140, 97530-97542, 97750-97762 as follows:

• A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.

• Physician or therapist required to have direct (one-on-one) patient contact.

• Therapeutic procedure, one or more areas, each 15 minutes;

Additionally, the definition of CPT codes 97750-97755, Therapeutic Procedures, Tests and Measurement includes, “with written report, each 15 minutes.” In the case of the timed therapeutic CPT codes, documentation should reflect the thought process and skilled decision making of the licensed therapy provider. As such, documentation of patient/client care needs to be more than a litany of procedures related to a date of service. Documentation must include evidence of knowledge and skill related to the procedures performed. It also should provide verification of professional judgment. This concept of clinical decision making can be incorporated into clinical documentation.


Billing - CPT Codes: Not Permitted

In the same 15-minute (or other) time period, a therapist cannot bill any of the following pairs of CPT codes for outpatient therapy services provided to the same, or to different patients.

Examples include:

a. Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97542);

b. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032 - 97039);

c. Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) and (b) above -- (CPT codes 97032- 97542). For example:

any CPT code for a therapeutic procedure (eg. 97116-gait training) with any attended modality CPT code (eg. 97035-ultrasound);

d. Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110 - 97542) with the group therapy CPT code (97150) requiring constant attendance. For example: group therapy (97150) with neuromuscular reeducation (97112);

e. 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);


f. Any untimed evaluation or reevaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 - 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150)

Group and Individual CPT Codes Billed on Same Day:

Billing for both individual (one-on-one) and group services provided to the same patient in the same day:

This is allowed, provided the CPT and CMS rules for one-on-one and group therapy are both met. However, the group therapy session must be clearly distinct or independent from other services and billed using a -59 modifier.

The group therapy CPT code (97150) and the direct one-on-one 15-minute CPT Codes for therapeutic procedures (97110 - 97542) are subject to Medicare’s National Correct Coding Initiative (NCCI). The NCCI edits require the group therapy and the one-on-one therapy to occur in different sessions, timeframes, or separate encounters that are distinct or independent from
each other when billed on the same day. The therapist would use the -59 modifier to bill for both group therapy and individual therapy CPT codes to distinguish that the two coded services represent different sessions or separate encounters on the same day. Without the -59 modifier, payment would be made for the lower-priced group therapy CPT Code, in accordance with CPT/CCI rules. The CCI edits are based upon interpretation of coding rules.


Therapeutic Activities (CPT code 97530)

AOTA is concerned that the description for this code envisions the use of therapeutic activities as a prerequisite to more advanced functional activities. For example, coverage is limited, in part, to when “there is a clear correlation between the type of exercise performed and the patient’s underlying functional deficits.” Patients often have limitations in mobility, ADL or IADL skills and require skilled therapy to be retrained to perform these skills. In occupational therapy, the “therapeutic activity” may be the performance of a specific ADL or mobility task that is critical to the patient’s ability to function independently and not an “exercise” that is a building block to being able to perform these functional activities. The description needs to be inclusive of these skilled treatments, recognizing that occupational therapists often use “real life” activities as part of an intervention.


Procedure Code Short Description Provider Max Daily Units Prior Authorization Required

97530 Therapeutic activities, direct one-on-one contact, each unit 15 mins PT, OT 3 Sometimes

The CPT© code 97530 is for therapeutic activities utilized to restore a patient’s functional performance with dynamic activities, such as training in specific functional movements or activities performed during daily living routines. This could be used to train a patient with oculomotor/saccadic dysfunctions that are impacting performance.


Timed and Untimed Codes

When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (―untimed‖ HCPCS), the provider enters ―1‖ in the field labeled units. For untimed codes, units are reported based on the number of times the procedure is performed, as described in the HCPCS code definition (often once per day).

EXAMPLE: A beneficiary received a speech-language pathology evaluation represented by HCPCS ―untimed‖ code 92506. Regardless of the number of minutes spent providing this service only one unit of service is appropriately billed on the same day.


Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. Providers report procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute units of service.

EXAMPLE: A beneficiary received occupational therapy (HCPCS  code 97530 which is defined in 15 minute units) for a total of 60 minutes. The provider would then report revenue code 043X and 4 units.

Modifier 59 is used appropriately when two timed procedures are performed in different blocks of time on the same day.

Example 9: Column 1 Code / Column 2 Code - 97140/97530

CPT Code 97140 – Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

>CPT Code 97530 – Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15
minutes

Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy. Alternatively, the therapy time blocks may be split. For example, manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.

Correct coding initiative edit that prohibits billing for group therapy along with certain therapeutic procedure CPT codes (97110, 97112, 97116, 97140, 97530, 97532, 97533) in the same session unless a –59 modifier is used. To be reimbursed for both services, the providers documentation must support that the group therapy and the therapeutic procedure were performed during separate time intervals.



97110, 97712 and 97530 are examples of rehabilitation codes that insurance companies may want to change to 92065 when provided by an optometrist. The 92065 code is defined as “Orthoptics and/or pleoptic training, with continued medical direction and evaluation”. In the classical definition, Orthoptics/Pleoptics is used to treat strabismus and amblyopia. In 2002 the Department of Health & Human Services Centers for Medicare & Medicaid Services alerted the physician and provider
community that Medicare beneficiaries who are blind or visually impaired are eligible for physicianprescribed rehabilitation service. They have directed the providers to consider the physical medicine codes 97000 series for these services.


Each session using a service whose definition includes specific time requirements, either therapeutic procedures or prolonged services, must have the face-to-face time between the patient and physician or licensed therapist documented to the minute. Units are calculated as described in prolonged services. In the case of therapeutic services, 97530, 97532, and 97533
a minimum of 15 minutes of face-to-face time for each unit of service must be billed. If less than 15 minutes of therapeutic procedure time is involved no therapeutic service may be billed.

If less than 30 minutes of a therapeutic service code face-to-face time is recorded only one unit may be billed. Three units of therapeutic service require 45 to 60 minutes of face-to-face time.


97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve  functional performance), each 15 minutes

97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes


A. General

Effective with claims submitted on or after April 1, 1998, providers billing on Form CMS-1450 were required to report the number of units for outpatient rehabilitation services based on the procedure or service, e.g., based on the HCPCS code reported instead of the revenue code. This was already in effect for billing on the Form CMS- 1500, and CORFs were required to report their full range of CORF services on the Form CMS-1450. These unit-reporting requirements continue with the standards required for electronically submitting health care claims under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) - the currently adopted version of the ASC X12 837 transaction standards and implementation guides. The Administrative Simplification Compliance Act mandates that claims be sent to Medicare electronically unless certain exception are met.



B. Timed and Untimed Codes

When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units. For untimed codes, units are reported based on the number of times the procedure is performed, as described in the HCPCS code definition (often once per day).


EXAMPLE: A beneficiary received a speech-language pathology evaluation represented by HCPCS “untimed” code 92506. Regardless of the number of minutes spent providing this service only one unit of service is appropriately billed on the same day.

Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. Providers report procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute units of service. EXAMPLE: A beneficiary received occupational therapy (HCPCS “timed” code 97530 which is defined in 15 minute units) for a total of 60 minutes. The provider would then
report revenue code 043X and 4 units.


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