CPT-97537

“Community/work reintegration, in training direct
one-on-one contact, each 15 minutes”

CODE TYPE

Timed based code Billed in 15 minutes increment

ADD-ON CODE

No add-on code

Community/Work Reintegration

The process of integration of an individual back into society and the work environment to make him an active member of society following a brain injury such as stroke, TBI, or MVA. The patient is trained in activities that will assist him with mobility, seating systems, and environmental control systems for navigating the community.

Training includes:

Independent Living
Social participation
Activities such as cooking, shopping, driving, and managing money

Return to normal activity is the main objective of Physical Medicine Rehabilitation and requires a multidisciplinary team approach consisting of a physical therapist, vocational and occupational therapist and physician etc.

Community integration training is usually performed with other therapeutic procedures such as gait training (97116)
and self-care management training (97535).

Coding Guidelines

Require the skills of qualified healthcare professionals that includes:

Physical Therapist
Occupational Therapist
Chiropractors
Physical Therapist Assistant
Occupational Therapy Assistant

» Billed in 15 minutes increment
» Sometimes CPT 97537 is not paid separately and is bundled into other physical therapy services provided on the same day
» The billing guidelines for CPT 97537 varies from state to state
» Requires physical therapy modifier (GP, GN, GO, CO, CQ)
» CMS 8-minute rule 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 97537 to be billed:

CMS 8-Minute Rule:

A minimum of 8 minutes of direct contact with the patient must be provided for a single unit of 97537 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)

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.

Reimbursement Guidelines

For reimbursement following elements must be documented in the Physical Therapy Notes:

Documentation of medical condition to justify the medical necessity
Documentation of the necessity of skill intervention required as well as documentation of the type and level of skilled assistance given to the patient and continued analysis of patient progress (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)
Total direct time spent by the provider with the patient
To meet coverage criteria, therapy services have these requirements in common:

The patient’s condition has the potential to improve and Community/work reintegration training is reasonably expected to return the patient into society and the work environment
Documentation of improvement from therapy using objective assessment tools and measurements and functional accomplishments
The therapy plan is developed by a qualified/certified healthcare professional

Part of an active treatment plan tailored to the specific needs of the patient

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CPT-97537

CATEGORY

CODE TYPE

ADD-ON CODE

Community/Work Reintegration

Coding Guidelines

CMS 8-Minute Rule:

CMS 8-Minute Rule:

Ama Rule Of Eights:

Physical Therapy Modifiers

Total No. Of Billable Units

Reimbursement Guidelines

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