How to submit claims for physician or NP or Physical or Occupational Therapist (PT or OT) or Speech-Language Pathologist (SLP) - In therapy billing

For claims submitted by a physician or NPP:

•    Services performed by non-employees or those not under a physician’s or NPP’s direct supervision are not covered.
•    Services not relating to a written treatment plan are not medically necessary.
•    Services that do not require the professional skills of a physician or NPP to perform or supervise are not medically necessary.
For claims submitted by a Physical or Occupational Therapist (PT or OT) or Speech-Language Pathologist (SLP) in independent practice:
•    An order, sometimes called a referral, for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician.
•    Claims submitted by anyone other than a therapist enrolled as a Medicare provider are not covered.
•    Services not performed by or under the direct supervision of the therapist are not covered.
•    Services performed by people who are not employees of the therapist are not covered.
•    Services not furnished in the therapist’s office or in the patient’s home are not covered.
•    Physical therapy services that do not require the professional skills of a qualified PT to perform or supervise are not medically necessary.
•    Occupational therapy services that do not require the professional skills of a qualified OT to perform or supervise are not medically necessary.
•    Speech-language pathology services that do not require the professional skills of a qualified SLP to perform or supervise are not medically necessary.
Maintenance Therapy

Maintenance therapy after therapeutic goals and/or rehabilitative potentials are reached is medically reasonable and necessary but is not covered. However, a qualified professional may develop a maintenance program for the patient to pursue outside of a therapy program and plan of care, generally administered and supervised by family or caregivers. Periodic evaluations of the patient’s condition and response to treatment may be covered when medically necessary if the judgment and skills of a qualified professional are required. Examples include:
•    Design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease.
•    Instructing the patient, family member(s) or caregiver(s) in carrying out the maintenance program.
•    Infrequent re-evaluations required to assess the patient’s condition and adjust the program.

If a maintenance program is not established until after the therapy program has been completed (and the skills of a therapist are not necessary), development of a maintenance program is not considered reasonable and necessary for the patient’s condition.

Note: Bill these services (e.g., codes 99212, 99213, 99214, 99215, 97002, 97004) with the appropriate evaluation/re-evaluation. It is expected these services will be infrequently required.

General Modality Guidelines (Codes 97012, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039)

•    Modality codes 97012 (mechanical traction) and 97016, 97018, 97022, 97024, 97026, 97028 (vasopneumatic device, paraffin bath therapy, whirlpool therapy, diathermy, and ultraviolet therapy) require supervision by the qualified professional; codes 97032, 97033, 97034, 97035, 97036, 97039 (electrical stimulation, contrast bath therapy, ultrasound therapy, hydrotherapy, and physical therapy treatment unlisted) require direct (one-on-one) contact with the patient by the qualified professional.
•    Therapeutic exercise and activities are essential for rehabilitation. The use of modalities as stand-alone treatment is not indicated as a sole approach to rehabilitation. Therefore, an overall course of rehabilitative treatment is expected to consist predominantly of therapeutic procedures (such as codes 97110 (therapeutic exercises), 97112 (neuromuscular re-education), 97116 (gait training therapy) and/or 97530 (therapeutic activities)), with adjunctive use of modalities. Although passive modalities may play a larger role in the early stages of rehabilitation and in treating exacerbations it is expected that modalities will comprise a small portion of the total therapy service time involved during the course of rehabilitative therapy. Further, it is expected that the record will demonstrate both the patient’s clinical progress and concomitant appropriate increasingly active therapeutic treatment.

•    When modality codes 97012 (mechanical traction) and 97018 (paraffin bath therapy) are used alone (absent therapeutic procedures and not as a precursor to active treatment) and solely to promote healing, relieve muscle spasm, reduce inflammation and edema, or as analgesia, a limited number of visits (e.g., 1–2) visits may be medically necessary to determine the effectiveness of treatment and for patient education. It is usually not medically reasonable and necessary to continue modality-only treatment by the qualified professional.

•    Generally, adjunctive use of services billed with modality codes 97012 (mechanical traction) and 97018 (paraffin bath therapy) is coverable only if they enhance the therapeutic procedures. Documentation supporting the medical necessity and clinical justification for the services’ continued use must be made available to Medicare upon request.

•    Generally, only one heating modality per day of therapy is reasonable and necessary. Medicare would not expect to see multiple heating modalities billed routinely on the same day. Exceptions could include musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation containing clinical justification supporting the medical necessity for multiple heating modalities such as codes 97018, 97024, and 97035 on the same day is essential.

•    Generally, only one hydrotherapy modality is coverable per day when the sole purpose is to relieve muscle spasm, inflammation or edema. Documentation must be available supporting the use of multiple modalities as contributing to the patient’s progress and restoration of function. Because some of the modalities are considered components of other modalities and procedures they are not separately reimbursed. Please refer to the Correct Coding Initiative.

•    Medicare does not provide payment for the therapeutic modality described as iontophoresis (procedure code 97033).

•    Medicare does not provide payment for the therapeutic modality described as phonophoresis.

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