Physical Medicine Codes

[Shu Manwill]

Thispage provides an overview of Current Procedural Terminology (CPT American Medical Association) coding policies for Medicare Part B (outpatient) speech-language pathology services, including a complete list of CPT codes and special coding rules. Although these coding guidelines are based on Medicare policies, keep in mind that other third party payers may adopt similar policies. CPT Assistant references are American Medical Association policies for coding best practice. Speech-language pathologists (SLPs) should also verify payment rules with their local Medicare Administrative Contractor and review ASHA's annual analysis of the Medicare Physician Fee Schedule for Medicare Part B policy changes and national payment rates.

Most CPT/HCPCS codes reported by speech-language pathologists are untimed and do not include time designations in the code descriptor. An untimed code is billed once per day, regardless of the time spent providing the service. On the other hand, timed codes include a time designation in the descriptor (for example, "per hour", "first hour", "initial 15 minutes", "each additional 30 minutes") and may be billed multiple times per day to represent the amount of time spent in direct patient care. Bill a timed only when face-to-face time spent in evaluation or treatment is at least 51% of the time designated in the code's descriptor. An exception is 96125, where allowable time includes interpretation of test results and preparation of the report.

Code modifiers are appended to a CPT or HCPCS code to provide additional information about the service provided. For example, untimed codes may include modifiers to represent atypical procedures. Untimed CPT codes represent the "typical" time it takes to complete a specific evaluation or treatment. For significantly atypical procedures, a -22 modifier can be used to indicate that the work is substantially greater than typically required and a -52 modifier for an abbreviated procedure. Modifier -22 should not be used frequently because the Medicare contractor could make the determination that the procedure reflects typical service delivery. Claims with the -22 modifier require an additional description of the need for extended services. Modifiers -22 and -52 may not be used in conjunction with timed codes.

Modifier -59 is used to establish one procedure as distinct from another procedure billed on the same day, but should only be used based on instruction from the payer. Medicare publishes National Correct Coding Initiative (CC) edits that may require modifier -59.

Medicare Part B services provided under plans of care for speech-language pathology or dysphagia services also require a -GN modifier. The requirement applies to physician offices as well as facilities and private practices. Occupational therapy and physical therapy modifiers are GO and GP, respectively. For therapy services that exceed the outpatient therapy payment trigger, a -KX modifier is required, indicating services are medically necessary and that documentation is available for review.

CMS staff have concluded that speech-language pathologists should not report physical medicine codes 97110 (Therapeutic exercises, each 15 minutes) and 97112 (Neuromuscular reeducation, each 15 minutes). Although CMS has not issued a formal policy statement regarding this issue, agency officials have stated their position, based on the official descriptors and vignettes for the codes. Additionally, Chapter 11, Section H-2 of the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services states

Please note that cognitive therapy by speech-language pathologists is covered in most Medicare Part B Local Coverage Determinations (LCDs). Some Medicare contractors may allow other exceptions in LCDs, but speech-language pathologists should also take the NCCI policies into consideration.

Note: CMS requires that the "-GN" modifier be added to every code that is rendered under a speech-language pathology or dysphagia plan of treatment (-GO indicates occupational therapy; -GP indicates physical therapy).

This is an add-on code for 92607. Additional time may be reported for an evaluation spanning multiple days. Billing must occur in conjunction with 92607 on the claim form and should be submitted using the last date of service. Do not bill 92608 separately from 92607. (Reference: CPT Assistant, March 2003, p. 5)

Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (list separately in addition to code for primary procedure)

Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour

This is a timed code for each hour of standardized testing. If billed on the same day as 92521-92524, documentation should explain the need for the cognitive evaluation in addition to the speech-language evaluation.

Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact

Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (list separately in addition to code for primary procedure)

Some LCDs may include this as a billable service for SLPs. However, ASHA does not recommend billing 97000 codes in conjunction with other 92000 codes that are typically used to report cognitive, speech, language, voice, and swallowing services.

Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes

These procedures are generally not considered to be speech-language pathology codes billable to Medicare, although some may be performed by SLPs "incident to" a physician. This means the SLP's services are billed under the physician's NPI and the physician must be on premises when services are provided. Some MACs may allow payment of the listed 97000 series codes performed solely by the SLP.

Report 92526 instead of 97032 when electrical stimulation is provided as part of a full swallowing treatment session. Most MACs don't allow SLPs to bill for electrical stimulation when performed as a stand alone service. Don't report 92526 if the SLP performs only electrical stimulation.

The American Speech-Language-Hearing Association (ASHA) is the national professional, scientific, and credentialing association for 234,000 members, certificate holders, and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology assistants; and students.

Coding for Timed Codes

Over the years there has been much confusion over the coding of minutes when billing private payers. APTA recommends that, to the extent possible, billing be consistent to all payers.

Medicare National Correct Coding Initiative

CMS developed the NCCI to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims.

Coding Interpretations: Group Therapy patient Scenarios

APTA staff provide interpretation of the one-on-one and group codes, regarding the delivery of outpatient physical therapy services.

CPT stands for current procedural terminology codes. Physical therapy CPT codes are utilized to describe the services rendered when submitting a claim to a third-party payer. A therapist will select physical therapy CPT codes based on the type of interventions they used and for the amount of time they administered that intervention. These codes provide healthcare providers a uniform language of coding for medical services and procedures.

Timed code. Therapeutic procedure, one or more areas, each 15 minutes; activities that facilitate movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. Therapeutic taping or other inhibition/facilitation techniques fit in this category.

Skilled improvement of gait, including stair training. Focuses on the biomechanics of gait. Walking exercises to improve endurance or cardiovascular health would not go in this category.

Timed code. Skilled hand movements and passive movements of the joints and soft tissue intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling. Includes soft tissue mobilization, joint mobilization, manipulation, manual traction, muscle energy techniques (performed using resistance applied by PT), and manual lymphatic drainage. PROM is not manual therapy.

Timed code. Dynamic activities used to promote improved function. Typically utilize multiple parameters such as strength, range of motion, motor control, balance, endurance, etc. Sit to stands, transfers, bed mobility or sport-specific training may fall in this category.

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