Orthopedic Coding Alert

Don't use 97110 as a one-size-fits-all exercise code

Do you know which type of provider contact you must maintain to report 97032, 97110 and 97124? If not, you may be coding physical therapy incorrectly.

Orthopedic surgeons submit over 1.3 million claims for electrical stimulation, therapeutic exercises and massage each year, according to Medicare data. Keep your PT billing on the up-and-up with four expert tips about the following CPT Codes

97032 - Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes

97110 - Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97124 - ... massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).

Step 1. Memorize 2 Basics

When reporting therapy codes, remember these fundamentals. Codes 97032, 97110 and 97124 require: 

The physician or therapist must stay with the patient throughout the therapy, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. CPT classifies 97032 as a modality that requires constant attendance. And, a physician or therapist must provide one-on-one direct patient contact to report therapeutic procedures (97110, 97124). 
 

Time-based reporting in 15-minute increments. Use units to indicate session lengths. Bill one unit per 15-minute period, Hammer says.
 
Although the codes indicate strict 15-minute increments, Medicare and some other payers allow practices to bill one unit of therapy if the therapy session lasts anywhere between eight and 22 minutes.

You should not report any timed therapy code if the service lasts less than eight minutes, but you can report two units of therapy if the session lasts between 23 and 37 minutes, according to CMS Program Memorandum AB-00-14.60, released in March 2000. Three units of the timed codes reflect 38 to 52 minutes of therapy.
 
Tip: The provider "must indicate one-to-one direct continuous contact" to bill 97110 and 97124, and he should document the total time he spent in specific patient service, Hammer says. Doing so can help you avoid
audit scrutiny.
 
Step 2. Know State Provider Rules

Many coders wonder who qualifies as a physical therapy provider. For the answer, look at two regulations.

First, CPT's therapeutic procedure notes state, "physician or therapist required." Therefore, 97110 and 97124 require that a physician or therapist perform the service, Hammer says.

A physical therapy assistant (PTA) may also provide therapy. But to bill the service, the encounter must "meet all the incident-to billing criteria," Hammer says.
Watch out: "Every state has its own requirements about who can bill the codes," says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky. Physicians can usually bill the therapy codes without a problem.

State laws, however, may restrict PTA procedures. A therapist must usually supervise the service, Corcoran says. In particular, if the PTA provides the service to a Medicare patient, the PT has to stay in the room during the therapy.

Step 3. Bill Specific Modality, Exercise

When identifying a physical therapy service, you should code the specific modality or therapeutic exercise the provider performs.

Example: If your practitioner uses electrodes to stimulate a patient's muscle(s), report 97032 per 15-minute period.

Reporting 97032 for electrical stimulation may seem like Coding 101. But coders often use one code as a catch-all.

Pitfall: Coders often mistakenly bill all exercise-related activities with 97110, Corcoran says. "But it's better, and more compliant, to be specific.

"You should bill 97110 if you perform exercises with the patient," Corcoran says.
 
But when the physician or PT provides a more specific procedure, such as massaging a car-accident patient's injured neck, you should instead report 97124. Using this code tells the payer that the physician or therapist performed massage.

Step 4. Avoid Concurrent Therapy

You cannot report any two CPT codes requiring either constant attendance or direct one-on-one patient contact to Part B carriers for the same patient during the same 15-minute period, according to a recent CMS "Medlearn Matters" article.

Therefore, you should not report both 97032 and 97110 concurrently. Medicare's assumption is that if you administer one-on-one patient contact to the patient, you can't also administer a constant-attendance procedure to her at the same time.

Note: For the full text of the CMS Medlearn Matters document, "11 Part B Billing Scenarios for PT and OT," go to the CMS Web site at http://www.cms.hhs.gov/medlearn/therapy/billing.asp.