In this sixth in our series of Blogs asking the question “Is your practice ready for a Medicare audit?” we explore specific coverage guidelines and documentation requirements for some of the most common Modalities, Exercises and Activities therapists use in treating their patients. CMS is quite explicit in defining what the clinician is required to document the medical record to establish the medical necessity of what was provided.  These are fully defined in LCD L26884.

Practicality will guide where in the patient record the therapist should document the required information.  Certain elements will be noted in the Plan of Care and updated in the 10 Session Progress Note.  Visit specific information and data on should be recorded in the daily SOAP note or Flow Sheet.

MODALITIES

CPT 97035 – Ultrasound (to one or more areas)

Covered ultrasound may be pulsed or continuous width, and should be used in conjunction with therapeutic procedures, not as an isolated treatment.  Specific indications for the use of ultrasound application include but are not limited to:

• limited joint motion that requires an increase in extensibility;
• symptomatic soft tissue calcification;
• neuromas.

Supportive Documentation Requirements

• Area(s) being treated
• Frequency and intensity of ultrasound
• Objective clinical findings such as measurements of range of motion and functional limitations to support the need for ultrasound *
• Subjective findings to include pain ratings, pain location, effect on function*

If no objective and/or subjective improvement are noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of ultrasound.

Documentation must clearly support the need for ultrasound more than 12 visits.

*Required at least every 10 visits

CPT G0283 – Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care.

Most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283.  It is classified as a “supervised” modality, even though it is labeled as “unattended.”  A supervised modality does not require direct (one-on-one) patient contact by the provider after skilled application by the qualified professional/auxiliary personnel.

Most electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples include Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation).   Electrical Stimulation should be utilized with appropriate therapeutic procedures to effect continued improvement.

When used for control of pain and swelling, there should be documented objective and/or subjective improvement in swelling and/or pain within 6 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality.

Some patients can be trained in the use of a home TENS unit for pain control. Only 1-2 visits should be necessary to complete the training (which may be billed as 97032). Once training is completed, code G0283 should not be billed as a treatment modality in the clinic.

Supportive Documentation Requirements for G0283

• Type of electrical stimulation used (e.g., TENS, IFC)
• Area(s) being treated
• If used for pain include pain rating, location of pain, effect of pain on function*

Documentation must clearly support the need for electrical stimulation more than 12 visits.

*Required at least every 10 visits

THERAPEUTIC PROCEDURES

The use of these procedures in attempting to reduce impairments and restore function is expected to result in improvement of the limitations/deficits in a reasonable and generally predictable period of time. These procedures require the therapist or qualified assistant to have direct (one-on-one) patient contact. The expected goals documented in the treatment plan, affected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary.  Documentation must support the use of each procedure as it relates to a specific therapeutic goal as defined in the Plan of Care.

CPT 97110 – Therapeutic Exercises to develop strength and endurance, range of motion and flexibility (one or more areas, each 15 minutes).

Therapeutic exercises for the purpose of restoring strength, endurance, range of motion and flexibility where loss or restriction is a result of a specific disease or injury and has resulted in a functional limitation and 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 are generally covered.

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 a Home Exercise Program. (HEP).  An 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 an HEP as the patient or caregiver master the techniques involved in the performance of the exercise.

Exercises that do not require, or no longer require, the skilled assessment and intervention of a qualified professional/auxiliary personnel and those done to promote overall fitness, flexibility, endurance (in absence of a complicated patient condition), aerobic conditioning, weight reduction, and maintenance exercises to maintain range of motion and/or strength are non-covered.  Lack of exercise equipment at home does not make continued treatment in the clinic skilled or reasonable and necessary.

For many patients a passive-only exercise program should not be used more than 2-4 visits to develop and train the patient or caregiver in performing PROM. Documentation would be necessary to support services beyond this level (such as PROM where these is an unhealed, unstable fracture, or new rotator cuff repair, requiring the skills of a therapist to ensure that the extremity is maintained in proper position and alignment during the PROM).

Supportive Documentation Requirements for 97110

• Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect 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.
• If used for pain include pain rating, location of pain, effect of pain on function*

Documentation must clearly support the need for continued therapeutic exercise greater than 12-18 visits.

*Required at least every 10 visits

CPT 97112 – Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (one or more areas, each 15 minutes)

This procedure may be reasonable and necessary for restoring prior function which has been affected by:

• loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs, and/or fingers;
• nerve palsy, such as peroneal nerve injury causing foot drop;
• muscular weakness or flaccidity as result of a cerebral dysfunction, a nerve injury or disease or having had a spinal cord disease or trauma;
• poor static or dynamic sitting/standing balance;
• postural abnormalities;
• loss of gross and fine motor coordination;
• hypo/hypertonicity.

If an exercise/activity is taught to the patient and performed for the purpose of restoring functional balance, motor coordination, kinesthetic sense, posture, or proprioception for sitting or standing activities, CPT (97112) is the appropriate code.

When therapy is instituted because there is a history of falls or a falls screening has identified a significant fall risk, documentation should indicate:

• specific fall dates and/or hospitalization(s) and reason for the fall(s), if known;
• most recent prior functional level of mobility, including assistive device, level of assist, frequency of falls or “near-falls”;
• cognitive status;
• prior therapy intervention;
• functional loss due to the recent change in condition;
• balance assessments (preferably standardized), lower extremity ROM and muscle strength testing;
• patient and caregiver training;
• carry-over of therapy techniques to objectively document progress.

It may not be reasonable and necessary to extend visits for a patient with falls, or any patient receiving therapy services, if the purpose of the extended visits is to:

• remind the patient to ask for assistance
• offer close supervision of activities due to poor safety awareness;
• remind a patient to slow down;
• offer routine verbal cues for compensatory or adaptive techniques already taught;
• remind a patient to use an assistive device;
• train multiple caregivers; or
• begin a maintenance program.

In these instances, once the appropriate cues have been determined by the qualified professional/auxiliary personnel, training of caregivers can be provided and the care should be turned over to supportive personnel or caregivers since repetitive cues and reminders do not require the skills of a therapist.

Supportive Documentation Requirements for 97112

• Objective loss of ADLs, mobility, balance, coordination deficits, hypo- and hypertonicity, posture and effect on function*
• Specific exercises/activities performed (including progression of the activity), purpose of the exercises as related to function, instruction given, and/or assistance needed, to support that the skills of a therapist were required

Documentation must clearly support the need for continued neuromuscular reeducation greater than 12-18 visits.

*Required at least every 10 visits

CPT 97140 – Manual Therapy Techniques one or more regions, each 15 minutes.

• Manual traction may be considered reasonable and necessary for cervical dysfunctions such as cervical pain and cervical radiculopathy.
• Joint Mobilization (peripheral and/or spinal) may be considered reasonable and necessary if restricted or painful joint motion is present and documented.  It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.
• Myofascial release/soft tissue mobilization, one or more regions, may be reasonable and necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems.
• Manipulation, which is a high-velocity, low-amplitude thrust technique or Grade V thrust technique, may be reasonable and necessary for treatment of painful spasm or restricted motion in the periphery, extremities or spinal regions.

When the patient and/or caregiver has been instructed in the performance of specific techniques, the performance of these same techniques should not be continued in the clinic setting and counted as minutes of skilled therapy.

CPT code 97124 (massage) is not covered on the same visit as this code.

Supportive Documentation Requirements  for 97140.

• Area(s) being treated
• Soft tissue or joint mobilization technique used
• Objective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on function.*

Documentation must clearly support the need for continued manual therapy treatment beyond 12-18 visits.

*Required at least every 10 visits

CPT 97530 – Therapeutic Activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involve movement.  Movement activities can be for a specific body part or could involve the entire body.  This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, pushing, pinching, grasping, transfers, bed mobility and overhead activities) to restore functional performance in a progressive manner.  The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination.

Therapeutic activities require the skills of the therapist to design the activities to address a specific functional need of the patient and to instruct the patient in their performance.  To be considered a covered service, these dynamic activities must be part of an active treatment plan and must be directed at a specific outcome.

In order for therapeutic activities to be covered, the following requirements must be met:

• the patient has a documented condition for which therapeutic activities can reasonably be expected to restore or improve functioning;
• there is a clear correlation between the type of therapeutic activity performed and the patient’s underlying medical condition;
• the patient’s condition is such that he/she is unable to perform the therapeutic activities without the skilled intervention of the qualified professional/auxiliary personnel.

Documentation must clearly support the need for continued therapeutic activity treatment beyond 10-12 visits.

In our next Blog we will discuss the required elements of SOAP Notes.

Genco Healthcare helps practices achieve and maintain a culture of compliance.  We also assist Healthcare Attorneys in defending their clients who have been audited or subject to pre payment review.  Consequently, we have our finger on the pulse of precisely what Medicare’s expectations are when it comes to medical documentation.  Contact us by email David@Gencohealthcare.net or visit our website http://www.gencohealthcare.net/.