1. PHYSICAL Therapy Don’t get out of joint-exercise your coding muscles!
Julianne Gordon, DPT
Susan L. LeFevre, CPC

2. ~Welcome to tonight’s presentation of Physical Therapy~ We will be discussing physical therapy evaluations and the therapies available to help patients improve their ability to move and to perform their activities of daily living.

3. Coding for Physical Therapy evaluations and
procedures can be confusing. Medicare has
guidelines that third party payers might not
follow and procedure documentation can be unclear as to what was actually done. The Department of Defense has additional guidelines coders need to follow.
Tonight we will discuss what each procedure
means and what documentation should look
like so the work done can receive optimal
reimbursement and the documentation would
pass an audit or review.

4. What is physical therapy?
Physical therapy is a branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities.
Physical therapy is used for many types of patients, from infants born with musculoskeletal birth defects, to adults suffering from any number of conditions or the after effects of an injury or surgery.

5. Who performs physical therapy?
Physical therapy evaluations and procedures are performed by a licensed physical therapist (PT).
A physical therapist assistant (PTA) acting under a physical therapist’s supervision can work with patients during the procedures.
The assistant will provide specific treatments to the patient according to the treatment plan created by the
physical therapist and will document what was
done and the patient’s response to the treatment.

6. Definitions and licensing requirements in the United States vary as each state has its own physical therapy practice act defining the profession within that state.
The American Physical Therapy Association (APTA) has drafted a model definition in order to limit this variation.
The association is responsible for accrediting physical
therapy education programs throughout the United
States.

7. We will start with the two codes that are available for evaluations and then we’ll look at the therapies available to improve a patient’s function. Documentation and coding guidance will be touched on throughout.

8. Physical Therapy Evaluations
97001-Initial Evaluation
Initial evaluations include a history of the problem and exam of the affected body area(s). Range of motion measurements and any therapeutic procedures done as part of the assessment are included. This results in a diagnosis, an indication of the level of impairment, patient goals and a predicted outcome based on the treatment plan.
This is a 1 unit code no matter how many body areas are examined or how much time is spent with the patient.
If procedures are done after the assessment, they can be reported.
The documentation should be clear that they were not a part of the evaluation.
No modifiers are necessary with initial evaluations when procedures are also done.

9. Modifier -59 should be appended
97002-Re-evaluation
Per Chapter 15 of Medicare’s Benefit Policy Manual:
Continuous assessment of the patient’s progress is a component of on- going therapy services and is not payable as a re-evaluation.
A re-evaluation is not a routine, recurring service. A formal re- evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.
Indications include new clinical findings, a significant change in the patient’s condition or failure to respond to the interventions outlined in the plan of care.
Chart notes should be clear about the reason for the re- evaluation. Training assistants to document the complaints of the day is a good way to support the need for another evaluation.
Modifier -59 should be appended
to if procedures are also done .

10. Physical Therapy Treatment
CPT groups treatments into modalities and other therapeutic procedures
Modalities
can be supervised or constantly attended
supervised modalities include the application of the modality to one or more areas
supervised modalities are untimed codes; only 1 unit of service would normally be reported
electrical stimulation has a code under each type, documentation should state attended if done
constant attendance modalities are timed codes with 15 minute increments per unit
an unlisted modality code is available that would be used
for either supervised or constant attendance therapy
Therapeutic procedures
require direct contact by the provider
are timed codes with 15 minute increments
~Medicare does not count set-up time as PT time. Time for breaks during or in between procedures such as for the rest room does not count. Only actual time doing the procedure should be used as procedure time.
~Medicare and the Department of Defense use number of PT units documented with an 8 minute threshold for any particular therapeutic procedure while others use the full 15 minutes and modifier -52, reduced services.

11. Supervised Modalities
(Non-timed)
97010-Application of a modality to 1 or more areas; hot or cold packs
In general, cold packs should be used during acute injuries, usually within 48 to 72 hours after the injury. The application of cold packs help to relieve pain and swelling.
Examples of injuries where you can use cold packs are mild ankle sprains and muscle strains. Severe cases of sprains and strains require immediate medical attention.
After 48 to 72 hours or after the swelling has subsided, hot packs can be used. This can help to relieve pain, reduce muscle spasm, and increase blood flow to the injured area for faster healing or repair. Also, the application of a hot pack on an injured joint can reduce stiffness.
Hot packs should never be used during the acute phase of injury as this will cause more swelling and pain. It should only be applied if there is no more swelling.

12. 97012; mechanical traction
Mechanical traction uses tables that the patient lies down on, either on their back or face down, depending on which therapy the therapist decides would be most beneficial for their condition.
For patients suffering from low back pain, there is lumbar traction, which is designed to specifically target the lumbar curve, restoring the lumbar spine to it's appropriate degree of curvature.
Cervical traction is designed for the cervical curve, helping to reduce neck tension and is especially beneficial for headache sufferers.

13. 97014; electrical stimulation (unattended)
Electrical stimulation uses an electrical current to cause a single muscle or a group of muscles to contract.
By placing electrodes on the skin in various locations the physical therapist can recruit the appropriate muscle fibers.
Contracting the muscle via electrical stimulation helps strengthen the affected muscle.
The physical therapist can change the current setting to allow for a forceful or gentle muscle contraction.
Along with increasing muscle strength, the contraction of the muscle also promotes blood supply to the area that assists in healing.

14. 97016; vasopneumatic device therapy
Vasopneumatic compression is used to reduce swelling and inflammation in the upper or lower extremities following surgery or other injury.
Typically, a boot or sleeve is used to cover the injured limb. The boot or sleeve is then filled with air by a small compressor thus causing compression of the limb. Compression is maintained a set period of time and then released.
Elevation is commonly used in conjunction with vasopneumatic compression.

15. 97018; paraffin bath therapy
Paraffin treatment is a form of deep heat therapy.
Liquefied paraffin wax is very efficient at absorbing and retaining heat.
Heat transfers from the wax into the affected area as the wax solidifies.
The heat increases circulation and relieves pain and stiffness.
Paraffin increases blood supply to the skin, while also opening pores and trapping moisture from underlying layers of skin which softens the skin.
A paraffin wax treatment is ideal for patients suffering from arthritis, eczema, dermatitis and stiff joints.

16. 97022; whirlpool Therapy
Whirlpools use jets to generate a combination of air and water to create a gentle or deep massage effect.
Most whirlpools in a physical therapy clinic are small, and only an arm or leg will be able to be placed in it.
The temperature of the water in the whirlpool can be warm or cold, depending on the desired goal.
Warm whirlpools can increase circulation, as the heat helps to open up small arteries in the body helping to bring fresh blood, oxygen, and cells to the injured area, which can promote healing.
The typical temperature of a warm whirlpool is degrees Fahrenheit.
Cold whirlpools cause the arteries in the body to close, which can help to decrease circulation to the body part being treated. This helps manage inflammation and swelling in the injured body part.
The temperature of a cold whirlpool is usually between 50 and 60 degrees Fahrenheit.

17. Diathermy is a form of treatment that uses
electromagnetic current at high frequencies to heat
tissues located at different depths.
Low heat is typically used to relieve
muscle pain and facilitate repair of tissues.
A patient who undergoes this type of
procedure could stop further
reliance on pain relievers.

18. 97026; infrared therapy
Therapists are using infrared therapy in the
treatment of chronic pain resulting from arthritis,
diabetes and injuries.
Infrared therapy reduces stiffness and muscle
spasm while increasing the release of nitric oxide,
a vital transporter of nutrients.
Treatments typically consist of 30-minute durations
three times per week for a four-week span.
Infrared treatment is done in conjunction with other physical therapy treatments such as spine flexibility exercises, core muscle strengthening and postural correction.

19. 97028; ultraviolet therapy
UV light therapy utilizes infrared light that emits diodes (LEDs) which direct a stream of warmth deep within muscle tissues.
Circulation and blood flow is increased to the targeted areas for relief of joint and muscle pain, stiffness and aches.

20. Constant Attendance Modalities
97032; electrical stimulation
This serves the same purpose as but this is the constant attendance timed code.
Documentation should include the word attended so the correct credit can be given and the note supports the selection of the timed procedure code.

21. 97033; electric current therapy (iontophoresis)
Iontophoresis is a safe, well-documented method of increasing penetration of molecules into surface tissues.
Iontophoresis uses locally applied direct current to deliver medications across skin.

22. 97034; contrast bath
A contrast bath treatment involves using a both warm bath and cold bath on the same body part during treatment.
The injured body part is repeatedly moved from the warm to cold water.
The theory of a contrast bath is to create rapid opening and closing of the arteries around the body part being treated. This creates a pumping effect in the body part, which helps to decrease swelling around the injured site.

23. 97035; ultrasound
Ultrasound is a form of deep heating in which sound waves are applied to the skin and penetrate into the soft tissues.
The heat induces vasodilation drawing blood into the target tissues.
Increased blood flow delivers needed oxygen and nutrients, and removes cell wastes.
The deep heat helps to relieve pain, inflammation, reduces muscle spasms, and accelerates healing. Depending on the treatment area, range of motion may be increased.
Ultrasound can also be helpful in acute injuries for non-thermal effects, meaning no heat is generated, but it can help increase blood flow so that way inflammation or swelling can be reduced.
The machine pictured on the right is a combination of electrical stimulation and ultrasound; only 1 timed code can be reported for the same 15 minutes. E-stim has more RVU value so 97014, electrical stimulation should be selected. The documentation should include that the procedures were combined, along with the time spent.

24. 97036; Hubbard tank
This form of underwater therapy assists patients to overcome conditions where movement is limited because of paralysis or pain or where muscles have been weakened thorough injury or illness.
It takes place in pools with hoists for lifting people in and out of the pool, as well as walking bars and specially designed handles for those who have difficulty or who find it painful to move around without that added assistance.
It is essential for the water to be at body temperature for effective treatment.

25. Therapeutic procedures
97110-Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Research has shown that therapeutic exercise programs have proven to be very effective in ensuring a rapid recovery for various types of injuries.
Therapeutic exercises include a broad spectrum of activities, from passive range of motion stretches to stabilization exercises to high-speed agility drills.
The ultimate goal of a therapeutic exercise program is improved function.
The physical therapist will gradually progress a program by increasing the demands the exercises place on the body until you have the strength, endurance, flexibility, mobility, stability, coordination, and balance needed to achieve the plan goals.
What differentiates a therapeutic exercise program from other exercise programs? With therapeutic exercise, the physical therapist must use his or her specialized expertise and experience, combined with the latest evidence-based research in rehabilitation, to design an individualized program that includes exercises that are specific to each person’s injury, ability, and stage of recovery.
Therapeutic exercise can often include a variety of purposes. It is
up to the provider to clearly state what procedure was done and
how long it was done so the correct code can be reported. For
example if the purpose of the exercise is to improve balance
the time spent should be reported as 97112, neuromuscular
re-education.

26. 97112; neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and/or proprioception
Proprioceptors are sensory receptors that respond to joint movement (kinesthesia) and joint position (joint position sense), but do not typically contribute to conscious sensation.
Neuromuscular reeducation is a general term that refers to techniques that attempt to retrain the neuromuscular system to function properly.
The basis of this idea is that the formation of certain patterns of communication between muscles and nerves allow people to perform simple everyday acts such as climbing stairs.
These normal patterns of movement can be disrupted by injuries or may be impaired in people with certain medical conditions.
The general aim of neuromuscular reeducation is to strengthen the communication between the muscles and nerves to get patients moving the way they are accustomed to through a combination of
balance, strength, and flexibility training.

27. 97113; aquatic therapy/exercises
The pull of gravity on the body is not as strong in the water.
The water supports the weight of the body, reduces joint stress and pain, and provides gentle resistance to rapidly promote strengthening and conditioning while reducing the risk of further injury.
Aquatic therapy has been associated with a variety of beneficial outcomes, including improved circulation, strength, and endurance; increased range of motion and flexibility; decreases in swelling; and a faster return to normal activity.

28. 97116-Gait training Many orthopedic conditions result in impaired gait
97116-Gait training Many orthopedic conditions result in impaired gait. Deconditioning, weakness, pain, postural imbalances, and loss of joint mobility are some of the factors that impair safety, efficiency, and effectiveness of ambulation. PTAs apply knowledge of pathology, kinesiology and therapeutic exercise through progressive gait training techniques.

29. 97124; massage therapy
Massage therapy is a healing art that has been used for thousands of years. Today, it is used both for recreational and medicinal purposes.
Physical massage therapy is a practice of applying varying amounts of pressure to the body to relive tension, promote relaxation and stimulate circulation.
Physical massage has become an integral part of certain therapies centered on treating complications like bursitis, depression, diabetes and high-blood pressure.
According to massagetherapy.com, “There are more than 250 variations of massage, bodywork, and somatic therapies." For example, deep tissue massage is characterized by the application of intense pressure to specific points of the body. Swedish massage utilizes a variety of kneading, tapping and rolling the hands along the back, neck and arms.
Because there are so many different types of massage work, it is important that the documentation clearly states what is being done. Deep tissue massage is actually considered manual therapy, discussed on the next slide.

30. The documentation should clearly
97140; manual therapy
Manual physical therapy is a specialized form of physical therapy delivered with the hands as opposed to a device or machine.
In manual therapy, practitioners use their hands to put pressure on muscle tissue and manipulate joints in an attempt to decrease pain caused by muscle spasm, muscle tension, and improve joint stiffness caused by joint dysfunction.
Manual therapy is an effective in rapidly returning the injured person to a productive status once the joint dysfunction is corrected.
The documentation should clearly
indicate manual therapy was done so it
is not mistaken for massage.

31. 97150-Therapeutic Procedures, group (2 or more individuals)
This code is used whenever there is more than one person in constant attendance by the provider during the same period of time.
No other code should be reported and the code should be reported for each patient in the group.
The documentation should indicate that the work was done in a group with notation of the number of patients.
This is a non-timed code, even though every other code in this section is timed, so the units should only be one per patient.
If only one person shows up for the class, select the code for the procedure being done and document the total time spent.

32. 97530-Therapeutic activities (use of dynamic activities to improve functional performance)
Therapeutic activities involves the use of dynamic activities to improve functional performance.
Examples include bending, reaching, lifting, carrying, pushing and pulling.
In addition, bed mobility and transfer training are examples of therapeutic activities. These activities are usually directed at a loss or restriction of mobility, strength, balance or coordination.
Notice the bolded words?
They are part of the description
of several other codes. Documentation
should be clear about what is being done.

33. 97532-Cognitive skills training
Understanding individual cognitive skills helps to understand how learning is impacted.
These skills include:
1. Processing Speed: The efficiency with which the brain processes the data it receives. Faster
processing speed leads to more efficient thinking and learning.
2. Auditory Processing: This is the specific skill of processing sounds. This involves analyzing,
segmenting and blending sounds. Auditory skills are essential if a student is to read, spell, and
learn new words or concepts well.
3.Visual Processing: This is the ability to receive and manipulate visual information. Creating
mental images also greatly effects reading comprehension and long-term memory.
4. Memory: Memory includes long-term memory, storage and recall and short-term working
memory. The combined process helps create new concepts and understanding.
5. Logic and Reasoning: These skills are necessary for problem solving and planning.
Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system insult.
Cognitive rehabilitation consists of tasks designed to reinforce or re-establish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurologic systems.
Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational, or speech therapist; in the hospital, physician office or clinic, or at home.
Cognitive rehabilitation must be distinguished from occupational therapy occupational therapy describes rehabilitation that is directed at specific environments (i.e., home or work). In contrast, cognitive rehabilitation consists of tasks designed to develop the memory, language, and reasoning skills that can then be applied to specific environments, as described by the occupational therapy codes.

34. 97533-Sensory integration
Sensory integration is the neurological process that organizes sensation from one’s own body and the environment, thus making it possible to use the body effectively within the environment.
The information sent to our brains from each of our senses; movement, touch, sight, hearing, taste, and smell, is processed. Our brain tells us how that feels, what it looks like, what it sounds like, or how that tastes, and smells. This is simple sensory integration. Our brains perceive sensory information, process it, and reports back to us what is happening.
Sometimes there can be a problem with the encoding of the sensory information. This disorder is known as sensory integration disorder, or SID.
Sensory integration disorders may be the result of a learning disability, illness or brain injury.

35. 97535-Self care management
This should be reported for devoting time to provide 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.
Limited mobility and weakness are common reasons that patients have difficulty showering, bathing, and toileting safely on their own. Most of these individuals however wish to be as independent as possible while still avoiding injury.
An initial evaluation will fully assess the patients needs and reveal any deficits such as with bathroom activities or meal preparation.
The therapist will go to the home site to set up adaptive equipment and instruct the patient on its use.
The documentation should relate the ADL instruction to the patient’s expected functional goals and indicate that it is part of an active treatment plan directed at a specific goal.

36. 97537-Community/work reintegration
This procedure retrains the patient with social and/or work tasks to assist him or her in normal functioning or adapting.
A patient’s work reintegration is designed to help the patient adapt to new tasks and skills.
The therapist should be assessing a specific worker and their tasks, not the workplace as a whole.

37. 97542-Wheelchair management training Wheelchair management is defined as direct one-on-one assessment, fitting and/or training in the use of manual or power driven wheelchairs.

38. And the last available therapeutic code is:
97545-Work hardening/conditioning; initial 2 hours
each additional hour
Work hardening programs refer to physical conditioning programs for injured workers who are out of work, or who are working at less than full capacity.
Work hardening is a highly specialized rehabilitation program that transitions the patient from standard rehabilitation to return to work by simulating workplace activities and surroundings in a monitored environment.
In general, work hardening programs include a systematic program of gradually progressive, work-related activities performed with proper body mechanics, with the goal of physically and psychologically reconditioning the patient in order to facilitate return to full employment.

39. Physical Therapists and assistants also provide wound treatment and assessments & measurements as well as orthotic and prosthetic training. HCPCS L codes should be reported for prefabricated orthotics and exercise equipment that is given to a patient. The documentation should discuss the fitting and adjustment of the orthotic and should indicate any equipment given. Next, we will discuss a few diagnosis codes and then move on to some procedure documentation and Medicare scenarios.

40. Diagnosis coding
Evaluations
Evaluations would be reported with the therapist’s diagnosis.
Patients are often sent to PT as a part of routine surgical follow-up care, to include non-surgical fractures. Some aftercare diagnosis code examples are:
V54.10-V54.19 aftercare for healing traumatic fractures
V54.20-V54.29 aftercare for healing pathologic fractures
V aftercare following joint replacement (use additional code to identify site)
V other orthopedic aftercare
V aftercare following surgery of the nervous system
V aftercare following surgery of the musculoskeletal system
Therapies only
V57.1, care involving use of rehabilitation procedures, other physical therapy, should be the first-listed diagnosis when the patient is in for procedures only.
The reason(s) for the physical therapy as documented by the therapist should be listed second.
Assistants should include a chief complaint such as: in for PT due
to (add the physical therapist’s dx) and then document the patient’s
complaint of the day if any. (Helps support a re-evaluation)

41. Resources for Physical Therapy documentation and coding guidance
2012 AMA CPT Manual, copyrighted
2012 Ingenix ICD-9 Manual, copyrighted
Medicare Claims Processing Manual: Chapter 5
Medicare Benefit Policy Manual: Chapter 15
The CPT Assistant, copyrighted
The National Correct Coding Initiative
Each other and chapter meetings

42. We hope we have helped to take the puzzle out of physical therapy procedures and that reimbursement grows due to a better understanding of the available therapies. Thanks for attending the presentation!