1. health and fitness
2. therapy

An Independent Licensee of the
Blue Cross and Blue Shield Association.
APPENDIX F
OCCUPATIONAL THERAPY &
PHYSICAL THERAPY GUIDELINES
At the end of this section there is a complete list of physical medicine evaluations, reevaluations, modalities and procedures with their related unit limitations and guidelines;
please refer to that chart for further information.
The information contained here gives guidelines about services that might be performed
by an occupational or physical therapist. This section is not intended to be
comprehensive. If there is a service not addressed and you have specific questions about
coverage, please call the CSC Provider Benefits Only Line (800-432-0272 or 785-2914183) to determine coverage of a specific service for a specific patient.
Submit the appropriate procedure code from the AMA-CPT codebook.
Acknowledgement:
Current Procedural Terminology (CPT®) is copyright 2014
American Medical Association. All Rights Reserved. No fee schedules, basic units,
relative values or related listings are included in CPT. The AMA assumes no liability for
the data contained herein. Applicable – ARS/DFARS Restrictions Apply to Government
Use.
NOTE:
The revision date appears in the footer of the document. Links within the
document are updated as changes occur throughout the year.
Acupuncture
•
•
•
Most policies do not cover this service.
Please call the CSC Provider Benefits Only Line (800-432-0272 or 785-291-4183) to
determine coverage by a specific patient’s contract.
When covered you should use the appropriate procedure code from the AMA-CPT
codebook:
 97810
 97811 + Add-on code


97813
97814 + Add-on code
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-1
Revision Date: March 2014
Anodyne Therapy
•
•
This service should be coded using 97799 with a description of "anodyne therapy" in
box 19 or the electronic narrative. It should not be confused with Infrared Therapy
that is coded 97026.
It is considered experimental/investigational and is provider write-off unless a Policy
Memo No. 1 Limited Patient Waiver is signed prior to performance of the service.
Limited Patient Waiver
•
Use modifier "GA" to demonstrate waiver on file.
Anti-Gravity Lumbar Traction-Reverse
(Inversion)
•
•
Use 97139.
It is considered experimental/investigational and is provider write-off unless a Policy
Memo No. 1 Limited Patient Waiver is signed prior to performance of the service.
Limited Patient Waiver
•
Use modifier "GA" to demonstrate waiver on file.
Aqua Massage Therapy
•
•
This service should be coded using 97039 with a description of "aqua massage
therapy" in box 19 or the electronic narrative. It should not be billed using 97124.
It is considered experimental/investigational and is provider write-off unless a Policy
Memo No. 1 Limited Patient Waiver is signed prior to performance of the service.
Limited Patient Waiver
•
Use modifier "GA" to demonstrate waiver on file.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-2
Revision Date: March 2014
Assistants: Certified Physical Therapist
Assistant (CPTA) or Certified Occupational
Therapy Assistant (COTA)
•
Services provided by a certified physical therapist assistant (CPTA) or certified
occupational therapy assistant (COTA)
BCBSKS and FEP will only reimburse the above services if a physical therapist or
occupational therapist, respectively, are on site at the time of service.
Cold Laser Therapy/Soft Laser Therapy/
Low Laser Therapy
•
•
This service should be coded using 97039. It should not be confused with Infrared
Therapy that is coded 97026.
It is considered experimental/investigational and is provider write-off unless a Policy
Memo No. 1 Limited Patient Waiver is signed prior to performance of the service.
Limited Patient Waiver
•
•
When using an unspecified code (97039) you must attach a document explaining
what the service is.
Use modifier "GA" to demonstrate waiver on file.
Cryotherapy
•
•
This service should be coded as 97010.
Do not use procedure code 17340, as this is for direct application of chemicals to the
skin.
Dressing Changes
•
This service should be coded as 97799 with a description of "dressing change" in
box 19 or the electronic narrative.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-3
Revision Date: March 2014
Extension/Flexion Joint Devices
•
•
•
Dynamic
 See procedure codes E1800, E1802, E1805, E1810, E1815, E1825, E1830, and
E1840.
 Covered for up to 3 months of rental if:
6 weeks post-operative or 6 weeks post injury and physical therapy has failed to
improve ROM.
Bi-directional
 See procedure codes E1801, E1806, E1811, E1816, and E1818.
 Covered for up to 3 months of rental if:
6 weeks post-operative or 6 weeks post injury and physical therapy has failed to
improve ROM.
Content of service procedures
 Procedure codes E1820 and E1821 are content of service of the device itself and
may not be billed separately.
Fluidotherapy
•
•
This service should be coded as 97022.
Will consider for reimbursement if medically necessary and an integral part of the
patient’s treatment plan.
Foot Orthotics
•
•
•
Most policies do not cover this service.
Please call the CSC Provider Benefits Only Line (800-432-0272 or 785-291-4183) to
determine coverage for a specific patient.
When covered, you should use the appropriate procedure code from the HCPCS
procedure code listing.
Functional Electrical Stimulation (FES)
This policy is being revised.
Horizontal Therapy
•
This service should be coded using 97014.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-4
Revision Date: March 2014
Hot and Cold Therapies
•
•
This service will be denied content of service unless it is the only service provided on
that date.
Certain therapies are considered duplicative services as follows:
o Infrared (97026) and Ultraviolet (97028)
o Microwave (97024) and Infrared (97026)
Ice Massage/Ice Therapy
The use of ice directly on the patient with direct provider attendance. This service
is not the same as “cold packs”; which are coded 97010.
•
•
•
•
Ice therapy will be denied "content of service" unless it is the only service provided
on that date.
Ice therapy should be coded as 97039 with a description of "ice therapy" in box 19 or
the electronic narrative.
Unit of service is 15 minutes. Indicate units if more than one.
More than one unit of service on a given date requires medical records.
Ineligible Providers
•
•
The following providers are not considered eligible providers as defined in the local
BCBSKS member contracts, or for the Federal Employee Program (FEP). Their
services cannot be billed incident to an eligible provider if they provide services.
o Athletic trainers, massage therapists, exercise physiologists, occupational
therapy aides, physical therapy aides and chiropractic assistants.
Services performed by these specialties are considered patient responsibility and
should not be billed to BCBSKS.
Kinesio Taping
•
•
This service should be coded as 97039 with a description of "Kinesio taping"
submitted in the 2400 NTE segment or box 19.
It is considered experimental/investigational, and is provider write-off unless a Policy
Memo No. 1 Limited Patient Waiver is signed prior to performance of the service.
Limited Patient Waiver
•
Use modifier "GA" to demonstrate waiver on file.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-5
Revision Date: March 2014
Magnatherm
•
•
This service should be coded as 97024.
Magnatherm is considered one unit of service per area.
Maintenance Care
Ongoing physical medicine treatment after a condition has stabilized or reached a
clinical plateau (maximum medical improvement) does not qualify as medically
necessary, and would be considered “maintenance care”.
Massage
•
•
This service must be coded as 97124, regardless of delivery.
This will be denied content of service unless it is the only service provided on date of
service.
•
Coverage Criteria
BCBSKS will consider massage therapy for possible coverage if the following are
met.
The massage must be:
 Medical in nature
 Medically necessary
 An integral part of the treatment plan
 Performed by a MD, DO, DC, PA, ARNP, PT, OT
 Performed by a PTA or COTA under the direct supervision (on-site) of the
physical or occupational therapist respectively.
•
Limitation of Units of Massage Therapy per Date of Service
 Massage therapy 97124 is coded by 15-minute increments.
 One unit of service per date of service will be considered for coverage without
medical records.
 If more than one unit of massage is performed on any given date you must
attach medical records to support the care.
 Claims paying with one unit of service will be subject to audit procedures.
Processing of claims received without this information may be delayed until
such information is provided.
 Refunds will be required if services were performed by someone other than
the licensed eligible provider.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-6
Revision Date: March 2014
McConnell Strapping/Taping
•
This service should be coded as 97039 with a description of "McConnell
strapping” or “McConnell taping" in box 19 or the electronic narrative.
• Includes reimbursement for the tape and the taping procedure.
• A separate charge may be billed for the evaluation or re-evaluation; if
performed.
Multiple Therapies
•
•
•
•
If electrical stimulation, unattended (97014), electrical stimulation, attended (97032)
and ultrasound (97035) are provided to the same area at the same session, attach
medical records. If medical records are not attached, only 97032 (since it has the
highest MAP) will be allowed.
If infrared (97026) and ultraviolet (97028) are provided to the same area at the same
session, attach medical records. If medical records are not attached, only 97028
(since it has the highest MAP) will be allowed.
If diathermy, e.g., microwave (97024) and infrared (97026) are provided to the same
area at the same session, attach medical records. If medical records are not
attached, only 97024 (since it has the highest MAP) will be allowed.
If infrared (97026) and electrical stimulation, attended (97032) are provided to the
same area at the same session, attach medical records. If medical records are not
attached, only 97032 (since it has the highest MAP) will be allowed.
Muscle Testing and Range of Motion Testing
•
•
Performing routine muscle testing and range of motion or muscle testing (i.e., those
tests that are an integral part of the assessment performed each visit to determine
the patient’s status from one visit to the next and to determine the level of care
required for the current visit) are considered content of the evaluation or therapy(ies)
billed that particular day and should not be billed separately.
Muscle and range of motion testing that are much more in-depth than the routine
tests can be coded separately if they meet the criteria outlined in the AMA-CPT book
for each test and all criteria is documented in the medical record. Most of the nonroutine testing requires an in-depth written report and review with the patient to be
considered an independent service.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-7
Revision Date: March 2014
Nerve Conduction Studies and Related Services
•
Out-of-State Vendors
It is in violation of your contract with BCBSKS to use the services of an out-of-state
vendor to conduct or read nerve conduction studies, diagnostic ultrasound, or any
other related service since your contract indicates you must use the services of a
contracting provider when referring services. BCBSKS does not contract with out-ofstate vendors for these services.
Policy Memo No. 1
•
Certification for In-State Providers
 Reimbursement guidelines are based on the certification of the performing
provider.
 For more information see Policy Memo No. 1.
Policy Memo No. 1
•
Medical Policy
To review medical necessity guidelines visit our website and the Medical Policy
section.
Policy Memo No. 1
Posture Pump
•
•
This service should be coded 97139 with a description of "posture pump" in box 19
or the electronic narrative.
This service is considered not medically necessary and is a provider write-off unless
the Policy Memo No. 1 Limited Patient Waiver is signed before performance of the
service.
Limited Patient Waiver
•
Use modifier "GA" to demonstrate waiver on file.
Rehabilitation Services
Rehabilitation services are covered only if they are expected to result in significant
improvements. BCBSKS will determine whether significant improvement has, or is likely
to occur.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-8
Revision Date: March 2014
Strapping
•
•
•
BCBSKS will consider for reimbursement strapping that is covered under your
licensure if this is the only service performed that day.
You should select the most appropriate code for the strapping from the AMA-CPT
procedure codebook.
Physical medicine modalities and procedures are eligible for reimbursement when
billed on the same day.
Codes 29200 – 29280 and 29520 – 29550 will deny as content of service to codes
97001 – 97004, and may not be billed separately.
Sympathetic Therapy
•
•
This service should be coded using 97799 with a description of "Sympathetic
therapy" in box 19 or the electronic narrative.
This service is considered experimental/investigational and is provider write-off
unless a Policy Memo No. 1 Limited Patient Waiver is signed prior to performance of
the service.
Limited Patient Waiver
•
Use modifier "GA" to demonstrate waiver on file.
Tiered Reimbursement
•
See Policy Memo No. 1, Section XXIV. Tiered Reimbursement and Provider Number
Requirements.
Policy Memo No. 1
•
Tiered reimbursement for chiropractors, physical therapists, occupational therapists,
CPTAs, and COTAs is defined in the 2011 Competitive Allowance Program (CAP)
letter dated July, 2010.
Transcutaneous Electrical Nerve Stimulator
(TENS) – 4 Lead
•
This service should be coded as E0730.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-9
Revision Date: March 2014
•
The purchase of E0720 2-Lead is always considered “not medically necessary”. A
Policy Memo No. 1 Limited Patient Waiver must be signed by the patient for the
patient to be held financially responsible for the 2-Lead TENS. Use modifier "GA" to
indicate waiver on file.
Limited Patient Waiver
•
•
•
If the patient for this item does not sign a waiver, the contracting provider will be held
liable for the charge.
Rental of E0730 or E0720 is denied not medically necessary.
Training the patient to use the equipment is reimbursed in the amount allowed for
the equipment. If you have an outside vendor supplying the device, you should look
to them for the reimbursement of this service.
Vasopneumatic Devices
•
•
This service should be coded 97016.
This service will be denied content of service unless it is billed with one of the
following diagnosis codes: 457.0, 457.1 or 757.0.
Vertebral Axial Decompression Therapy
(i.e., VaxD; IDD; DR 5000; DR 9000; SpinaSystem; etc.)
•
•
•
•
•
•
•
This service should be coded using S9090.
There is a national “S” procedure code assigned to this service. It is as follows:
o
S9090 Vertebral axial decompression therapy, per session
All claims for this service must be coded using S9090, with one unit of service per
day.
Based on the lack of scientific evidence (blinded studies, appropriate number
participants in studies already conducted, documented long term results) S9090 will
be treated as 97012, having the same allowance and unit limitation guidelines.
This policy will remain in effect until such time that such scientific studies performed
within accepted standards are available.
To ensure correct coding of this service there will be periodic audits performed at
random.
Those claims found to have been coded incorrectly will require appropriate refunds
and patients’ credits.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-10
Revision Date: March 2014
Wheelchair Evaluation
•
•
•
This service should be coded using 97799 with a description of "wheelchair
evaluation" in box 19 or the electronic narrative.
Include length of time in Box 24G.
If the therapist is an employee of the wheelchair supplier, this service is content of
the wheelchair and will be denied as a provider write-off.
Wound Debridement Billed with Evaluation
•
•
BCBSKS will not cover both services on the same date; unless there is a separate
and identifiable service for the exam other than wound assessment.
Medical records should be submitted for separate and identifiable services.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-11
Revision Date: March 2014
Documentation Guidelines
DOCUMENTATION GUIDES – OCCUPATIONAL THERAPISTS
The following information was sent to Occupational Therapists via letter dated
September 23, 2009.
Consultants from the state of Kansas, who perform peer reviews for Blue Cross and Blue
Shield of Kansas (BCBSKS), recently decided communication needed to be sent to their
peers with the purpose of informing you of two main concerns and recommended
solutions. The groups' stated goals are to assist Occupational Therapists in obtaining
appropriate compensation for their services provided and improving the process in
performing these reviews. The two main areas of concern are:
1)
Documentation of medical necessity
2)
Documentation of services provided
MEDICAL NECESSITY DOCUMENTATION
Do you require evidence of necessity before you pay for something? So does BCBSKS.
Before BCBSKS can appropriately reimburse you for services, it must be determined if
services are documented and can be supported by your records as being medically
necessary. Medical necessity is required as a fiduciary steward and is a standard of care
that is supported by the profession of occupational therapy, as well as all payer sources
(See references). In many instances, this requires that you or your office remit all
appropriate and legible documentation for the claim in question.
When records are requested from you, consider what documentation will support the
provision of and need for the services, and what a peer reviewer will be able to use to
discern the medical necessity without knowing the patient as well as you do.
DOCUMENTATION STANDARDS
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)
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-12
Revision Date: March 2014
b. Complete history and thorough systems review (patient stated problems, comorbidities, medications, review of past-present care)
c. Objective, functional, measurable data (at a minimum):
 ROM (relate to function deficits and sx)
 Neuro (relate to function deficits and sx)
 Tissue integrity (trigger pts, pain patterns, spasms, relate to function
deficits and sx)
 Movement pattern deficits (relate to function deficits and sx)
 Functional deficits (relate to sx)
 Posture (relate to function deficits and sx)
 Strength (relate to function deficits and sx)
 Specific Tests (relate to function deficits and sx)
d. Clearly delineated, measurable, time-framed goals that relate to function
 Description of movement or activity
 Connect to specific function deficit or sx
 Measurable & Time-framed (What does patient need to be doing
before DS?)
 Identify who will accomplish the goal
Examples:
 "Pt. Improve shldr flex to 160 to reach into cupboards at home 3
wks"
 "Pt. Reduce and control pain to 2 / 10 to enable pain free
sleeping 2 wks"
 "Pt. Safely walk inside home no external assistance 2 wks"
 "Pt. Increase mid scapular strength 4+ / 5 to reduce pain to 1 /
10 and sit at computer all day for work 4 wks"
e. Clearly stated plan of care delineating what will be provided, at what
frequency and duration
Examples:
 "Gt train walker, 100', indep, no falls or stumbles for goal #3"
 "T Ex isotonic, closed chain, progress no weight to 3 lbs, related
to goal #4"
 "US, 1.5w/cm@ X 8 minutes Left trap and levator, decrease
spasms, trigger pts, increase circulation, pain modulation for
goal #2"
 Discharge to Specialty Exercise Program"
f. Clearly stated medical reason and rationale for each modality utilized –
97010, 97014, 97035, etc—especially when utilizing more than one modality
to the same area and same session
7) Daily Notes that include:
a. Statements that demonstrate the skill required by the OT or OTA, under the
supervision and
b. Direction of an OT, not just statements of completion of activities (this can be
seen on the flow sheet). Why can't patient perform their own exercises at
home?
c. Statements that demonstrate co-founding factors that delay progress
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-13
Revision Date: March 2014
d. Time In and Time Out
e. Time for each CPT code billed
Examples:
 Subjective complaints / descriptive / numerical pain / percentage
of improvement
 Complicating factors
 Flow sheet (show progression and skill)
 Observation of movement / measurements / function gain – loss
/ skill need / education of patient
* Type and amount of manual, visual, verbal cues
* Why needed
* "Constant verbal and tactile cues for shldr flex without
substitution. Ther ex resulted increase shldr flx to 120 to
comb hair, still unable to reach into cupboards at home".
 Factors that modify frequency / intensity / progression
* "Performing shldr flex and abd ex incorrectly resulting
increased impingement."
* "Painted bedroom with repeated overhead mvts increased
pain"
* "Computer station ergonomic corrections not made,
enhances poor posture and muscle imbalances aggravating
sx"
 Statement of clinical decision and problem solving
* "Poor control and contraction transverse ab muscles resulting
in continued compression and sheering lumbar with pain and
radicular sx requires neuro-ed ex and educ."
* "Poor blood sugar control resulting fatigue and avoidance of
exercise. Speak to MD."
* "Quad control in open chain good, transition into controlled
functional closed chain in preparation for running."
 Plan for next visit = intervention and objective
8) Progress notes (or re-eval) completed every 10 treatment sessions or every 30
days (whichever is less) that include:
a. Statements of pertinent subjective nature
b. Comparison of objective, functional, measurable data (at a minimum as
indicated ROM, Strength, Neuro, Ambulation, Special tests, etc.)
c. Clearly delineated and updated measurable, time-framed goals that relate to
function (i.e., what does the patient need to be doing before discharge from
therapy?)
d. Clearly stated, updated plan of care delineating what will be provided,
frequency and duration
e. Clear stated medical reason and rationale for continuance of each service
utilized
 Evaluate status and modify plan. May simply mean continue
current goals but state why
 Billing 97002 – Re-Eval
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-14
Revision Date: March 2014
* Unanticipated change
* Failure to respond
* New direction or plan
 Compare similar data points
 Goals addressed, updated
 Reasons for lack of progress, changes needed
9) Flow sheets that include:
a. Date of service, area being treated, and name of OT or OTA providing
services
b. Clearly delineated CPT Code
c. Activity completed for each CPT code including name of activity, repetitions,
weights, resistance, etc.
d. Modalities (parameters, time frame, and specific location(s) treated)
RESPONSIBILITIES
It is imperative that you and your staff are fully aware of the professional, fiduciary, and
legal standards/requirements of complete and thorough documentation. A BCBSKS
professional relations representative is readily available to assist you. Please refer to
the important resources at the end of this document that will increase the successful
and timely adjudication and remittance of payment for the valuable services you
provide.
BCBSKS and Occupational Therapy peer review consultants strive to provide you the
information necessary to meet the requirements of documentation to successfully and
timely adjudicate claims for remittance of payment for the valuable services you provide.
Please contact your BCBSKS professional relations representative should you have
questions or require additional information.
RESOURCES
1) Medicare documentation standards http://www.cms.hhs.gov
2) BCBSKS policies and procedures
http://www.bcbsks.com/CustomerService/Providers/index.htm
3) Your BCBSKS contractual agreements
4) Kansas statutes and rules/regulations http://ksbha.org/statutes.html
http://ksbha.org/regs.html
Signature Requirements
1.
In the content of health records, each entry must be authenticated by the
author. Authentication is the process of providing proof of the authorship
signifying knowledge, approval, acceptance or obligation of the
documentation in the health record, whether maintained in a paper or
electronic format accomplished with a handwritten or electronic signature.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-15
Revision Date: March 2014
Individuals providing care for the patient are responsible for documenting the
care. The documentation must reflect who performed the service.
a. The handwritten signature must be legible and contain at least the first
initial and full last name along with credentials and date. A typed or printed
name must be accompanied by a handwritten signature or initials with
credentials and date.
b. An electronic signature is a unique personal identifier such as a unique
code, biometric, or password entered by the author of the electronic
medical record (EMR) or electronic health record (EHR) via electronic
means, and is automatically and permanently attached to the document
when created including the author’s first and last name, with credentials,
with automatic dating and time stamping of the entry. After the entry is
electronically signed, the text-editing feature should not be available for
amending documentation. Example of an electronically signed signature:
“Electronically signed by John Doe, M.D. on MM/DD/YYYY at XX:XX
A.M.”
c. A digital signature is a digitized version of a handwritten signature on a
pen pad and automatically converted to a digital signature that is affixed to
the electronic document. The digital signature must be legible and contain
the first and last name, credentials, and date.
d. Rubber stamp signatures are not permissible. This provision does not
affect stamped signatures on claims, which remain permissible.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-16
Revision Date: March 2014
BCBSKS POLICIES
While this is not a totally exhaustive listing, these are some of the more common
policies that apply to Occupational Therapy (as well as other providers):
1. BCBSKS limits the number of CPT codes billed per date of service to FOUR (4).
(Blue Shield Report Newsletter March 15, 2000)
a. Claims with greater than 4 services will require submission of all appropriate
medical records AT THE TIME OF SUBMISSION OF THE CLAIM. See
Documentation standards previously outlined in this letter to determine
what documentation needs to be submitted with the claim.
b. The claim will be denied and returned with a request for records if they are
not received with the claim.
2. BCBSKS limits the number of UNITS allowed per CPT code per date of service
(BUSINESS PROCEDURE MANUAL):
http://www.bcbsks.com/CustomerService/Providers/Publications/professional/ma
nuals/pdf/unit_limitation.pdf
3. 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.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-17
Revision Date: March 2014
DOCUMENTATION CHECKLIST for SUBMISSION of RECORDS
ACCIDENT
____ Details of accident
____ Initial evaluation that includes:
1. Diagnosis (medical and occupational therapy)
2. History, patient stated problems, co-morbidities, medications review of pastpresent care
3. Objective functional, measurable data (at a minimum as indicated ROM,
Strength, Neuro, Ambulation, Special tests, etc.)
4. Clearly delineated, measurable, time-framed goals that relate to function
5. Clearly stated plan of care delineating what will be provided, frequency and
duration
6. Clearly stated medical reason and rationale for each modality utilized
____ Daily Notes that include:
1. Statements that demonstrate the skill required by the OT or OTA under the
supervision and direction of an OT
2. Statements that demonstrate co-founding factors that delay progress
3. Tim In and Time Out
4. time for each CPT Code billed
____ Progress notes completed every 10 treatment sessions or every 30 days
(whichever is less) that include:
1. Statements of pertinent subjective nature
2. Comparison of objective, functional, measurable data (at a minimum as
indicated ROM, Strength, Neuro, Ambulation, Special tests, etc.)
3. Clearly delineated and updated measurable, time-framed goals that relate to
function
4. Clearly stated, updated plan of care delineating what will be provided,
frequency and duration and why continued care is medically necessary.
5. Clearly stated medical reason and rationale for continuance of each modality
utilized
____ Flow sheets that include:
1. Date of each service
2. Clearly delineated CPT code
3. Activity completed for each CPT Code including name of activity, repetitions,
weights, resistance, etc.
4. Modalities (parameters, time frame, and specific location(s) treated)
____ Patient's name on each page of the records
____ Record legible?
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-18
Revision Date: March 2014
DOCUMENTATION CHECKLIST for SUBMISSION of RECORDS
NON-ACCIDENT
____ Initial evaluation that includes:
1. Diagnosis (medical and occupational therapy)
2. History, patient stated problems, co-morbidities, medications, review of pastpresent care.
3. Objective, functional, measurable data (at a minimum as indicated ROM,
Strength, Neuro, Ambulation, Special tests, etc.)
4. Clearly delineated, measurable, time-framed goals that relate to function
5. Clearly stated plan of care delineating what will be provided, frequency and
duration
6. Clearly stated medical reason and rationale for each modality utilized
____ Daily Notes that include:
1. Statements that demonstrate the skill required by the OT or OTA under the
supervision and direction of an OT
2. Statements that demonstrate co-founding factors that delay progress
3. Time In and Time Out
4. Time for each CPT Code billed
____ Progress notes completed every 10 treatment sessions or every 30 days
(whichever is less) that include:
1. Statements of pertinent subjective nature
2. Comparison of objective, functional, measurable data (at a minimum as
indicated ROM, Strength, Neuro, Ambulation, Special tests, etc.)
3. Clearly delineated and updated measurable, time-framed goals that relate to
function
4. Clearly stated updated plan of care delineating what will be provided,
frequency and duration and why continued care is medically necessary
5. Clearly stated medical reason and rationale for continuance of each modality
utilized
____ Flow sheets that include:
1. Date of each service
2. Clearly delineated CPT Code
3. Activity completed for each CPT Code including name of activity, repetitions,
weights, resistance, etc.
4. Modalities (parameters, time frame, and specific location(s) treated)
____ Patient's name on each page of the records
____ Record legible?
____ Does the record reflect why more than 4 CPT Codes were utilized?
____ Does the record reflect why more than allowable number of units per CPT
code utilized?
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-19
Revision Date: March 2014
DOCUMENTATION GUIDES – PHYSICAL THERAPISTS
The following information was sent to Physical Therapists via letter dated September 21,
2009.
Physical Therapists from the state of Kansas, who perform peer reviews for Blue Cross
and Blue Shield of Kansas (BCBSKS), recently decided communication needed to be
sent to their peers with the purpose of informing you of two main concerns and
recommended solutions. The groups' stated goals are to assist Physical Therapists in
obtaining appropriate compensation for their services provided and improving the
process in performing these reviews. The two main areas of concern are:
1)
Documentation of medical necessity
2)
Documentation of services provided
MEDICAL NECESSITY DOCUMENTATION
Do you require evidence of necessity before you pay for something? So does BCBSKS.
Before BCBSKS can appropriately reimburse you for services, it must be determined if
services are documented and can be supported by your records as being medically
necessary. Medical necessity is required as a fiduciary steward and is a standard of care
that is supported by the profession of physical therapy, as well as all payer sources (See
references). In many instances, this requires that you or your office remit all appropriate
and legible documentation for the claim in question.
When records are requested from you, consider what documentation will support the
provision of and need for the services, and what a peer reviewer will be able to use to
discern the medical necessity without knowing the patient as well as you do.
DOCUMENTATION STANDARDS
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 as required by K.S.A. 652921 and BCBSKS beneficiary insurance contract
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 physical therapy)
b. Complete history and thorough systems review (patient stated problems, comorbidities, medications, review of past-present care)
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-20
Revision Date: March 2014
c. Objective, functional, measurable data (at a minimum):
 ROM (relate to function deficits and sx)
 Neuro (relate to function deficits and sx)
 Tissue integrity (trigger pts, pain patterns, spasms, relate to function
deficits and sx)
 Movement pattern deficits (relate to function deficits and sx)
 Functional deficits (relate to sx)
 Posture (relate to function deficits and sx)
 Strength (relate to function deficits and sx)
 Specific Tests (relate to function deficits and sx)
d. Clearly delineated, measurable, time-framed goals that relate to function
 Description of movement or activity
 Connect to specific function deficit or sx
 Measurable & Time-framed (What does patient need to be doing
before DS?)
 Identify who will accomplish the goal
Examples:
 "Pt. Improve shldr flex to 160 to reach into cupboards at home 3
wks"
 "Pt. Reduce and control pain to 2 / 10 to enable pain free
sleeping 2 wks"
 "Pt. Safely walk inside home no external assistance 2 wks"
 "Pt. Increase mid scapular strength 4+ / 5 to reduce pain to 1 /
10 and sit at computer all day for work 4 wks"
e. Clearly stated plan of care delineating what will be provided, at what
frequency and duration
Examples:
 "Gt train walker, 100', indep, no falls or stumbles for goal #3"
 "T Ex isotonic, closed chain, progress no weight to 3 lbs, related
to goal #4"
 "US, 1.5w/cm@ X 8 minutes Left trap and levator, decrease
spasms, trigger pts, increase circulation, pain modulation for
goal #2"
 "Discharge to Specialty Exercise Program"
f. Clearly stated medical reason and rationale for each modality utilized –
97010, 97014, 97035, etc—especially when utilizing more than one modality
to the same area and same session
7) Daily Notes that include:
a. Statements that demonstrate the skill required by the PT or PTA, under the
supervision and
b. Direction of a PT, not just statements of completion of activities (this can be
seen on the flow sheet). Why can't patient perform their own exercises at
home?
c. Statements that demonstrate co-founding factors that delay progress
d. Time In and Time Out
e. Time for each CPT code billed
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-21
Revision Date: March 2014
Examples:
 Subjective complaints / descriptive / numerical pain / percentage
of improvement
 Complicating factors
 Flow sheet (show progression and skill)
 Observation of movement / measurements / function gain – loss
/ skill need / education of patient
* Type and amount of manual, visual, verbal cues
* Why needed
* "Constant verbal and tactile cues for shldr flex without
substitution. Ther ex resulted increase shldr flx to 120 to
comb hair, still unable to reach into cupboards at home".
 Factors that modify frequency / intensity / progression
* "Performing shldr flex and abd ex incorrectly resulting
increased impingement."
* "Painted bedroom with repeated overhead mvts increased
pain"
* "Computer station ergonomic corrections not made,
enhances poor posture and muscle imbalances aggravating
sx"
 Statement of clinical decision and problem solving
* "Poor control and contraction transverse ab muscles resulting
in continued compression and sheering lumbar with pain and
radicular sx requires neuro-ed ex and educ."
* "Poor blood sugar control resulting fatigue and avoidance of
exercise. Speak to MD."
* "Quad control in open chain good, transition into controlled
functional closed chain in preparation for running."
 Plan for next visit = intervention and objective
8) Progress notes (or re-eval) completed every 10 treatment sessions or every 30
days (whichever is less) that include:
a. Statements of pertinent subjective nature
b. Comparison of objective, functional, measurable data (at a minimum as
indicated ROM, Strength, Neuro, Ambulation, Special tests, etc.)
c. Clearly delineated and updated measurable, time-framed goals that relate to
function (i.e., what does the patient need to be doing before discharge from
therapy?)
d. Clearly stated, updated plan of care delineating what will be provided,
frequency and duration
e. Clear stated medical reason and rationale for continuance of each service
utilized
 Evaluate status and modify plan. May simply mean continue
current goals but state why
 Billing 97002 – Re-Eval
* Unanticipated change
* Failure to respond
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-22
Revision Date: March 2014
* New direction or plan
 Compare similar data points
 Goals addressed, updated
 Reasons for lack of progress, changes needed
9) Flow sheets that include:
a. Date of service, area being treated, and name of PT or PTA providing
services
b. Clearly delineated CPT Code
c. Activity completed for each CPT code including name of activity, repetitions,
weights, resistance, etc.
d. Modalities (parameters, time frame, and specific location(s) treated)
RESPONSIBILITIES
It is imperative that you and your staff are fully aware of the professional, fiduciary, and
legal standards/requirements of complete and thorough documentation. A BCBSKS
professional relations representative is readily available to assist you. Please refer to
the important resources at the end of this document that will increase the successful
and timely adjudication and remittance of payment for the valuable services you
provide.
BCBSKS and Physical Therapy peer review consultants strive to provide you the
information necessary to meet the requirements of documentation to successfully and
timely adjudicate claims for remittance of payment for the valuable services you provide.
Please contact your BCBSKS professional relations representative should you have
questions or require additional information.
SIGNATURE REQUIREMENTS
1.
In the content of health records, each entry must be authenticated by the
author. Authentication is the process of providing proof of the authorship
signifying knowledge, approval, acceptance or obligation of the
documentation in the health record, whether maintained in a paper or
electronic format accomplished with a handwritten or electronic signature.
Individuals providing care for the patient are responsible for documenting the
care. The documentation must reflect who performed the service.
a. The handwritten signature must be legible and contain at least the first
initial and full last name along with credentials and date. A typed or printed
name must be accompanied by a handwritten signature or initials with
credentials and date.
b. An electronic signature is a unique personal identifier such as a unique
code, biometric, or password entered by the author of the electronic
medical record (EMR) or electronic health record (EHR) via electronic
means, and is automatically and permanently attached to the document
when created including the author’s first and last name, with credentials,
with automatic dating and time stamping of the entry. After the entry is
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-23
Revision Date: March 2014
electronically signed, the text-editing feature should not be available for
amending documentation. Example of an electronically signed signature:
“Electronically signed by John Doe, M.D. on MM/DD/YYYY at XX:XX
A.M.”
c. A digital signature is a digitized version of a handwritten signature on a
pen pad and automatically converted to a digital signature that is affixed to
the electronic document. The digital signature must be legible and contain
the first and last name, credentials, and date.
d. Rubber stamp signatures are not permissible. This provision does not
affect stamped signatures on claims, which remain permissible.
RESOURCES
1) "Defensible Documentation" by American Physical Therapy Association
http://www.apta.org/
2) Kansas Physical Therapy Association http://www.kpta.com/
3) Medicare documentation standards http://www.cms.hhs.gov
4) BCBSKS policies and procedures
http://www.bcbsks.com/CustomerService/Providers/index.htm
5) Your BCBSKS contractual agreements
6) Kansas statutes and rules/regulations http://ksbha.org/statutes.html
http://ksbha.org/regs.html
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-24
Revision Date: March 2014
EXAMPLES OF RED FLAGS:








Duplicative services or physiologic effects
Misuse of CPT codes
Billing/use of 97124 and 97140 for the same body part on the same DOS
# of units / treatment greater than BCBSKS policy allowable
Billing/use of 97002 on each DOS
Upcoding (e.g. 97032 instead of 97014)
Use of unlisted procedure and modality codes
Billing/use of two or more superficial heating modalities to the same body part –
Use of 97010, 97014, 97035 same body part, same session with no documented
rationale and objective data to support necessity for each modality
 Continued use of modalities for periods greater than 10 treatment sessions with
no documented rationale and objective data to support patient improvement and
ongoing treatment.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-25
Revision Date: March 2014
BCBSKS POLICIES
While this is not a totally exhaustive listing, these are some of the more common
policies that apply to Physical Therapy (as well as other providers):
6. BCBSKS limits the number of CPT codes billed per date of service to FOUR (4).
(Blue Shield Report Newsletter March 15, 2000)
a. Claims with greater than 4 services will require submission of all appropriate
medical records AT THE TIME OF SUBMISSION OF THE CLAIM. See
Documentation standards previously outlined in this letter to determine
what documentation needs to be submitted with the claim.
b. The claim will be denied and returned with a request for records if they are
not received with the claim.
7. BCBSKS limits the number of UNITS allowed per CPT code per date of service
(BUSINESS PROCEDURE MANUAL):
http://www.bcbsks.com/CustomerService/Providers/Publications/professional/ma
nuals/pdf/unit_limitation.pdf
8. BCBSKS has limitations on services provided for CPT code 97535 (Blue Shield
Report Newsletter August 30, 2005)
b. "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
9. Vertebral Axial Decompression therapy must be billed using HCPCS code
S9090. (Blue Shield Report May 28, 2003)
d. Reimbursement based on CPT code 97012
e. VaxD, IDD, DR 5000, DR 9000, SpinaSystem, and similar vertebral axial
decompression therapy are subject to this billing policy
f. ALLOW ONE (1) unit per day based on documented medical necessity
10. Accident Related Documentation
b. 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 physical
therapy services.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-26
Revision Date: March 2014
DOCUMENTATION CHECKLIST for SUBMISSION of RECORDS
ACCIDENT
____ Details of accident
____ Initial evaluation that includes:
7. Diagnosis (medical and physical therapy)
8. History, patient stated problems, co-morbidities, medications review of pastpresent care
9. Objective functional, measurable data (at a minimum as indicated ROM,
Strength, Neuro, Ambulation, Special tests, etc.)
10. Clearly delineated, measurable, time-framed goals that relate to function
11. Clearly stated plan of care delineating what will be provided, frequency and
duration
12. Clearly stated medical reason and rationale for each modality utilized
____ Daily Notes that include:
5. Statements that demonstrate the skill required by the PT or PTA under the
supervision and direction of a PT
6. Statements that demonstrate co-founding factors that delay progress
7. Tim In and Time Out
8. time for each CPT Code billed
____ Progress notes completed every 10 treatment sessions or every 30 days
(whichever is less) that include:
6. Statements of pertinent subjective nature
7. Comparison of objective, functional, measurable data (at a minimum as
indicated ROM, Strength, Neuro, Ambulation, Special tests, etc.)
8. Clearly delineated and updated measurable, time-framed goals that relate to
function
9. Clearly stated, updated plan of care delineating what will be provided,
frequency and duration and why continued care is medically necessary.
10. Clearly stated medical reason and rationale for continuance of each modality
utilized
____ Flow sheets that include:
5. Date of each service
6. Clearly delineated CPT code
7. Activity completed for each CPT Code including name of activity, repetitions,
weights, resistance, etc.
8. Modalities (parameters, time frame, and specific location(s) treated)
____ Patient's name on each page of the records
____ Record legible?
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-27
Revision Date: March 2014
DOCUMENTATION CHECKLIST for SUBMISSION of RECORDS
NON-ACCIDENT
____ Initial evaluation that includes:
1. Diagnosis (medical and physical therapy)
2. History, patient stated problems, co-morbidities, medications, review of pastpresent care.
3. Objective, functional, measurable data (at a minimum as indicated ROM,
Strength, Neuro, Ambulation, Special tests, etc.)
4. Clearly delineated, measurable, time-framed goals that relate to function
5. Clearly stated plan of care delineating what will be provided, frequency and
duration
6. Clearly stated medical reason and rationale for each modality utilized
____ Daily Notes that include:
5. Statements that demonstrate the skill required by the PT or PTA under the
supervision and direction of a PT
6. Statements that demonstrate co-founding factors that delay progress
7. Time In and Time Out
8. Time for each CPT Code billed
____ Progress notes completed every 10 treatment sessions or every 30 days
(whichever is less) that include:
6. Statements of pertinent subjective nature
7. Comparison of objective, functional, measurable data (at a minimum as
indicated ROM, Strength, Neuro, Ambulation, Special tests, etc.)
8. Clearly delineated and updated measurable, time-framed goals that relate to
function
9. Clearly stated updated plan of care delineating what will be provided,
frequency and duration and why continued care is medically necessary
10. Clearly stated medical reason and rationale for continuance of each modality
utilized
____ Flow sheets that include:
5. Date of each service
6. Clearly delineated CPT Code
7. Activity completed for each CPT Code including name of activity, repetitions,
weights, resistance, etc.
8. Modalities (parameters, time frame, and specific location(s) treated)
____ Patient's name on each page of the records
____ Record legible?
____ Does the record reflect why more than 4 CPT Codes were utilized?
____ Does the record reflect why more than allowable number of units per CPT
code utilized?
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-28
Revision Date: March 2014
Multiple Services, for One Patient,
on Same Date of Service,
Performed by Multiple Providers
These services must be submitted on the same claim. If billed on separate claims one
service will be denied as a duplicate of the other, or the claim will be sent back for
additional information.
Please review the following chart and the list at the end of this section to determine
whether medical records are required (after the chart, other reasons medical records
must be attached are listed; you also should review that):
Example 1 - One Patient/Same Date of Service/Same Office
PT 97530 3 Units Submit medical records for both providers to support medical
OT 97530 2 Units necessity of the 5 units.
Example 2 - One Patient/Same Date of Service/Same Office
DC 97035 1 Unit
Medical records not required since the limit for 97035 is 2 for a
OT 97036 3 Units date of service, and the limit for 97036 is 4 for a date of service
Example 3 DC 97010
PT 97012
PT 97018
OT 97022
OT 97024
One Patient/Same Date of Service/Same Office
1 Unit
Submit medical records for ALL providers to support medical
necessity of the 5 units.
1 Unit
1 Unit
1 Unit
1 Unit
Example 4 - One Patient/Same Date of Service/Same Office
PT 97001 Submit medical records for both providers to support medical necessity of
OT 97003 performing 2 initial evaluations on the same day.
Example 5 - One Patient/Same Date of Service/Same Office
PT 97001 Submit medical records for both providers to support medical necessity of
OT 97004 performing 2 evaluations (one initial and one re-evaluation) on the same
day.
Example 6 - One Patient/Same Date of Service/Same Office
PT 97002 Submit medical records for both providers to support medical necessity of
OT 97004 performing 2 re-evaluations on the same day.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-29
Revision Date: March 2014
Example 7 - One Patient/Same Date of Service/Same Office
PT 97002 Submit medical records for both providers to support medical necessity of
OT 97003 performing 2 evaluations (one re-evaluation and one initial) on the same
day.
Example 8 - One Patient/Re-Evaluation Billed Within 30 Days of the Last
Evaluation/Same Office
PT 97002 Submit medical records to support medical necessity of performing 2
evaluations within 30 days of the last evaluation (initial or re-evaluation).
OT 97004 Submit medical records to support medical necessity of performing 2
evaluations within 30 days of the last evaluation (initial or re-evaluation).
Multiple Units of Physical Medicine Modalities
and Procedures on Same Date of Service
BCBSKS has guidelines that require we review certain services when the units
performed on a given date of service exceed the unit limitation placed on the particular
physical medicine modalities and/or procedures, regardless of who performed the
service.
These guidelines involve more than 4 physical medicine modalities and/or procedures
being billed on one date of service; or the guidelines involve the BCBSKS daily unit limit
being exceeded. When multiple providers provide service on the same date of service
the limitations are accumulated by procedure code and number of units billed, not by
the individual provider, each having a separate limit.
•
Units on Time-Based Physical Medicine Codes
When only one service is provided in a day, providers should not bill for services
performed for less than 8 minutes. For any single timed CPT code in the same day
measured in 15 minute units, providers bill a single 15-minute unit for treatment
greater than or equal to 8 minutes through and including 22 minutes. If the duration
of a single modality or procedure in a day is greater than or equal to 23 minutes
through and including 35 minutes, then 2 units should be billed. Time intervals for 1
through 8 units are as follows:
 1 unit: ≥8 m inute s through 22 m inute s
 2 units:
≥ 23 minutes through 37 minutes
 3 units:
≥ 38 minutes through 52 minutes
 4 units:
≥ 53 minutes through 67 minutes
 5 units:
≥ 68 minutes through 82 minutes
 6 units:
≥ 83 minutes through 97 minutes
 7 units:
≥ 98 minutes through 112 minutes
 8 units:
≥ 113 minutes through 127 minutes
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-30
Revision Date: March 2014
At the end of this section there is a chart that outlines the unit limits for each code,
please refer to that for information of when medical records are required.
Physical Medicine Evaluation,
Modalities and Procedures
At the end of this section there is a complete list of physical medicine evaluation, reevaluation, modalities and procedures with their related unit limitations and guidelines;
please refer to that chart for further information.
•
97001 through 97004
These codes are used to report physical and occupation therapy evaluation and reevaluation. These codes identify a dynamic process in which clinical judgments are
made based on data gathered. These evaluations result in the development of a plan
for management of a patient’s problems as they relate to his or her disease or
disability.
Since some of the physical medicine services include an evaluation component as
part of pre-service work, use of these codes is dependent on whether the service
being provided is a significant, separate service, or if it is simply a component of the
more involved procedure. Since patient circumstances vary, deciding when to use
these codes depends on the specific patient encounter and identifying what is actually
done.
These codes are to be used for the services of a physical or occupational
therapist and should not be used by physicians to bill their evaluations of the
patient. Those services must be coded using the appropriate level of E and M
code.



97001 (physical therapy initial evaluation)
The PT examines the patient. This includes taking a comprehensive history,
systems review and tests and measures. Tests and measures may include but are
not limited to tests of range of motion, motor function, muscle performance, joint
integrity, neuromuscular status and review of orthotic or prosthetic devices. The PT
formulates an assessment, prognosis and note anticipated intervention.
97002 (physical therapy re-evaluation)
The PT re-examines the patient to obtain objective measures of progress towards
stated goals. Tests and measures include but are not limited to those noted in
97001. The PT modifies the treatment plan as is indicated to support medical
necessity of skilled intervention.
97003 (occupational therapy initial evaluation)
The OT evaluates the patient. Various movements required for activities of daily
living are examined. Dexterity, range of movement, and other elements may also
be studied.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-31
Revision Date: March 2014

•
97004 (occupational therapy re-evaluation)
The OT re-evaluates the patient to gauge progress of therapy. Dexterity, range of
movement, and other elements may also be studied.
 Utilization Guidelines for Re-evaluations
 A re-evaluation is allowed once every 30 days.
 If an additional re-evaluation is submitted within the 30 days, medical records
must be submitted with the second re-evaluation.
97010 through 97799
 These codes must be billed separately.
 If you deliver more than one unit of service the number must be recorded in the
units field of the CMS 1500 claim form.
 Medical records supporting medical necessity must accompany the claim when:
 Two like modalities (i.e., heat) are billed on the same day.
 If the unit limit, that is shown on the chart at the end of this section, is
exceeded.
 When the same modality is applied to two different locations on the same day,
always identify the areas (i.e., right shoulder and left elbow) on claim attachment.
 When two modalities are performed by one machine at the same time only one
modality may be billed.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-32
Revision Date: March 2014
PLEASE REVIEW THE FOLLOWING GUIDELINES CAREFULLY
Physical Medicine Exams/Modality/Procedure Guidelines
~~More than four (4) modalities or procedures on the same day require medical records~~
Code
A4556
Description
ELECTRODES, (e.g., apnea monitor), per pair
Units
Allowed
Per Day
2 PAIRS
PER 30
DAYS
Special Instructions
NOTE: Do not bill in-office use of electrodes under
this code. Those electrodes are content of the
modality being performed.
Content of service of rental of equipment.
Covered if equipment purchased for home use.
Submit date purchased and by whom on claim
attachment.
Multiple units required in Box 24G if more than one pair
2 pairs = 002 units of service
4 electrodes = 002 units of service
A4557
LEAD WIRES
2 PAIRS
EVERY
6 Months
NOTE: Do not bill in-office use of lead wires under
this code. Those lead wires are content of the
modality being performed.
Content of service of rental of equipment.
Covered if equipment purchased for home use.
Submit date purchased and by whom on claim
attachment.
2 pairs = 002 units of service
4 lead wires = 002 units of service
A9150
NON-PRESCRIPTION DRUG
VITAMINS and NUTRITIONAL SUPPLEMENTS
These items are non-covered and should not be
billed to BCBSKS. If a patient requires a denial
you may submit vitamins and nutritional
supplements with procedure code A9150.
64550
APPLICATION OF SURFACE
(TRANSCUTANEOUS) NEUROSTIMULATOR
Included in the equipment reimbursement.
BIOFEEDBACK training by any modality
Usually non-covered.
90901
If using an outside vendor you should look to them for
reimbursement of this service.
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
90911
95992
Usually non-covered.
BIOFEEDBACK training, perineal muscles,
anorectal or urethral sphincter, including EMG
and/or manometry by any modality
CANOLITH REPOSITIONING PROCEDURE(S)
(e.g., Epley maneuver, Semont maneuver),
per day
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
ONE
If the diagnosis is other than benign paroxysmal
positional vertigo submit office records.
This code is per session, regardless of time spent or
areas treated.
Submitting medical records will not change the unit
limit for this code.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-33
Revision Date: March 2014
Code
97001
Description
PHYSICAL THERAPY EVALUATION
Units
Allowed
Per Day
ONE
Special Instructions
MDs, DOs, DCs please use the appropriate E and
M procedure code.
To be used only by Licensed Physical Therapists.
Initial visit for evaluation of treatment.
97002
PHYSICAL THERAPY RE-EVALUATION
ONE
MDs, DOs, DCs please use the appropriate E and
M procedure code.
To be used only by Licensed Physical Therapists.
A re-evaluation is allowed once every thirty days.
If an additional re-evaluation is submitted within thirty
days, medical records must be submitted with the
second re-evaluation.
97003
OCCUPATIONAL THERAPY EVALUATION
ONE
MDs, DOs, DCs please use the appropriate E and
M procedure code.
To be used only by Licensed Occupational
Therapists.
Initial visit for evaluation of treatment.
97004
OCCUPATIONAL THERAPY REEVALUATION
ONE
MDs, DOs, DCs please use the appropriate E and
M procedure code
To be used only by Licensed Occupational
Therapists.
A re-evaluation is allowed once every thirty days.
If an additional re-evaluation is submitted within thirty
days, medical records must be submitted with the
second re-evaluation.
97005
ATHLETIC TRAINING EVALUATION
NON-COVERED
97006
ATHLETIC TRAINING RE-EVALUATION
NON-COVERED
97010
HOT OR COLD PACKS
Unattended
One or more areas is one unit of service
The clinician applies heat (dry or moist) or cold to
one or more body parts with appropriate padding
to prevent skin irritation. The patient is given
necessary safety instructions. The treatment
requires supervision only.
ONE
TRACTION (MECHANICAL)
Unattended
One or more areas is one unit of service
The clinician applies sustained or intermittent
mechanical traction to the cervical and/or lumbar
spine. The mechanical force produces distraction
between the vertebrae thereby relieving pain and
increasing tissue flexibility. Once applied, the
treatment requires supervision.
ONE
97012
This code will be denied content of service unless it is
the only service provided on that date.
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-34
Revision Date: March 2014
Code
97014
Description
ELECTRICAL STIMULATION,
INTERFERENTIAL THERAPY, HORIZONTAL
THERAPY
Units
Allowed
Per Day
ONE
97018
97022
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
Unattended
One or more areas is one unit of service
The clinician applies electrical stimulation to one
or more areas in order to stimulate muscle
function, enhance healing, and alleviate pain
and/or edema. The clinician chooses which type
of electrical stimulation is appropriate. The
treatment is supervised after the electrodes are
applied.
97016
Special Instructions
Billing of electrodes
The electrodes and other supplies used to administer
any modality are content of service of the modality.
Do not bill them under A4556.
That code is for take home supplies dispensed by a
home medical equipment supplier.
VASOPNEUMATIC DEVICES
Unattended
One or more areas is one unit of service
The clinician applies a vasopneumatic device to
treat extremity edema (usually lymphedema.) A
pressurized sleeve is applied. Girth
measurements are taken pre and post treatment.
Supervision is required.
ONE
PARAFFIN BATH
Unattended
One or more areas is one unit of service
The clinician uses a paraffin bath to apply
superficial heat to a hand or foot. The part is
repeatedly dipped into the paraffin forming a
"glove." Use of paraffin facilitates treatment of
arthritis and other conditions that cause
limitations in joint flexibility. Once the paraffin is
applied and the patient instructions provided, the
procedure requires supervision
WHIRLPOOL (FLUIDOTHERAPY)
Unattended
One or more areas is one unit of service
The clinician uses a whirlpool to provide
superficial heat in an environment that facilitates
tissue debridement, wound cleaning and/or
exercise. The clinician decides the appropriate
water temperature, provides safety instruction
and supervises the treatment.
ONE
This code will be denied content of service unless it is
billed with one of the following diagnosis codes:
457.0, 457.1 or 757.0.
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
ONE
By accepted professional definition and by description
in the AMA-CPT book the treatment provided by the
use of an “aqua massage” unit would be appropriately
described as a massage (97124) and not whirlpool.
Whirlpool (97022) would not be appropriate as
whirlpool is descriptive of a specific apparatus and
treatment.
A key component of whirlpool is immersion of the
body part in the water.
By the following descriptions, whirlpools would not
correctly describe the use of an aqua massage table.
1. The clinician utilizes whirlpool to provide
superficial heat in an environment that
facilitates tissue debridement, would
cleaning, and/or exercise.
Warm whirlpool
Equipment needed:
a. Towels- these are to be used for padding
and drying off.
b. Chair- Padding-this is to be placed on the
side of the whirlpool.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-35
Revision Date: March 2014
Code
Description
Units
Allowed
Per Day
Special Instructions
Treatment:
a. The patient should be positioned
comfortable, allowing the injured part to be
immersed in the whirlpool.
b. Direct flow should be 6 to 8 inches from
the body segment.
c. Temperature should be 98 to 110
degrees F (37 to 45 degrees C) for
treatment of the arm and hand. For
treatment of the leg, the temperature should
be 98 to 104 degrees F (37 to 40 degrees
C), and for full body treatment, the
temperature should be 98 to 102 degrees F
(37 to 39 degrees C).
d. Time of application should be 15 to 20
minutes.
Considerations:
a. Patient positioning should allow for
exercise of the injured part.
b. The size of the body segment to be
treated will determine whether an upper
extremity, lower extremity, or full body
whirlpool should be used.
c. Frequency.
The above is from “Therapeutic Modalities in Sports
Medicine, Third Edition, Mosby-Year Book Inc., 1994.
If more than one unit of service attach medical
records.
97024
97026
DIATHERMY (eg, microwave) Magnatherm
Unattended
One or more areas is one unit of service
The clinician uses diathermy as a form of
superficial heat for one or more body areas. After
application and safety instructions have been
provided, the clinician supervises the treatment.
INFRARED
Unattended
One or more areas is one unit of service
The clinician uses infrared light as a form of
superficial heat that will increase circulation to
one or more localized areas. Once applied and
safety instructions have been provided, the
treatment is supervised.
ONE
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
ONE
DO NOT USE this code to bill any of the following:
•
Anodyne Therapy
•
Cold Laser Therapy
•
Low Laser Therapy
•
Soft Laser Therapy
For information concerning these therapies please
refer to information given earlier.
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
97028
ULTRAVIOLET
Unattended
One or more areas is one unit of service
The clinician applies ultra light to treat
dermatological problems. Once applied and
safety instructions have been provided, the
treatment is supervised.
ONE
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-36
Revision Date: March 2014
Code
97032
Description
ELECTRICAL STIMULATION (MANUAL)
Attended
One or more areas
15 minutes is one unit of service
The clinician applies electrical stimulation to one
or more areas to promote muscle function,
wound healing edema and/or pain control. This
treatment requires direct contact by the provider.
Units
Allowed
Per Day
ONE
Special Instructions
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code.
Billing of electrodes
The electrodes and other supplies used to administer
any modality are content of service of the modality.
Do not bill them under A4556.
That code is for take home supplies dispensed by a
home medical equipment supplier.
97033
IONTOPHORESIS
Attended
One or more areas
15 minutes is one unit of service
The clinician uses electrical current to administer
medication to one or more areas. Iontophoresis
is usually prescribed for soft tissue inflammatory
conditions and pain control. This service requires
constant attendance by the clinician.
TWO
If more than two units (23 through 37 minutes; not
areas treated) of service attach medical records.
Medication may be billed separately, give NDC
number, dosage and use the appropriate J procedure
code, if within your licensure to dispense prescription
drugs.
If it is not within your scope of licensure to dispense
prescription drugs the patient must obtain the drug
from their physician or pharmacy and provide it for
use with this procedure.
DO NOT use supply code(s) for the medication.
97034
97035
CONTRAST BATHS
Attended
One or more areas
15 minutes is one unit of service
The clinician uses hot and cold baths in a
repeated alternating fashion to stimulate the
vasomotor response of a localized body part.
This service requires constant attendance of the
clinician.
ULTRASOUND
Attended
One or more areas
15 minutes is one unit of service
The clinician applies ultrasound to increase
circulation to one or more areas. A water bath or
some form of ultrasound lotion must be used as
coupling agent to facilitate the procedure. The
delivery of corticosteroid medication via
ultrasound is called phonophoresis. This service
requires constant attendance of the clinician.
ONE
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code
ONE
This code is one or more areas so the unit of service
is limited to one regardless of the time spent or the
number of areas treated.
Sending in medical records will not change the units
reimbursed on this code
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Use 97035 for phonophoresis.
Medication may be billed separately, give NDC
number, dosage and use the appropriate J procedure
code, if within your licensure to dispense prescription
drugs.
If it is not within your scope of licensure to dispense
prescription drugs the patient must obtain the drug
from their physician or pharmacy and provide it for
use with this procedure.
DO NOT use supply code(s) for the medication.
.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-37
Revision Date: March 2014
Code
97036
97039
97110
Description
HUBBARD TANK
Attended
One or more areas
15 minutes is one unit of service
The Hubbard tank is used when it is necessary
to immerse the full body into water. Care of
wounds and burns may require use of the
Hubbard tank to facilitate tissue cleansing and
debridement. This service requires constant
attendance of the clinician.
UNLISTED MODALITY
One or more areas
15 minutes is one unit of service
This code is used if the clinician performs a
modality to one or more areas that is not listed
under the current codes.
THERAPEUTIC PROCEDURE
Attended
One or more areas
15 minutes is one unit of service
The clinician and/or the patient perform(s)
therapeutic exercises to one or more body areas
to develop strength, endurance, and flexibility.
This service requires direct contact of the
clinician.
Units
Allowed
Per Day
FOUR
TWO
Special Instructions
If more than four units (61+ minutes; note areas
treated) of service attach medical records.
Specify type of modality and time on claim
attachment.
Attach medical records.
FOUR
DO NOT USE THIS CODE FOR MASSAGE
THERAPY (97124).
This code includes:
a. General exercise
b. Gym equipment
c. Open chain bike or treadmill for
endurance
d. Formulation of or changes to HEP
If more than four units (53 through 67 minutes; note
areas treated) of service attach medical records.
97112
NEUROMUSCULAR REEDUCATION Attended
One or more areas
15 minutes is one unit of service
The clinician and/or the patient perform(s)
activities to one or more body areas that facilitate
reeducation of movement, balance, coordination,
kinesthetic sense, posture, and proprioception.
This service requires direct contact of the
clinician.
FOUR
This code includes:
a. Closed chain exercise
b. BAPS board
c. Transitional movement posture training
d. Plyometrics
e. NDT techniques
f. PNF stretches
g. Feldenkrais
h. Vestibular exercises
If more than four units (53 through 67 minutes; note
areas treated) of service attach medical records.
97113
AQUATIC THERAPY
Attended
One or more areas
15 minutes is one unit of service
The clinician directs and/or performs therapeutic
exercises with the patient in the aquatic
environment. This code requires skilled
intervention by the clinician and documentation
must support medical necessity of the aquatic
environment.
FOUR
This code includes:
a. Back stabilization to increase
stabilization with lifting
b. Exercise to increase ROM, strength
c. Exercise to decrease weight bearing
If more than four units (53 through 67 minutes; note
areas treated) of service attach medical records.
Use modifier 22 when submitting any claim
attachment.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-38
Revision Date: March 2014
Code
97116
97124
Description
GAIT TRAINING
Attended
15 minutes is one unit of service
The clinician instructs the patient in specific
activities that will facilitate ambulation and stair
climbing with or without an assistive device.
Proper sequencing and safety instructions are
included when appropriate. This service requires
direct contact of the clinician.
MASSAGE
Attended
One or more areas
15 minutes is one unit of service
The clinician uses massage to provide muscle
relaxation, increase localized circulation, soften
scar tissue or mobilize mucous secretions in the
lung via tapotement and/or percussion. This
service requires direct contact of the clinician.
Units
Allowed
Per Day
TWO
Special Instructions
This code includes:
a. Gait drills
b. Steps
c. Crutch training
If more than four units (53 through 67 minutes; note
areas treated) of service attach medical records.
ONE
This code will be denied content of service unless it is
the only service provided on that date.
General Guidelines:
This code includes:
a. Stroking
b. Compression for pain relief or muscle
spasm
c. Percussion for pain relief or muscle
spasm
See previously in this manual a section on
massage and the guidelines that are applied.
97139
97140
97150
UNLISTED THERAPEUTIC PROCEDURE
One or more areas
15 minutes is one unit of service
This code is used if the clinician performs a
therapeutic procedure to one or more areas that
is not listed under the current codes.
ONE
MANUAL THERAPY TECHNIQUES
Attended
One or more areas
15 minutes is one unit of service
The clinician performs manual therapy
techniques including soft tissue and joint
mobilization, manual traction and/or manual
lymphatic drainage to one or more areas. This
service requires direct contact of the clinician.
TWO
Specify type of therapeutic procedure and time on
claim attachment.
Attach medical records.
i.e., Anti-Gravity Lumbar Traction-reverse (Inversion)
Posture Pump
Use "GA" modifier
Get Limited Patient Waiver
MDs, DOs, DCs do not use this code for your
manipulations, they must be coded under 9892598943
DO NOT USE THIS CODE FOR MASSAGE
THERAPY (97124)
This code includes:
FOUR
a. Lymphatic drainage
UNITS
b. Manual traction
WILL BE
c. MFR
ALLOWED
d. Soft tissue work
FOR LYMe. Trigger point therapy
PHATIC
f. Joint mobilization
DRAINAGE
If more than two units (23 through 37 minutes; note
areas treated) of service attach medical records.
THERAPEUTIC PROCEDURE(S)
One or more areas
15 minutes is one unit of service
The clinician supervises the GROUP activities
(two or more patients) of therapeutic procedures
on land or the aquatic environment. The patients
do not have to be performing the same activity
simultaneously, however, the need for skilled
intervention must be documented.
Usually non-covered.
Attach medical records.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-39
Revision Date: March 2014
Code
97530
Description
THERAPEUTIC ACTIVITIES
Attended
15 minutes is one unit of service
The clinician uses dynamic therapeutic activities
designed to achieve improved functional
performance (e.g., lifting, pulling, bending). This
service requires direct contact of the clinician.
Units
Allowed
Per Day
FOUR
Special Instructions
This code includes:
a. Body mechanics with functional activities
b. Sport related drills
c. Dynamic stabilization exercises
d. Simulated activities
e. Transfers
This code should be used for kinetic activity
procedure(s).
If more than four units (53 through 67 minutes; note
areas treated) of service attach medical records.
97532
97533
97535
97537
DEVELOPMENT OF COGNITIVE SKILLS
Attended
15 minutes is one unit of service
The clinician uses procedures to improve
attention, memory, problem solving, (includes
compensatory training). This service requires
direct (one on one) patient contact by the
clinician.
SENSORY INTEGRATIVE TECHNIQUES
15 minutes is one unit of service
The clinician uses procedures to enhance
sensory processing and promote adaptive
responses to environmental demands. This
service requires direct (one on one) patient
contact by the clinician.
SELF CARE/HOME MANAGEMENT TRAINING
15 minutes is one unit of service
The clinician instructs and trains the patients in
self-care and home management activities (e.g.,
activities of daily living and use of adaptive
equipment in the kitchen, bath and/or car). This
service requires direct contact of the clinician.
COMMUNITY/WORK REINTEGRATION
TRAINING
15 minutes is one unit of service
The clinician instructs and trains the patient in
community re-integration activities (e.g., work
task analysis and modification, safe accessing of
transportation, money management, vocation
activities). This service requires direct
supervision by the clinician.
Usually non-covered.
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
FOUR
By Report.
Attach medical records.
By Report. May be denied Content of Service.
Attach medical records.
Usually non-covered.
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
MDs, DOs, DCs do not use this code unless you
are truly performing the services listed.
This code includes:
a. Shopping
b. Transportation
c. Money management
d. A vocational activity or work
environment/modification analysis
e. Work task analysis
If more than one unit (16+ minutes; note areas
treated) of service attach medical records.
97542
WHEELCHAIR MANAGEMENT/PROPULSION
TRAINING
15 minutes is one unit of service
The clinician instructs and trains the patient in
proper wheelchair skills (e.g., propulsion, safety
techniques). This service requires direct contact
by the clinician.
By Report.
Specify time.
Attach medical records containing pertinent
information for review.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-40
Revision Date: March 2014
Code
97545
97546
97602
97750
97755
97760
Description
Units
Allowed
Per Day
Usually non-covered.
WORK HARDENING/CONDITIONING
Initial 2 hours
This code is used for a procedure where the
injured worker is put through a series of
conditioning exercises and job simulation tasks
in preparation for return to work. Endurance,
strength, and proper body mechanics are
emphasized. The patient is also educated in
problem solving skills related to job task
performance and employing correct lifting and
positioning techniques.
WORK HARDENING AND CONDITIONING
Each additional hour
This code is used for a procedure where the
injured worker is put through a series of
conditioning exercises and job simulation tasks
in preparation for return to work. Endurance,
strength, and proper body mechanics are
emphasized. The patient is also educated in
problem solving skills related to job task
performance and employing correct lifting and
positioning techniques.
REMOVAL OF DEVITALIZED TISSUE NONSELECTIVE
Per session
The clinician performs non-selective
debridement, without anesthesia, (e.g., wet to
moist dressings, enzymatic, abrasion), including
topical application(s), wound assessment, and
instruction(s) for on going care.
PHYSICAL PERFORMANCE TEST OR
MEASUREMENT WITH WRITTEN REPORT
15 minutes is one unit of service
The clinician performs a test of physical
performance evaluating function of one or more
body areas and evaluates musculoskeletal
functional capacity. A written report must be
included in this service.
ASSISTIVE TECHNOLOGY ASSESSMENT
(e.g., to restore, augment or compensate for
existing function, optimize functional task and/or
maximize environmental accessibility), direct
one-on-one contact by provider, with written
report, each 15 minutes
ORTHOTICS MANAGEMENT AND TRAINING
15 minutes is one unit of service
The clinician fits and/or trains the patient in use
of an orthotic device for one or more body parts.
This does not include fabrication time, if
appropriate, or cost of the materials.
Special Instructions
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
Usually non-covered.
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
ONE
This code is per session, regardless of time spent or
areas treated.
Submitting medical records will not change the unit
limit for this code.
FOUR
This code includes:
a. Biodex
b. KT1000 tests
If more than four units (53 through 67 minutes; note
areas tested) of service attach medical records.
Usually non-covered
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272 (Topeka
291-4183).
N/A
Content of original dispensing of orthotic/prosthetic.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-41
Revision Date: March 2014
Code
97761
97762
97799
97810
97811
Add-on
code
Description
PROSTHETIC TRAINING
15 minutes is one unit of service
The clinician fits and/or trains the patient in use
of a prosthetic device for one or more body parts.
This does not include fabrication time, if
appropriate, or cost of the materials.
CHECKOUT FOR ORTHOTIC/PROSTHETIC
USE
Established patients
15 minutes is one unit of service
The clinician evaluates the effectiveness of an
existing orthotic or prosthetic device and makes
necessary recommendations for changes, as
appropriate.
UNLISTED PHYSICAL
MEDICINE/REHABILITATION SERVICE OR
PROCEDURE
This code is used if the clinician performs a
physical medicine/rehabilitation service or
procedure to one or more areas that is not listed
under the current codes.
Units
Allowed
Per Day
TWO
Special Instructions
Content of original dispensing of orthotic/prosthetic.
Covered when billed by different provider from the
one supplying orthotic/prosthetic.
If more than two units (23 through 37 minutes; note
areas treated) of service attach medical records.
N/A
ACUPUNCTURE
One or more needles; without electrical
stimulation
INITIAL 15 minutes of personal one-on-one
contact with the patient
The physician applies acupuncture using one or
more needles. The physician inserts a fine
needle as dictated by acupuncture meridians to
relieve pain. More than one needle may be used
as needed. The needles may be twirled or
manipulated.
ACUPUNCTURE
One or more needles; without electrical
stimulation
EACH ADDITIONAL 15 minutes of personal
one-on-one contact with the patient, with reinsertion of needle(s)
The physician applies acupuncture using one or
more needles. The physician inserts a fine
needle as dictated by acupuncture meridians to
relieve pain. More than one needle may be used
as needed. .
Content of original dispensing of orthotic.
Specify type of service or procedure and time.
Attach medical records.
Use modifier 22 when submitting any claim
attachment.
i.e., Anodyne Therapy
Use "GA" modifier
Specify in Box 19
Get Limited Patient Waiver.
Usually non-covered.
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
Usually non-covered.
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-42
Revision Date: March 2014
Code
97813
97814
Add-on
code
S8950
National S
Code
S9090
National S
Code
Description
Units
Allowed
Per Day
Usually non-covered.
ACUPUNCTURE
One or more needles; with electrical
stimulation
INITIAL 15 minutes of personal one-on-one
contact with the patient
The physician applies acupuncture using one or
more needles. The physician inserts a fine
needle as dictated by acupuncture meridians to
relieve pain. More than one needle may be used
as needed. Electrical stimulation is employed by
energizing the needles with micro-current.
ACUPUNCTURE
One or more needles; with electrical
stimulation
EACH ADDITIONAL 15 minutes of personal
one-on-one contact with the patient, with reinsertion of needle(s)
The physician applies acupuncture using one or
more needles. The physician inserts a fine
needle as dictated by acupuncture meridians to
relieve pain. More than one needle may be used
as needed. Electrical stimulation is employed by
energizing the needles with micro-current.
COMPLEX LYMPHEDEMA THERAPY (CLT)
Each 15 minutes
CLT consists of lymphatic drainage, compression
bandaging, skin care, and patient specific
physical therapy exercises. The basic concept of
CLT is to maximize central lymphatic drainage.
This is accomplished by opening collateral
vessels to channel peripheral lymph into
normally functioning lymphotomes. The correct
application of this technique requires extensive
training.
VERTEBRAL AXIAL DECOMPRESSION
THERAPY
Per session
This service is provided on mechanical traction
machines, with provider intervention as
appropriate.
Some of the brand names for these machines
are: VaxD; IDD; DR 5000; DR 9000;
SpinaSystem
Special Instructions
Questions about whether a BCBSKS member has this
coverage may be directed to: 1-800-432-0272
(Topeka 291-4183).
Usually non-covered.
Questions about whether a BCBSKS member has this
coverage may be directed to 1-800-432-0272
(Topeka 291-4183).
FOUR
Attach medical records if providing more than 4 units
(53 through 67 minutes; note areas treated).
ONE
This code is per session, regardless of time spent or
areas treated.
Submitting medical records will not change the unit
limit for this code.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-43
Revision Date: March 2014
REVISIONS
01/01/2011
05/10/2011
Changed revision date to "January 2011" from "August 3, 2010."
Updated all references to the copyright date of Current Procedural
Terminology. Changed from "© 2009" to "© 2010."
Page F-3 Under Assistants: Certified Physical Therapist Assistant
(CPTA) or Certified Occupational Therapy Assistant (COTA), 2nd
paragraph, added "and FEP" after BCBSKS.
Page F-6 Added a first bullet under "Ice Massage/Ice Therapy:"
• Ice therapy will be denied "content of service" unless it is the
only service provided on that date."
Page F-15 Changed BOEING provider from Washington State Health
Insurance to BCBS of Illinois.
Page F-20 Removed the first bulleted item under "Medical records . . ."
 More than 4 modalities/procedures are billed on the same day.
Your evaluation/re-evaluation does not count as one of the 4.
Page F-15 Added a link to Blue Shield Report S-7-10 dated December
6, 2010, which provides complete contact information for the Boeing
Company.
Page F-18 First line of page, corrected typing error: “baill” should read
“bill.”`
Page F-21 Under 90901
• In “Units Allowed Per Day” column, removed “ONE.”
Page F-21 Under 90911
• In “Units Allowed Per Day” column, removed “ONE.”
Page F-21 Under 95992
• Removed “Per visit one” from “Description” column
• In “Description” column, added “PROCEDURE(S)”
• In “Description” column, added “(e.g., Epley maneuver, Semont
maneuver), per day”
In “Units Allowed Per Day” column, changed “TWO” to “ONE.”
Page F-24 Under 97022 – Last line of cell, corrected typing error,
“attachment.”
Page F-25 Under 97032 – Replaced language in “Special Instructions”
column. Language did read:
If more than one unit (16+ minutes; note areas treated) of service; attach medical records.
Use modifier 22 when submitting any claim attachment.
Billing of electrodes
The electrodes and other supplies used to administer any modality are content of service of the
modality.
Do not bill them under A4556.
That code is for take home supplies dispensed by a home medical equipment supplier.
Page F-25 Under 97033 – Under “Special Instructions” column, changed
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-44
Revision Date: March 2014
REVISIONS
5/10/2011,
continued
“31+” to “23 through 37.”
Page F-25 Under 97034 – Replaced language in “Special Instructions”
column. Language did read:
If more than one unit (16+ minutes; not areas treated) of service attach medical records.
Use modifier 22 when submitting any claim attachment.
Page F-25 Under 97035 – Under “Special Instructions” column, replaced
language above wavy lines. Language did read:
If more than one unit (16+ minutes; note areas treated) of service attach medical records.
Use modifier 22 when submitting any claim attachment.
Page F-26 Under 97110 – Under “Special Instructions” column, changed
number of minutes from “61+” to “53 through 67.”
Page F-26 Under 97112 – Under “Special Instructions” column, changed
number of minutes from “61+” to “53 through 67.”
Page F-26 Under 97113 – Under “Special Instructions” column, changed
number of minutes from “61+” to “53 through 67.”
Page F-27 Under 97116 – Under “Special Instructions” column, changed
number of minutes from “61+” to “53 through 67.”
Page F-27 Under 97139 –Under “Special Instructions” column, changed
“GET” to “Get” on last line.
Page F-27 Under 97140 – Under “Special Instructions” column, changed
number of minutes from “31+” to “23 through 37.”
Page F-28 Under 97530 – Under “Special Instructions” column, changed
number of minutes from “61+” to “53 through 67.”
Page F-28 Under 97532 – Under “Units Allowed Per Day” column,
deleted “FOUR.”
Page F-29 Under 97545 – Under “Units Allowed Per Day” column,
deleted “ONE.”
Page F-30 Under 97750 – Under “Special Instructions” column, changed
number of minutes from “61+” to “53 through 67.”
Page F-30 Under 97761 – Under “Special Instructions” column, changed
number of minutes from “31+” to “23 through 37.”
Page F-30 Under 97799 –Under “Special Instructions” column, changed
“GET” to “Get” on last line.
Page F-31 Under 97810 – Under “Units Allowed Per Day” column,
deleted “ONE.”
Page F-31 Under 97813 – Under “Units Allowed Per Day” column,
deleted “ONE.”
Page F-32 Under S8950 – Under “Special Instructions” column,
changed number of minutes from “61+” to “53 through 67.”
Page F-32 Under S9090 – Under “Units Allowed Per Day” column,
added “ONE.”
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-45
Revision Date: March 2014
REVISIONS
6/17/2011
7/15/2011
6/14/2012
6/21/2013
Changed revision date in the footer to “June, 2011” from “May, 2011.”
Page F-28 Under 97150 – Under “Special Instructions” column, deleted
“Specify type and time on claim attachment.”
Page F-28 Under 97533 – Under “Special Instructions” column, deleted
“Specify time,” and deleted the words “containing pertinent information
for review” from the sentence beginning “Attach medical records.”
Page F-28 Under 97535 – Under “Special Instructions” column, deleted
“Denied Content of Service,” and added the current verbiage.
Changed revision date in the footer to “July, 2011” from “June, 2011.”
Page F-8 Under heading, McConnell Taping, added the word
“Strapping/.” Also added “McConnell strapping or” to the verbiage under
the first bullet.
Changed revision date in the footer to “June, 2012” from July, 2011”.
Changed copyright date for Current Procedural Terminology to 2011.
Pages F-15-29 Added a section entitled “Documentation Guidelines”.
Guidelines specific to Occupational Therapists appear on pages F-15-21;
while those specific to Physical Therapists are found on pages F-22-29.
Changed revision date in the footer to “June, 2013” from “June, 2012”.
Changed copyright date for Current Procedural Terminology to 2012.
Page F-6 Under “Ice Massage Therapy”, removed last bullet:Use modifier
“22” to indicate attachment to claim.
Page F-7 Added the section on “Maintenance Therapy” after the section
titled “Magnatherm”.
Page F-9 Under “Massage” section, removed the next-to-last sub-bullet
in the section:

Use modifier “22” when submitting any claim attachment.
Pages F-9 – 10 In section “Multiple Therapies”, removed the words
“please append modifier 22 and” under each bullet.
Page F-11 Added the section “Rehabilitation Services” after the “Posture
Pump” section.
Page F-15 Under “Wound Debridement Billed with Evaluation” section,
removed the second and fourth bullets:
•
•
The reasoning for this guideline is as follows: The CPT-Assistant indicates
"Active wound care procedures include assessment of the wound, the
technique of debridement (selective or nonselective) without the use of
anesthesia, cleansing of the wound, dressing of the wound (including
application of topical ointments, wound bed protection and bulk dressing) and
any patient/family instruction. Before beginning the debridement technique, the
wound is examined to assess the drainage, color, texture, temperature,
vascularity, condition of surrounding tissue, and size of the area to be targeted
for debridement of necrotic tissue." (CPT Assistant - May 02:5.)
Use modifier “22” to indicate attachment to claim.
Page F-30 Deleted a page after page F-30 related to Boeing:
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-46
Revision Date: March 2014
REVISIONS
6/21/13,
continued
BOEING
For current information please refer to
Blue Shield Report S-7-10 dated December 6, 2010
Blue Cross and Blue Shield of Illinois (BCBSIL) is the new benefits
administrator for The Boeing Company, previously administered by
Regence BlueShield of Washington.
BCBS of Illinois
Benefits Administrator
Eligibility and Benefits
1-800-676-2583
Pages F-31 – 32 In section “Multiple Services, for One Patient, on Same
Date of Service, Performed by Multiple Providers”, removed the
statement, “Use modifier 22” from Examples 1, 3, 4, 5. 6, 7, and 8.
Page F-34 Removed final bullet on the page:

Use modifier “22” when submitting any claim attachment.
Page F-35 Under “97010 through 97799”, third sub-bullet, removed the
verbiage “(use modifier “22”)”.
Under 4th sub-bullet, removed the statement:
Use modifier “22” when submitting any claim attachment.
Pages F-36 – 46 Within the table in the “Special Instructions” column,
the sentence, “Use modifier 22 when submitting any claim attachment”,
was removed from each of the following codes:
A4556
A4557
95992
97002
7/09/2013
97004
97022
97033
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97530
97533
97535
97537
97542
97750
97761
97799
S8950
Changed revision date in the footer to “July, 2013” from “June, 2013”.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-47
Revision Date: March 2014
REVISIONS
7/09/2013,
continued
Page F-7 Title of last section on the page was changed to “Maintenance
Care” from “Maintenance Therapy”. All related verbiage was deleted, and
a new definition inserted.
Old verbiage:
Maintenance therapy is defined as a “treatment plan” that seeks to prevent
disease, promote health, and prolong and enhance the quality of life; or “therapy”
that is performed to maintain or prevent deterioration of a chronic condition. If a
treatment becomes supportive rather than corrective in nature, the treatment is
then considered maintenance therapy.
BCBSKS does not consider maintenance therapy medically necessary, and will
be denied as a provider write-off unless a waiver is obtained.
03/12/2014
Pages F-15 and F-23 – Added verbiage on Signature Requirements from
Policy Memo No. 1.
BCBSKS-Business Procedure Manual
Appendix F: Occupational Therapy and Physical Therapy Guidelines
Current Procedural Terminology © 2014 American Medical Association. All Rights Reserved.
NOTE: Codes published herein are current on the revision date and are subject to change.
Contains Public Information
Page F-48
Revision Date: March 2014