Part B Insider (Multispecialty) Coding Alert

Billing for CPT 97755 just became much more complicated

It's been a source of  confusion for coders since it took effect in January. And now it'll be ensnared in a web of confusing edits.
 
New code 97755 (Assistive technology assessment [e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility], direct one-on-one contact by provider, with written report, each 15 minutes) has raised questions because providers haven't been sure how to report this code. For instance, it's been unclear how many units of the code you can report in one day.

Cigna Healthcare and a few other carriers have already introduced local coverage decisions explaining that physicians had to justify the use of 97755 by documenting the problem that required the tests, the tests performed and the test reports themselves. You couldn't bill more than five units of any type of PM&R services in one day, unless you submit documentation proving the medical necessity of these services.

As of April 1, 97755 will be a component of 21 different codes, mostly from the evaluation and  therapeutic services and physical medicine and rehab sections of the CPT book. The Column 1 codes are 92597-92604, 92607-92609, 97001-97004 and 97504-97535. All of these edits except the ones involving 97504-97535 have a "0" in the modifier column, meaning you can't override them.

Also, 97755 will become mutually exclusive with 97703 (Checkout for orthotic/prosthetic use, established patient, each 15 minutes).

The confusion surrounding 97755 is "fairly typical when a new code comes out in an area that's relatively subjective," as opposed to something clear-cut like cast removal, says Jean Acevedo with Acevedo Consulting in Delray Beach, Fla. She compares it to other hard-to-define recently introduced codes like nutrition management for diabetics. Usually, it takes a while for the carriers to begin writing policies, she notes.

But she points to the fairly extreme clinical example in CPT Changes 2004 -- An Insider's View: a 29 year old man, recently discharged to his home from the rehab hospital with no voluntary motion except for head rotation, and dependent on a ventilator for respiration.

"It doesn't surprise me that this particular code would be bundled into the evaluation codes," adds Acevedo. "I don't know that anybody that's used it yet." She notes that in Miami, the code pays $36.68 per unit, while a basic physical therapy evaluation (97001) pays $79.52.

These new edits make perfect sense, adds Judy Thomas with the American Occupational Therapy Association in Tucson, Ariz. "It's an assessment unto itself," and shouldn't necessarily be performed alongside other evaluations, she notes. "It's a very high tech code. This is not for low-tech assistive technology or adaptive equipment."

This code is "for people who are severely disabled and need a lot of assistance with doing their activities of daily living," Thomas notes. She gives the example of a wheelchair-bound patient who needs "something that was computer generated with switches or devices that they could be used either with breathing or with head movement."

"This is not for teaching people how to use a reacher or something like that," Thomas adds. Also, the code is probably intended for a younger population than Medicare beneficiaries, people who've suffered an automobile or diving accident that resulted in spinal damage, and who need "sophisticated technology" to be productive.

"We hope people do not try to use it inappropriately, because it is for very specialized assessment," performed by people with special certification in assistive technology, Thomas insists. And also, by the time someone requires this type of assessment, they've already undergone occupational or physical therapy separately. "It would not be appropriate to use with any other type of code," she adds.

Also, 97750 (Physical performance test for measurement... with written report, every 15 minutes) became a component of range of motion measurement codes 95851 and 95852.

There were already other edits considering 97703 a component of fitting and training code 97504, and experts have recommended avoiding 97703 unless you spend a lot of time examining the patient during functional activities to make sure the orthotic fits properly.