02/01/2017

Proper Billing and Documentation for CPT Code 97110

What would need to be done/document in order to bill CPT code 97110?

Below are the bullet points from the Outpatient Physical and Occupational Therapy Services (L33631) LCD Policy that outline the documentation requirements for CPT 97110:

 Supportive Documentation Requirements (required at least every 10 visits) for 97110:

• Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on function.
• If used for pain include pain rating, location of pain, effect of pain on function. 
• Specific exercises performed, purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills of a therapist were required.
• When skilled cardiopulmonary monitoring is required, include documentation of pulse oximetry, heart rate, blood pressure, perceived exertion, etc.
• Documentation should include not only measurable indicators such as functional loss of joint motion or muscle strength, but also information on the impact of these limitations on the patient’s life and how improvement in one or more of these measures leads to improved function.
• Documentation of progress should show the condition is responsive to the therapy chosen and that the response is (or is expected to be) clinically meaningful. Metrics of progress that are functionally meaningful (or obviously related to clinical functional improvement) should be documented wherever possible. For example, long courses of therapy resulting in small changes in range of motion might not represent meaningful clinical progress benefiting the patient’s function.
• Documentation should describe new exercises added, or changes made to the exercise program to help justify that the services are skilled. Documentation must also show that exercises are being transitioned as clinically indicated to an independent or caregiver-assisted exercise program (“home exercise program” HEP ).  The HEP is an integral part of the therapy plan of care and should be modified as the patient progresses during the course of treatment. It is appropriate to transition portions of the treatment to the HEP as the patient or caregiver master the techniques involved in the performance of the exercise.
• If an exercise is taught to a patient and performed for the purpose of restoring functional strength, range of motion, endurance training, and flexibility, CPT code (97110) is the appropriate code. For example, a gym ball exercise used for the purpose of increasing the patient’s strength should be considered as therapeutic exercise when coding for billing. Also, the minutes spent taping, such as McConnell taping, to facilitate a strengthening intervention would be counted under 97110.
• Lack of exercise equipment at home does not make continued treatment in the clinic skilled or reasonable and necessary. The home program may need to be carried out through community resources.
• Documentation must clearly support the need for continued therapeutic exercise greater than 12-18 visits. 

Below is the link to the Outpatient Physical and Occupational Therapy Services (L33631) LCD Policy:

http://nyspma.org/aws/NYSPMA/asset_manager/get_file/145957?ver=8833