Eli's Rehab Report

Question: We keep getting denials for CPT 97535 and 97537. Would you explain why?

Alabama Subscriber

Answer: In this case, the devil is in the details. One key, however, is that 97535 (Self-care/home management training [e.g., activities of daily living 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) and 97537 (Community/work reintegration training [e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment], direct one-on-one contact by provider, each 15 minutes) both require direct one-on-one time with the patient.
 
That means you can’t bill these codes if your therapist spends time discussing with a patient’s family members how the patient should care for himself at home or how he should get around town. Also, because these are timed codes, you must have clear documentation of the time the therapist spends with the patient, and your documentation should clearly show what the therapist did.
 
Be clear: Specificity in documentation is particularly essential if both a PT and an OT (or an OT and SLP) are billing 97535 for the same patient.
 
You need appropriate documentation to support that each discipline has separate goals and that the therapists aren’t duplicating services. Avoid these common mistakes: You should not use 97535 for instruction in home exercise programs, using orthotics or adaptive devices for ambulation.
 
Medicare tends not to cover work-skill-related services. So don’t use 97537 in this context for a Medicare beneficiary and expect to be paid. Medicare typically covers 97537 when the patient is disabled permanently and training for re-entry into the community is necessary to reach specific functional goals. But if those goals are primarily social and/or diversional, you usually won’t be reimbursed.
 
Example: If a patient has to ride a bus to his therapy visits and/or to go grocery shopping, Medicare will probably cover four to six OT visits that address the necessary skills to ride the bus safely and independently. You can use 97535 or 97537 to bill for this type of treatment; just remember to include the appropriate supporting documentation.

 -- You Be the Coder and Reader Questions were reviewed by Marvel Hammer, RN, CPC, CCS-P, CHCO, owner of MJH Consulting in Denver.