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NCCI Policies for Therapy Procedures

Evaluations

An occupational therapist may report only one evaluation/re-evaluation (CPT codes 97165-97168) on a single date of service.

A physical therapist may report only one evaluation/re-evaluation (CPT codes 97161-97164) on a single date of service.

A physician or facility shall not report both an occupational therapy evaluation/re-evaluation service and physical therapy evaluation/re-evaluation service if performed by the same practitioner.

If the two services are performed by two different practitioners on the same date of service, both procedures may be reported.


Evaluations and other Assessment Codes

CPT codes 97750 (Physical performance test or measurement), 97755 (Assistive technology assessment), and 97763 (Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes) are not separately reportable for the same date of service with a physical therapy evaluation/re-evaluation CPT code (e.g., 97161­97164) or occupational therapy evaluation/re-evaluation CPT code (e.g., 97165-97168) when the two services are performed by a single practitioner or two practitioners of the same specialty.

If the two services are performed by two different practitioners of different specialties, the two services may be reported using an NCCI PTP-associated modifier. For example, if a physical therapist performs one service and an occupational therapist performs the other service, the two services may be reported separately.

If a physical therapist performs one service and a different physical therapist performs the other service, the two services are not separately reportable.


Billing more than one Service in a 15 Minute Period

Providers shall not report more than one physical medicine and rehabilitation therapy service for the same fifteen (15) minute time period.

Exception: The only exception involves a “supervised modality” defined by CPT codes 97010­-97028, which may be reported for the same fifteen (15) minute time period as other therapy services.)

Some CPT codes for physical medicine and rehabilitation services include an amount of time in their code descriptors. Some NCCI PTP edits pair a “timed” CPT code with another “timed” CPT code or a non-timed CPT code.

These edits may be bypassed with modifier 59 or XU if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.

NCCI does not include all edits pairing two physical medicine and rehabilitation services (excepting “supervised modality” services) even though they shall not be reported for the same fifteen (15) minute time period.


Re-evaluations

NCCI contains PTP edits with Column One codes of the physical medicine and rehabilitation therapy services and Column Two codes of the physical therapy and occupational therapy re­evaluation CPT codes of 97164 and 97168 respectively.

The re­evaluation services shall not be routinely reported during a planned course of physical or occupational therapy.

If the patient’s status should change and a re-evaluation is medically reasonable and necessary, it may be reported with modifier 59 or XU appended to CPT code 97164 or 97168 as appropriate.


Re-evaluations and Orthotic/Prosthetic Management

CPT codes 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes) and 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes) are not separately reportable for the same date of service with physical therapy re-evaluation CPT code 97164 or occupational therapy re­evaluation CPT code 97168 when the two services are performed by a single practitioner or two practitioners of the same specialty.

If the two services are performed by two different practitioners of different specialties, the two services may be reported using an NCCI PTP-associated modifier.


Assistive Technology Assessment

The procedure coded as CPT code 97755 (Assistive technology assessment...direct one-on-one contact with written report, each 15 minutes) is intended for use on severely impaired patients requiring adaptive technology.

For example, a patient with the use of only one or no limbs might require the use of high-level adaptive technology.


Manual Therapy Techniques and Therapeutic Activities

The NCCI PTP edit with Column One CPT code 97140 (Manual therapy techniques, one or more regions, each fifteen (15) minutes) and Column Two CPT code 97530 (Therapeutic activities, direct patient contact, each fifteen (15) minutes) is often inappropriately bypassed by using modifiers 59 or -X{EPSU}.

Providers should only use modifiers 59 or -X{EPSU} with the Column Two CPT code 97530 of this NCCI PTP edit if the two procedures are performed in distinctly different fifteen (15) minute intervals.

The two codes cannot be reported together if performed during the same fifteen (15) minute time interval.


Wound Debridement and Surgical Debridement

Wound debridement CPT codes 97597-97602 shall not be reported in conjunction with surgical debridement (CPT codes 11042-11047) for the same wound. Similarly, CPT code 97602 shall not be reported in conjunction with CPT codes 97597 and 97598 for the same wound.


Cardiac Rehabilitation and other Therapy Services

Physical or occupational therapy services performed at the same patient encounter as cardiac rehabilitation or pulmonary rehabilitation services are included in the cardiac rehabilitation or pulmonary rehabilitation benefit and are not separately reportable.

If physical therapy or occupational therapy services are performed at a separate, medically reasonable and necessary patient encounter on the same date of service as cardiac rehabilitation or pulmonary rehabilitation services, both types of services may be reported using an NCCI PTP-associated modifier.

Physical and occupational therapy services are not separately reportable with therapeutic pulmonary procedures (e.g., HCPCS codes G0237-G0239) for the same patient encounter.


Ultrasound and Wound Care

CPT Code 97610 (Low frequency, non-contact, non-thermal ultrasound..., per day) is not separately reportable for treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598).

Reference

National Correct Coding Initiative Policy Manual Ch. XI

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