Eli's Rehab Report

Billing for functional capacity exams doesn't have to be so strenuous as long as coders remember that before they can bill CPT 97750 , the physician must write a report of the exam results.

In most cases, 97750 (Physical performance test or measurement [e.g., musculoskeletal, functional capacity], with written report, each 15 minutes) can be billed with an E/M service if the documentation demonstrates that the physiatrist performed separate and distinct services, says Michael Calabrese, president of Reliant Billing and Consulting in Clifton, N.J.

For example, suppose a truck driver injures his back and undergoes physical and occupational therapy before returning to work. The physiatrist evaluates the patient and believes he is well enough to go back to his job, but first performs an FCE to confirm that the patient will be able to load boxes on and off his truck. He asks the patient to bend to the floor, pick up 50 pounds, and lift it onto a shelf at shoulder level. The patient successfully repeats the procedure four more times, and the physiatrist writes his assessment of the patient's condition. For this visit, the physiatrist should bill 97750 and the appropriate E/M service (99211-99215) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended.

The chart documentation should include the date, the patient's name, the tasks performed, and the assessment. For example, "Based on testing, this patient can return to work, although he is advised to lift no more than 50 pounds a maximum of 25 percent of the day, 35 pounds for half of the day, and 20 pounds for the remaining 25 percent of each workday. Patient should report back with any problems immediately. Patient's muscle strength and functional capacity is rated at 75 percent of his normal capacity, and he is advised to continue his range-of-motion and strength-training exercises at home on his own." In addition, the patient's file must include a copy of the current treatment plan, which must be signed by the physiatrist every 30 days.

Because this is a timed code, the total time spent on the FCE should be added together and reported as separate units of the code. For instance, if the physiatrist or therapist spends 30 minutes with the patient, report two units of 97750.

Physiatrists and therapists who perform functional capacity exams must include a written report of the exam results in the patient's file, or 97750 cannot be reported. Some practices are tempted to bill separately for the physiatrist's work writing the report, using either 99090 (Analysis of clinical data stored in computers [e.g., ECGs, blood pressures, hematologic data) or 99080 (Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form).

However, Calabrese says, no additional codes should be used for the work involved in writing the report. "Since a report is being provided, no direct analysis of the data is being performed by the treating doctor. Therefore, no additional coding would be appropriate. Just because some people are billing for it this way doesn't make it right."

The November 2001 CPT Assistant echoes Calabrese's assertion, stating, "Post-service effort [for 97750] includes writing-up of report/documentation of treatment, calls to the referring physician to report progress, and communication with other team members."