Eli's Rehab Report

As reported in the December 2000 Physical Medicine & Rehab Coding Alert, a new CPT code for cognitive skills development (97532, development of cognitive skills to improve attention, memory, problem solving, [includes compensatory training], direct [one-on-one] patient contact by the provider, each 15 minutes) was added to the physical medicine and rehabilitation (PM&R) section of CPT 2001. Clinical examples of how this code will be used can help your PM&R practice prepare for its use. Although most insurers have not yet established review policies outlining reimbursement guidelines and applicable diagnoses for 97532, the following information from practicing therapists offers a more thorough understanding of its proposed importance.

Purpose of Cognitive Skills Development

There are three categories of cognitive impairment: attention, short-term memory and problem solving. Cognitive skills training allows individuals with these types of impairments to live independently, return to work and function safely in their environments. Patients with diagnoses such as psychiatric disorders, brain injury and cerebrovascular accidents (CVA) may require cognitive skills development to help them regain many of their prior abilities.

Any patient who comes in with a neurological impairment requires a cognitive assessment, during which well determine whether the patient would benefit from further cognitive skills development training, says Tammy Miller, OTR, an occupational therapist with Integrated Health Services, an inpatient/outpatient skilled rehab and skilled nursing facility in Gainesville, Fla. Many of the patients with cognitive problems suffer from CVAs (436) or may have a combination of symptoms, such as problems taking their medication or malnutrition. They may need help establishing a routine to achieve all of their daily goals, and teaching them cognitive skills can help with that.

Kim Warchol, OTR/L, president of Dementia Care Specialists Inc., an occupational therapy private practice outside of Chicago specializing in dementia care, education and products, says that treatment and evaluation occur simultaneously with the patients therapy. She introduces modified activities and conditions to the patient, assesses their effectiveness, and either continues the therapy or alters it, depending on the patients outcomes. Therefore, she says, 97532 is occasionally billed when a patient is being assessed and trained at the same time.

Both Miller and Warchol perform their therapy in functional contexts, such as therapy houses (an area in the therapy setting designed to look like an actual house) or in the patients home or nursing facility. Warchol says the best outcomes are achieved when training occurs in the environment where the patient will most likely be expected to function.

For example, a 65-year-old female patient suffering from Addisons disease (255.4) also suffers from associated dementia (294.8). Due to steady doses of corticosteroids, the patients condition is stabilized while at the rehab facility. After the patient returns to her home, however, she still experiences problems with short-term memory loss, causing her occasionally to forget to take her medication, which could be life threatening.

The therapist goes to the patients home and observes the patients activities during dinner, which is her normal medication time. As the therapist watches the patient, he or she assesses the patients cognitive function level to determine the best way to help improve her cognitive function skills. The therapist then shows the patient a series of routines so she can incorporate the medication administration into her daily dinner schedule. The therapist also works with the patient on activities to improve her short-term memory, such as showing her how to pre-plan her activities, incorporate them into her schedule and backtrack if she discovers that she has forgotten any important steps in her day. This would be billed as 97532, with the appropriate number of units, depending on how long the therapist is with the patient (see more on billing 97532 in the shaded box More Information on Billing the New Time-based Therapy Codes at the end of this article).

Cognitive Skills Development vs. ADL

Cognitive skill development training in the example above will help the patient strengthen her ability to set and maintain a routine, but differs from standard activities of daily living training (ADL, 97535). It would be difficult to bill cognitive skills development as ADL because, with cognitive skills, were assessing new problem-solving skills as well as new learning abilities, and that occurs on an ongoing basis, Miller says. Were really looking at new learning with a functional task, and it may not be a task related to basic ADL or self-care.

Warchol agrees that there is a fine line between cognitive skills development training and ADL. I may choose to use the new code (97532) if I had the client engaged in some training to improve cognitive functioning, if the cognitive disability was reversible and could be improved, or if I had the client engaged in an activity that was for the primary purpose of assessment/probing for change and improvement in function.

I would use the ADL code (97535) if I was providing caregiver training as a part of a functional maintenance plan, Warchol says. For example, if a stroke patient suffering from right-side paralysis was leaving a nursing home and returning to the community, the therapist might take the patient into a mock-up of a house and show him how to bathe, dress and feed himself using only his left side. This would most likely be billed as ADL.

I have been taught to always look at the outcome of the intervention to best decide which CPT code to use, Warchol says. If the therapy has helped improve the patients cognitive skill level, 97532 may be the best choice. Conversely, if the patient is learning new ways to function in his daily life, the ADL/self-care code is often a good, safe choice, Warchol explains.