Billing and Coding: Home Health Physical Therapy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim

Title XVIII of the Social Security Act, §1835(a)(2)(A) procedure for payment of claims of providers of services

42 CFR §484.2 Definitions

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, §11.2 Electromagnetic Therapy - National Coverage Decision was made to allow for Medicare coverage of electromagnetic therapy for the treatment of certain types of wounds

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, §6.2.4 Coding

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Home Health Physical Therapy L34564.

Coding Guidelines

1. For CPT^® codes 97010 (Hot or Cold Packs), 97018 (Paraffin Bath), 97022 (Whirlpool), and 97026 (Infrared Application), documentation must reflect medical necessity and be made available to the Medicare Administrative Contractor (MAC) upon request.

2. When both a modality/procedure and an evaluation service are billed on the same day, the evaluation may be reimbursed only if the medical necessity for the evaluation is clearly documented.

3. CPT^® codes 95851 (range of motion measurements and report), 95852 (Range of motion measurements hand, with or without comparison with normal side) and 97750 (Physical performance test or measurement [e.g., musculoskeletal, functional capacity], with written report, each 15 minutes) should not be billed with an initial evaluation.

4. CPT^® code 97140 (Manual therapy techniques) excludes manipulation performed in the home setting.

5. When billing a “z” code as a diagnosis code, documentation should include the name of the orthotic/prosthetic device, date the patient received the device and the date training/teaching began.

6. Associated with several procedure codes are guidelines on the number of visits generally needed to accomplish the task. If more visits are needed the documentation should support the necessity of the additional visits.

7. As of July 1999, Physical Therapy must report time spent with the patient in 15-minute increments. The following code should be used by Physical Therapy:

• G0151 Physical therapy

8. The related LCD is based on impairments of structure/function and functional limitations. While the pathophysiology is an important factor, the purpose ofthe related LCD is to show the specific functional limitation of the patient.

9. "Clinical note means a notation of a contact with a patient that is written and dated by a member of the health team, and that describes signs and symptoms, treatment and drugs administered and the patient's reaction, and any changes in physical or emotional condition." (42 CFR §484.2)

10. "Progress note means a written notation, dated and signed by a member of the health team, that summarizes facts about care furnished and the patient's response during a given period of time." (42 CFR §484.2)

Therapeutic Exercises (CPT^® code 97110)

A physical therapist may use this code when addressing impairments of exercise tolerance due to cardiopulmonary impairments.

Self-Care/Home Management Training (CPT^® code 97535)

This code should not be used globally for all home instructions. When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity.

Wheelchair Management Training (CPT^® code 97542)

When billing 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient and/or caregiver.