Procedure Codes (CPT Codes)
The following codes are timed codes and billed for every 15 minutes of services, with the exception of the group code, for which one unit is billed for the entire visit. Medicare reimbursement rates listed below are approximations due to variations in amounts allowed dependent on the locality of service provision.

97113 – Aquatic Therapy; Therapeutic Exercises or Procedures performed in water, utilizing buoyancy, resistance and other therapeutic properties of water to facilitate movement, strengthening and functional recovery; Services designed to restore range of motion, strength, mobility or functional ability due to a disease, illness or injury
Medicare Reimbursement: $29.00-32.00

97110 – Therapeutic Exercise; Performed to improve a patient’s range of motion, strength, or mobility in active, active-assisted, passive, or resistive modes. Use of therapeutic equipment, such as a treadmill, isokinetic device, or bicycle is common.
Medicare Reimbursement: $25.00-28.00

97112 – Neuromuscular Reeducation;P rovided to improve impairments affecting areas such as sitting or standing balance, coordination, kinesthetic sense, posture, and proprioception. Common techniques include proprioceptive neuromuscular facilitation (PNF), use of equipment/boards designed to facilitate balance and proprioception, and Neuro-Developmental Techniques.
Medicare Reimbursement: $25.50-28.50

97116 – Gait Training; Performed when patient’s ability to walk is impaired due to neurological, muscular, or skeletal abnormalities or trauma. Treadmill, gait analysis and training equipment may be utilized in the process. Repetitive walking for unstable patients or walking solely to increase endurance are usually considered not requiring the skills of a licensed therapist and therefore not medically necessary.
Medicare Reimbursement: $21.50-24.00

97530 – Therapeutic Activities; Utilized to restore a patient’s functional performance with dynamic activities, such as training in specific functional movements or activities performed during daily living routines.
Medicare Reimbursement: $25.50-28.50

97150 – Group Therapy; Provided to a group of patients with therapist in constant attendance, but by definition, not providing one on one direct care. An example includes an instructional class, therapeutic in nature, designed for a group of similar patients.
Medicare Reimbursement: $15.50-17.50

Note: For Medicare and any payers following Medicare payment methodologies, refer to the Correct Coding Initiative for specific codes that are bundled and not separately payable. In addition, use the following modifiers when billing outpatient rehabilitation services:

-GP Service delivered under an outpatient physical therapy plan of care

-GO Service delivered under an outpatient occupational therapy plan of care

Reimbursement Pointers

1. Insurance Verification – Always contact the insurance company for verification of coverage for therapy services. In some situations, authorization for care must also be obtained. Document the information received thoroughly, as it may be needed for an appeal at a later date.

2. Request for specific Code reimbursement – Payment policies of a specific payer may dictate which codes may be used, both for diagnosis codes and procedure codes. Ask for any limitations on use of codes and request reimbursement amounts by the codes the therapist(s) anticipates using to define the services provided.

3. For Medicare, refer to the Local Medical Review Policy (LMRP) of the intermediary or carrier who is contracted to administer Medicare claims.

Support for Medical Necessity Substantiation

1. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, levels of assistance required).

2. Documentation should demonstrate the patient’s inability to effectively perform land based exercise.

3. Establishment of the patient’s goals and plan of care should include progression from water to land based exercises/procedures as soon as patient is able.

4. Ongoing care documentation should address the patient’s discernable progress towards restoration of function specific to the individual patient’s needs. Expected outcomes of care should be clear.

In Addition, for Medicare:

5. Refer to the ICD-9-CM Codes (Diagnosis Codes) in your intermediary or carrier’s Local Medical Review Policy (LMRP) for appropriate covered diagnoses to use for these therapeutic procedures.

6. Licensed therapist must provide one on one care throughout the period billed.

7. Always keep Medicare’s Medical Necessity Clause in Mind:

“Payable Physical Therapy - To be covered PT services, the services must relate directly and specifically to an active written treatment regimen established by the physician after any needed consultation with the qualified physical therapist and must be reasonable and necessary to the treatment of the individual's illness or injury. The services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified physical therapist or under his supervision. Services which do not require the performance or supervision of a physical therapist are not considered reasonable or necessary PT services.”

Sample Utilization Guidelines (Trailblazer Health)

• For non-neurological injuries/illnesses, it is expected that patient will progress to independent care within 2 months; however “the contractor recognizes variability in strength, recovery time, and the ability to be educated, and allows for a recertification for additional therapy, as long as adequate medical documentation by the supervising physician is recorded in the medical record and the patient continues to demonstrate progress. ”
• First four weeks of therapy - maximum of 16 sessions;
• Second four weeks of therapy require an update to the treatment plan - maximum of 12 sessions;
• Claims that indicate therapy has exceeded eight weeks will be reviewed with specific attention to clinical justification and medical necessity of the procedures
• The patient must have documentation showing sustained progress toward defined goals.

"CPT codes copyright 2003 American Medical Association.  All Rights Reserved.  CPT is a trademark of the AMA.  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 FARS/DFARS Restrictions Apply to Government Use."