Auditors have identified frequent compliance issues with providers of all disciplines reporting of CPT code 97110; Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

The new audit probe will focus on; medical necessity, correct billing of timed codes and relationship to other therapy codes provided under same POC.

We offer the following Documentation Guidance to help you receive a Successful Review for your Outpatient therapy CPT Code(s) 97110

  • Physical and/or occupational therapy initial evaluation
    • Diagnosis and description of problem being evaluated
    • Objective, measurable current functional status
    • Subjective patient self-report of status
    • Clinician’s clinical judgments that describes the patient’s status
    • Determination of the need for treatment
    • Documentation to support the services require the skills of a therapist
  • Advance Beneficiary Notice of Non-Coverage (ABN), if applicable
  • Physician certification and recertification of the therapy plan of care
  • Physical and/or occupational therapy plan of care
    • Diagnoses
    • Long term measurable treatment goals
    • Type, amount, duration and frequency of therapy services
  • Physical and/or occupational therapy progress reports
    • Written by a clinician – not an assistant.
    • Minimum progress reports are every 10 treatment days
    • Assessment of patient progress towards goals
    • Plans for continuing treatment
    • Changes to goals
  • Physical and/or occupational daily treatment notes
  • Physical and/or occupational therapy treatment log
    • Total time spent for each modality billed
  • Physical and/or occupational therapy re-evaluation(s) as necessary
  • Physical and/or occupational therapy discharge note
  • Any additional documentation needed to support Medicare guidelines

We remind you that your total units of therapy being billed are constrained by your total therapy time and subject to the “8 minute” rules on individual therapy line items.

Under typical interpretation of time standards, you should not bill for any daily therapy (one unit total for the day) if it is less than 8 minutes however some carriers “may permit” billing of one unit for “modalities” greater than 5 minutes. Most however, will consider the service to be “incidental” to some other primary procedure for that day and not pay separately for the additional service.

For any single code, reported without any additional therapy services, providers should bill a single 15 minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes.

If the duration of the single modality or procedure is greater than or equal to 23 minutes and less than 38 minutes, then two (2) units are billed.

Time intervals for larger numbers of units are as follows:

3 units > 38 minutes to < 53 minutes
4 units > 53 minutes to < 68 minutes
5 units > 68 to < 83 minutes
6 units > 83 minutes to < 98 minutes

The schedule shown above is intended to assist you in rounding time into 15 minute increments. It does not imply that any minute until the 8th should be excluded from the total count as the timing of active treatment counted includes all active therapy time.

It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were also performed for more than 15 minutes. Regardless of what some consultants may recommend, if you perform therapeutic exercises (97110) for 15 minutes and massage (97124) for 15 minutes you should report one unit of each service and not combine the times to two units under either code especially to receive a higher reimbursement OR to hide it where NCCI or non-coverage edits would preclude payment.

If however, any 15 minute timed service is performed for 7 minutes or less on the same day as another 15 minute timed service that was also performed for 7 minutes or less, the total time of the two combined is 8 minutes or greater. In this case you would legitimately bill “one unit for the service performed for the most minutes”. Your documentation will show the actual services in support of the billing.

Good Luck !