Physical Therapy: For Calendar Year 2022, the combined outpatient physical therapy and speech language pathology cap is 2,150.00.
Physical Therapy is a covered service when that service is medically reasonable and necessary to restore a patient’s level of function that was lost or reduced due to injury or illness. To substantiate medical necessity, there must be a written indication in the medical record regarding the expected improvement.
Prior to treatment, a physician must certify the Medical Necessity for the therapy and establish a “Plan of Treatment.”
Plan of Treatment:
The “Plan of Treatment” must meet the following requirements:
The plan must be written.
The plan must contain the diagnosis and anticipated goals.
The plan must indicate the type, amount, frequency, and duration of the physical therapy services.
The plan must be signed and dated by the physician.
The plan must be re-evaluated at least every 30 days and subsequently re-certified if it is necessary for treatment to continue.
Physical Therapy Guidelines:
1. Physical Therapy codes 97010-97028 do not require the DPM, MD, DO or PT to have direct patient contact during the administration of therapy. Note: 97020 (Diathermy) deleted in ’06 and included into 97024 Diathermy.
2. Physical Therapy codes 97032-97140 do require the DPM, MD, DO or PT to have direct patient contact during the administration of these therapies.
3. Unlisted therapy code 97139 should not be used unless there is no other appropriate code.
4. Post-operative physical therapy is considered INCLUDED in the surgery payment.
5. Hydrotherapy, hot/cold packs, and infrared therapy are not payable separately as these services do not require a Physician to administer.
6. Incidental physical therapy is not payable. The application of a modality, such as ultrasound singly, during an office visit, is considered included in the E/M service and not additionally payable.
7. In Block 19 of the CMS-1500 claim form (comment field, electronically), included, as appropriate, a statement indicating certification + date or re-certification + date.
8. Progress (or lack of progress) notes must be accurately documented in the medial record.
9. Report the initial physical therapy evaluation with codes 97161, 97162 or 97163. Append the GP modifier.
10. Report the re-evaluation for physical therapy with code 97164. Append the GP modifier.
11. If modalities or treatments are provided on the same day, you may bill the physical therapy codes in addition to the appropriate physical therapy evaluation code.
*Physical therapy evaluations include a patient history and an examination with development of a plan of care, conducted by a physician or other qualified health care professional, which is based on the composite of the patient’s presentation.
Coordination, consultation, and collaboration of care with physicians, other qualified health care professionals, or agencies is provided consistent with the nature of the problem(s) and the needs of the patient, family, and/or other caregivers.
At a minimum, each of the following components noted in the code descriptors must be documented, in order to report the selected level of physical therapy evaluation.
Physical therapy evaluations include the following components:
*Clinical decision making
*Development of plan of care
The level of the physical therapy evaluation performed is dependent on clinical decision making and on the nature of the patient’s condition (severity). For the purpose of reporting physical therapy evaluations, the body regions and body systems are defined as follows:
Body regions: head, neck, back, lower extremities, upper extremities, and trunk.
Body systems: musculoskeletal, neuromuscular, cardiovascular pulmonary, and integumentary
A review of body systems include the following:
*For the musculoskeletal system: the assessment of gross symmetry, gross range of motion, gross strength, height, and weight
*For the neuromuscular system: a general assessment of gross coordinated movement (eg. balance, gait, locomotion, transfers, and transitions) and motor function (motor control and motor learning)
*For the cardiovascular pulmonary system: the assessment of heart rate, respiratory rate, blood pressure, and edema
*For the integumentary system: the assessment of pliability (texture), presence of scar formation, skin color, and skin integrity
A review of any of the body systems also includes the assessment of the ability to make needs known, consciousness, orientation (person, place, and time), expected emotional/behavioral responses, and learning preferences (eg. learning barriers, education needs)
Body structures: The structural or anatomical parts of the body, such as organs, limbs, and their components, classified according to body systems.
Personal factors: Factors that include sex, age, coping styles, social background, education, profession, past and current experience, overall behavior pattern, character, and other factors that influence how disability is experienced by the individual. Personal factors that exist but do not impact the physical therapy plan of care are not to be considered, when selecting a level of service.
Now the Codes:
97161 Physical therapy evaluation: low complexity, requiring these components:
*A history with no personal factors and/or comorbidities that impact the plan of care;
*An examination of body system(s) using standardized tests and measures addressing 1- 2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
*A clinical presentation with stable and/or uncomplicated characteristics; and
*Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family.
97162 Physical therapy evaluation: moderate complexity, requiring these components:
*A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
*An examination of body systems using standardized tests and measures addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
*An evolving clinical presentation with changing characteristics; and
*Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family.
97163 Physical therapy evaluation: high complexity, requiring these components:
*A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;
*An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
*A clinical presentation with unstable and unpredictable characteristics; and
*Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family.
97164 Re-evaluation of physical therapy established plan of care, requiring these components:
*An examination including a review of history and use of standardized tests and measures is required; and
*Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family.
Additional Physical Therapy Information:
The Bipartisan Budget Act of 2018 (BBA of 2018) repeals the application of the Medicare outpatient therapy caps and its exceptions process. In place of the therapy caps, the new law:
• retains the former cap amounts as a threshold above which claims must include the −KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record – for CY 2022 the −KX modifier threshold is $2,150 for PT and SLP services combined and $2,150 for OT services; and
• retains the targeted medical review process, but at a lower annual threshold amount – in a calendar year before 2028: $3,000 for PT and SLP services combined and $3,000 for OT services in a calendar year before 2028.
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