Neurology & Pain Management Coding Alert

Question: A physician comes to our office to perform trigger point injections for myofascial pain. He provides an evaluation and performs the injections, for which we are paid. He also provides therapeutic stretching and myofascial release with the patient, reporting 97530 and 97140, respectively. These last two codes are suddenly being rejected universally. What's the problem?

Georgia Subscriber

Answer: Although inconsistent, your payers' refusal to reimburse both 97140 (Manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes) and 97530 (Therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes) for the same session is justifiable.

According to identical statements in several Medicare carrier local medical review policies (LMRPs), "Separate payment is not made for myofascial release/soft tissue mobilization performed in conjunction with joint mobilization or manual manipulation (97140). If any of these procedures are performed, only one is reimbursable per patient on the same date of service." National Medicare guidelines also state specifically, "The term 'therapeutic activities' [as used in the descriptor for 97530] is considered to cover a broad range of activities, and generally other modalities of physical therapy are not payable on the same date of service" [emphasis added]. In other words, if you report 97140, you cannot also report 97530, and vice versa.

Requirements for reporting therapy codes 97010-97546 are particularly demanding. According to Medicare guidelines, the ordering physician must have taken a history from the patient, carefully examined the patient and established an etiology or diagnosis for the patient's complaints prior to ordering therapeutic activities. The patient must have a condition for which therapeutic activities can reasonably be expected to restore or improve the functioning of the patient, and the patient's condition must be such that he or she is unable to perform therapeutic activities except under the direct supervision of a physician or physical therapist.

When therapeutic activities are ordered, the type of activity and duration of therapy prescribed must be documented. For each day that therapeutic activities are billed, there must be a progress note in the patient's medical record "stat[ing] the patient's diagnosis along with some comment about change or lack of change since the last visit. Also, there must be an explicit description of the service provided to the patient. Specifically, the exact type of activity the patient performed must be listed, and the duration of activity must be indicated in the medical record," Medicare says.

In addition, the billing physician must maintain an established treatment plan in the patient's clinical record. The physician must see the patient at least every 30 days and review, initial and date the treatment plan, which must be kept on file in the physician's office and available for carrier review on request.

Many carrier LMRPs mandate that it is not reasonable or medically necessary to perform any individual procedure for more than 30 minutes a day. Therefore, claims for more than two units of 97140 or 97530 are likely to face rejection.