CPT-97761

“Prosthetic(s) training, upper and/or lower extremity(iies) initial prosthetic(s) encounter each 15 minutes”

CATEGORY

Orthotic and Prosthetic Training and Management

CODE TYPE

Timed based code
Billed in 15 minutes increment

ADD-ON CODE

NO ADD-ON CODE

PROSTHETIC TRAINING

Prosthetic management and training involve direct, one-to-one patient contact. This includes the assessment, fitting, and/or training in the use of prostheses.

  • Orthotics:

    • Orthotics are used to increase functional efficiency of function.
    • Used as adjunct along other physical therapy techniques like muscle strengthening, gait training, etc.

    Assessment Includes:

    • Physical capabilities
    • Level of amputation
    • Psychological status
    • Patient’s expectation
    • Complete Gait analysis

    CPT 97760 and 97761 are used for initial orthotic and prostheses assessment and training.

CODING GUIDELINES

» Require the professional skills of qualified healthcare professionals that includes:

  • Physical Therapist
  • Occupational Therapist
  • Chiropractors
  • Physical Therapist Assistant
  • Occupational Therapy Assistant

» Billed in 15 minutes increment

» Requires a therapy modifier (GP, GN, GO, CO, CQ)

» CMS 8-minute rule and AMA rule of Eights are applied

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

  • 99761 is considered medically reasonable and necessary if:

    • Indication for proper use and application of prosthetic is present.
    • Functional use of the orthotics is documented.
    • Distinct treatment procedures for both upper and lower extremity(ies).

REIMBURSEMENT GUIDELINES

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

    1. Total direct time spent by the provider with the patient as well as total duration of treatment.
    2. Documentation of results of assessment and patient’s functional level.
    3. CPT 97761 does not include cost of material or casting time. It is suggested to confirm specific insurance coding and billing criteria for casting supplies.
    4. Payment made not be made in following conditions:
    • If physical therapy services are provided to a patient in a hospital
      outpatient department
    • If physical therapy services are provided to an inpatient by an independently
      practicing healthcare provider.

CMS 8-Minute Rule:

A minimum of 8 minutes of direct contact with the patient must be provided for a single unit of 97124 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

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)

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CPT-97761