97799 Unlisted physical medicine/rehabilitation service or procedure:
For all claims submitted for unlisted services or procedures, the following documentation must be submitted:
* A description of the service or procedure; and,
* A treatment plan including information indicating the medical necessity of the service or procedure
* Microamperage E-stimulation (MENS) has not been proven effective and will be denied as such. If MENS therapy is billed to Medicare for a denial, such as in cases of supplemental coverage, providers should bill using procedure code 97799, placing “MENS therapy” in Item 19 on the CMS 1500 form or equivalent electronic field. An Advance Beneficiary Notice (ABN) should be obtained when MENS is utilized.
* Vertebral Axial Decompression (VAX-D®)
As noted in Medicare National Coverage Determination Manual, Pub. 100-3, Section 160.11 (formerly Coverage Issues Manual (CIM) 35-97), Vertebral Axial Decompression (VAX-D®) is not covered by Medicare. Medicare notes that there is insufficient scientific data to support a finding of significant benefits of this technique. If billing for a denial for the provision of this service, you must use procedure code 97799, Unlisted physical medicine/rehabilitation service or procedure, and enter “VAX-D®” in Item 19 on the CMS 1500 claim form, or electronic equivalent. An Advance Beneficiary Notice (ABN) should be obtained when VAX-D® is utilized. DO NOT bill using 64722, decompression, unspecified nerves, or 97012, application of modality.
* MedX or SPINEX® or DRX9000™
NAS, based on the advice of Physical Therapy consultants, considers MedX or SPINEX® or DRX9000™ treatments to also be non-covered, and such services will be denied as not proven effective. Use procedure code 97799, Unlisted physical medicine/rehabilitation service or procedure, and enter “MedX” or “SPINEX®” or “DRX90000™” in Item 19 on the CMS 1500 claim form, or electronic equivalent. An Advance Beneficiary Notice (ABN) should be obtained when MedX or SPINEX® are utilized.
NAS will deny VAX-D®, MedX, SPINEX® and other similar devices as not proven effective. Providers may not bill the beneficiary unless the provider has previously informed the beneficiary that this service will be denied by Medicare and has obtained his/her signature on a valid Advan.
97150 Therapeutic procedure(s), group (2 or more individuals):
* Since many group procedures do not require the professional skills of a provider, the need for skilled intervention must be documented and submitted upon request.
* Documentation must be maintained in the medical record identifying the specific treatment technique(s) used in the group, how the treatment technique will restore function, the frequency and duration of the particular group setting, and the treatment goal in the individualized plan. The number of persons in the group must also be furnished. The medical record must be made available upon request.
* Group therapy is defined as payment for physical therapy services (which includes speech-language pathology services) and occupational therapy services provided simultaneously to two or more individuals by a practitioner. The individuals can be, but need not be, performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required.
97504 Orthotics fitting and training, upper extremity(ies), lower extremity(ies), and/or trunk, each 15 minutes:
* The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training (97116), prosthetic training (97520), or self care/home management training (97535).
* It is unusual to require more than 30 minutes of static orthotic training. In some cases, dynamic training may require more additional time and when this occurs the medical record must document the medical necessity of additional time.
* Note: The following items are included in the Durable Medical Equipment Regional Contractor (DMERC) reimbursement for an orthosis within 90 days of delivery of the orthosis and, therefore, are not separately billable to Medicare:
a. Evaluation of the orthosis and/or gait
b. Fitting of the orthosis
c. Cost of base component parts and labor contained in HCPCS base codes
d. Repairs due to normal wear or tear
e. Adjustments of the orthosis or the orthotic component made when fitting the orthotic or component when the adjustments are not necessitated by changes in the patient’s functional abilities.
