Neurology & Pain Management Coding Alert

Question: How much time does our provider need to spend before qualifying for one unit of 97750?

Maine Subscriber

Answer: You should report one unit of code 97750 (Physical performance test or measurement [e.g., musculoskeletal, functional capacity], with written report, each 15 minutes) for each 15 minutes of a physical performance test or measurement.

CPT^® and Medicare use the threshold concept, meaning that the therapy codes can be billed when the service time has exceeded the threshold time of the code. For example, if the code descriptor is based on 15 minutes (like 97750), the service would need to be at least 8 minutes before it would be billable.

CPT^® addresses this in the front section “Instructions for Use of the Codebook.” Part of the CPT^® instructions state, “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes.”

Medicare addresses this in the Medicare Claims Processing Manual Chapter 5 20.2: “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 procedure codes for services delivered on any single calendar day using CPT^® codes and the appropriate number of 15 minute units of service. … When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT^® code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. …”

Remember: Third party payers may have a different rule for interpreting time per unit. Always check with the payer if you have questions about how to calculate units.

During the service represented by 97750, the provider evaluates the patient’s physical performance (such as the musculoskeletal and functional capacity) through tests and activities of daily living. The provider assesses the physical performance of the patient and completes a written report detailing the tests performed, results, and treatment options. He instructs the patient about activities such as those related to work and safety.