Wednesday, September 7, 2016

CPT CODE 97010 - 97012 - Modality procedure service

97010 - Application of a modality to 1 or more areas; hot or cold packs Average fee amount $5 -$10

97012 - Application of a modality to 1 or more areas; traction, mechanical Average fee amount $ 13 - $20

Traction/Mechanical Modality (CPT code 97012)

        Traction is generally used for joints, especially of the lumbar or cervical spine, with the expectation of relieving pain in or originating from those areas, or increasing the range of motion of the joint. Specific indications for the use of mechanical traction include, but are not limited to, neck and back disorders such as disc herniation, lumbago, cervicalgia, sciatica, cervical and lumbar radiculopathy. This modality is generally used in conjunction with therapeutic procedures and not as an isolated treatment.


* 97010 is bundled into the payment for other services and is not separately reimbursable.

97012 Application of a modality to one or more areas; traction, mechanical

* Supervised treatment would not be expected to exceed up to 4 sessions per week for longer than one month. Patients requiring continued treatment beyond this time are usually trained in the use of a home traction unit. Continued treatment by a provider may require documentation supportive of medical necessity.

* This modality is typically used in conjunction with therapeutic procedures, not as an isolated treatment.

Mechanical Traction:

CPT 97012 Mechanical traction is described as force used to create a degree of tension of soft tissues and/or to allow for a separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration of time, and angle of the pull (degrees) using mechanical means. Used in describing cervical and pelvic traction that are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body’s own weight to create the force). A common question is whether a roller table type of traction meets the above-noted requirements. According to the ACA’s interpretation, table type traction would normally meet the requirements of autotraction.

It should also be noted that manual traction, using one's hands or a towel to perform the traction, is identified under manual therapy CPT 97140 and, presumably, would not be recognized under mechanical traction. ..


Billing and Coding Guidelines

Optum will not separately reimburse for CPT code 97010. Payment for CPT 97010 is considered bundled into the fee provided for other services.

The 97010 CPT code is described in the CPT manual as a supervised modality:

Any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy. The application of a modality that does not require direct (one-on-one) patient contact by the provider. Application of a modality to one or more areas; hot or cold packs.

CMS national policy effective January 1, 1997 precludes separate payment for hot packs/cold packs (CPT 97010). Regardless of whether billed alone or in conjunction with another code, CMS does not make payment separately for this code.


Physical Medicine & Rehabilitation (PM&R): Supervised Modalities – Update to article in September 2006

This article details a revision to the information that was published in the September 2006 Network Bulletin relating to a new reimbursement policy for 2 supervised therapy modalities,  CPT codes 97010 and 97014. Since that time, information has been obtained clarifying the most appropriate HCPCS code to be billed in lieu of 97014.

When unattended electrical stimulation is delivered, 97014 is no longer considered the most appropriate code to describe the treatment. Rather, practitioners utilizing this modality should submit an appropriate HCPCS code (G0283) which better describes the service being rendered.

Billing - CPT Codes: Permitted

In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 - 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.

CPT codes 97010 describe Physical Medicine and Rehabilitation modalities that do not require direct (one-on-one) patient contact by the provider.

Reimbursement Guidelines

Consistent with the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare Community Plan will not reimburse CPT codes 97010. Reimbursement for 97010 is included in the payment for other services.


You must still document that you provided the hot/cold pack to the patient, its purpose, and the duration of treatment in the patient’s medical record. Medicare carriers and FIs differ on whether to bill 97010 on the claim and whether a dollar amount should be attached. Check with your Medicare carrier or fiscal intermediatry (FI) for specific information. Just because Medicare doesn’t pay for hot or cold packs, doesn’t mean that the same is true of other insurance payers. If other payers reimburse for hot and cold packs, suppliers and providers of therapy services should bill those payers for the services rendered.

97012—Mechanical traction. This includes both cervical and lumbar-pelvic mechanical traction. This CPT code does not include over-the-door cervical traction or other noncovered forms of traction. Specific indications for mechanical traction include cervical or lumbar radiculopathy, lumbago, sciatica, disc herniation, and other back disorders.


Procedure Code 97012, Mechanical Traction/Spinalator

The American Chiropractic Association (ACA) receives numerous requests for clarification on describing the work associated with mechanical traction.

According to CPT, mechanical traction is described as the force used to create a degree of tension of soft tissues and/or to allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time), and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body's own weight to create the force).

A common question is whether roller table type traction meets the above requirement. Roller table type traction normally meets the requirement of autotraction, the use of the body's own weight to create the force.

It is the position of the American Chiropractic Association that modalities such as mechanical traction are not included in the work of the CMT codes. Code 97012 should be used to describe these services, subject to documented medical necessity.


Description


This policy addresses coverage and coding for Physical Therapy (PT) services.

Definitions

PT is a branch of rehabilitative health to help patients regain or improve their physical abilities, such as mobility, strength, gait, endurance, coordination and balance. PT services are reported under CPT codes 97010-97799.

Policy Statement

The physical medicine codes 97010-97028, 97032-97036, 97039 require a physician or therapist to be in constant attendance.

The codes 97110- 97124 should be used for physical therapy procedures. Additional physical therapy codes 97140-97542 and 97597-97606 should be used as defined in
CPT.


A Physical therapists evaluations and re-evaluation services should be submitted using CPT codes 97161-97164. These codes may be reported separately if the patient’s condition requires significant separately identifiable services, above and beyond the usual pre-service and postservice work associated with the procedure performed.

The modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service) is not valid with the physical therapy (PT) evaluations and re-evaluation codes 97161-97164. The evaluation or re-evaluation codes will be allowed, as appropriate, when billed with other physical or occupational services on the same date. Because the modifier -25 is not valid with 97161-97164, if submitted, the service will be denied.


“Timed” Unit Reporting

When a procedure/service indicates time, more than half of the designated time must be spent performing the service in order for a unit to be billed. In the case of a fifteen (15) minute service, at least eight (8) minutes must be performed; for a thirty (30) minute service, at least sixteen (16) minutes must be performed; and for a sixty (60) minute service, at least thirty-one (31) minutes must be performed, and so on.


As defined in Appendix A of the AUC Minnesota Uniform Companion guide, section A.3.4.2. Units (basis for measurement), if more than one modality or therapy is performed, time cannot be combined to report units. Do not follow Medicare’s rounding rules for speech (ST), occupational (OT) and physical therapy (PT) services. Each modality and unit(s) is reported separately by code definition. Do not combine codes to determine total time units. For example, if two fifteen (15) minute defined modalities are performed, but only seven (7) minutes or less are spent per modality, then neither service should be reported.


Exclusions:

Hot and Cold Pack

Blue Cross will not reimburse providers for the physical medicine hot and cold pack modality, CPT code 97010. Blue Cross reviewed the utilization of the hot and cold pack therapy code and determined that this modality is used in conjunction with and/or to enhance other services performed. Thus, 97010 will be denied as provider liability, whether billed alone or with another service.


Massage and Manual Therapy Exclusion

Blue Cross will not reimburse providers for massage or manual therapy services (97124 and 97140). Massage or manual therapy will deny either as incidental (provider liability) or subscriber liability.

Massages that are provided as preparation for a physical medicine therapy are considered an integral part of the therapy. As such, we will deny it as provider liability. If a massage is billed alone, then it may be denied as a subscriber contract exclusion.


Provider liable:

Massage and manual therapy may be denied incidental or mutually exclusive (provider liable) to physical medicine procedures billed on the same date of service. Refer to the ‘General Coding - 003 - Code Editing Policy’ for incidental and mutually exclusive denials. This denial will be upheld regardless of submission of the -59 modifier. Additionally, submission of the –GA modifier will not affect or change the denial. The patient is not responsible and must not be balance billed for any procedures for which payment has been denied or reduced by Blue Cross as the result of a coding edit. Edit denials are designed to ensure appropriate coding and to assist in processing claims accurately and consistently.


The code combinations and outcomes are listed below.

CODE DENIAL TO CODES

97124 Incidental 97110, 97112-97113, 97116, 97139-97140, 97150, 97530, 97532- 97533, 97535, 97537, 97542, 97545-97546, 98925-98929, 98940- 98943

97140 Incidental 97139, 97150, 97545-97546

97140 Mutually Exclusive 97530, 97532-97533

97140 Incidental 98925-98929, 98940-98943



Questions and Answers


Q: Does this policy affect only chiropractors and physical therapists?

A: No, this reimbursement policy applies to all participating and non-participating physicians and non-physician specialists. Facility claims, however, will not be affected.


Q: Does this policy mean I will not be reimbursed for hot and cold packs and unattended electrical stimulation?

A: In accordance with CMS' national coding policy, UnitedHealthcare will not separately reimburse hot and cold pack treatment as this treatment is considered included in the payment of other services. Unattended electrical stimulation should be reported with the appropriate HCPCS G-code (G0281, G0282 or G0283). Unattended electrical stimulation reported with an appropriate HCPCS code will be considered for reimbursement, subject to applicable coverage documents and Medical Policies. Please refer to Medical Policy Electrical Stimulation and Electromagnetic Therapy for Wounds for information related to electrical stimulation wound therapy. CPT codes 97010 or 97014 will not be reimbursed.


BCBSKS POLICIES

While this is not a totally exhaustive listing, these are some of the more common policies that apply to Physical Therapy (as well as other providers):

1. BCBSKS limits the number of CPT codes billed per date of service to FOUR (4). (Blue Shield Report Newsletter March 15, 2000)

a. Claims with greater than 4 services will require submission of all appropriate medical records AT THE TIME OF SUBMISSION OF THE CLAIM. See Documentation standards previously outlined in this letter to determine what documentation needs to be submitted with the claim. b. The claim will be denied and returned with a request for records if they are not received with the claim.

2. BCBSKS limits the number of UNITS allowed per CPT code per date of service (BUSINESS PROCEDURE MANUAL): http://www.bcbsks.com/CustomerService/Providers/Publications/professional/manuals/pdf/unit_limitation.pdf

3. BCBSKS has limitations on services provided for CPT code 97535 (Blue Shield Report Newsletter August 30, 2005)

a. "DENY content of service to other codes billed same setting in the following situations":

1) Home exercise program

2) Instructions for use of DME such as TENS units, cervical traction

3) Instructions for orthotics or prosthetics such as AFO's, compression stockings

4) Instructions for home care such as correct posture or sleeping positions

4. Vertebral Axial Decompression therapy must be billed using HCPCS code S9090. (Blue Shield Report May 28, 2003)

a. Reimbursement based on CPT code 97012

b. VaxD, IDD, DR 5000, DR 9000, SpinaSystem, and similar vertebral axial decompression therapy are subject to this billing policy

c. ALLOW ONE (1) unit per day based on documented medical necessity

5. Accident Related Documentation

a. Payment for services related to an accident is NOT the same as those services for general medical coverage. In the event the services are being rendered as related to an accident, it is imperative that your documentation is clear and concise about:

1) The details of the accident (simple statements like "they fell on 4-10-09" are insufficient)
2) The objective, functional, measurable data that supports the medical problems that are a direct result of the accident and need for physical therapy services.


Vertebral Axial Decompression Therapy (i.e., VaxD, IDD, DR 5000, DR 9000, SpinaSystem, etc.)

• All claims for this service must be coded using S9090, with one unit of service per day.
• Based on the lack of scientific evidence (blinded studies, appropriate number of
parti cipants in studies already conducted, documented long-term results) S9090 will be allowed based on the 97012 allowance and unit limitation guidelines.
• This policy will remain in effect until such time that scientific studies performed within accepted standards are available.
• To ensure correct coding of this service there will be periodic audits performed at random.
• Those claims found to have been coded incorrectly will require appropriate refunds and patients' credits

Code Description Units Allowed Per Day Special Instructions

97002 PHYSICAL THERAPY RE-EVALUATION ONE A re-evaluation is allowed once every 30 days for dates of services before January 1, 2017. If an additional re-evaluation is submitted within 30 days, medical records must be submitted with the second re-evaluation.

97003 OCCUPATIONAL THERAPY EVALUATION ONE Initial visit for evaluation of treatment for dates of services before January 1, 2017.

97004 OCCUPATIONAL THERAPY REEVALUATION ONE A re-evaluation is allowed once every 30 days for dates of services before January 1, 2017. If an additional re-evaluation is submitted within 30 days, medical records must be submitted with the second re-evaluation.

97005 ATHLETIC TRAINING EVALUATION Use for dates of service before January 1, 2017. Non-covered, patient responsibility.

97006 ATHLETIC TRAINING RE-EVALUATION Use for dates of service before January 1, 2017.

Non-covered, patient responsibility.
97010 HOT OR COLD PACKS

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