Eli's Rehab Report

Nugget: Billing for 15-minute increments for one-on-one time spent with the patient is crucial when coding for reintegration training.

Because code 97537 covers many different aspects of community/work reintegration training, some PM&R billers are confused about whether they should bill separately for each different therapeutic technique.

Physiatrist coders who are billing the community reintegration training code (CPT 97537 , community/work reintegration training, [e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis], direct one-on-one contact by provider, each 15 minutes) should bill each 15-minute unit that the doctor or therapist spends on the training, regardless of the number of skills being addressed, says Sylvia Albert, CPC, a biller at AcSel Corporation, a reimbursement firm in Virginia Beach, Va.

If were training a patient with a new prosthesis, how to cook dinner, then we help the patient figure out how to cut the food. I dont know whether we need to list each separate task for each unit spent, says Mimi Wresh, who handles the billing at the office of Donna Reese, an occupational therapist in private practice in Lawrenceville, N.J.

The community/work reintegration training code was introduced in 1997, and it covers training that is medically necessary, when performed in conjunction with a patients individual treatment plan aimed at improving or restoring specific functions impaired by an identified illness or injury, according to the Medicare Part B Billing Manual for Physical Medicine and Rehabilitation. Some of the diagnoses that support medical necessity for this code include multiple sclerosis (340), anoxic brain damage (348.1), and traumatic amputation of leg(s) (897.0-897.7).

Though 97537 covers training for both vocational and nonvocational purposes, Medicares HCPCS 1999 states, When services provided by an occupational therapist are related solely to specific employment opportunities, work skills or work settings, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are not covered. HCPCS does cite examples of some vocational services that may be billed. For instance, an assessment of sitting and standing tolerance might be nonvocational for a mother of young children or a retired individual living alone, but would be a vocational test for a sales clerk.

Documenting Time Units

Its appropriate to bill 97537 on an outpatient basis as well as an inpatient, and the clinician may take the patient out to the community to work on various skills, says Albert. The CPT guidelines state that a physician or therapist must have direct (one-on-one) patient contact to bill this code.

Kathryn McCann, who deals with the code as regulatory counsel at the American Occupational Therapy Association, agrees. The therapist should only report those 15-minute increments that represent direct one-on-one time spent with each patient. She states that community reintegration training furnished in a group can be coded using either 97150 (therapeutic procedure[s], group [2 or more individuals]), or 97537. But she stresses that total time spent with the group when billing the 97537 code should be allocated among the clients participating in the group, according to the direct one-on-one time spent with each participant.

Tabitha Rautenstrauch, OT, a practicing occupational therapist at Piedmont Hospital Center for
Rehabilitative Medicine in Atlanta, often integrates other therapy codes into the time spent with her patients during community work training. Because the training is going to involve a lot of different codes, including therapeutic exercise (97110, therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) and other activities, depending on the patients diagnosis, I bill one unit for each 15-minute increment spent on each code, then list them separately. But Id be careful not to put too many of one code on a bill for more than four units of time.

For instance, if the therapist is treating a patient with burned wrists and hands (944.34-944.38), the therapist might first do 15 minutes of therapeutic exercises (one unit of 97110), then 30 minutes training the patient on how to wash his hair (two units of 97537).

There is no fixed limit on how many units can be billed for a given session, says McCann, although some local medical review policies issued by carriers and fiscal intermediaries indicate that the usual treatment session is generally about 45 minutes and that the medical necessity of additional time must be well documented.

Therapists should always check with their insurance providers to determine the applicable time limits allowed for therapeutic procedures.