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

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 July 1, 2025, through September 30, 2025, are as follows:

Top Denial Reasons

  • Denial Reason 1: The requested records were not received
  • Denial Reason 2: The documentation submitted does not support the medical necessity as listed in coverage requirements
  • Denial Reason 3: The documentation submitted did not include a progress report which was completed a minimum of every 10th treatment visit throughout the episode of care or within 7 calendar days from the end date of the reporting period

Educational Resources

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.

Note: 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 $2410.00) are subject to targeted medical review. Modifier KX must be appended to avoid denials.

The progress report(s) must provide justification of medical necessity for continued treatment and support 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 (or within seven calendar days after the end of the reporting period to meet delayed requirements) 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.

Last Updated Oct 21 , 2025