Therapeutic Activities - Current Procedural Terminology (CPT) 97530 - JE Service Specific Targeted Review Interim Findings - JE Part B
Therapeutic Activities - Current Procedural Terminology (CPT) 97530 - JE Service Specific Targeted Review Interim Findings
Current Review Results
In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs post-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.
Summary of Findings
Since the initiation of the review, 118 claims were reviewed from September 1, 2020 through December 17, 2020. The breakdown of those findings are as follows:
- 0 claims were allowed.
- 118 claims were denied in full for the following reasons:
- The documentation submitted was incomplete and/or insufficient.
- The service was denied because the certification for therapy and/or plan of care was not submitted or signed.
- The service was denied because the documentation submitted did not have therapy time appropriately documented.
- The service was denied because the initial evaluation was not submitted or signed.
- The service was denied because the progress report was not submitted or signed after the 10th visit.
- The service billed is not a covered Medicare benefit or is an excluded service.
- The service was denied because the documentation submitted did not support the services billed.
The overall error rate since the initiation of this service specific targeted review is 100%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice, although this will not affect the error rate of the post-payment review.
Plan of Care and Certification/Recertification Requirements
The minimum plan of care requirements includes: a) diagnoses; b) long term treatment goals and; c) type, amount, frequency and duration of therapy services. Frequency "refers to the number of times in a week the type of treatment is provided" which can be tapered as necessary. The plan must be established before treatment is begun. Certification requires a dated physician/non-physician practitioner (NPP) signature on the plan of care or some other document that indicates approval of the plan of care.
The format of all certifications and re-certifications and the method by which they are obtained is determined by the individual facility. Initial certification should be obtained as soon as possible after the plan of care is established. Timeliness is met when the initial certification is signed within 30 days of initial treatment under that plan. Recertifications must be signed during the duration of the plan of care or within 90 days, whichever is less. Delayed certifications/recertifications are acceptable without justification for 30 days after they are due. Delayed certification/recertifications may still be satisfied at any later date when the physician/NPP makes a certification accompanied by a reason for the delay.
The physician/NPP certification of the plan of care is good for the duration of the plan of care or for 90 days, whichever is less, i.e. if frequency and duration on a certified plan of care is documented as 2x's/week x 4 weeks, then that certification is good for 4 weeks (not 90 days).
Treatment beyond the duration certified by the physician/NPP requires that the plan be recertified for the extended duration of treatment. Also, it must be noted that medical necessity documentation (even in instances when the certification/recertification extends beyond 30 days), must be documented every 10 treatment days as per the Progress Report requirements. For additional information reference the Internet Only Manual (IOM) 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Sections 220.1.2, 220.1.3, 220.3(D).
Therapy Evaluation and Assessment Services
Therapy evaluation and assessment services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants. These services can only be provided by qualified clinicians i.e., a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP).
Therapy evaluation and re-evaluation codes can only be billed when the medical record supports a completed comprehensive evaluation. Documentation must support that the evaluative service was medically necessary based on the patient's current status and medical/functional history. Medicare does not reimburse for services related solely to workplace skills and activities. Additional evaluative services may be necessary when an episode of care is interrupted by a short-stay inpatient hospitalization or outpatient surgery that could reasonably impact the patient's therapy progression. Treatment codes should not be submitted for time spent providing evaluative services.
The progress report(s) must provide justification of medical necessity for continued treatment and supports that required therapy services are complex and sophisticated such that they can only be safely and effectively provided by or under the supervision of a qualified therapist. The minimum progress report period shall be at least once every 10 treatment days which includes assessment of the patient's response to therapy services, plans for continued treatment or treatment revisions, updates to short or long term goals and objective functional assessment. If each element required in a progress report is included in the treatment encounter notes, at least once during the progress reporting period, then a separate progress report is not required. Without the elements of the progress report documented in the medical record, medical necessity is difficult to establish.
Physical therapy assistants (PTAs) or occupational therapy assistants (OTAs) may write elements of the progress report dated between qualified therapist reports. Reports written by assistants are not complete progress reports. The qualified therapist must write a progress report during each progress report period regardless of when the assistant writes other reports.
For additional information, reference:
- Noridian Coverage Article, "Medical Necessity of Therapy Services"
- Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3(D), 220-230
Time-based services are billed only for the total time-based minutes that the service was provided. If only one time-based 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 time-based service is provided in addition to another time-based service, then the total combined minutes for all the time-based services is used to determine accurate billing of the total time-based unit(s).
Additionally, if 2 services are performed, but the total number of time-based minutes allows 3 units to be billed, it is appropriate to bill 3 units based on the total time-based minutes, assigning the additional unit to the service that took the most amount of time.
The expectation remains that the provider's direct treatment time for each time-based unit billed will average 15 minutes. If a provider is consistently billing less than 15 minutes for a unit, this may be highlighted for review.
For additional information, reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims processing Manual (MCPM), Chapter 5, Section 20.2.
Timed Code Units
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. If a provider is consistently billing less than 15 minutes for a unit, this may be highlighted for review.
The following are examples to help clarify appropriate billing practices based on total timed code treatment minutes for therapy services:
Example 1 - The treatment encounter note supports:
- 30 minutes initial evaluation, Current Procedural Terminology (CPT®) 97162
- 5 minutes therapeutic exercises, CPT® 97110
- When the visit includes both untimed and timed-based services, the documentation needs to clearly indicate that the total time of the visit was 35 total visit minutes. This documentation supports coding of 1 unit for CPT® 97162 and no coding for CPT® 97110 since the required minimum 8 minute threshold is not met.
Example 2 - The treatment encounter note supports:
- 20 minutes of manual therapy, CPT® 97140
- 20 minutes of therapeutic exercises, CPT® 97110
- The total timed code treatment time is 40 minutes, which allows 3 units to be billed (3 units = 38-52 minutes). Even though each service is performed for only 1 unit of time individually, the total time allows for 3 units. Since both services are performed for the same amount of time, choose 1 service to bill 2 units and the other service is billed for 1 unit.
Example 3 - The treatment encounter note supports:
- 35 minutes of manual therapy, CPT® 97140
- 7 minutes of gait training, CPT® 97116
- Total time-based treatment time is 42 minutes, which allows for 3 units to be billed. The first 30 minutes counted towards CPT® 97140 which supports 2 full units (per the 15 minute relative work value for each unit). The remaining time spent on CPT® 97140 (5 minutes) compared to the time spent on CPT® 97116 (7 minutes) and the service that took more time is the service that should receive the remaining 1 unit. The documentation supports 2 units of CPT® 97140 and 1 unit of CPT® 97116
Example 4 - 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.
Example 5 - The treatment encounter note supports:
- 20 minutes of manual therapy, CPT® 97140
- 10 minutes of therapeutic exercises, CPT® 97110
- 10 minutes of gait training, CPT® 97116
- 8 minutes of ultrasound, CPT® 97035
- Total time-based treatment time is 48 minutes, which allows for 3 units to be billed. Therefore, even though each individual service is performed for 1 unit worth of time, the total time allows for only 3 units. This documentation supports 1 unit each of CPT® 97140, 97110, 97116. The ultrasound is not able to be billed, as the total units that can be billed are constrained by the total timed code treatment minutes. (In order to bill 4 units, there must be 53-67 total time-based treatment minutes).
Example 6 - The treatment encounter note supports:
- 10 minutes of vasopneumatic device, CPT® 97016
- 21 minutes of therapeutic exercises, CPT® 97110
- 9 minutes of manual therapy, CPT® 97140
- The total treatment time is 40 minutes and the total time-based treatment is 30 minutes. This documentation supports 1 unit of CPT® 97016, 1 unit of CPT® 97110 and 1 unit of CPT® 97140.
For additional information, reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 5, Section 20.2.
When additional documentation has been requested to verify compliance with the CPT®/HCPCS code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 184.108.40.206(C).
For additional educational resources, please visit our Education and Outreach department.
Provider Action Required
Providers should review individual claim determinations.
To review individual claim comments via the Noridian Medicare Portal, complete the following steps:
- Log into Noridian Medicare Portal at https://www.noridianmedicareportal.com/
- Choose Claim Status from the menu bar.
- On the Claim Status Inquiry page:
- Fill in all Provider/Supplier Details.
- Select MEDB under Program drop down box
- Fill in all Beneficiary Details
- Fill in Claim Details.
- Click the Submit Inquiry button at the bottom of the form.
- On the Claim Status Results page
- Choose View Claim.
- On the right side of the page will the heading: Related Inquiries
- Choose Noridian Comments.
- Scroll down the page and under the Claim Status Line Details the comment will display.
Note: If documentation was sent late (>45 days from the date of the ADR), the claim may have been reopened by the examiner. These reviews are not currently available on the portal.
Initial documentation must be sent by fax, mail or esMD. Additional documentation requested can be submitted fax, mail or Noridian Medicare Portal.
Further provider action recommended includes:
- Provide education regarding errors noted to applicable staff members.
- Verify documentation supports medical necessity of outpatient therapy services.
- Ensure ADR submissions are timely, complete, and include all documentation to support medical necessity and a valid physician order.
- If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.
This service specific targeted review will continue until medical review results demonstrate provider compliance with Medicare guidelines and education provided. This file is reviewed at least quarterly; providers with low/no errors after a reasonable sample will no longer be reviewed for this file. Remaining providers will continue to be reviewed.-
If you would like to receive information regarding findings specific to your facility prior to the completion of the review, send an email to firstname.lastname@example.org. In order to facilitate the response, follow these instructions:
- Complete the Subject line with the following information: Results request for CPT 97530 targeted review
- In the body of the email, include the following elements:
- Your name, title, and telephone number
- The facility name
- NPI Number
- Short description of information you would like to receive
- Indicate if you would like to receive results via phone call, fax or US Mail and include a fax number or mailing address as applicable.
Upon request receipt, Noridian Medical Review will respond as timely as possible. Requests may take up to two weeks to be completed.
If you have any questions, contact the Provider Contact Center
Last Updated Mon, 08 Feb 2021 16:14:42 +0000