Procedure codes and Description

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

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

97537 Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes

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

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.

In cases that a state determines a procedure code that is not identified by CPT as a timed therapeutic procedure will be reimbursed as a timed therapeutic procedure, the documentation requirements described in this policy will apply

CPT code 97530 FAQ

is cpt code 97530 physical therapy ?

CPT 97530 – Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. It is therapeutic activity that covers a broad range of rehabilitative techniques involving movement of the entire body which may include such activities as bending, lifting, carrying, reaching, catching, transfers and overhead activities to improve functional performance in a progressive manner. These are dynamic activities designed to improve loss or restriction in mobility, strength, balance and coordination.

how often can cpt 97161 be billed (Change the question – Mandatory requirements for billing CPT 97161)?
Diagnosis, Long term goals (LTG), type of treatment, Amount of treatment, Frequency of treatment and duration of treatment

can 97530 be billed with 97140 ?
Yes, both the CPT codes 97530 & 97140 can be billed together

is 97530 a timed code ?
Yes, this is time based code (Each 15 minutes corresponds – 1 unit)

Reimbursement Guidelines

Documentation Requirements – Timed Therapeutic Intervention

Optum will align timed therapeutic treatment documentation requirements with the American Physical Therapy Association’s Defensible Documentation for Patient/Client Management document and Centers for Medicare and Medicaid Services (CMS) National Policy.

Background Information

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.

General Guidelines

In addition to the documentation requirements referenced in Optum’s Guideline for Record Keeping policy, there are specific requirements that must be evident in the patient medical record for reimbursement of certain time-based therapeutic procedure interventions. Documentation of certain timed-based procedures should be recorded on the day of the patient visit and include both of the following:

A. Substantiation that the skilled services of a licensed therapy provider or physician were required.

B. Substantiation that services met the one-on-one timed-based requirement.

40. Skilled Intervention

1. Documentation to support skilled intervention is required. Demonstration of skilled care requires documentation of the type and level of skilled assistance given to the patient, clinical decision making or problem solving, and continued analysis of patient progress. This may be documented by recording both the type and amount of manual, visual, and/or verbal cues used by the licensed therapy provider to assist the patient in completing the exercise/activity completely and

correctly. Skilled care may also be documented through explanation regarding rationale for choosing the interventions and/or the rationale for the continued use of the intervention. Another way of documenting skilled care may be to provide documented observation regarding responses before, during, and after an intervention as well as the patient’s specific response to the intervention.

2. Services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute skilled physical medicine and rehabilitation services. Services provided by practitioners/staff who are not qualified licensed therapy providers are not skilled intervention services. Unskilled services are palliative procedures that are repetitive or reinforce previously

learned skills, or maintain function after a maintenance program has been developed.

3. The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a licensed therapy provider. Services that do not require the skill of a licensed therapy provider are not considered skilled services, even if they are performed or supervised by a qualified professional.

4. While a patient’s particular medical condition is a valid factor in deciding if skilled physical medicine and rehabilitation services are needed, a patient’s diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a licensed therapy provider are needed to treat the illness or injury, or whether the services can be carried out by unskilled personnel.

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 timed codes, units are reported based on the number of times the procedure is performed, as described in the HCPCS code definition.

EXAMPLE: A beneficiary received a speech-language pathology evaluation represented by HCPCS “untimed” code 92521. 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 these “timed” 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 a total of 60 minutes of occupational therapy, e.g., HCPCS “timed” code 97530 which is defined in 15 minute units, on a given date of service. The provider would then report 4 units of 97530.

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 activities/procedures performed.

The following timed modalities and procedures should be reported no more than 4 (four) units per code per day per discipline; additional units require supportive documentation.

97032, 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97760, 97761, 97762.

General Guidelines for Therapeutic Procedures

(CPT codes 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761 and 97762)

Therapeutic procedures are procedures that attempt to reduce impairments and restore function through the applications of clinical skills and/or services.

CPT codes 97110, 97112, 97113, 97116, 97124, 97139 and 97140 are designed for one or more areas.

Use of these procedures requires the physical therapist to have direct (one-on-one) patient contact. Only the actual time of the provider’s direct contact with the patient proving a service which requires the skills and expertise of that provider is considered for coverage. Supervision of a previously taught exercise or exercise program, patients performing an exercise independently without direct contact by the provider, or use of different exercise equipment without requiring the intervention/skills of the therapist are not covered. The patient may be in the facility longer than that period of time, but only the time the provider 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. Use of these procedures is expected to result in improvement of the limitations/deficits in a reasonable and generally predictable amount of time.

Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code. CPT codes 97110, 97112, 97113, 97116, and 97530 describe several different types of therapeutic interventions. The expected goals documented in the treatment plan, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, because any one or a combination of these procedures may be used in a treatment plan, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

On each treatment visit the treatment record must support the codes billed and must specify which exercise/activity is being performed for each code billed. Documentation must also justify the coverage of multiple services/units of each code. In general, no more than 1-2 services/units of time for each code are needed on a date of service. Similarly, no more than 2-3 of these different codes are generally covered on a visit date. Documentation must support each code and the number of services/units of time. For example, 10 units of time for 5 different codes would be unlikely.