Eli's Rehab Report

Question: The physical performance test code (97750 ) seems very broad. Can you please tell me what exactly a therapist does to bill for this code, and how to document it?

Mississippi Subscriber

Answer: These tests are often performed to monitor the effectiveness of a patients rehabilitation program. For example, a truck driver injures his back and undergoes physical and occupational therapy before returning to work. The physiatrist and therapist believe that the patient is well enough to go back to his job, so the therapist 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 then the therapist writes his or her assessment of the patients condition. The documentation should include the date, the patients name, 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. Patients 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 patients file must include a copy of the current treatment plan, which must be signed by the patients physician every 90 days.

Any additional tests that are performed, such as the patient performing floor-to-waist lifts or stair climbing, require separate documentation explaining the reason for the test and the assessment. Because this is a timed code, there is no need to report the number of areas tested, and the time should be added together and reported as separate units of the code. For instance, if the therapist spent 30 minutes with the patient, two units of 97750 would be reported.