Coding Questions: Documenting activities of daily living
Q: I provide patients self-care home recommendations and information on how to modify their activities of daily living (ADLs) from an ergonomic and injury prevention point of view. Can I bill for this type of work?
A: You can charge patients and insurance companies for this type of service using CPT code 97535.
CPT code 97535 is self-care/home-management training (such as ADL and compensatory training, meal preparation, safety procedures, and instructions in the use of assistive technology devices/adaptive equipment) with direct, one-on-one contact by the provider, each 15 minutes.
This should be reported for the provider/therapist devoting a separate and distinct procedural service to the patient for the purpose of instructing the patient in managing an injury at home and preventing a secondary injury, and instructing the patient on how to prevent future exacerbations.
Examples of ADL instruction include showing patients how to retrieve items off the floor, lift pots from the stove, reach for items in cupboards, open drawers, and perform exercises to help hasten the healing process.
The following clinical example, courtesy of the American Medical Association (AMA) illustrates CPT code 97535:
A 65-year-old woman was recently discharged from the hospital with a diagnosis of cerebral vascular accident (CVA) resulting in a right hemiparesis. The patient lives alone and wants to be able to remain in her home.
The initial evaluation revealed performance deficits in bathroom activities and meal preparation. At the home site, the provider/therapist recommends and sets up the proper adaptive equipment in the bathroom, so the patient can safely transfer to toilet and bathtub by using compensatory techniques.
In the kitchen, the provider/therapist teaches and observes meal preparation that use one-handed techniques and special adaptive equipment. The provider/therapist must assure that the patient’s functional level is sufficient to perform necessary self-care and home-management activities within safe limits.
Some common diagnostic codes that link to or combine with 97535 are:
723.4 Cervical radiculitis
724.1 Thoracic spine pain
Thoracic or lumbosacral neuritis or radiculitis, unspecified
719.7 Difficulty in walking
724.02 Lumbar spinal stenosis
724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.6 Lumbosacral or sacroiliac pain, instability, ankylosis
Documentation for CPT code 97535 should relate the ADL instruction to the patient’s expected functional goals and indicate it is part of an active treatment plan directed at a specific goal.
Here is a sample appeal letter and letter of medical necessity for CPT Code 97535:
Dear (insurance company):
The purpose of this letter is to provide you information that will allow you to understand the medical reasonableness for the activities of daily living (ADL) procedural service (CPT code 97535) provided to Mrs. Patient. We hope this information will allow you to authorize payment.
On March 23, 200X, Mrs. Patient presented to my office with low back pain, lumbar disc degeneration, and leg pain. The most recent re-evaluation findings revealed painful and restricted lumbar range of motion. Due to these findings, we performed the following procedure on April 23, 200X: CPT code 97535 – Self-care/home-management training (ADL and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment).
The ADL service procedure was provided by me (one-on-one) in order to give the patient specific, detailed home-care instructions and exercises in order to hasten the healing process and help the patient reach her improvement goals as soon as possible. The objective is to promote proper biomechanical movement, and prevent pain and possible re-injury.
Please consider payment for this service, as it was clinically indicted and medically necessary. Feel free to contact me if any further information is needed.
Marty Kotlar, DC, CHCC, CBCS, is the president of Target Coding. Target Coding, in conjunction with Foot Levelers, offers continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, by e-mail at firstname.lastname@example.org, or through the Web site, www.TargetCoding.com.