CATEGORY
Physical medicine and rehabilitation therapeutic Procedures
CODE TYPE
Timed-based code
Billed in 15 minutes increment
ADD-ON CODE
No add-on code
THERAPEUTIC ACTIVITIES
Code CPT 97530 consists of all therapeutic activities that cover a wide range of rehabilitation exercises. It includes methods which involve whole body movements and overhead activities to progressively improve performance.
These workouts often focus on mobility, strength, balance, and coordination as their main objectives.
Types of Activities that are included:
- Bending
- Pulling
- Twisting
- Lifting
- Carrying
- Catching
- Overhead activities
CODING GUIDELINES
- One-on-one therapy code (involves direct contact with patient)
- Billed in 15-minutes increment
- Require a therapy modifier (GP, GN, GO, CO, CQ)
- CMS 8-minute and AMA rule of Eights are applied
CMS 8-Minute Rule:
A minimum of 8 minutes of direct contact with the patient must be provided for a single unit of 97530 to be billed.
| Units | Number of Minutes |
|---|---|
| 1 unit | ≥ 08 minutes through 22 minutes |
| 2 units | ≥ 23 minutes through 37 minutes |
| 3 units | ≥ 38 minutes through 52 minutes |
| 4 units | ≥ 53 minutes through 67 minutes |
| 5 units | ≥ 68 minutes through 82 minutes |
| 6 units | ≥ 83 minutes through 97 minutes |
| 7 units | ≥ 98 minutes through 112 minutes |
| 8 units | ≥ 113 minutes through 127 minutes |
The pattern remains the same for treatment times of more than 2 hours.
AMA Rule of Eights:
“AMA guidelines state that incremental intervals of treatment performed on the same session may be added together when determining total time in direct contact of a qualified healthcare provider with the patient is necessary. Each unique timed service is counted separately instead of combining the time from multiple units”
PHYSICAL THERAPY MODIFIERS
Below mentioned modifiers are used when services are provided for the respective plan of care:
| MODIFIERS | PLAN OF CARE |
|---|---|
| GP | Outpatient Physical Therapy |
| GO | Outpatient Occupational Therapy |
| GN | Outpatient Speech-Language Pathology |
| CQ | Outpatient Physical Therapy by a Physical Therapist Assistant (completely or partially) |
| CO | Outpatient Occupational Therapy by an Occupational Therapy Assistant (completely or partially) |
BILLING GUIDELINES
- The 97530 CPT code is commonly billed with procedure code CPT 97140 (manual therapy techniques) with modifier 59 to override CCI edits.
- According to CCI guidelines, it is only appropriate to report these procedures separately when performed in two distinct and separate 15-minute intervals.
TOTAL NO. OF BILLABLE UNITS
06 units are allowed per date of service by CMS but more units can be billed if justified by medical notes.
MEDICAL NECESSITY
- Therapeutic activities (CPT 97530) are considered medically necessary for patients needing a broad range of rehabilitative techniques that involve movement.
- Broad range of techniques designed to improve movement of either a single body segment or multiple body regions.
- The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the professional skills of a therapist and are designed to address a specific functional need of the patient.
- These dynamic activities must be part of an active treatment plan and be directed at a specific outcome.
REIMBURSEMENT GUIDELINES
For reimbursement, following elements must be documented in the Physical Therapy Notes:
- Documentation of medical condition that justify medical necessity of manual therapy
- Total direct time spent by the provider with patient
- In order to meet coverage criteria, therapy services must have these requirements in common:
- Patient condition has the potential to improve
- Documentation of improvement from therapy using objective assessment tools, Measurements and functional accomplishments
- Therapy is not being provided to treat loss of function in conditions that are transient and expected to resolve spontaneously reversible
- Therapy plan must be developed by a qualified/certified healthcare professional
