Wiki Physical Therapy Documentation for CPT 97110

[HeatherrLaw]

I am new to coding for Physical Therapy and would like some guidance or feedback on documentation. I have a PT who bills 97110 and 97140 typically. PT does document specific exercises performed during visit but does not state a start and end time. In some articles it does not talk specifically about time but in others it emphasized that 97110 is a time based code. My question is do the times need to be documented on note in order to bill code?

Example of current documentation for CPT 97110, 97110, 97140 coded on claim:
therEx:
horizontal ABD in supine (red tb) 2 x 12 reps
weighted shrugs (eccentric) #8 dumbbells with 5 second hold

UBE for 12 mins

Manual therapy - Right shoulder GHJ distraction grade 2 inferior & posterior.

Progressed with exercise today. will benefit from continue skilled PT services

 

[TThivierge]

Hi Heather
Ensure they put time and area body PT was performed on in documentation....use modifiers GP or GO or RT or LT or 96 or 97 with these CPT codes but check with payer, add referring doctor name on claim. They need to list pain in which body area and laterality see dx blocks M25, M54,G56 ,G57, M79 R10, flank pains, M54.2 neck pain. If constant pain for back/chronic see dx G89 blocks. Provider must document chronic pain and list body area then add dx G89.29 under it. Also proper Z dx code listed on claim last such as Z71.2 Exercise Counseling, Z73.6 Lack of limitations or disabled, see R53, or M62. If have limited strength can use the weakness or muscle spasm or sprains. Ensure document these phrases in record. Also if hurt from an injury ensure put date of injury on claim, how did it happen(see car accident, fall down stairs, or dog bite) Etc see dx blocks W01-W14, or X50 . Add too dx blocks plus where it happened see dx Y92 blocks (use last on claim). Oh yes DJD degenerative joint ds. is same as osteoarthritis. sSe dx code M47, M48, M11-M20. If paraplegia or have amputations add those too if documented. Add history if repeat pain or illness see dx blocks Z87-Z87 related to current treatment.
I hope this data helps you
Lady T