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OT Therapy Coding

Taylor Posted Thu 12th of September, 2019 11:18:13 AM
We have come across an issue lately where we are fitting patients with a JAS Brace or a splint (97763) and then they are also doing therapy for the patient (97110 and 97140) to fill in the whole 45-minute session. We got a denial from Humana for 97110 and 97140 as procedure modifier is invalid, but when I enter these codes into the check edits, it is requesting modifiers on both these codes. I did 59 on both 97110 and 97140 but it is still getting denied. What more can I do?
SuperCoder Answered Fri 13th of September, 2019 03:05:51 AM

Hi,

As per CMS guidelines, “CPT code 97763 is designated as “always therapy” and must always be reported with the appropriate therapy modifier, GN, GO or GP, to indicate whether it’s under a Speech-language pathology (SLP), Occupational Therapy (OT) or Physical Therapy (PT) plan of care, respectively.”

If 97763 procedure is performed by an occupational therapist, then also add modifier GO with CPT 97763.

 

Please also check below link (page no. 2):

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm10303.pdf

 

Hope this helps!

 

Thanks

Taylor Posted Tue 17th of September, 2019 13:27:21 PM
We have done that as well as adding a 59 and GO to the other codes but insurances are still denying as inclusive.
SuperCoder Answered Wed 18th of September, 2019 10:25:08 AM

Hi,

 

As per CMS guidelines, CPT codes 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97533, 97535,97537, 97542, 97760, 97761, 97763, and G0515 describe different types of therapeutic interventions. The expected goals documented in the treatment plan, affected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of these procedures may be used in a treatment plan, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

For billing 97763, 97110, and 97140 documentation must clearly support the medical necessity.

 

Supportive documentation recommendations for billing 97763, 97110 and 97140 are as follows:

 

Supportive Documentation Recommendations for 97110:

  • Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on function
  • If used for pain include pain rating, location of pain, effect of pain on function Specific exercises performed, purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills of a therapist were required
  • When skilled cardiopulmonary monitoring is required, include documentation of pulse oximetry, heart rate, blood pressure, perceived exertion, etc.

 

Supportive Documentation Recommendations for 97140:

  • Area(s) being treated
  • Soft tissue or joint mobilization technique used
  • Objective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on function
  • For MLD/CDP, supportive documentation should include:
    • medical history related to onset, exacerbation and etiology of the lymphedema
    • comorbidities prior treatment
    • cognitive and physical ability of patient and/or caregiver to follow self- management techniques;
    • pain/discomfort descriptions and ratings;
    • limitation of function related to self-care, mobility, ADLs and/or safety; prior level of function;
    • limb measurements of affected and unaffected limbs at start of care and periodically throughout treatment;
    • description of skin condition, wounds, infected sites, scars.

 

 

Supportive Documentation Recommendations for 97763:

  • Reason for assessment
  • Findings from the assessment
  • Specific device, modifications made, instruction given

 

Please also check your payer specific guidelines for billing CPT 97763, 97110, and 97140.

 

Please also check below link for complete guidelines:

>https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34049&ver=24&SearchType=Advanced&CoverageSelection=Local&ArticleType=BC|SAD|RTC|Reg&PolicyType=Both&s=All&CptHcpcsCode=97763&kq=true&bc=IAAAACAAAAAA&

 

Hope this helps!

 

Thanks

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