Eli's Rehab Report

Many therapists are familiar with 97545 (Work hardening/conditioning; initial 2 hours), which is used when therapists are trying to get a patient in back-to-work condition. What many therapists and coders do not realize, however, is that one of the top workers' compensation red flags occurs when work hardening is documented, but work conditioning is actually performed. This is because work hardening simulates a specific occupation to allow the patient to practice a particular job, whereas work conditioning offers the patient exercises to get the body ready for employment. Because work hardening involves more specific goals, insurers recognize that it takes much longer to perform, and thus more units of 97545 and its add-on code, +97546 ( each additional hour), would be billed.

CPT 97545 and 97546 were added to CPT Codes in 1993 but are not covered by Medicare for treating an illness or injury because they relate to specific work skills. These codes, however, are frequently billed by PM&R coders to workers' compensation insurers when employees are injured on the job and need to get back to working condition.

According to Helene Fearon, PT, who represents the American Physical Therapy Association (APTA) as co-chairperson of the Health Care Professional Advisory Committee on the CPT Editorial Panel, the code descriptor for 97545 is printed as a 'slash' code work hardening/ work conditioning but the code is under review so we can try to get the two tasks separated because it's so difficult to describe one versus the other using the same code."

The following examples may help practices differentiate between work hardening and work conditioning and the amount of time normally spent on each.

Work Hardening

"Suppose a UPS driver was hit by a car while delivering a package " says Laureen Jandroep OTR CPC CCS-P CPC-H CCS consultant and CPC trainer for A+ Medical Management and Education in Absecon N.J. "To get him in condition to go back to work the therapists would offer him education on how to build strength perform exercises with him and simulate his work environment a warehouse a truck a delivery location and they would go over the steps of the job with him. They would practice these tasks over and over working to increase the amount of time spent during the rehabilitation period."

Fearon says that the APTA defines work hardening as "very specific to a return-to-work goal a specific job or a specific category of work and all of the programs in that work-hardening area should be geared toward getting the client back to that situation." Work hardening is multidisciplinary Fearon adds involving several types of providers (such as occupational therapists physical therapists vocational counselors etc.).

Time Spent on Work Hardening

Fearon says that work hardening takes place several hours a day and several days per month. "Because it's multidisciplinary work hardening cannot be described with a 15-minute code and the tasks involved [such as therapeutic exercise or activities of daily living] cannot be 'teased out' and billed using their own codes. That would be unbundling. APTA says the guidelines for work hardening should be four hours a day building up to eight hours a day for four to eight weeks. The first two hours are billed with 97545 and every additional hour should be coded using the add-on code +97546."

In fact many workers' compensation insurers insist that a significant amount of time be spent on work hardening. According to Section 325:993 of the Medical Society for the State of New York's (MSSNY's) Position Statement on Workers' Compensation 10-30 treatment days should be billed for a work-hardening program. Most workers' compensation insurers require that any work-hardening program that takes more than six weeks to complete needs written authorization to continue because six weeks is usually the maximum time allowed. Work hardening for some job skills may require additional time however and insurers do allow for that if the therapist or physician can prove medical necessity.

Work Conditioning

"Work conditioning is defined as a general approach to getting an individual back in condition to be able to work in some arena " Fearon says. "It could be as general as working at a job any job versus not working. It basically involves exercise but doesn't involve vocational rehabilitation or work simulation because those would be part of the work hardening."

For instance a 46-year-old construction worker falls off of a scaffolding on the job and injures his head requiring surgery and resulting in paralysis on the left side of his body. The therapist works with the patient for an hour a day for six weeks going over therapeutic exercises range-of-motion activities and strengthening exercises to allow the patient to gain enough strength and balance to find a new position.

According to the MSSNY's workers' compensation position statement "Non-multidisciplinary 'work conditioning' programs will be reimbursed utilizing existing PT OT and Physical Medicine codes" and not the work hardening/conditioning codes. This means that the construction worker's one-hour training would be billed using four units of the timed code 97110 (Therapeutic procedure one or more areas each 15 minutes; therapeutic exercises to develop strength and endurance range of motion and flexibility).

Workers' compensation laws vary on a state-by-state basis and there is no national standard that requires that the other PM&R codes be billed instead of 97545 when work conditioning is performed. However some states have found that requiring the timed therapeutic procedure code makes determining whether a therapist is billing for work hardening or the lower-paying work conditioning easier.

"Work conditioning can be done in a half-hour or an hour treatment so you wouldn't even bill the full code 97545 for it in many cases since two hours were not performed " Fearon says. In those cases she recommends that practices add modifier -52 (Reduced services) to 97545. In addition the documentation would have to be sent with a paper claim so the insurer could determine the payment.

Practices should not reduce their fees when filing a claim containing modifier -52 because workers' compensation reviewers often will see the modifier and automatically reduce the fee reported. Therefore if you have already reduced your fee the insurer probably will further discount it. The documentation you supply with your claim will help guide the payer to determine how much it will reimburse. When in doubt you should ask the insurer for help.

Get Workers'Compensation Policy in Writing

Remember to get your state's workers' compensation policy in writing before billing for any services because the guidelines vary so widely. You also should remember that your state workers' compensation bureau may not send out its updated manuals unless you specifically request one. Coders who want to ensure they are working with the most current set of rules can check the U.S. Department of Labor's Employment Standards Administration Web site. This is the division that administers workers' compensation nationwide and its Web site includes links to national and state information. The address for this Web site clearinghouse is www.dol.gov/dol/esa/public/owcp_org.htm. At the minimum each state's Web site will provide you with the contact information you need to obtain the most up-to-date information about your state's regulations and fee schedules.

" so we can try to get the two tasks separated because it's so difficult to describe one versus the other using the same code."

The following examples may help practices differentiate between work hardening and work conditioning and the amount of time normally spent on each.

Work Hardening

"Suppose a UPS driver was hit by a car while delivering a package " says Laureen Jandroep OTR CPC CCS-P CPC-H CCS consultant and CPC trainer for A+ Medical Management and Education in Absecon N.J. "To get him in condition to go back to work the therapists would offer him education on how to build strength perform exercises with him and simulate his work environment a warehouse a truck a delivery location and they would go over the steps of the job with him. They would practice these tasks over and over working to increase the amount of time spent during the rehabilitation period."

Fearon says that the APTA defines work hardening as "very specific to a return-to-work goal a specific job or a specific category of work and all of the programs in that work-hardening area should be geared toward getting the client back to that situation." Work hardening is multidisciplinary Fearon adds involving several types of providers (such as occupational therapists physical therapists vocational counselors etc.).

Time Spent on Work Hardening

Fearon says that work hardening takes place several hours a day and several days per month. "Because it's multidisciplinary work hardening cannot be described with a 15-minute code and the tasks involved [such as therapeutic exercise or activities of daily living] cannot be 'teased out' and billed using their own codes. That would be unbundling. APTA says the guidelines for work hardening should be four hours a day building up to eight hours a day for four to eight weeks. The first two hours are billed with 97545 and every additional hour should be coded using the add-on code +97546."

In fact many workers' compensation insurers insist that a significant amount of time be spent on work hardening. According to Section 325:993 of the Medical Society for the State of New York's (MSSNY's) Position Statement on Workers' Compensation 10-30 treatment days should be billed for a work-hardening program. Most workers' compensation insurers require that any work-hardening program that takes more than six weeks to complete needs written authorization to continue because six weeks is usually the maximum time allowed. Work hardening for some job skills may require additional time however and insurers do allow for that if the therapist or physician can prove medical necessity.

Work Conditioning

"Work conditioning is defined as a general approach to getting an individual back in condition to be able to work in some arena " Fearon says. "It could be as general as working at a job any job versus not working. It basically involves exercise but doesn't involve vocational rehabilitation or work simulation because those would be part of the work hardening."

For instance a 46-year-old construction worker falls off of a scaffolding on the job and injures his head requiring surgery and resulting in paralysis on the left side of his body. The therapist works with the patient for an hour a day for six weeks going over therapeutic exercises range-of-motion activities and strengthening exercises to allow the patient to gain enough strength and balance to find a new position.

According to the MSSNY's workers' compensation position statement "Non-multidisciplinary 'work conditioning' programs will be reimbursed utilizing existing PT OT and Physical Medicine codes" and not the work hardening/conditioning codes. This means that the construction worker's one-hour training would be billed using four units of the timed code 97110 (Therapeutic procedure one or more areas each 15 minutes; therapeutic exercises to develop strength and endurance range of motion and flexibility).

Workers' compensation laws vary on a state-by-state basis and there is no national standard that requires that the other PM&R codes be billed instead of 97545 when work conditioning is performed. However some states have found that requiring the timed therapeutic procedure code makes determining whether a therapist is billing for work hardening or the lower-paying work conditioning easier.

"Work conditioning can be done in a half-hour or an hour treatment so you wouldn't even bill the full code 97545 for it in many cases since two hours were not performed " Fearon says. In those cases she recommends that practices add modifier -52 (Reduced services) to 97545. In addition the documentation would have to be sent with a paper claim so the insurer could determine the payment.

Practices should not reduce their fees when filing a claim containing modifier -52 because workers' compensation reviewers often will see the modifier and automatically reduce the fee reported. Therefore if you have already reduced your fee the insurer probably will further discount it. The documentation you supply with your claim will help guide the payer to determine how much it will reimburse. When in doubt you should ask the insurer for help.

Get Workers'Compensation Policy in Writing

Remember to get your state's workers' compensation policy in writing before billing for any services because the guidelines vary so widely. You also should remember that your state workers' compensation bureau may not send out its updated manuals unless you specifically request one. Coders who want to ensure they are working with the most current set of rules can check the U.S. Department of Labor's Employment Standards Administration Web site. This is the division that administers workers' compensation nationwide and its Web site includes links to national and state information. The address for this Web site clearinghouse is www.dol.gov/dol/esa/public/owcp_org.htm. At the minimum each state's Web site will provide you with the contact information you need to obtain the most up-to-date information about your state's regulations and fee schedules.