SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Outpatient Physical and Occupational Therapy Services

A57067

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A57067
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Outpatient Physical and Occupational Therapy Services
Article Type
Billing and Coding
Original Effective Date
09/19/2019
Revision Effective Date
06/02/2022
Revision Ending Date
05/24/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners.

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(20) excludes payment for PT or OT services furnished incident to the physician by personnel that do not meet the qualifications that apply to therapists, except licensing.

Code of Federal Regulations
42 CFR, Sections 410.59 and 410.61 describe outpatient occupational therapy services and the plan of treatment for outpatient rehabilitation services, respectively.

42 CFR, Sections 410.60 and 410.61 describe outpatient physical therapy services and the plan of treatment for outpatient rehabilitation services, respectively.

42 CFR, Sections 410.74, 410.75, 410.76, and 419.22 define the services of non-physician practitioners.

42 CFR, Sections 424.24 and 424.27 describe therapy certification and plan requirements.

42 CFR, Sections 424.4, 482.56, 484 and 485.705 define therapy personnel qualification requirements.

42 CFR, Section 486 describes coverage for services rendered by physical therapists in independent practice.

Federal Register
Federal Register, Vol. 72, No. 227, November 27, 2007, pages 66328-66333 and 66397-66408, revises personnel qualification standards for therapy services and certification requirements.

Federal Register, July 22, 2002, Decision Memo for Neuromuscular Electrical Stimulation (NMES) for Spinal Cord Injury (CAG 00153R), at:
http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=55&

CMS Publications:
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

    220 through 230 Coverage and documentation requirements for physical and occupational therapy services.


CMS Publication 100-03, Medicare National Coverage Decisions Manual, (multiple sections):

    provides coverage information on several specific types of therapy services. See body of LCD for individual references.


CMS Publication 100-04, Claims Processing Manual, Chapter 5:

    10.2 Financial limitation for therapy services (therapy cap).


CMS Publication 100-04, Claims Processing Manual, Chapter 5:

    20-100 HCPCS coding and therapy billing requirements.


CMS Publication 100-04, Claims Processing Manual, Chapter 20:

    1-10 Orthotics billing.


CMS, “11 Part B Billing Scenarios for PTs and OTs”, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp#TopOfPage

Communication from CMS that the Contractor LCD is not required to include the Z51.89 ICD-10-CM code.

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Outpatient Physical and Occupational Therapy Services L34049.

 

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

 

Therapy services shall be payable when the medical record and the information on the claim consistently and accurately report covered therapy services. Documentation must be legible, relevant and sufficient to justify the medical necessity of the services billed.

Medicare requires a legible identifier of the person(s) who provided the service. The method used shall be a hand written or an electronic signature to sign an order or other medical documentation for medical review purposes. Electronic or hand written signatures that have been communicated through facsimile are also acceptable.

Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:

  • Paint a picture of the patient’s impairments and functional limitations requiring skilled intervention;
  • Describe the prior functional level to assist in establishing the patient’s potential and prognosis;
  • Describe the skilled nature of the therapy treatment provided;
  • Justify that the type, frequency and duration of therapy is medically necessary for the individual patient’s condition;
  • Clearly document both Timed Code Treatment Minutes and Total Treatment Time in order to justify the units billed;
  • Identify each specific skilled intervention/modality provided to justify coding;
  • Provide outcome measures or results f other assessment tools or measurement instruments, as appropriate, to demonstrate the clinical progress being attained by the patient in regards to the patient’s identified functional limitations.

 

Documentation may be submitted in any format as long as all the necessary information is captured. Forms 700 & 701 are not required documents. The documentation must establish that the patient needs the unique skills of a therapist to improve functioning. This is accomplished through a description of the patient’s condition, and any complexities that impact that condition. Not only should documentation describe the needs of the patient that require the unique skills of a therapist, but should also describe the services provided that required the expertise, knowledge, clinical judgment, decision making and abilities of a clinician that assistants, qualified auxiliary personnel, caretakers or the patient cannot provide independently. A therapist’s skills may be documented, for example, by the descriptions of the skilled treatment, the changes made to the treatment due to an assessment of the patient’s needs on a particular treatment day, or due to progress judged sufficient to modify the treatment toward the next more complex or difficult task.

Documentation should establish the variables that influence the patient’s condition, especially those factors that influence the therapist’s (or clinician's) decision to provide more services than are typical for the individual’s condition. Documentation should establish through objective measurements that the patient is making progress toward goals. When regression or plateaus occur, the reasons for the lack of progress should be noted to justify continued treatment.

Only a clinician may perform an initial examination, evaluation, reevaluation and assessment or establish a diagnosis or a plan of care. The clinician may include as part of the evaluation or reevaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or reevaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.

  

Initial Evaluation

The initial evaluation, which must be performed by a clinician, should document the medical necessity of a course of therapy through objective findings and subjective patient self-reporting. Documentation of the initial evaluation should list the conditions being treated and any complexities that make treatment more lengthy or difficult.

Where it is not obvious, describe the impact of the conditions and complexities so that it is clear to the medical reviewer that the services planned are appropriate for the individual.

The initial evaluation establishes the baseline data necessary for assessing expected rehabilitation potential through functional testing using standardized scales appropriate to the patient's diagnosis, the setting of realistic goals and the objective measurement of progress using these same scales. Initial evaluations need to provide objective, measurable documentation of the patient’s impairments and how any noted deficits affect ADLs/IADLs and result in functional limitations. Functional limitations refer to the inability to perform actions, tasks and activities that constitute the “usual activities” for the patient. Functional limitations must be meaningful to the patient and caregiver, and must have potential for improvement. In addition, the remediation of such limitations must be recognized as medically necessary.

To support medical necessity, the evaluation should include the following items.

  • Presenting condition or complaint...."What brings the patient to therapy at this time?”
  • Patients should exhibit a significant change from their “usual” physical or functional ability to warrant an evaluation.
  • Provide an objective description of the changes in function that now necessitate skilled therapy. Simply stating “decline in function” does not adequately justify the initiation of therapy services.
  • Diagnosis and description of specific problem(s) to be evaluated
  • Include area of the body, and conditions and complexities that could impact treatment
  • Subjective complaints and date of onset
  • Relevant medical history
  • Applicable medical history, medications, comorbidities (factors that make therapy more complicated or require extra precautions)
  • Prior diagnostic imaging/testing results
  • Prior therapy history for the same diagnosis, illness or injury
  • If recent therapy was provided, documentation must clearly establish that additional therapy is reasonable and necessary
  •  Social support/environment ?Does the patient live alone, with a caregiver, in a group home, in a residential care facility, in a skilled nursing facility (SNF), etc? ?What level of support is available, and what level of independence is required for the patient to be safe in the home environment?
  • Does the home situation have obstacles that the patient must overcome (e.g., stairs without handrails)?
  • What are the patient’s usual responsibilities in the home environment?
  • Prior level of function
  • Key piece of information used for establishing potential, prognosis and realistic functional goals
  • Functional status just prior to the onset of the treating condition requiring therapy
  • Record in objective, measurable and functional terms
  • Functional testing ?Objectively measure and/or describe the patient’s current level of functioning.

 

Examples, based on the patient’s need, may include:

  • mobility status (transfers, bed mobility, gait, etc);
  • self-care dependence (toileting, dressing, grooming, etc);
  • meaningful ADLs/IADLs;
  • pain, and how it limits function; and
  • balance.

 Objective impairment testing

  • Testing done to determine the source or cause of the functional limitation(s), such as ROM, manual muscle testing, coordination, tone assessment, balance etc.
  • Use concise, objective measurements. Avoid minimal/moderate/severe types of descriptions when more specific definitions or measurements are available. For example, when measuring shoulder flexion AROM, document degrees of motion, rather than documenting, “Shoulder flexion: minimal loss of motion.”

 

  Assessment

  • Summary of the therapist’s analysis of the condition being evaluated based on the examination of the patient. Clinical reasoning for treatment should be evident when further therapy is recommended.
  • Prognosis for return to prior functional status, or the maximum expected conditio
  • Plan of care (see paragraph below)
  • Signature and credentials of the therapist or physician/NPP completing the initial evaluation and plan of care.

 

Each therapy discipline must have a separate plan of care. The plan of care (POC) must contain ALL of the following information.

  •  Required POC Element
  •  Additional Points
  •  Diagnosis

 

The diagnosis should be specific and as relevant to the problem being treated as possible. In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.

  

Bill the most relevant diagnosis. As always, when billing for therapy services, the ICD-10 code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason. For example, when a patient with diabetes is being treated for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible in accordance with State and local laws and the contractors Local Coverage Determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position.

 

Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.

 

Long Term Goals (LTGs)

 LTGs should:

  •  pertain to the functional impairment findings documented in the evaluation;
  •  reflect the final level the patient is expected to achieve as a result of therapy in the current setting;
  •  be realistic, and should have a positive effect on the quality of the patient’s everyday functions;
  •  be function-based and written in objective, measurable terms with a predicted date for achieving the goals.

 

 Type of Treatment

 

The type of treatment includes the type of therapy discipline operating under this POC (PT or OT) and should describe the types of treatment modalities, procedures or interventions to be provided.

 Amount of Treatment

 Refers to the number of times in a day the type of treatment will be provided. Where not specified, one treatment session a day is assumed.

 Treatment provided more than one session per day per discipline will require additional documentation to support this amount of therapy.

 

Frequency of Treatment

 Refers to the number of times in a week that the type of treatment is provided.

 Treatment more than two or three times a week is expected to be a rare occurrence. Treatment frequency of greater than three times per week requires documentation to support this intensity.

 

Duration of Treatment

Refers to the number of weeks, or the number of treatment sessions, for this plan of care.

Clinicians could also estimate the duration of the entire episode of care in this setting.

   

Re-evaluations

Re-evaluation documentation must include clear justification for the need for further tests and measurements after the initial evaluation, such as new clinical findings, a significant, unanticipated change in the patient’s condition, or failure to respond to the interventions in the plan of care. It is expected that clinicians continually assess the patient’s progress as part of the ongoing therapy services. This assessment is not considered a formal re-evaluation; the time of any assessment is included and billed within the appropriate treatment intervention CPT code.

Re-evaluations must be performed by clinicians and contain all applicable components of the initial evaluation. Resolved problems do not need to be re-evaluated; new or ongoing problems may need to be re-evaluated, especially if there is an anticipated change to the long term goals.

 

Progress Reports

Progress reports provide justification for the medical necessity of treatment. Progress reports shall be written by a clinician at least once every 10 treatment days or at least once every 30 calendar days, whichever is less. Writing progress notes more frequently than the minimum is encouraged to support the medical necessity of treatment. A progress report is not a separately billable service.

 

In CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, sections 220-230, Medicare defines the minimum REQUIRED elements of a progress report. It is essential that clinicians include all required elements in their documentation (either in a progress report or treatment note).

 

Progress note elements include(CMS required elements are italicized): ? Date of the beginning and end of the reporting period that this report refers to;

  •  Date that the report was written by the clinician, or if dictated, the date on which it was dictated;
  •  Objective reports of the patient’s subjective statements, if they are relevant;
  •  Objective measurements (impairment/function testing) to quantify progress and support justification for continued treatment;
  •  Description of changes in status relative to each goal currently being addressed in treatment. Descriptions shall make identifiable reference to the goals in the current plan of care;
  •  Assessment of improvement, extent of progress (or lack thereof) toward each goal;
  •  Plans for continuing treatment, including documentation of treatment plan revisions as appropriate;
  •  Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment;
  •  Signature with credentials of the clinician who wrote the report.

 

No specific format is required to demonstrate patient progress as long as all information noted in the bullets above are included at least once in the medical record for each progress report period (10 treatment days or 30 calendar days, whichever is less). Progress report information may be included in the treatment notes, progress reports and/or formal re-evaluations (when re-evaluation guidelines are met).

 

During each progress report period, the clinician must personally furnish in its entirety at least one billable service on at least one day of treatment. Verification of the clinician’s treatment shall be documented by the clinician’s signature on the treatment note and/or progress report.

 

Treatment Notes

Medical record documentation is required for every treatment day, and every therapy service to justify the use of codes and units on the claim.

The treatment note must include the following required information:

  • date of treatment;
  • identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;
  • record of the total time spent in services represented by timed codes under timed code treatment minutes;
  • record of the total treatment time in minutes, which is a sum of the timed and untimed services;
  • signature and credentials of each individual(s) that provided skilled interventions.

 

In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:

  • patient comments regarding pain, function, completion of self management/home exercise program (HEP), etc;
  • significant improvement or adverse reaction to treatment;
  • significant, unusual or unexpected changes in clinical status;
  • parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;
  • description of the skilled components of the specific exercises, training, or activities;
  • instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;
  • communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);
  • communication with patient, family, caregiver;
  • equipment provided
  • any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.

 

If grid or checklist forms are used for daily notes or exercise/activity logs, include the signature and credentials of the qualified professional/auxiliary personnel providing the service each day. Listing of exercise names (e.g., pulleys, UBE, TKE, SLR) does not alone imply that skilled treatment has been provided, especially if the exercises have been performed over multiple sessions. Be sure to occasionally document the skilled components of the exercises so they do not appear repetitive and therefore, unskilled. Documenting functional activities performed (e.g., “ambulated 35 feet with min assist”, “upper body dressing with set up and supervision”) also does not alone imply that skilled treatment was provided. The skilled components/techniques of the qualified professional/auxiliary personnel used to improve the functional activity should be occasionally documented to support medical necessity.

 

When documenting treatment time, consistently use the CMS language of total “Timed Code Treatment Minutes” and “Total Treatment Time”. Do not use other language or abbreviations when referring to treatment minutes as it may be difficult for medical review to determine the type of minutes documented. The amount of time for each specific intervention/modality provided may also be recorded voluntarily.

 

Do not record treatment time as “Time in / Time out” for the entire session as this does not accurately reflect the actual treatment time. Do not “round” all treatments to 15-minute increments, but rather record the actual treatment time. Also do not record as “units” of treatment, instead of minutes.

 

Only “intra-service care” of skilled therapy services should be reflected in the time documentation. Do not include unbillable time, such as time for:

  • changing;
  • waiting for treatment to begin;
  • waiting for equipment;
  • resting;
  • toileting; or
  • performing unskilled or independent exercises or activities.

 

Discharge Notes

A discharge note is required for each episode of treatment and must be written by the clinician. The discharge note is a progress report covering the time from the last progress report up to the date of discharge, and includes all required components of a progress report. The discharge note may be considered the last opportunity to justify the medical necessity of the entire treatment episode. Therefore, if a discharge summary has been completed, it may be prudent to submit it with any request of records for medical review, even if the claim under review is for a treatment period prior to the date of discharge.

In the case of an unanticipated discharge, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified auxiliary personnel. In the case of a discharge anticipated within 3 treatment days of the progress report, the clinician may provide objective goals which, when met, will authorize the assistant or qualified auxiliary personnel to discharge the patient. In that case, the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist. There must be indication that the clinician has reviewed the treatment notes and agrees to the discharge.

 

Certifications and Recertifications

Medicare beneficiaries receiving outpatient therapy services must be under the care of a physician/NPP. Orders (sometimes called referrals) and certifications are common means of demonstrating such evidence of physician involvement.

 

Certification, which is a coverage condition for therapy payment, requires a dated physician/NPP signature on the therapy plan of care or some other document that indicates approval of the plan of care. A certification often differs from an order or referral in that it must contain all required elements of a plan of care. To assist medical review in determining that the certification requirements are met, certifications/recertifications should include the following elements(CMS required elements are italicized):

  • The date from which the plan of care being sent for certification becomes effective (for initial certifications, the initial evaluation date will be assumed to be the start date of the certified plan of care);
  • Diagnoses;
  • Long term treatment goals;
  • Type, amount, duration and frequency of therapy services;
  • Signature, date and professional identity of the therapist who established the plan; and
  • Dated physician/NPP signature indicating that the therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan. (Note: The CORF benefit does not recognize an NPP for certification.)

 

Effective January 1, 2008, the interval length shall be determined by the patient’s needs, not to exceed 90 days. Certifications which include all the required plan of care elements will be considered valid for the longest duration in the plan (such as 3x/wk for 6 weeks which will be considered as a total of 18 treatments). If treatment continues past the longest duration specified, a recertification will be required.

 

Documentation Requirements for Unlisted Procedure Codes

Unlisted modality - In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxilliary personnel, the time spent by the qualified professional/auxilliary personnel, one-on-one with the beneficiary.

 

Unlisted therapeutic procedure - Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.

 

Unlisted physical medicine/rehabilitation service or procedure - Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.

 

Unlisted procedure, casting or strapping - Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.

 

Untimed CPT Codes

When a therapy treatment modality or procedure is not defined in the AMA CPT Manual by a specific time frame (such as “each 15 minutes”), the modality or procedure is considered an “untimed” service. Untimed services are billed based on the number of times the procedure is performed, often once per day. Untimed services billed as more than “1” unit will require significant documentation to justify treatment greater than one session per day per therapy discipline. The minutes spent providing untimed services are reflected in the documentation under “Total Treatment Time”(and are not included in the minutes for timed CPT codes when determining the number of timed-based units that may be billed).

Time Based Codes (if applicable)

  • When billing time-based codes the CPT time rule applies
  • Exact times MUST be documented in the medical record
    • The code reported should be selected based on the time closest to that indicated in the code descriptor
  • Many CPT codes for therapy modalities and procedures specify that direct (one-on-one) time spent in patient contact is 15 minutes. The time counted is the time the patient is treated using skilled therapy modalities and procedures, and is recorded in the documentation as “Timed Code Treatment Minutes.” Pre- and post-delivery services are not to be counted when recording the treatment time. The time counted is the “intra-service” care that begins when the qualified professional/auxiliary personnel is directly working with the patient to deliver the service. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment. The intra-service care includes assessment. The time the patient spends not being treated because of a need for toileting or resting should not be counted. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. Time spent “supervising” a patient performing an activity that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the “Timed Code Treatment Minutes.” Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.
    • When determining the allocation of units, it is easiest to separate out each service first into “15-minute time blocks”. For example:
      • 24 minutes 97112 = one 15-minute block + 9 remaining minutes
      • 23 minutes 97110 = one 15-minute block + 8 remaining minutes
  • Each code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most “remaining minutes” (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is 2 units 97112 + 1 unit 97110.

 

The first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise and 20 minutes self-care/home management training. The total “Timed Code Treatment Minutes” documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in “Timed Code Treatment Minutes’ will determine the number of units billed.

 

Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.

  • Do not bill for documentation time separately(except for standardized cognitive performance testing). This is incorporated in the HCPCS/CPT fee reimbursed for each individual service provided.
  • Do not code higher than what the procedure requires. Coding in this manner may allow the provider to collect inappropriate revenues without incurring additional costs.
  • Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.
  • Do not “unbundle” services/procedures. Unbundling refers to the practice of splitting a single payment code into two or more codes. This may lead to inappropriate multiple payments.
  • Do not bill separately for supplies used to provide therapy services, such as electrodes, theraband, theraputty, etc.
  • Therapists, or therapy assistants, working together as a “team” to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient. For example, if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.

 

Examples of treatment time documentation

A treatment session includes 20 minutes therapeutic exercise (97110), 15 minutes therapeutic activities (97530) and 20 minutes unattended electrical stimulation (G0283).
Time documentation in the treatment note

      Timed Code Treatment Minutes: 35 minutes

 

      Total Treatment Time: 55 minutes


A 30 minute OT initial evaluation is completed (97162), followed by 20 minutes fluidotherapy (97022).
Time documentation in the treatment note

      Timed Code Treatment Minutes: 0 minutes

 

      Total Treatment Time: 50 minutes



 

The first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise (CPT 97110) and 20 minutes self-care/home management training (CPT 97535). The total “Timed Code Treatment Minutes” documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in “Timed Code Treatment Minutes’ will determine the number of units billed.

Once the minutes have been summed, use the chart below to determine the total allowable units, based on the total Timed Code Treatment minutes.

1 unit > 8 minutes through 22 minutes

2 units > 23 minutes through 37 minutes

3 units > 38 minutes through 52 minutes

4 units > 53 minutes through 67 minutes

5 units > 68 minutes through 82 minutes

6 units > 83 minutes through 97 minutes

7 units > 98 minutes through 112 minutes

8 units > 113 minutes through 127 minutes



When the total Timed Code Treatment minutes for the day is less than 8 minutes, the service(s) should not be billed.

It is important to allocate the total billable units for timed services to the appropriate CPT codes based upon the number of minutes spent providing each individual service. Any timed service provided for at least 15 minutes, must be billed one unit. Any timed service provided for at least 30 minutes, must be billed two units, and so on. When determining the allocation of units, it is easiest to separate out each service first into “15-minute time blocks”. For example:

20 minutes of Therapeutic Exercise (CPT 97110) = one 15-minute block + 5 remaining minutes

  • At least 1 unit must be allocated to this code


38 minutes of Self-care/Home Management Training (97535) = two 15-minute blocks + 8 remaining minutes

  • At least 2 units must be allocated to this code
  • If 38 minutes of CPT 97535 is the only treatment provided, then 3 units would be billed. However, as demonstrated in the examples below, there may be treatment sessions in which the correct billing would only allow 2 units, based on the “remaining minutes”.

The “remaining minutes” (those minutes remaining after the “15-minute blocks” have been allocated) are considered when the total billable units for the day allow for an additional unit to be billed. See the following examples:

 

24 minutes of neuromuscular reeducation (CPT 97112)

23 minutes of therapeutic exercise (CPT 97110)

____________________________________________

47 total Timed Code Treatment minutes

 

Utilizing the chart above, 47 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first

 


24 minutes 97112 = one 15-minute block + 9 remaining minutes

23 minutes 97110 = one 15-minute block + 8 remaining minutes

 

Each code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most “remaining minutes” (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is

 

2 units 97112 + 1 unit 97110

 

 

 

 

20 minutes of neuromuscular reeducation (CPT 97112)

20 minutes therapeutic exercise (CPT 97110)

________________________________________

40 total Timed Code Treatment minutes

 


Utilizing the chart above, 40 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first

 

20 minutes 97112 = one 15-minute block + 5 remaining minutes

20 minutes 97110 = one 15-minute block + 5 remaining minutes

 

Each code contains one 15-minute block, therefore, each code shall be billed for at least 1 one unit. As 3 units is allowed, a review of the “remaining minutes” is required to determine which code should be billed the additional unit. Since the “remaining minutes” for each service are the same in this example, either of the codes may be billed for the additional unit. The correct coding is either one of the following

 

2 units 97112 + 1 unit 97110

OR    

1 unit 97112 + 2 units 97110

 

4 minutes assessing shoulder strength prior to initiating and progressing therapeutic exercise (CPT 97110)

32 minutes therapeutic exercise (CPT 97110)

7 minutes manual therapy (CPT 97140)

_______________________________________

43 total Timed Code Treatment minutes

 

Utilizing the chart above, 43 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first

 

36 minutes 97110 = two 15-minute blocks + 6 remaining minutes

7 minutes 97140 = zero 15-minute blocks + 7 remaining minutes

 

Code 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the “remaining minutes”, and apply the additional unit to the service with the most remaining minutes. The correct coding is

 

2 units 97110 + 1 unit 97140

 

 

 

 

18 minutes of therapeutic exercise (CPT 97110)

13 minutes of manual therapy (CPT 97140)

10 minutes of gait training (CPT 97116)

8 minutes of ultrasound (CPT 97035)

_______________________________________

49 total Timed Code Treatment minutes

 


Appropriate billing for a total of 49 minutes is 3 units. To allocate those 3 units, determine the 15-minute blocks first

 

18 minutes 97110 = one 15-minute block + 3 remaining minutes

13 minutes 97140 = zero 15-minute blocks + 13 remaining minutes

10 minutes 97116 = zero 15-minute blocks + 10 remaining minutes

8 minutes 97035 = zero 15-minute blocks + 8 remaining minutes

 

Code 97110 shall be billed for at least one unit as it contains one 15-minute block. The additional 2 units billable (for a total of 3 units for the day), must be applied to the services with the greatest remaining minutes. The correct coding is

 

1 unit 97110 + 1 unit 97140 + 1 unit 97116

 

There are not enough total minutes for the day to allow billing for the ultrasound. However, the ultrasound will still be documented in the treatment notes.

 

 

 

7 minutes of neuromuscular reeducation (CPT 97112)

7 minutes of therapeutic exercise (97110)

7 minutes of manual therapy (97140)

___________________________________________


21 total Timed Code Treatment minutes


 

The clinician shall select which CPT code to bill since each service was performed for the same amount of time and only one unit is allowed. The correct coding is

 

1 unit 97112

OR

1 unit 97110

OR


1 unit 97140



For treatment sessions with both timed and untimed services, the units and time documented for any untimed CPT codes should not be included in the counting of units and time for the timed CPT codes for a calendar day. The minutes for the timed codes are reflected in the Timed Code Treatment Minutes, with the units allocated as described above. The untimed minutes are reflected in the Total Treatment Time, which is a combination of the timed code minutes and the untimed code minutes. Per CMS, it is important that the total number of timed treatment minutes support the billing of units on the claim, and that the total treatment time reflects services billed as untimed codes. For example:

 

35 minutes OT evaluation (CPT 97162-untimed code)

25 minutes therapeutic exercise (CPT 97110)

8 minutes therapeutic activities (CPT 97530)

_____________________________________

Total Timed Code Treatment minutes = 33 minutes

Total Treatment Time = 68 minutes

 

The evaluation, being an untimed code, is billable as “1” unit. Do not include the evaluation minutes in the total timed code treatment minutes when determining the appropriate number of units to bill for the timed codes. 33 total minutes of timed codes is billable as 2 units. To allocate the 2 timed code units, break out the 15-minute blocks first

 

25 minutes 97110 = one 15-minute block + 10 remaining minutes

8 minutes 97530 = zero 15-minute blocks + 8 remaining minutes

 

Since code 97110 has one 15-minute block, at least 1 unit of 97110 shall be billed. To determine which code shall be billed with the second unit,
compare the remaining minutes. Since code 97110 has more remaining minutes, the second timed code unit shall be applied to this code. Correct coding for this session is

 

1 unit 97162 + 2 units 97110

 

The medical record documentation will note that the therapeutic activities were performed.

 

 


 

40 minutes PT evaluation (CPT
97163-untimed)

20 minutes unattended electrical stimulation (CPT G0283-untimed)

10 minute therapeutic exercise for home exercise program (CPT 97110)

 

Total Timed Code Treatment Minutes = 10 minutes

Total Treatment Time = 70 minutes

 

The untimed services are billable as 1 unit each. 10 minutes for the timed code is billable as “1” unit. The correct coding for this session is

 

1 unit 97163 + 1 unit G0283 + 1 unit 97110

 



Payment for therapy services is based on the qualified professional/auxiliary personnel's time spent in treating the individual patient. For this reason, in the same time period (such as from 1:00 to 1:15) a clinician cannot bill any of the following pairs of CPT codes for therapy services provided to the same, or to different patients.

  1. Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97762)
  2. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032-97039)
  3. Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) or (b) above - (CPT codes 97032-977622), for example, any CPT code for a therapeutic procedure (e.g., 97116 - gait training) with any attended modality CPT code (e.g., 97035 - ultrasound)
  4. Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110-97762) with the group therapy CPT code (97150) requiring constant attendance, for example, group therapy (97150) with neuromuscular reeducation (97112)
  5. Any CPT code for modalities requiring constant attendance (CPT codes 97032-97039) with the group therapy CPT code (97150) for example, group therapy (97150) with ultrasound (97035)
  6. Any untimed evaluation or reevaluation code (CPT codes 97161-97168) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032-97039), therapeutic procedures (CPT 97110-97762) and group therapy (CPT code 97150)



Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.

  • Do not bill for documentation time separately(except for CPT code 96125). This is incorporated in the HCPCS/CPT fee reimbursed for each individual service provided.
  • Do not code higher than what the procedure requires. Coding in this manner may allow the provider to collect inappropriate revenues without incurring additional costs.
  • Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.
  • Do not “unbundle” services/procedures. Unbundling refers to the practice of splitting a single payment code into two or more codes. This may lead to inappropriate multiple payments.
  • Do not bill separately for supplies used to provide therapy services, such as electrodes, theraband, theraputty, etc.
  • Therapists, or therapy assistants, working together as a “team” to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient. For example, if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.

Utilization Guidelines and Maximum Billable Units per Date of Service
Rarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed.

The following interventions should be reported no more than one unit per code per day per discipline; additional units will be denied:
97012, 97016, 97018, 97022, 97024, 97028, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97597, 97598, 97605, 97606, G0281, G0283, G0329.

The following timed interventions should be reported no more than 2 (two) units per code per day per discipline; additional units will be denied: 97033, 97034, 97035, 97036.

The following interventions should be reported no more than 4 (four) units per code per day per discipline; additional units will be denied:
97032, 97110, 97112, 97113, 97116, 97124, 97530, 97533, 97535, 97537, 97542, 97760, 97761, 97763, 97129, 97130.

Denials due to the limits described in this section of the LCD may be appealed.

Documentation Requirements for Unlisted Procedure Codes (97039, 97139, 97799, 29799)
97039 - In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxilliary personnel, the time spent by the qualified professional/auxilliary personnel, one-on-one with the beneficiary.

97139 - Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.

97799 - Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.

29799 - Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.

Other Comments:
For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.
In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxiliary personnel, the time spent by the qualified professional/auxiliary personnel, one-on-one with the beneficiary.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
074x Clinic - Outpatient Rehabilitation Facility (ORF)
075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0420 Physical Therapy - General Classification
0421 Physical Therapy - Visit
0424 Physical Therapy - Evaluation or Re-evaluation
0429 Physical Therapy - Other Physical Therapy
0430 Occupational Therapy - General Classification
0431 Occupational Therapy - Visit
0434 Occupational Therapy - Evaluation or Reevaluation
0439 Occupational Therapy - Other Occupational Therapy
N/A

CPT/HCPCS Codes

Group 1

(86 Codes) >> Includes AQUATIC THERAPY
Group 1 Paragraph

For most revenue codes, Outpatient Prospective Payment System (OPPS) requirements mandate CPT/HCPCS coding on the claim. When the revenue code you are reporting requires CPT/HCPCS coding, the appropriate code(s) may be chosen from the list below when submitting your claim to Medicare.

This list represents common physical and occupational therapy services and is not all-inclusive.

Group 1 Codes
Code Description
29065 Application of long arm cast
29075 Application of forearm cast
29085 Apply hand/wrist cast
29086 Apply finger cast
29105 Apply long arm splint
29125 Apply forearm splint
29126 Apply forearm splint
29130 Application of finger splint
29131 Application of finger splint
29200 Strapping of chest
29240 Strapping of shoulder
29260 Strapping of elbow or wrist
29280 Strapping of hand or finger
29345 Application of long leg cast
29355 Application of long leg cast
29365 Application of long leg cast
29405 Apply short leg cast
29425 Apply short leg cast
29445 Apply rigid leg cast
29505 Application long leg splint
29515 Application lower leg splint
29520 Strapping of hip
29530 Strapping of knee
29540 Strapping of ankle and/or ft
29550 Strapping of toes
29580 Application of paste boot
29799 Casting/strapping procedure
90901 Biofeedback train any meth
90912 Bfb training 1st 15 min
90913 Bfb training ea addl 15 min
95851 Range of motion measurements
95852 Range of motion measurements
96125 Cognitive test by hc pro
97010 Hot or cold packs therapy
97012 Mechanical traction therapy
97016 Vasopneumatic device therapy
97018 Paraffin bath therapy
97022 Whirlpool therapy
97024 Diathermy eg microwave
97026 Infrared therapy
97028 Ultraviolet therapy
97032 Electrical stimulation
97033 Electric current therapy
97034 Contrast bath therapy
97035 Ultrasound therapy
97036 Hydrotherapy
97039 Physical therapy treatment
97110 Therapeutic exercises
97112 Neuromuscular reeducation
97113 Aquatic therapy/exercises
97116 Gait training therapy
97124 Massage therapy
97129 Ther ivntj 1st 15 min
97130 Ther ivntj ea addl 15 min
97139 Physical medicine procedure
97140 Manual therapy 1/> regions
97150 Group therapeutic procedures
97161 Pt eval low complex 20 min
97162 Pt eval mod complex 30 min
97163 Pt eval high complex 45 min
97164 Pt re-eval est plan care
97165 Ot eval low complex 30 min
97166 Ot eval mod complex 45 min
97167 Ot eval high complex 60 min
97168 Ot re-eval est plan care
97530 Therapeutic activities
97533 Sensory integration
97535 Self care mngment training
97537 Community/work reintegration
97542 Wheelchair mngment training
97597 Rmvl devital tis 20 cm/<
97598 Rmvl devital tis addl 20cm/<
97602 Wound(s) care non-selective
97605 Neg press wound tx <=50 cm
97606 Neg press wound tx >50 cm
97607 Neg press wnd tx <=50 sq cm
97608 Neg press wound tx >50 cm
97750 Physical performance test
97755 Assistive technology assess
97760 Orthotic mgmt&traing 1st enc
97761 Prosthetic traing 1st enc
97763 Orthc/prostc mgmt sbsq enc
97799 Physical medicine procedure
G0281 Elec stim unattend for press
G0283 Elec stim other than wound
G0329 Electromagntic tx for ulcers

Group 2

(15 Codes)
Group 2 Paragraph

Telehealth Codes

 

 

Group 2 Codes
Code Description
98966 Hc pro phone call 5-10 min
98967 Hc pro phone call 11-20 min
98968 Hc pro phone call 21-30 min
98970 Qnhp ol dig assmt&mgmt 5-10
98971 Qnhp ol dig assmt&mgmt 11-20
98972 Qnhp ol dig assmt&mgmt 21+
98975 Rem ther mntr 1st setup&edu
98976 Rem ther mntr dev sply resp
98977 Rem ther mntr dv sply mscskl
98980 Rem ther mntr 1st 20 min
98981 Rem ther mntr ea addl 20 min
G2010 Remot image submit by pt
G2012 Brief check in by md/qhp
G2250 Remot img sub by pt, non e/m
G2251 Brief chkin, 5-10, non-e/m
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(770 Codes)
Group 1 Paragraph

The following ICD-10-CM Codes do not support the medical necessity for the CPT/HCPCS code 97035.

Group 1 Codes
Code Description
E84.0 Cystic fibrosis with pulmonary manifestations
E84.9 Cystic fibrosis, unspecified
I70.232 - I70.235 Atherosclerosis of native arteries of right leg with ulceration of calf - Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg
I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.242 - I70.245 Atherosclerosis of native arteries of left leg with ulceration of calf - Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg
I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
I70.332 - I70.335 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf - Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of foot
I70.338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.339 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified site
I70.342 - I70.345 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf - Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot
I70.348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.349 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site
I70.432 - I70.435 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf - Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot
I70.438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.439 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site
I70.442 - I70.445 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf - Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot
I70.448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.449 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site
I70.532 - I70.535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf - Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot
I70.538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.539 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of unspecified site
I70.542 - I70.545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf - Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot
I70.548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.549 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of unspecified site
I70.632 - I70.635 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf - Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot
I70.638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.639 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site
I70.642 - I70.645 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf - Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of foot
I70.648 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.649 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of unspecified site
I70.732 - I70.735 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of calf - Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of foot
I70.738 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.739 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of unspecified site
I70.742 - I70.745 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of calf - Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of foot
I70.748 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.749 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of unspecified site
I83.001 - I83.005 Varicose veins of unspecified lower extremity with ulcer of thigh - Varicose veins of unspecified lower extremity with ulcer other part of foot
I83.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg
I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site
I83.011 - I83.015 Varicose veins of right lower extremity with ulcer of thigh - Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.019 Varicose veins of right lower extremity with ulcer of unspecified site
I83.021 - I83.025 Varicose veins of left lower extremity with ulcer of thigh - Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.029 Varicose veins of left lower extremity with ulcer of unspecified site
I83.201 - I83.205 Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation - Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation
I83.208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation
I83.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation
I83.211 - I83.215 Varicose veins of right lower extremity with both ulcer of thigh and inflammation - Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.219 Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation
I83.221 - I83.225 Varicose veins of left lower extremity with both ulcer of thigh and inflammation - Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation
I87.011 - I87.013 Postthrombotic syndrome with ulcer of right lower extremity - Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.019 Postthrombotic syndrome with ulcer of unspecified lower extremity
I87.031 - I87.033 Postthrombotic syndrome with ulcer and inflammation of right lower extremity - Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.039 Postthrombotic syndrome with ulcer and inflammation of unspecified lower extremity
I87.311 - I87.313 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity - Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.319 Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity
I87.331 - I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity - Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity
I87.339 Chronic venous hypertension (idiopathic) with ulcer and inflammation of unspecified lower extremity
J40 Bronchitis, not specified as acute or chronic
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J43.0 - J43.2 Unilateral pulmonary emphysema [MacLeod's syndrome] - Centrilobular emphysema
J43.8 Other emphysema
J43.9 Emphysema, unspecified
J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.20 - J45.22 Mild intermittent asthma, uncomplicated - Mild intermittent asthma with status asthmaticus
J45.30 - J45.32 Mild persistent asthma, uncomplicated - Mild persistent asthma with status asthmaticus
J45.40 - J45.42 Moderate persistent asthma, uncomplicated - Moderate persistent asthma with status asthmaticus
J45.50 - J45.52 Severe persistent asthma, uncomplicated - Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J60 Coalworker's pneumoconiosis
J61 Pneumoconiosis due to asbestos and other mineral fibers
J62.0 Pneumoconiosis due to talc dust
J62.8 Pneumoconiosis due to other dust containing silica
J63.0 - J63.6 Aluminosis (of lung) - Pneumoconiosis due to other specified inorganic dusts
J64 Unspecified pneumoconiosis
J65 Pneumoconiosis associated with tuberculosis
J66.0 Byssinosis
J66.1 Flax-dressers' disease
J66.2 Cannabinosis
J66.8 Airway disease due to other specific organic dusts
J67.0 - J67.9 Farmer's lung - Hypersensitivity pneumonitis due to unspecified organic dust
J81.0 Acute pulmonary edema
J82.81 Chronic eosinophilic pneumonia
J82.82 Acute eosinophilic pneumonia
J82.83 Eosinophilic asthma
J82.89 Other pulmonary eosinophilia, not elsewhere classified
J98.3 Compensatory emphysema
L89.000 - L89.004 Pressure ulcer of unspecified elbow, unstageable - Pressure ulcer of unspecified elbow, stage 4
L89.009 Pressure ulcer of unspecified elbow, unspecified stage
L89.010 - L89.014 Pressure ulcer of right elbow, unstageable - Pressure ulcer of right elbow, stage 4
L89.019 Pressure ulcer of right elbow, unspecified stage
L89.020 - L89.024 Pressure ulcer of left elbow, unstageable - Pressure ulcer of left elbow, stage 4
L89.029 Pressure ulcer of left elbow, unspecified stage
L89.100 - L89.104 Pressure ulcer of unspecified part of back, unstageable - Pressure ulcer of unspecified part of back, stage 4
L89.109 Pressure ulcer of unspecified part of back, unspecified stage
L89.110 - L89.114 Pressure ulcer of right upper back, unstageable - Pressure ulcer of right upper back, stage 4
L89.119 Pressure ulcer of right upper back, unspecified stage
L89.120 - L89.124 Pressure ulcer of left upper back, unstageable - Pressure ulcer of left upper back, stage 4
L89.129 Pressure ulcer of left upper back, unspecified stage
L89.130 - L89.134 Pressure ulcer of right lower back, unstageable - Pressure ulcer of right lower back, stage 4
L89.139 Pressure ulcer of right lower back, unspecified stage
L89.140 - L89.144 Pressure ulcer of left lower back, unstageable - Pressure ulcer of left lower back, stage 4
L89.149 Pressure ulcer of left lower back, unspecified stage
L89.150 - L89.154 Pressure ulcer of sacral region, unstageable - Pressure ulcer of sacral region, stage 4
L89.159 Pressure ulcer of sacral region, unspecified stage
L89.200 - L89.204 Pressure ulcer of unspecified hip, unstageable - Pressure ulcer of unspecified hip, stage 4
L89.209 Pressure ulcer of unspecified hip, unspecified stage
L89.210 - L89.214 Pressure ulcer of right hip, unstageable - Pressure ulcer of right hip, stage 4
L89.219 Pressure ulcer of right hip, unspecified stage
L89.220 - L89.224 Pressure ulcer of left hip, unstageable - Pressure ulcer of left hip, stage 4
L89.229 Pressure ulcer of left hip, unspecified stage
L89.300 - L89.304 Pressure ulcer of unspecified buttock, unstageable - Pressure ulcer of unspecified buttock, stage 4
L89.309 Pressure ulcer of unspecified buttock, unspecified stage
L89.310 - L89.314 Pressure ulcer of right buttock, unstageable - Pressure ulcer of right buttock, stage 4
L89.319 Pressure ulcer of right buttock, unspecified stage
L89.320 - L89.324 Pressure ulcer of left buttock, unstageable - Pressure ulcer of left buttock, stage 4
L89.329 Pressure ulcer of left buttock, unspecified stage
L89.40 - L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unspecified stage - Pressure ulcer of contiguous site of back, buttock and hip, unstageable
L89.500 - L89.504 Pressure ulcer of unspecified ankle, unstageable - Pressure ulcer of unspecified ankle, stage 4
L89.509 Pressure ulcer of unspecified ankle, unspecified stage
L89.510 - L89.514 Pressure ulcer of right ankle, unstageable - Pressure ulcer of right ankle, stage 4
L89.519 Pressure ulcer of right ankle, unspecified stage
L89.520 - L89.524 Pressure ulcer of left ankle, unstageable - Pressure ulcer of left ankle, stage 4
L89.529 Pressure ulcer of left ankle, unspecified stage
L89.600 - L89.604 Pressure ulcer of unspecified heel, unstageable - Pressure ulcer of unspecified heel, stage 4
L89.609 Pressure ulcer of unspecified heel, unspecified stage
L89.610 - L89.614 Pressure ulcer of right heel, unstageable - Pressure ulcer of right heel, stage 4
L89.619 Pressure ulcer of right heel, unspecified stage
L89.620 - L89.624 Pressure ulcer of left heel, unstageable - Pressure ulcer of left heel, stage 4
L89.629 Pressure ulcer of left heel, unspecified stage
L89.810 - L89.814 Pressure ulcer of head, unstageable - Pressure ulcer of head, stage 4
L89.819 Pressure ulcer of head, unspecified stage
L89.890 - L89.894 Pressure ulcer of other site, unstageable - Pressure ulcer of other site, stage 4
L89.899 Pressure ulcer of other site, unspecified stage
L89.90 - L89.95 Pressure ulcer of unspecified site, unspecified stage - Pressure ulcer of unspecified site, unstageable
L97.201 - L97.204 Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin - Non-pressure chronic ulcer of unspecified calf with necrosis of bone
L97.209 Non-pressure chronic ulcer of unspecified calf with unspecified severity
L97.211 - L97.214 Non-pressure chronic ulcer of right calf limited to breakdown of skin - Non-pressure chronic ulcer of right calf with necrosis of bone
L97.219 Non-pressure chronic ulcer of right calf with unspecified severity
L97.221 - L97.224 Non-pressure chronic ulcer of left calf limited to breakdown of skin - Non-pressure chronic ulcer of left calf with necrosis of bone
L97.229 Non-pressure chronic ulcer of left calf with unspecified severity
L97.301 - L97.304 Non-pressure chronic ulcer of unspecified ankle limited to breakdown of skin - Non-pressure chronic ulcer of unspecified ankle with necrosis of bone
L97.309 Non-pressure chronic ulcer of unspecified ankle with unspecified severity
L97.311 - L97.314 Non-pressure chronic ulcer of right ankle limited to breakdown of skin - Non-pressure chronic ulcer of right ankle with necrosis of bone
L97.319 Non-pressure chronic ulcer of right ankle with unspecified severity
L97.321 - L97.324 Non-pressure chronic ulcer of left ankle limited to breakdown of skin - Non-pressure chronic ulcer of left ankle with necrosis of bone
L97.329 Non-pressure chronic ulcer of left ankle with unspecified severity
L97.401 - L97.404 Non-pressure chronic ulcer of unspecified heel and midfoot limited to breakdown of skin - Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of bone
L97.409 Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity
L97.411 - L97.414 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin - Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone
L97.419 Non-pressure chronic ulcer of right heel and midfoot with unspecified severity
L97.421 - L97.424 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin - Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone
L97.429 Non-pressure chronic ulcer of left heel and midfoot with unspecified severity
L97.501 - L97.504 Non-pressure chronic ulcer of other part of unspecified foot limited to breakdown of skin - Non-pressure chronic ulcer of other part of unspecified foot with necrosis of bone
L97.509 Non-pressure chronic ulcer of other part of unspecified foot with unspecified severity
L97.511 - L97.514 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin - Non-pressure chronic ulcer of other part of right foot with necrosis of bone
L97.519 Non-pressure chronic ulcer of other part of right foot with unspecified severity
L97.521 - L97.524 Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin - Non-pressure chronic ulcer of other part of left foot with necrosis of bone
L97.529 Non-pressure chronic ulcer of other part of left foot with unspecified severity
L97.801 - L97.804 Non-pressure chronic ulcer of other part of unspecified lower leg limited to breakdown of skin - Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of bone
L97.809 Non-pressure chronic ulcer of other part of unspecified lower leg with unspecified severity
L97.811 - L97.814 Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin - Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone
L97.819 Non-pressure chronic ulcer of other part of right lower leg with unspecified severity
L97.821 - L97.824 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin - Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone
L97.829 Non-pressure chronic ulcer of other part of left lower leg with unspecified severity
N39.3 Stress incontinence (female) (male)
N39.41 Urge incontinence
N39.42 Incontinence without sensory awareness
N39.43 Post-void dribbling
N39.46 Mixed incontinence
N39.490 Overflow incontinence
R15.0 Incomplete defecation
R15.1 Fecal smearing
R15.2 Fecal urgency
R15.9 Full incontinence of feces
R33.8 Other retention of urine
R35.0 Frequency of micturition
S31.020A Laceration with foreign body of lower back and pelvis without penetration into retroperitoneum, initial encounter
S31.040A Puncture wound with foreign body of lower back and pelvis without penetration into retroperitoneum, initial encounter
S31.832A Laceration with foreign body of anus, initial encounter
S31.834A Puncture wound with foreign body of anus, initial encounter
S71.001A Unspecified open wound, right hip, initial encounter
S71.002A Unspecified open wound, left hip, initial encounter
S71.009A Unspecified open wound, unspecified hip, initial encounter
S71.011A Laceration without foreign body, right hip, initial encounter
S71.012A Laceration without foreign body, left hip, initial encounter
S71.019A Laceration without foreign body, unspecified hip, initial encounter
S71.031A Puncture wound without foreign body, right hip, initial encounter
S71.032A Puncture wound without foreign body, left hip, initial encounter
S71.039A Puncture wound without foreign body, unspecified hip, initial encounter
S71.051A Open bite, right hip, initial encounter
S71.052A Open bite, left hip, initial encounter
S71.059A Open bite, unspecified hip, initial encounter
S71.101A Unspecified open wound, right thigh, initial encounter
S71.102A Unspecified open wound, left thigh, initial encounter
S71.109A Unspecified open wound, unspecified thigh, initial encounter
S71.111A Laceration without foreign body, right thigh, initial encounter
S71.112A Laceration without foreign body, left thigh, initial encounter
S71.119A Laceration without foreign body, unspecified thigh, initial encounter
S71.131A Puncture wound without foreign body, right thigh, initial encounter
S71.132A Puncture wound without foreign body, left thigh, initial encounter
S71.139A Puncture wound without foreign body, unspecified thigh, initial encounter
S71.151A Open bite, right thigh, initial encounter
S71.152A Open bite, left thigh, initial encounter
S71.159A Open bite, unspecified thigh, initial encounter
T20.20XA Burn of second degree of head, face, and neck, unspecified site, initial encounter
T20.211A Burn of second degree of right ear [any part, except ear drum], initial encounter
T20.212A Burn of second degree of left ear [any part, except ear drum], initial encounter
T20.219A Burn of second degree of unspecified ear [any part, except ear drum], initial encounter
T20.23XA Burn of second degree of chin, initial encounter
T20.24XA Burn of second degree of nose (septum), initial encounter
T20.25XA Burn of second degree of scalp [any part], initial encounter
T20.26XA Burn of second degree of forehead and cheek, initial encounter
T20.27XA Burn of second degree of neck, initial encounter
T20.29XA Burn of second degree of multiple sites of head, face, and neck, initial encounter
T20.60XA Corrosion of second degree of head, face, and neck, unspecified site, initial encounter
T20.611A Corrosion of second degree of right ear [any part, except ear drum], initial encounter
T20.612A Corrosion of second degree of left ear [any part, except ear drum], initial encounter
T20.619A Corrosion of second degree of unspecified ear [any part, except ear drum], initial encounter
T20.63XA Corrosion of second degree of chin, initial encounter
T20.64XA Corrosion of second degree of nose (septum), initial encounter
T20.65XA Corrosion of second degree of scalp [any part], initial encounter
T20.66XA Corrosion of second degree of forehead and cheek, initial encounter
T20.67XA Corrosion of second degree of neck, initial encounter
T20.69XA Corrosion of second degree of multiple sites of head, face, and neck, initial encounter
T21.20XA Burn of second degree of trunk, unspecified site, initial encounter
T21.21XA Burn of second degree of chest wall, initial encounter
T21.22XA Burn of second degree of abdominal wall, initial encounter
T21.23XA Burn of second degree of upper back, initial encounter
T21.24XA Burn of second degree of lower back, initial encounter
T21.25XA Burn of second degree of buttock, initial encounter
T21.26XA Burn of second degree of male genital region, initial encounter
T21.27XA Burn of second degree of female genital region, initial encounter
T21.29XA Burn of second degree of other site of trunk, initial encounter
T21.60XA Corrosion of second degree of trunk, unspecified site, initial encounter
T21.61XA Corrosion of second degree of chest wall, initial encounter
T21.62XA Corrosion of second degree of abdominal wall, initial encounter
T21.63XA Corrosion of second degree of upper back, initial encounter
T21.64XA Corrosion of second degree of lower back, initial encounter
T21.65XA Corrosion of second degree of buttock, initial encounter
T21.66XA Corrosion of second degree of male genital region, initial encounter
T21.67XA Corrosion of second degree of female genital region, initial encounter
T21.69XA Corrosion of second degree of other site of trunk, initial encounter
T22.20XA Burn of second degree of shoulder and upper limb, except wrist and hand, unspecified site, initial encounter
T22.211A Burn of second degree of right forearm, initial encounter
T22.212A Burn of second degree of left forearm, initial encounter
T22.219A Burn of second degree of unspecified forearm, initial encounter
T22.221A Burn of second degree of right elbow, initial encounter
T22.222A Burn of second degree of left elbow, initial encounter
T22.229A Burn of second degree of unspecified elbow, initial encounter
T22.231A Burn of second degree of right upper arm, initial encounter
T22.232A Burn of second degree of left upper arm, initial encounter
T22.239A Burn of second degree of unspecified upper arm, initial encounter
T22.241A Burn of second degree of right axilla, initial encounter
T22.242A Burn of second degree of left axilla, initial encounter
T22.249A Burn of second degree of unspecified axilla, initial encounter
T22.251A Burn of second degree of right shoulder, initial encounter
T22.252A Burn of second degree of left shoulder, initial encounter
T22.259A Burn of second degree of unspecified shoulder, initial encounter
T22.261A Burn of second degree of right scapular region, initial encounter
T22.262A Burn of second degree of left scapular region, initial encounter
T22.269A Burn of second degree of unspecified scapular region, initial encounter
T22.291A Burn of second degree of multiple sites of right shoulder and upper limb, except wrist and hand, initial encounter
T22.292A Burn of second degree of multiple sites of left shoulder and upper limb, except wrist and hand, initial encounter
T22.299A Burn of second degree of multiple sites of unspecified shoulder and upper limb, except wrist and hand, initial encounter
T22.60XA Corrosion of second degree of shoulder and upper limb, except wrist and hand, unspecified site, initial encounter
T22.611A Corrosion of second degree of right forearm, initial encounter
T22.612A Corrosion of second degree of left forearm, initial encounter
T22.619A Corrosion of second degree of unspecified forearm, initial encounter
T22.621A Corrosion of second degree of right elbow, initial encounter
T22.622A Corrosion of second degree of left elbow, initial encounter
T22.629A Corrosion of second degree of unspecified elbow, initial encounter
T22.631A Corrosion of second degree of right upper arm, initial encounter
T22.632A Corrosion of second degree of left upper arm, initial encounter
T22.639A Corrosion of second degree of unspecified upper arm, initial encounter
T22.641A Corrosion of second degree of right axilla, initial encounter
T22.642A Corrosion of second degree of left axilla, initial encounter
T22.649A Corrosion of second degree of unspecified axilla, initial encounter
T22.651A Corrosion of second degree of right shoulder, initial encounter
T22.652A Corrosion of second degree of left shoulder, initial encounter
T22.659A Corrosion of second degree of unspecified shoulder, initial encounter
T22.661A Corrosion of second degree of right scapular region, initial encounter
T22.662A Corrosion of second degree of left scapular region, initial encounter
T22.669A Corrosion of second degree of unspecified scapular region, initial encounter
T22.691A Corrosion of second degree of multiple sites of right shoulder and upper limb, except wrist and hand, initial encounter
T22.692A Corrosion of second degree of multiple sites of left shoulder and upper limb, except wrist and hand, initial encounter
T22.699A Corrosion of second degree of multiple sites of unspecified shoulder and upper limb, except wrist and hand, initial encounter
T23.201A Burn of second degree of right hand, unspecified site, initial encounter
T23.202A Burn of second degree of left hand, unspecified site, initial encounter
T23.209A Burn of second degree of unspecified hand, unspecified site, initial encounter
T23.211A Burn of second degree of right thumb (nail), initial encounter
T23.212A Burn of second degree of left thumb (nail), initial encounter
T23.219A Burn of second degree of unspecified thumb (nail), initial encounter
T23.221A Burn of second degree of single right finger (nail) except thumb, initial encounter
T23.222A Burn of second degree of single left finger (nail) except thumb, initial encounter
T23.229A Burn of second degree of unspecified single finger (nail) except thumb, initial encounter
T23.231A Burn of second degree of multiple right fingers (nail), not including thumb, initial encounter
T23.232A Burn of second degree of multiple left fingers (nail), not including thumb, initial encounter
T23.239A Burn of second degree of unspecified multiple fingers (nail), not including thumb, initial encounter
T23.241A Burn of second degree of multiple right fingers (nail), including thumb, initial encounter
T23.242A Burn of second degree of multiple left fingers (nail), including thumb, initial encounter
T23.249A Burn of second degree of unspecified multiple fingers (nail), including thumb, initial encounter
T23.251A Burn of second degree of right palm, initial encounter
T23.252A Burn of second degree of left palm, initial encounter
T23.259A Burn of second degree of unspecified palm, initial encounter
T23.261A Burn of second degree of back of right hand, initial encounter
T23.262A Burn of second degree of back of left hand, initial encounter
T23.269A Burn of second degree of back of unspecified hand, initial encounter
T23.271A Burn of second degree of right wrist, initial encounter
T23.272A Burn of second degree of left wrist, initial encounter
T23.279A Burn of second degree of unspecified wrist, initial encounter
T23.291A Burn of second degree of multiple sites of right wrist and hand, initial encounter
T23.292A Burn of second degree of multiple sites of left wrist and hand, initial encounter
T23.299A Burn of second degree of multiple sites of unspecified wrist and hand, initial encounter
T23.601A Corrosion of second degree of right hand, unspecified site, initial encounter
T23.602A Corrosion of second degree of left hand, unspecified site, initial encounter
T23.609A Corrosion of second degree of unspecified hand, unspecified site, initial encounter
T23.611A Corrosion of second degree of right thumb (nail), initial encounter
T23.612A Corrosion of second degree of left thumb (nail), initial encounter
T23.619A Corrosion of second degree of unspecified thumb (nail), initial encounter
T23.621A Corrosion of second degree of single right finger (nail) except thumb, initial encounter
T23.622A Corrosion of second degree of single left finger (nail) except thumb, initial encounter
T23.629A Corrosion of second degree of unspecified single finger (nail) except thumb, initial encounter
T23.631A Corrosion of second degree of multiple right fingers (nail), not including thumb, initial encounter
T23.632A Corrosion of second degree of multiple left fingers (nail), not including thumb, initial encounter
T23.639A Corrosion of second degree of unspecified multiple fingers (nail), not including thumb, initial encounter
T23.641A Corrosion of second degree of multiple right fingers (nail), including thumb, initial encounter
T23.642A Corrosion of second degree of multiple left fingers (nail), including thumb, initial encounter
T23.649A Corrosion of second degree of unspecified multiple fingers (nail), including thumb, initial encounter
T23.651A Corrosion of second degree of right palm, initial encounter
T23.652A Corrosion of second degree of left palm, initial encounter
T23.659A Corrosion of second degree of unspecified palm, initial encounter
T23.661A Corrosion of second degree back of right hand, initial encounter
T23.662A Corrosion of second degree back of left hand, initial encounter
T23.669A Corrosion of second degree back of unspecified hand, initial encounter
T23.671A Corrosion of second degree of right wrist, initial encounter
T23.672A Corrosion of second degree of left wrist, initial encounter
T23.679A Corrosion of second degree of unspecified wrist, initial encounter
T23.691A Corrosion of second degree of multiple sites of right wrist and hand, initial encounter
T23.692A Corrosion of second degree of multiple sites of left wrist and hand, initial encounter
T23.699A Corrosion of second degree of multiple sites of unspecified wrist and hand, initial encounter
T24.201A Burn of second degree of unspecified site of right lower limb, except ankle and foot, initial encounter
T24.202A Burn of second degree of unspecified site of left lower limb, except ankle and foot, initial encounter
T24.209A Burn of second degree of unspecified site of unspecified lower limb, except ankle and foot, initial encounter
T24.211A Burn of second degree of right thigh, initial encounter
T24.212A Burn of second degree of left thigh, initial encounter
T24.219A Burn of second degree of unspecified thigh, initial encounter
T24.221A Burn of second degree of right knee, initial encounter
T24.222A Burn of second degree of left knee, initial encounter
T24.229A Burn of second degree of unspecified knee, initial encounter
T24.231A Burn of second degree of right lower leg, initial encounter
T24.232A Burn of second degree of left lower leg, initial encounter
T24.239A Burn of second degree of unspecified lower leg, initial encounter
T24.291A Burn of second degree of multiple sites of right lower limb, except ankle and foot, initial encounter
T24.292A Burn of second degree of multiple sites of left lower limb, except ankle and foot, initial encounter
T24.299A Burn of second degree of multiple sites of unspecified lower limb, except ankle and foot, initial encounter
T24.601A Corrosion of second degree of unspecified site of right lower limb, except ankle and foot, initial encounter
T24.602A Corrosion of second degree of unspecified site of left lower limb, except ankle and foot, initial encounter
T24.609A Corrosion of second degree of unspecified site of unspecified lower limb, except ankle and foot, initial encounter
T24.611A Corrosion of second degree of right thigh, initial encounter
T24.612A Corrosion of second degree of left thigh, initial encounter
T24.619A Corrosion of second degree of unspecified thigh, initial encounter
T24.621A Corrosion of second degree of right knee, initial encounter
T24.622A Corrosion of second degree of left knee, initial encounter
T24.629A Corrosion of second degree of unspecified knee, initial encounter
T24.631A Corrosion of second degree of right lower leg, initial encounter
T24.632A Corrosion of second degree of left lower leg, initial encounter
T24.639A Corrosion of second degree of unspecified lower leg, initial encounter
T24.691A Corrosion of second degree of multiple sites of right lower limb, except ankle and foot, initial encounter
T24.692A Corrosion of second degree of multiple sites of left lower limb, except ankle and foot, initial encounter
T24.699A Corrosion of second degree of multiple sites of unspecified lower limb, except ankle and foot, initial encounter
T25.211A Burn of second degree of right ankle, initial encounter
T25.212A Burn of second degree of left ankle, initial encounter
T25.219A Burn of second degree of unspecified ankle, initial encounter
T25.221A Burn of second degree of right foot, initial encounter
T25.222A Burn of second degree of left foot, initial encounter
T25.229A Burn of second degree of unspecified foot, initial encounter
T25.231A Burn of second degree of right toe(s) (nail), initial encounter
T25.232A Burn of second degree of left toe(s) (nail), initial encounter
T25.239A Burn of second degree of unspecified toe(s) (nail), initial encounter
T25.291A Burn of second degree of multiple sites of right ankle and foot, initial encounter
T25.292A Burn of second degree of multiple sites of left ankle and foot, initial encounter
T25.299A Burn of second degree of multiple sites of unspecified ankle and foot, initial encounter
T25.611A Corrosion of second degree of right ankle, initial encounter
T25.612A Corrosion of second degree of left ankle, initial encounter
T25.619A Corrosion of second degree of unspecified ankle, initial encounter
T25.621A Corrosion of second degree of right foot, initial encounter
T25.622A Corrosion of second degree of left foot, initial encounter
T25.629A Corrosion of second degree of unspecified foot, initial encounter
T25.631A Corrosion of second degree of right toe(s) (nail), initial encounter
T25.632A Corrosion of second degree of left toe(s) (nail), initial encounter
T25.639A Corrosion of second degree of unspecified toe(s) (nail), initial encounter
T25.691A Corrosion of second degree of right ankle and foot, initial encounter
T25.692A Corrosion of second degree of left ankle and foot, initial encounter
T25.699A Corrosion of second degree of unspecified ankle and foot, initial encounter
T30.0 Burn of unspecified body region, unspecified degree
T30.4 Corrosion of unspecified body region, unspecified degree
T31.0 Burns involving less than 10% of body surface
T31.10 Burns involving 10-19% of body surface with 0% to 9% third degree burns
T31.11 Burns involving 10-19% of body surface with 10-19% third degree burns
T31.20 - T31.22 Burns involving 20-29% of body surface with 0% to 9% third degree burns - Burns involving 20-29% of body surface with 20-29% third degree burns
T31.30 - T31.33 Burns involving 30-39% of body surface with 0% to 9% third degree burns - Burns involving 30-39% of body surface with 30-39% third degree burns
T31.40 - T31.44 Burns involving 40-49% of body surface with 0% to 9% third degree burns - Burns involving 40-49% of body surface with 40-49% third degree burns
T31.50 - T31.55 Burns involving 50-59% of body surface with 0% to 9% third degree burns - Burns involving 50-59% of body surface with 50-59% third degree burns
T31.60 - T31.66 Burns involving 60-69% of body surface with 0% to 9% third degree burns - Burns involving 60-69% of body surface with 60-69% third degree burns
T31.70 - T31.77 Burns involving 70-79% of body surface with 0% to 9% third degree burns - Burns involving 70-79% of body surface with 70-79% third degree burns
T31.80 - T31.88 Burns involving 80-89% of body surface with 0% to 9% third degree burns - Burns involving 80-89% of body surface with 80-89% third degree burns
T31.90 - T31.99 Burns involving 90% or more of body surface with 0% to 9% third degree burns - Burns involving 90% or more of body surface with 90% or more third degree burns
T32.0 Corrosions involving less than 10% of body surface
T32.10 Corrosions involving 10-19% of body surface with 0% to 9% third degree corrosion
T32.11 Corrosions involving 10-19% of body surface with 10-19% third degree corrosion
T32.20 - T32.22 Corrosions involving 20-29% of body surface with 0% to 9% third degree corrosion - Corrosions involving 20-29% of body surface with 20-29% third degree corrosion
T32.30 - T32.33 Corrosions involving 30-39% of body surface with 0% to 9% third degree corrosion - Corrosions involving 30-39% of body surface with 30-39% third degree corrosion
T32.40 - T32.44 Corrosions involving 40-49% of body surface with 0% to 9% third degree corrosion - Corrosions involving 40-49% of body surface with 40-49% third degree corrosion
T32.50 - T32.55 Corrosions involving 50-59% of body surface with 0% to 9% third degree corrosion - Corrosions involving 50-59% of body surface with 50-59% third degree corrosion
T32.60 - T32.66 Corrosions involving 60-69% of body surface with 0% to 9% third degree corrosion - Corrosions involving 60-69% of body surface with 60-69% third degree corrosion
T32.70 - T32.77 Corrosions involving 70-79% of body surface with 0% to 9% third degree corrosion - Corrosions involving 70-79% of body surface with 70-79% third degree corrosion
T32.80 - T32.88 Corrosions involving 80-89% of body surface with 0% to 9% third degree corrosion - Corrosions involving 80-89% of body surface with 80-89% third degree corrosion
T32.90 - T32.99 Corrosions involving 90% or more of body surface with 0% to 9% third degree corrosion - Corrosions involving 90% or more of body surface with 90% or more third degree corrosion
T81.30XA Disruption of wound, unspecified, initial encounter
T81.31XA Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter
T81.33XA Disruption of traumatic injury wound repair, initial encounter
T81.89XA Other complications of procedures, not elsewhere classified, initial encounter
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
074x Clinic - Outpatient Rehabilitation Facility (ORF)
075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
085x Critical Access Hospital
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals (such as physical therapists and occupational therapists in private practice) and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.


Code Description
0420 Physical Therapy - General Classification
0421 Physical Therapy - Visit
0424 Physical Therapy - Evaluation or Re-evaluation
0429 Physical Therapy - Other Physical Therapy
0430 Occupational Therapy - General Classification
0431 Occupational Therapy - Visit
0434 Occupational Therapy - Evaluation or Reevaluation
0439 Occupational Therapy - Other Occupational Therapy
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
06/02/2022 R15

R15

Revision Effective: 06/02/2022

Revision Explanation: Annual review, no changes were made.

01/01/2022 R14

R14

Revision Effective : 01/01/2022

Revision Explanation: Removed “The codes below are being added on a interim basis during the Public Health Emergency(PHE). Once the PHE has ended these codes will be removed.” from group 3 paragraph and replaced with Telehealth Codes. Added new codes for 2022 98975-98977 and 98980-98981.

 

05/27/2021 R13

R13
Revision Effective: 05/27/2021
Revision Explanation: Annual review, no changes were made.

01/01/2021 R12

R12
Revision Effective: 01/01/2021
Revision Explanation: Codes G2010 and G2012 were removed in error from group 2 during revision 11.

01/01/2021 R11

R11
Revision Effective: 01/01/2021
Revision Explanation: Codes G2250 and G2251 were removed form the paragraph section of group 2 and moved down to the list of codes for group 2 after the coding update to the MCD for quarterly CPT/HCPCS effective January 1, 2021.

01/01/2021 R10

R10
Revision Effective: 01/01/2021
Revision Explanation: HCPCS codes G2061-G2063 in group 2 were end dated effective 12/31/2020 and replaced with codes 98970-98972 beginning 01/01/2021. New codes G2250 and G2251 were also added to group 2 and will be added to the list once loaded into the MCD. 

10/01/2020 R9

R9
Revision Effective: 10/01/2020
Revision Explanation: During annual ICd-10 review J82 was deleted and replaced with J82.81, J82.81, J82.83, and J82.89

03/01/2020 R8

R8
Revision Effective: n/a
Revision Explanation: Annual review, no changes made.

03/01/2020 R7

R7
Revision Effective:03/01/2020
Revision Explanation: The group 2 HCPCS/CPT codes were added due to the PHE for COVID-19 and will be removed once the PHE has ended.

02/06/2020 R6

R6

Revision Effective:02/06/2020

Revision Explanation: Removed second bullet under Time Based codes related to psychotherapy as it was included in error.

01/01/2020 R5

R5

Revision Effective:01/01/2020

Revision Explanation: During annual HCPCS review codes 95831-95834 was replaced with codes 97161-97168, 90911 was replaced with 90912 nd 90913, and G0515 was replaced with codes 97129 and 97130 effective 01/01/2020.

11/28/2019 R4

R4

Revision Effective:11/28/2019

Revision Explanation: Under the ICd-10 Codes that support medical necessity the three groups were removed as they were added in error when removing all coding from the policy. The information list were some examples of coding that code be used for the therapy services.

11/14/2019 R3

R3

Revision Effective:11/14/2019

Revision Explanation: Added additional information concerning untimed and timed codes, additional information concerning documentation and other comments from policy was placed into the article text.

In revision 2 97535 should have been 97532.

10/03/2019 R2

R2

Revision Effective:10/03/2019

Revision Explanation: The CPT code listed for group 1 ICD-10 that supports medical necessity was incorrect. G0515 is the correct code for the ICD-10 code listed for group 1 and not 97535.

10/03/2019 R1

R1

Revision Effective:10/03/2019

Revision Explanation: The covered indications for 97532, 97116, and 97033 were left off in error when billing and coding article was created. These have ben added to the ICD-10 section that supports medical necessity.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/15/2023 11/22/2023 - N/A Currently in Effect View
05/19/2023 05/25/2023 - 11/21/2023 Superseded View
05/26/2022 06/02/2022 - 05/24/2023 Superseded You are here
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