by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Jul 13th, 2022
Chiropractors treat, among other things, issues with the musculoskeletal system. Active therapeutic procedures are accepted as effective ways to treat many common conditions and therefore can be billed and generate revenue for a clinic. Two common CPT codes that might be used in a chiropractic setting include:
97110 - Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97530 -Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
Though Medicare does not reimburse chiropractors for either of these codes, understanding their policies in relation to these services is wise since many private payers follow Medicare standards. Medicare states that, "Therapeutic procedures are procedures that attempt to reduce impairments and restore function through the application of clinical skills and/or services." So, first and foremost, in order for either of these services to be justified, there must be some sort of functional loss and the service must provide functional gains, requiring the skills of someone who knows what they are doing.
There are several other things that these codes have in common:
Codes in the Physical Medicine and Rehabilitation section of the CPT code book are not limited to any particular specialty group. That is, they are not just for physical therapists.
These codes require one-on-one contact, usually with a licensed provider, but some state scope of practice and some payers allow for delegation to unlicensed individuals. Check with your insurance plans and state board to be sure before allowing unlicensed individuals to perform these services.
- These codes are time-based, in 15-minute increments.
Per the Medicare 8-minute rule, which is the accepted standard for most carriers, a minimum of 8 minutes must be completed to bill for the first unit. Less than 8 minutes is not billable.
- To bill for two units of either of these codes (or both of them at the same encounter), the total time must be at least 23 minutes (8 + 15).
In the CPT code book there is a different method for calculating time-based codes, so verify with the payer if in doubt.
Some payers require modifier GP to be added to this code on the claim form. This tells the payer that there is a therapy plan in place for the code. If your records are reviewed, and you used the GP modifier, make sure you clearly have a plan around the service and it was not just arbitrarily added to an encounter with no clear purpose.
Therapeutic procedures are often billed as part of an ongoing series of encounters. It is essential to periodically document progress. It might be wise to link a documented goal to each procedure and comment on the progress of that goal as it relates to the service billed, every 2-3 visits, and in greater depth at a re-exam or discharge exam.
The specific exercise or activity needs to be documented. Think of the record as a script for a play. If it contains enough information to re-enact the encounter, then it is sufficient. Otherwise, it may be lacking.
Each service must include documented functional progress at reassessment and discharge. If no progress, the reason for lack of progress needs to be documented and/or an alternative treatment strategy.
Although Medicare does not pay chiropractors for 97110, we can learn from their policies. LCD L35036 tells us that:
|Therapeutic exercise is designed to develop strength and endurance, range of motion, and flexibility and may include: active, active-assisted or passive (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening) exercises. The exercise may be medically reasonable and necessary for a loss or restriction of joint motion, strength, functional capacity or mobility that has resulted from a specific disease or injury. It is considered medically reasonable and necessary if an exercise is taught to a patient and performed by a skilled therapist for the purpose of restoring functional strength, range of motion, endurance training, and flexibility. Documentation must show objective loss of joint motion, strength or mobility (e.g., degrees of motion, strength grades, levels of assistance). This therapeutic procedure is measured in 15-minute units with therapy sessions frequently consisting of several units.
Many therapeutic exercises may require the unique skills of a therapist to evaluate the patient’s abilities, design the program, and instruct the patient or caregiver in safe completion of the special technique. However, after the teaching has been successfully completed, repetition of the exercise, and monitoring for the completion of the task, in the absence of additional skilled care, is non-covered.”
The takeaway is that if the documentation shows that the patient has a loss of strength, range of motion, endurance, or flexibility, then 97110 can be justified. However, the treatment goals for exercise should clearly document anticipated improvement in those same parameters.
If we look at CMS policies (see LCD L35036) regarding 97530 we learn that:
|“This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance.
The activities are usually directed at a loss or restriction of mobility, strength, balance or coordination. They require the professional skills of a qualified professional and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.”
For 97530, the record needs to document some sort of loss of the ability to perform activities and explain how the procedure restores that loss. The activity description would often include a verb ending in “ing”. The patient’s condition should be such that he/she is unable to perform therapeutic activities except under the direct supervision of a physician or physical therapist. Related diagnoses might include:
97110 focuses on one parameter, such as strength. 97530 takes things to the next level and focuses on some activity that may be dependent on multiple parameters in addition to strength. For example, shoulder strengthening exercises might be billed as 97110, but tossing a ball against a trampoline and catching it, which focuses on multiple parameters, would be 97530.
In a clinical setting, a patient may begin care with stretches to improve ROM (billed as 97110). After four weeks of stretches, and the goals are reached, perhaps care starts to focus on strengthening exercises due to findings of weakness in the initial exam. This would also be billed as 97110. Once the strength goals are reached (maybe after another four weeks), the new procedure could focus more on the dynamic activity of lifting boxes, which would then be billed as 97530.
When deciding which code is more appropriate, make sure the documentation includes objective findings that line up with the official code description, and goals that focus on the parameters that are outlined by the code and the payer and CPT guidelines above.
|Disclaimer: The above article is the opinion of the author(s) and should not be interpreted by providers/payers as official guidance. For any questions about the content of this article, please contact the author(s).|
About the Author: Dr. Evan Gwilliam is a certified coder, auditor, and compliance officer. He trains clinicians on how to create rock solid records with PayDC, which is a dynamic cloud based EHR software. If you would like to learn more, email him at email@example.com.
About Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Dr. Gwilliam is a licensed chiropractic physician with a master's in business administration. He is also a certified professional coding instructor, compliance specialist, and medical auditor. He has published articles in multiple trade journals and travels the country to deliver training to physicians and staff on coding, documentation, and compliance. He is the Vice President of ChiroCode.