Avoid common PMR coding errors
Coding can be confusing. Vague code descriptions and varying carrier rules for how and when codes should be used cause some errors.
Most coding mistakes in physical medicine and rehabilitation (PMR), however, can be traced to a fundamental misunderstanding of the difference between modalities, procedures, and contact requirements for each.
DEFINITIONS AND DIFFERENCES
Modalities and procedures are distinct and separate as defined in the AMA CPT Manual:
• Modalities. The AMA CPT Manual defines a modality as any physical agent applied to produce therapeutic changes to biologic tissues. Types of physical agents include, but are not limited to, thermal, acoustic, light, mechanical, or electrical energy.
Modalities are further subdivided into “supervised” and “constant attendance” modalities based on the degree of contact necessary to perform the service.
Supervised modalities (CPT 97010-97028) do not require direct one-on-one patient contact by the provider. Constant-attendance modalities (CPT 97032-97039), however, do require direct one-on-one patient contact by the provider.
You should note that the definitional requirement for direct “one-on-one” contact is somewhat of a misnomer, since you can provide constant attendance to more than one patient at a time.
To avoid problems, it is best to take a literal definition of constant attendance — that is, the provider or therapist must be in constant attendance with the patient, and such attendance is necessary for effective or safe delivery of the therapy.
• Procedures. The AMA CPT Manual defines procedure as “a manner of effecting change through the application of clinical skills and or services that attempt to improve function.”
Procedures require a physician or therapist to have direct one-on-one patient contact.
Two parts are key to distinguishing between a modality and a procedure. The first part involves a “gizmo” analysis; the second part involves reporting.
• Modality/procedure determination (gizmo analysis). If the therapy is delivered by some device (a gizmo) and the clinical skill is limited to determining the settings of the device and/or location and duration of application, the service is clearly a modality.
When the effect of the therapy is more dependent on the clinical skill of the practitioner (even if a device is used), the service is more likely a procedure.
• Specific code selection. For modalities, the code is selected based on method of performance, or more accurately, the physical agent (gizmo) used and level of contact necessary; the specific outcome is irrelevant.
For procedures, the code is selected based on the therapeutic outcome intended — the method of performance is irrelevant provided that one-on-one contact is provided and necessary.
CORRECT MODALITY CODING
Here are some common modality-coding errors:
• Laser therapy. Laser therapy is clearly a modality (a gizmo delivers the physical agent of light) and requires constant attendance (someone has to hold the laser probe).
This modality is often incorrectly coded as infrared therapy. Although it is true that laser falls within the infrared spectrum, using the CPT code for infrared therapy (97026) when reporting laser therapy is incorrect because laser therapy requires constant attendance, not supervision.
When you perform laser therapy, use HCPCS code S8948 or if S-codes are not permitted (for instance, with Medicare claims), report CPT 97039 and document the time of performance.
• Electric stimulation. Three codes exist that relate to electric stimulation — CPT 97014/G0283, supervised electric stimulation; CPT 97032, attended manual electric stimulation; and CPT 97033, iontopheresis.
CPT 97014/G0283 is appropriate for pad-based e-stim, which requires supervision only. Although this is not a time-based service, accepted protocols require 15 minutes to as much as 30 minutes of treatment.
CPT 97032 can only be used when stimulation is manually applied. The requirement for constant attendance is derived from the manual-application requirement.
Usually a probe or other hand-held device is used and must be held for the entire therapy. This is a time-based service reported in 15-minute units.
CPT 97033 is appropriate only when iontopheresis — the introduction of ions of soluble salts into the body by an electric current — is applied. Applying topical gels to the skin prior to application of the electric stimulation pads is not considered iontopheresis.
Although the pads used in this treatment are similar to those used in supervised e-stim, constant attendance is required because of the potential for burning the patient’s skin during therapy.
• Ultrasound and phonopheresis. Ultrasound is a constant-attendance modality, which, according to the AMA CPT Assistant, is provided to increase tissue temperature for treating arthritis, neuromas, and adhesive scars, or for conditions in which increasing tissue temperature is the desired effect.
Continuous ultrasound clearly provides such a thermal effect, whereas pulsed ultrasound is generally a nonthermal form of ultrasound. Reporting of pulsed ultrasound, however, using CPT 97035 may be inaccurate.
Some pulsed ultrasound units, which have ultrasound heads
attached to a mechanical arm placed over the patient, are marketed as hands-free devices. Constant attendance is not required, and CPT 97035 is therefore inappropriate. The appropriate code for hands-free forms of ultrasound is CPT 97039.
Phonopheresis is ultrasound treatment that uses a steroidal cream in place of the usual types of conductive gels. Report the ultrasound with CPT 97035 and the steroidal cream with the supply code 99070. Phonopheresis is often misreported as an unlisted procedure (97039).
• Vasopneumatic therapy. Many providers incorrectly report vibratory massage with CPT 97016. Because vibromassage devices require constant attendance (not supervision), the correct code for vibratory therapy is 97039.
CORRECT PROCEDURE CODING
Modalities are coded on the basis of the physical agent applied or how they are performed. Procedures are reported on the basis of the therapeutic outcome intended, not the method of performance.
With the exception of the group-therapy procedure (CPT 97150), all therapeutic procedures are time-based and require direct one-on-one contact.
As a result, validation of your code selection (and units) depends on having evidence of the therapeutic outcome, time of performance, and level of contact needed/provided.
The requirement of clinical skill, the intended outcome, and direct one-on-one contact are tied together. For most musculoskeletal problems, either CPT 97110 or 97530 is appropriate for your skilled rehabilitation services. The problem is deciding the appropriate code. As you likely have discovered, the descriptions for these codes provide little help.
• Strength, endurance, range of motion, and flexibility. CPT 97110 and 97530 both address these outcomes, are time-based, and require direct one-on-one contact by the provider. Despite these similarities, there is a difference between these procedures.
CPT 97110 is appropriate when the outcome of the exercise is one of the following: strength, endurance, range of motion, or flexibility.
CPT 97530 is appropriate when the outcome of the exercise involves multiple parameters.
While the AMA provides a number of examples of how each of these procedures might be performed, don’t be fooled — they are just examples. Remember, the method
of performance does not determine the code.
Without a local carrier policy stating otherwise, to select an exercise or activity code correctly, you must determine (and hopefully document) how many therapeutic outcomes are served by the particular procedure or technique performed.
This should be defined in the treatment plan. For example: If you prescribe an elliptical walker exercise to improve strength and cardiovascular endurance, use 97530. If endurance is the only goal, use CPT 97110.
Simply put: If you are aiming at one outcome (strength, endurance, range of motion, or flexibility), use 97110. For more than one outcome, use 97530.
• Neuromuscular re-education and gait training. CPT 97112 and 97116 are commonly misreported. While both are time-based (in 15-minute units) and require direct one-on-one contact of the provider, they are not appropriate for most musculoskeletal rehabilitation scenarios.
CPT 97112 involves neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting or standing activities.
This code gets a lot of attention from fraud investigators because this service gets used to represent manual proprioceptive techniques or neuromuscular massage techniques.
This code is used correctly when the relationship of the procedure to sitting or standing activities is evident. Many carriers have placed restrictions on the use of 97112. These restrictions generally involve significant neurologic deficits, such as muscular dystrophy, stroke, and cerebral palsy, thereby establishing the primary neurologic emphasis of this service.
CPT 97116 is used to report gait training, including stair climbing, stance, swing, and double-support. Again, most carriers restrict use of this service to patients with substantial gait anomalies in which the gait deficiency is neurologically centered rather than due to relatively minor problems with activation patterns.
• Massage therapy. Massage is often miscoded and providers should exercise caution before attempting to bill for massage services.
Massage is a therapeutic procedure and, therefore, requires skilled application. It is also a time-based service that requires one-on-one contact. Given the near universal bundling of this service with manipulation, this service is not reportable is in many circumstances.
When massage is provided, CPT 97124 should be reported.
As with all procedures, your documentation must be clear concerning the service performed and therapeutic outcome to be achieved in order to select the correct procedure code.
Michael D. Miscoe, CPC, CHCC, CRA, is a certified professional coder, certified healthcare compliance consultant, certified rehab assistant, the president of Practice Masters Inc. (www.codingexperts.com), and a member of the National Advisory Board of the American Academy of Professional Coders. He can be reached at 814-754-1550 or by e-mail at firstname.lastname@example.org.