Procedure code and Description
97530 Therapeutic activities, direct one-on-one contact, each unit 15 mins PT, OT 3 Sometimes
97532 Cognitive skills development, each unit 15 mins PT, OT 3 Sometimes
97533 Sensory integration, each unit 15 mins PT, OT 4 Sometimes
97535 Self care / home management training (activities of daily living, including instruction on the use of assistive technology devices), each unit 15 mins PT, OT 4 Sometimes
97537 Community/work reintegration training, each unit 15 mins PT, OT 4 Sometimes
Self-Care/Home Management Training (procedure Code 97535)
This procedure is medically necessary only when it requires the professional skills of a therapist, is designed to address specific needs of the patient, and is part of an active treatment plan directed at a specific outcome.
The patient must have the capacity to learn from instructions.
Services provided concurrently by physicians, optometrists, physical therapists, and occupational therapists may be covered if separate and distinct goals are documented in the treatment plans.
Other Therapeutic Procedures (CPT codes 97532 and 97533):
Development of cognitive skills to improve attention, memory or problem solving, may be medially necessary for patients having neurologic conditions such as head injury or trauma, stroke, muscular dystrophy and/or multiple sclerosis or other neurological diseases. Reassessment of the patientts progress should occur every 2-3 months showing significant and measurable improvement. These procedures may be medically necessary when included in a patientts individual treatment plan aimed at improving or restoring specific functions which were impaired by an identified illness or injury and when the improved functional physical/cognitive abilities of the patient that are expected to be achieved are specified in the plan. If at anytime during the treatment period it becomes obvious that continued cognitive rehabilitation is not likely to be effective, that the service is no longer needed, or that all realistic attainable goals have been met then the treatment should be discontinued. The patient must have the capacity to learn from instructions.
97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training) direct (one-on-one) patient contact by the provider, each 15 minutes
* Compensatory training is provided to make up for a deficiency or loss of cognitive skills resulting from brain injury or psychiatric disorders.
* Cognitive impairments addressed by this code include attentional impairments (loss of focused, sustained, alternating and divided attention), memory impairments, and problem solving impairments (inability to initiate a behavioral response, to organize parts or concepts or thoughts into a whole, and to sequence thoughts so as to modify behavior). (CPT Assistant, Vol. 11, Issue 12, December 2001)
* This procedure is not medically reasonable and necessary when the patient’s cognitive skills are not expected to improve.
* This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures to effect continued improvement.
97533 Sensory integrative techniques to enhance sensory processing and promote adaptive response to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes
* These treatments are performed when a deficit in processing input from one of the sensory systems decreases the patient’s ability to make adaptive sensory, motor, and behavioral responses to environmental demands.
* These patients may demonstrate sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems. (CPT Assistant, Vol.11, Issue 12, December 2001)
* Sensory integrative interventions enhance sensory processing by persons with deficits in sensory systems (e. g., vestibular, proprioceptive, tactile) by increasing their ability to make adaptive sensory, motor, and behavioral responses to environmental demand.
* Sensory integrative treatments are almost exclusively provided to a pediatric population for responses to environmental demand and are almost exclusively provided for conditions such as autism, developmental disorders, attention deficit hyperactivity disorder, cerebral palsy, and motor apraxia. Similar techniques used in treatment for adults should be coded with 97112.
* This procedure is not medically reasonable and necessary when the patient’s sensory processing and adaptive responses are not expected to improve.
* This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures to effect continued improvement.
97535 Self care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one on one contact by provider, each 15 minutes:
* This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific outcome.
* The patient must have the capacity to learn from instructions.
* Medical treatment may generally require up to 12 visits in 4 weeks. Coverage beyond 12 visits in 4 weeks may require documentation supporting the medical necessity of continued treatment.
* Documentation must relate the training to expected functional goals that are attainable by the patient.
* The medical record should document the distinct goals and service rendered when self-care/home management training is done during the same visit as gait training (97116), orthotics fitting and training (97504) or prosthetic training (97520).
97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one on one contact by provider, each 15 minutes:
* This training may be medically necessary when performed in conjunction with a patient’s individual treatment plan aimed at improving or restoring specific functions which were impaired by an identified illness or injury and when expected outcomes that are attainable by the patient are specified in the plan.
* This training is medically necessary only when it requires the professional skills of a provider. Generally speaking, the professional skills of a provider are not required to effect improvement or restoration of function where a patient suffers a temporary loss or reduction of function which could reasonably be expected to improve as the patient gradually resumes normal activities. General activity programs and all activities which are primarily social or diversional in nature will be denied because the professional skills of a provider are not required.
* Services which are related solely to specific employment opportunities, work skills or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1) of the Social Security Act (Medicare Benefit Policy Manual, Pub. 100-2, Chapter 15, Section 220.2, formerly Ref. MCM 2217.B).
* The CPT code 97537 was modified in 2004. This code is expanded to complement the 97755 assessment code. The modification is intended to allow the post-assessment patient fitting and training for use of the advanced technology device/adaptive equipment.
* The patient must have the capacity to learn from instructions.
* Medical treatment may generally require up to 12 visits in 4 weeks.
* Documentation must relate the training to expected functional goals that are attainable by the patient.
97520 Prosthetic training, upper and/or lower extremities, each 15 minutes:
* The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training (97116), orthotics fitting and training (97504) or self care/home management training (97535).
* Periodic revisits beyond the third month may require supportive documentation of medical necessity if requested.
* In some cases, prosthetic training may require more than 30 minutes on a given date and when this occurs the medical record must document the medical necessity of the additional time.
* Note: The following items are included in the Durable Medical Equipment Regional Contractor (DMERC) reimbursement for a prosthesis within 90 days of delivery of the prosthesis and, therefore, are not separately billable to Medicare:
a. Evaluation of the residual limb and/or gait
b. Fitting of the prosthesis
c. Cost of base component parts and labor contained in HCPCS base codes
d. Repairs due to normal wear or tear
e. Adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component when the adjustments are not necessitated by changes in the residual limb or the patient’s functional abilities.
Therapeutic Activities (CPT code 97530)
1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques. Activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities to improve performance in a progressive manner. The activities are usually directed at a loss or impairment of mobility, strength, balance, coordination or cognition. They require the skills of occupational therapists and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active written plan of treatment and be directed at a specific outcome.
2. In order for therapeutic activities to be covered, the following requirements must be met:
a. The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning
b. The patient’s condition being such that he/she is unable to perform therapeutic activities except under the supervision of an occupational therapist
c. There being a clear correlation between the type of exercise performed and the patient’s underlying medical condition for which the therapeutic activities were prescribed
Cognitive Skills Development (CPT code 97532)
1. This procedure is reasonable and necessary for patients who have a disease or injury in which impairment of cognitive functioning is documented. Impaired functions may include but are not limited to ability to follow simple commands, attention to tasks, problem solving skills, memory, ability to follow numerous steps in a process, perform in a logical sequence and ability to compute.
2. This procedure is reasonable and necessary only when it requires the skills of an occupational therapist and is designed to address specific needs of the patient and is part of the written plan of care.
3. Treatment techniques utilized include but are not limited to recall of information, tabletop graded activities focusing on attentional skills (e.g. cancellation tasks, mazes), and graded processes in steps, which patient must follow to complete task, computer programs that focus on the above.
4. Development of cognitive skills must be reasonable and necessary to restore and improve functioning of the patient. Documentation must relate the training to expected functional goals that are attainable by the patient.
5. Services provided concurrently by physicians, occupational therapists and speech therapists may be covered, if separate and distinct goals are documented in the written plan of treatment.
Sensory Integration (CPT code 97533)
The use of sensory integrative techniques is considered reasonable and necessary when patients must develop adaptive skills for sensory processing. When there has been a disruption of the auditory, vestibular, proprioceptive, tactile and/or visual system; interventions are required to assist the patient in remaining functional in their environment. The loss of sensory systems often compromises the safety of the patient; therefore therapy should provide adaptations that allow the patient to interact with their environment that promotes well-being.
Self-Care/Home Management Training (CPT code 97535)
Self-care/home management training (97535) describes a group of interventions that focuses on activities of daily living skills and compensatory activities needed to achieve independence or adapt to an evolving deterioration in health and function. These include activities such as dressing, bathing, food preparation, and cooking. The patient/client may require adaptive equipment and/or assistive technology in the home environment. This code includes training the patient/client and/or caregiver in the use of the equipment.
This code should not be used globally for all home instructions. When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity.
Community/Work Reintegration Training (CPT code 97537)
Services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1) of the Social Security Act.
Services that are covered include complex IADL’s a person must do to maintain independence in the community. These tasks involve interaction with the physical and social environment. Examples of these activities may include telephone skills, written communication, handling mail, use of money, shopping from home, emergency procedure use/skills, and use of assistive technology device/adaptive equipment. This service is only covered when the skilled intervention of occupational therapy is required to achieve established goals.
BCBSKS has limitations on services provided for CPT code 97535 (Blue Shield Report Newsletter August 30, 2005)
a. “DENY content of service to other codes billed same setting in the following situations”:
1) Home exercise program
2) Instructions for use of DME such as TENS units, cervical traction
3) Instructions for orthotics or prosthetics such as AFO’s, compression stockings
4) Instructions for home care such as correct posture or sleeping positions
4. Vertebral Axial Decompression therapy must be billed using HCPCS code S9090. (Blue Shield Report May 28, 2003)
a. Reimbursement based on CPT code 97012
b. VaxD, IDD, DR 5000, DR 9000, SpinaSystem, and similar vertebral axial decompression therapy are subject to this billing policy
c. ALLOW ONE (1) unit per day based on documented medical necessity
5. Accident Related Documentation
a. Payment for services related to an accident is NOT the same as those services for general medical coverage. In the event the services are being rendered as related to an accident, it is imperative that your documentation is clear and concise about:
1) The details of the accident (simple statements like “they fell on 4-10-09” are insufficient)
2) The objective, functional, measurable data that supports the medical problems that are a direct result of the accident and need for occupational therapy services.
The following medical record standards (not all inclusive) are required; and if not met, may result in delay or denial of payment:
1) Documented referral from appropriate referral source.
2) Documented name (on each page of the record) and birth date of beneficiary
3) Legible handwriting (if it is not readable, it will be denied)
4) Avoidance of abbreviations (use only standard abbreviations well known to your peers)
5) Each CPT code submitted for payment must have the appropriate documentation to support the service rendered. Clearly document what you performed to differentiate between each service utilized – 97110, 97112, 97530, 97535, etc.
6) Initial evaluation that includes:
a. Diagnosis (medical and occupational therapy)
b. Complete history and thorough systems review (patient stated problems, comorbidities, medications, review of past-present care)
