Billing and Coding: Home Health Occupational 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. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.4 Application of the General Principles to Occupational Therapy

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, §160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation and §160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy)

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 Occupational Therapy L34560.

Coding Guidelines

1. Outcome and Information Set (OASIS) data should support the medical necessity of the services documented in the medical records. For therapy services the OASIS M2200 should be filled out completely. An updated and completed OASIS for the billing period should be in the patient's medical records and made available to the Medicare Administrative Contractor (MAC) upon request.

2. HCPCS code G0152 (services of occupational therapist in home health setting, each 15 minutes) is the only required HCPCS code in home health. All others are for informational purposes only.

3. It is usually not reasonable and necessary to have more than 1 form of heat treatment (paraffin bath, contrast baths) for a single condition per day. Therefore, documentation of the medical necessity of multiple heating modalities on the same date of service must be in the patient's medical records and made available to the MAC upon request.

4. CPT^® code 97140 (Manual Therapy Techniques) includes different treatment techniques. The patient's medical records should indicate which modalities were performed and this documentation made available to the MAC upon request.

5. ICD-10 codes for Migraines (G43.XX codes) are included in this billing and coding article for patients that require training in how to reduce pain during basic activities of daily living (BADLs) and instrumental activities of daily living (IADLs) by training in adaptive techniques, instruction in use of adaptive equipment and positioning. This can usually be done in 3-4 sessions.

6. An Occupational Therapist can only re-certify a patient under a plan of care if:

• The services that the patient requires meet the definition of "occupational therapy" services of CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.4 Application of the General Principles to Occupational Therapy, and;
• The patient's eligibility for home health services has been established by virtue of a prior need for skilled nursing care (other than solely venipuncture for the purposes of obtaining a blood sample), speech-language pathology services or physical therapy in the current or prior certification period.

Other Comments

1. The related policy is based on impairments of structure/function and functional limitations. While the pathophysiology is an important factor, the purpose of the related Home Health Occupational Therapy L34560 policy is to show the specific functional limitation of the patient.

2. "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)

3. "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)

Fabrication/Application of Casts, Splints and Strapping (CPT^® codes 29065-29280, 29345, 29365-29405, 29505-29550)

Note: When identifying orthotics fitting and training see CPT^® code 97760.

Range of Motion (ROM) Measurements (CPT^® codes 95851 and 95852)

To use CPT^® code 95851 for extremity ROM testing, every joint of an extremity would need to be tested with documentation of why such a thorough assessment was warranted.

Therapeutic Exercise (CPT^® code 97110)

An occupational 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)

This code is used for reporting the time associated with training the patient/client and/or caregiver in transfers in and out of the chair as well as propulsion on all surfaces.

1. When billing CPT^® code 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient.

Electrical Stimulation Therapy (CPT^® code 97032)

CPT^® code 97032 requires "visual, verbal and/or manual contact" (i.e., constant attendance).

Non-Covered ICD-10 Codes

Any ICD-10 code not listed in the ICD-10-CM Codes that Support Medical Necessity section of this billing and coding article may be subject to medical review.

Non-covered Indications

• Electrical Stimulation (CPT^® code 97032) used in the treatment of facial nerve paralysis, commonly known as Bell’s palsy (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy))
• Electrical Stimulation (CPT^® code 97032) used to treat motor function disorders such as multiple sclerosis (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation)
• Electrical Stimulation (CPT^® code 97032) for the treatment of strokes when it is determined there is no potential for restoration of function
• Electrical Stimulation when it is an isolated intervention utilized purely for strengthening of a muscle with at least fair graded strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activities

Supportive Documentation Recommendations for CPT^® code 97032

• Type of electrical stimulation used (in addition to the description specifying “manual” and “attended”)
• Area(s) being treated
• If used for muscle weakness, objective rating of strength and functional deficits
• If used for pain include pain rating, location of pain, effect of pain on function

HCPCS G0283 - Electrical stimulation (unattended), to 1 or more areas for indication(s) other than wound care, as part of a therapy plan of care. See CPT^® code 97032 for instructions in manual electrical stimulation

Most non-wound care electrical stimulation treatment provided as part of a therapy plan of care should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/assistive personnel) without constant, direct contact required throughout the treatment. Code G0283 is classified as a “supervised” modality. A supervised modality does not require direct (1-on-1) patient contact by the provider. Typically, electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation.

Examples of unattended electrical stimulation modalities include, but are not limited to, Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation).

Utilization of electrical stimulation may be necessary during the initial phase of treatment but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement.

Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring).

Documentation must clearly support the medical necessity of unattended electrical stimulation used for control of pain and swelling, with objective and/or subjective changes noted in swelling and/or pain within 12 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality. Typically, patients can be trained in the use of a TENS unit for self-management of their pain. Up to 2 visits should be necessary to complete the training. Once training is successfully completed, this procedure should not be billed as a treatment modality in the clinic, as the patient would be independent in application and use of the modality.