CATEGORY
physical medicine and rehabilitation therapeutic procedures
CODE TYPE
Timed-based code
ADD-ON CODE
97546 (Work hardening/conditioning; each additional hour)
CPTs 97545 and 97546 are billed when the patient sustains a work-related injury and the therapist provides work rehab to restore his functional level and physical capacity so he can safely return to his occupation.
Work Conditioning:
A comprehensive, goal-oriented, non-multidisciplinary program designed to restore muscle performance (strength, power, and endurance), motor function, ROM, and cardiovascular and pulmonary status of the patient to enable the patient to return to work. It does not involve retraining of specific job skills or vocational exercise or work simulation. The primary goal of the work conditioning program is to restore the functional level and physical capacity of the patient to the pre-injury level.
Work Hardening:
A highly structured, multi-disciplinary program, tailored to the needs of the patient according to his/her specific job requirements to enable the patient to return to work. It consists of vocational training, and the use of real or simulated work activities to restore the patient’s physical and vocational functions. Work hardening program focuses on productivity, safety procedures, and prevention of re-injury by training the patient about proper biomechanics (correct lifting and positioning techniques), positioning, and work ergonomics. It usually takes several hours a day and several days per month. The main goal is to offer individualized exercises to get the patient ready for a particular job.
WORK REHABILITATION PROGRAM COMPONENTS
A comprehensive initial evaluation by a physical therapist to recognize the patient’s functional deficits that interfere with his specific work tasks and establish an appropriate treatment plan and goals.
- It includes interventions to address impairments, activity limitations, and/or participation restrictions that interfere with the performance of work tasks
- Patient education is a part of work rehabilitation
- The patient is educated about their injury, the healing process, rehab goals, home/self-care management, and guidance about adherence to all medical and therapy recommendations
- The patient is also educated about the proper biomechanics, safety techniques, and ergonomics to lessen muscle fatigue, improve productivity and prevent similar injuries in the future
- Therapy is also provided to overcome the fear of re-injury as it can greatly affect a patient’s functional status and work capacity
- Conditioning exercises and job simulation tasks in preparation for safe return to work
- Training the worker in performing work-related activities through the use of real or simulated work activities
CASE SCENARIO
Work Conditioning:
A food delivery man is injured in a road traffic accident while delivering food. The therapist develops a plan consisting of ROM exercises and strengthening exercises to develop muscular strength and improve balance but does not simulate his work environment and perform specific functional activities used during his job for 1 hour a day over six weeks duration.
Work Hardening:
A worker fell off the ladder at the job site with his left hand extended and sustained a Colle’s fracture. His work rehabilitation involves strengthening exercises and simulation of his work environment. The patient practices these tasks over and over while increasing the time duration of a session to build his endurance.
CODING GUIDELINES
It does not require direct (One-on-one contact) with a qualified healthcare professional.
97545
Initial 2 hours of work conditioning/work hardening
97546
Each additional hour after the initial two hours
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) |
REIMBURSEMENT GUIDELINES
For reimbursement of these CPTs following elements must be documented in the Physical Therapy Notes:
- Documentation of work-related injury to justify the medical necessity of skilled intervention by the therapist.
- Documentation of physical and functional deficits that interfere with the patient’s work.
- Documentation of the skilled services rendered by the Physical Therapist.
- Documentation of the functional goals that are achievable by the patient.
- Total direct time spent by the provider with the patient as well as the total duration of the treatment session.
- Documentation of weekly assessment and reevaluation using objective assessment tools and measurements to ensure improvement is being made toward a functional return to work goals.
- Part of an active treatment plan tailored to the specific needs of the patient.
- Six weeks is usually the maximum time allowed and written prior authorization beyond that and documentation of the medical necessity for further treatment if required.
INSURANCES COVERAGE CRITERIA
- Medicare has restricted coverage for this CPT and is only covered.
- Check specific insurance coverage guidelines when billing these CPTs with physical therapy evaluation or reevaluation as third-payer may limit simultaneously reporting these codes on the same day.
- CPTs 97545 and 97546 are frequently billed to workers’ compensation insurances when employees are injured on the job and need to get back to pre-injury working conditions.
