Eli's Rehab Report

See how 97535 can adapt to computer-based programs

Don't miss out on the reimbursement for 97535 when your therapist gives a patient advice on activities of daily living (ADL). If you formalize one ADL session per treatment plan and establish medical necessity, then feel free to charge this code.

Get to Know CPT 97535

Code 97535 (Self-care/home management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment] direct one-on-one contact by provider, each 15 minutes) encompasses a lot of services. According to the Colorado Chapter of the American Physical Therapy Association (APTA), it includes (and is not limited to):

• instructing a patient or caregiver regarding transfer techniques on and off the toilet and getting in and out of the shower or bathtub

• instructing a patient or caregiver how to use adaptive equipment during meal preparation and feeding

• instructing a patient or caregiver in safety techniques to transfer from the bed to a chair or bedside commode.

Take a closer look: The code descriptor includes the phrase "use of assistive technology." CPT added this phrase to 97535 in 2002. If you're using an older CPT book, you may miss that, says Judy Troy, senior policy manager of the public affairs division of the American Occupational Therapy Association (AOTA).

As for how frequently you can use 97535, many payers, such as Cahaba Government Benefit Administrators for Alabama, warn that you should not report more than one to two service units on any given date.

Note: If you're wondering if ADL changes from patient to patient, you're not alone. The criterion for ADL is this: (1) a change in the level of assistance the patient needs, or (2) the modification of the task from normal due to the patient's disease or injury, says Pauline Franko, PT, MCSP, president of Encompass Consulting and Education LLC in Tamarac, Fla. In that sense, "ADL is ADL." For example, the ADL for a patient following a total knee or total hip replacement will differ from that of a patient with a lumbar spine injury.

"Although occupational therapists always have an ADL or IADL (Instrumental Activities of Daily Living) component to treatment, we encourage them to look at the full range of CPT codes and choose the descriptive code(s) in the context of what their treatment consisted of and the goal of improvement," Troy says. If your provider's services meet the definition of ADL, then you should report it.
 
Red flag: Make the distinction right now between ADL and an exercise program. You should not use 97535 for strengthening purposes, but for improving the patient's functioning. In other words, you should use 97535 only for ADLs like those listed above, compensatory training for ADL, safety procedures, and instructions for using adaptive equipment. You should also veer away from this code when your therapist instructs the patient how to use orthotics or assistive devices for gait.

Use This Documentation Guide

Your best bet: Get specific. Have a treatment plan and include ADL on that course of action. "Your documentation needs to clearly identify the ADL, such as transfer training for bathing or instruction to family members on specific techniques," Franko says. "Be consistently thorough, both at the evaluative stage and during the use of skilled techniques."

According to Cahaba Government Benefit Administrators Midwest of Iowa and South Dakota, your provider needs to address the specific ADL and specific safety procedures, what adaptive equipment the therapist used, and document the instruction along with the limitation or deficit the provider expects this training will affect. In other words, the documentation must relate to the functional goals attainable by the patient.

"As with documentation of any code, the therapy provider must describe for the payer his or her clinical reasoning and expertise necessary to provide the treatment," Troy adds.

Don't forget to establish medical necessity. Make the documentation show that the patient or caregiver has the capacity to learn from instructions and that this service is part of an active treatment plan directed at a specific outcome, some payers recommend.

Don't Be Duped by a Group Setting

If your provider performs an individualized ADL therapy service in a group setting, you shouldn't count 97535 out just because the descriptor states "direct one-on-one contact." Your therapist can still provide distinct individual attention to each group member.

For example: Three patients, all knee amputees who have recently been fitted with lower-limb prostheses, arrive in your office for therapy. The therapist performs ADL training, which includes stump management techniques, for a total of 60 minutes. The therapist instructs each of the patients one-on-one for 10-12 minutes to accommodate their individual goals or needs during this 60-minute demonstration. The therapist needs to be sure all three patients compliantly use their particular techniques in their home setting.

Result: You'd report one unit of 97353 and one unit of 97150 (Therapeutic procedure[s], group [2 or more individuals]) for the balance of the 60-minute period for each patient. A therapeutic procedure, by definition, is a way to effect change by applying clinical skills and/or services that attempt to improve function. In other words, you'd report this code combination three times, once for each patient the therapist worked with.

The reason is that this group has both the knee amputation and prostheses in common, so you can use this as the unifying element necessary to report the group code (97150). Also, the therapist has direct on-on-one contact with each individual patient for 10-12 minutes, so you can report the ADL code (97535).

Change With the Times

As technology advances, so do medical treatments--but never fear: Some CPT codes already adapt. Patients with upper-extremity over-use musculoskeletal disorder problems (such as carpal tunnel syndrome, thoracic outlet compression, rotator cuff or related problems, tennis elbow and other tendonitis problems, plus lower-back dysfunctions) may benefit from ADL training provided through Web-based programs.
 
If your therapist stays with the patient during the first page plays and shows her how to navigate the pages or features, you can charge this service as 97535 for the time spent one-on-one with the patient. Remember, your documentation must meet your payer's minimum time requirement (such as Medicare's eight-minute rule). You can also charge this code if your therapist talks to the patient about questions related to her everyday activities or wants to clarify issues specific to her situation.