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Eli's Rehab Report

Use Therapy Codes for Pulmonary Rehabilitation, Not Cardiac

Published on Wed Aug 01, 2001

Over 15 percent of patients seeing rehabilitation physicians suffer from cardiac or pulmonary conditions that require the rehabilitative care of a physiatrist or therapist. While physiatrists manage these diseases through a combination of exercise, dietary consulting, stress management and family counseling, therapists perform a range of services from manual therapy to therapeutic exercise. Many coders are not familiar with coding for these types of diagnoses, since most of their patients normally undergo cognitive or musculoskeletal therapy. The following tips can help differentiate between these two potentially difficult procedures.
 
Cardiac Rehabilitation
 
While cardiac rehabilitation most often involves therapeutic exercise (97110) and physical and occupational therapy evaluations (97001, 97003), these codes are normally not covered for cardiac rehabilitation programs when billed on their own. Despite that fact, clinics and independent therapists mistakenly assign therapy modality codes for these services using heart disease ICD-9 codes, and their claims are rejected.

Sue McCallum, a coding supervisor with Randall/ Stuart Billing in Washington, D.C., who works for four rehabilitation clinics, says that using the PM&R codes for the modalities seems to be the logical choice, but is incorrect. "One of our cardiac rehabilitation bills was sent to us by a client. The patient, who had coronary bypass surgery, was in rehabilitation at an outpatient clinic to find low-stress ways to rebuild muscle and increase his cardiac strength. The clinic sent us their explanation of benefits (EOB), which showed that Medicare had rejected all of their rehabilitation codes. They were stumped. We looked up their local policy and found that individual physical and occupational therapy codes are not covered for this type of condition. The rehabilitation has to be billed by the physician under the overall cardiac rehabilitation codes."

The two cardiac rehabilitation codes, which are found in the Intracardiac Electrophysiological Procedures section of CPT (rather than the Physical Medicine and Rehabilitation section), are CPT 93797 (physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring [per session]) and 93798 (... with continuous ECG monitoring [per session]). The attending physician must refer the patient, and the treating physiatrist must be on the premises during the therapy and trained in advanced life-support techniques and exercise therapy for coronary diseases. Also, the facility must be equipped with all emergency lifesaving equipment medically necessary for a cardiac patient.  
 
Greg Sweeney, PT, of the Cardiac Rehabilitation and Prevention Center at New York University Medical Center in Manhattan, says that a session billable under these codes would normally last about 90 minutes total. "For outpatient cardiac rehabilitation, we would have the patient perform three modalities of 15 minutes each, with rest and monitoring of their vital signs during and in between sessions. Training would include therapeutic exercises on the treadmill, stationary bikes, the stairmaster, and maybe some rowing machines, but nothing more comprehensive in the early stages."
 
Note: Some carriers require continuous ECG monitoring during all exercises for cardiac rehabilitation.
 
Also, Sweeney says, the physiatrist would look over the patient's records for the session, revise exercise routines, and talk with the patient about stress management and diet. This entire 90-minute package would be billed using 93797 or 93798.

Most Medicare carriers cover up to three cardiac rehabilitation sessions per week for 12 weeks, after which an extension can be sought on a case-by-case basis. This can be accomplished by writing a letter to the carrier explaining the special circumstances, with documented proof that the patient is improving.
 
Conditions Stemming from Heart Disease
 
Some patients may see an independent therapist to rebuild left-arm strength or build up atrophied muscles following the completion of their cardiac-rehabilitation program. Such conditions, which are normally not significant enough to require an extension, can be billed by a therapist when medically necessary. "If a patient is being treated by a therapist for weakness in his left arm, then you would code the claim using the muscle-weakness diagnosis (728.9)," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, owner of A+ Medical Management and Education, a coding and reimbursement consulting firm and a national CPC training curriculum site in Egg Harbor City, N.J. Strengthening exercises for the left arm would be coded using the therapeutic procedure code, 97110. "You wouldn't bill a heart surgery code if you're treating left-arm weakness."
 
Pulmonary Rehabilitation
 
Unlike cardiac, there is no specific code for pulmonary rehabilitation. Patients recovering from pulmonary conditions, such as emphysema (492.8) and chronic obstructive pulmonary disease (COPD, 496), often go through a series of training sessions with therapists to assess the patients' lung capacity and learn ways to continue appropriate exercises at home. Most Medicare carriers cover four of the physical medicine and rehabilitation modality codes for pulmonary patients, as outlined below:

  • 97110 (therapeutic procedure). "This is often used to help patients develop endurance on aerobic activities," McCallum says. For example, therapists can work with lung disease patients by showing them exercises that can help increase strength with the least impact on the lungs, such as slow, paced walking on a treadmill.

  • 97112 (... neuromuscular re-education of movement). This modality is often used for patients who may get lightheaded when they stand up or perform activities. "The therapist would work with them on ways to regain balance and maintain coordination," McCallum says. "For example, they may teach the patient how to find support and slowly stand from a sitting position to decrease the possibility of syncope."

  • 97116 (... gait training). Therapists frequently work with patients on activities such as stair climbing, sometimes timing the activity so they can measure progress in later sessions.

  • 97530 (therapeutic activities, direct [one-one-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes). "This is usually performed by occupational therapists," McCallum says. "They are very effective in simulating the patient's home setting so he or she will think of new, less strenuous ways of doing things. That way patients can save their energy for other activities."

    • Also, most carriers reimburse for 97750 (physical performance test or measurement, each 15 minutes), which requires the inclusion of a written report in the patient's chart discussing the test and the results.

    As with all therapy codes, billing for these modalities requires an expectation that the patient is going to improve, both physically and from a respiratory standpoint. "Therapy modalities will not be reimbursed for a patient whose condition is not reversible or is fatal," McCallum says. 
     
    Chest Physical Therapy
     
    Although postural drainage (manipulating the chest wall to facilitate lung function) is normally covered for pulmonary patients, some carriers have specific guidelines regarding which personnel are authorized to perform the service. According to HCFA, "Chest physical therapies can be carried out safely and effectively by nursing personnel. However, in some cases, patients may have acute or severe pulmonary conditions involving complex situations in which these procedures or therapies require the knowledge and skills of a physical therapist or respiratory therapist."
     
    When the pulmonary staff (respiratory technician, pulmonologist or nurse) performs the chest therapy, the correct code is 94667 (manipulation chest wall; initial demonstration and/or evaluation). However, when this service is performed by a physical therapist, it should be billed using 97140 (manual therapy techniques, each 15 minutes). In these cases, therapists should retain the treating physician's request for treatment and the details of the patient's condition in case proof of medical necessity of a therapist's services is requested.
     
    Private insurers are normally less rigid in their requirements for coding respiratory therapy. For example, Aetna U.S. Healthcare's policy for pulmonary rehabilitation states that as long as one of their listed ICD-9 codes is attached to the claim and medical necessity can be proven, any therapy code from the code range 97010-97799 can be reimbursed.  

    However, regardless of which insurer is being billed for the service, almost all carriers have frequency limits for such rehabilitation, so always request information from your carrier in writing before billing for any cardiac or pulmonary rehabilitation services.

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