CPT® 97530: Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes - JF Part B

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for CPT® 97530: Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 97530: Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The quarterly edit effectiveness results from April 1, 2025, through June 30, 2025, are as follows:

Top Denial Reasons

• Denial Reason 1 - Failure to return records
• Denial Reason 2 - Documentation does not support the Plan of Care was recertified within the duration of the prior plan of care, or within 90 days, whichever is less
• Denial Reason 3 - The documentation submitted does not support the medical necessity as listed in coverage requirements

Educational Resources

• Failure to Return Records
• Noridian Outpatient Therapy

Education

CPT® 97530 describes dynamic therapeutic activities aimed at improving functional performance (e.g., lifting, pulling, bending). CPT® 97535 involves training in daily living activities (e.g., using adaptive equipment in the kitchen, bathroom, or car). These services require direct one-on-one contact with a qualified health care provider and are billed in 15-minute units.

• Per CMS guidelines, at least 8 minutes of direct contact is required to report a single unit.
• Document both total direct contact time and total treatment time (including timed and untimed codes).
• Time from multiple intervals during the same session may be combined to determine total billable time.

CPT 97530 is not modifier 51-exempt and is subject to the Multiple Procedure Payment Reduction (MPPR). Under MPPR, the highest-valued procedure is paid at 100%, and subsequent procedures are reimbursed at 50% for the practice expense component.

These modifiers must be used with applicable therapy codes.

• GP: Physical therapy
• GO: Occupational therapy
• GN: Speech-language pathology

Claims exceeding the annual therapy threshold (currently $3,000) are subject to targeted medical review. Modifier KX must be appended to avoid denials

Effective for claims on or after January 1, 2025, when a patient is referred to for physical, occupational, or speech-language pathology therapy; by a physician or other qualified nonphysician practitioner:

• A signed and dated order or referral satisfies certification requirements, provided the order is included in the patient’s medical record
• Evidence that the plan of care (POC) was submitted to the referring provider within 30 days of the initial evaluation

Under this new exception, once the therapist has transmitted the POC, the responsibility shifts to the referring provider to either return the signature or indicate any changes. If neither action is taken, silence is considered as consent to the therapist submitted POC.

This new rule emphasizes and trusts the therapist’s clinical judgment, requiring only documentation of the order or referral.

There is no requirement for a physician or nonphysician practitioner (NPP) order or referral for patients to obtain outpatient therapy services, to clarify in § 424.24(c)(5) that references to an order or referral should not be interpreted as requiring an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.

When billing timed codes for outpatient therapy, billing should be based solely on the total timed code treatment minutes provided. If only one timed code service is provided for less than 8 minutes during a single therapy visit, then the service should not be billed. However, if during a single therapy visit 8 minutes of a timed code service is provided in addition to another timed code service, then the total combined minutes for all of the timed code services is used to determine accurate billing of the total timed code unit(s). Additionally, if 2 timed code services are performed, each individually spending 1 unit worth of time, but the total timed code minutes allows 3 units to be billed, then it would be appropriate to bill 3 units based on the total timed code minutes, assigning the additional unit to the service that took the most amount of time.

The expectation remains, however, that a provider’s direct treatment time for each timed code unit will average 15 minutes. A provider consistently billing less than 15 minutes for a unit may be highlighted for review.

It is the providers' responsibility to be familiar with the CPT® Manual and report appropriate CPT® codes based on services provided.

The following is an example to help clarify appropriate billing practices based on total timed code treatment minutes for therapy services:

Example - The treatment encounter note supports:

• 25 minutes of therapeutic exercises, CPT® 97110
• 24 minutes of therapeutic activities, CPT® 97530
• Total timed-based treatment time is 49 minutes, which allows for 3 units to be billed. Therefore, even though each individual service is performed for 2 units worth of time, the total time allows for only 3 units. The documentation supports 2 units of CPT® 97110 and 1 unit of CPT® 97530, billing more timed units to the service that took the most time.