CPT CODES & MPFS, NCCI EDITS, MEDICARE 8-23 MINUTE RULE, & STUDENTS
I.
Coding
a. Medicare Physician Fee Schedule (MPFS) can be found at http://www.cms.hhs.gov/PFSlookup/ and choose
b.
c.
“Physician Fee Schedule Search” at top left of page.
Timed codes are per 15 minutes and can be billed in numerous units (2, 3, etc.)
Non-timed codes can only be billed once per day.
REHAB CPT CODES & MEDICARE PHYSICIAN FEE SCHEDULE (MPFS)
Metropolitan Kansas City, MO Region
As of: February 24, 2012
DEFINITION
DESCRIPTION
TIMED?
CPT 4
MPFS
Non-Facility / Facility
TENS Application
Biofeedback
Biofeedback UROGENITAL
Evaluation – PT
Re-Evaluation – PT
Evaluation – OT
Re-Evaluation – OT
Evaluation – AT
Re-Evaluation – AT
Hot / Cold Pack
Traction – Mechanical
Electrical Stimulation
UNATTENDED
Electrical Stimulation
Stage ¾ Wound
UNATTENDED
Electrical Stimulation
Non-Wound Care
UNATTENDED
Vasopneumatic Devices
Paraffin
Whirlpool
Diathermy
Infrared
Ultraviolet
Electrical Stimulation –
Manual
Iontophoresis
Contrast Bath
Application of surface (trancutaneous) neurostimulator
Biofeedback training by any modality
Biofeedback training, perineal muscles, anorectal or urethral
sphincter, including EMG and/or manometry
Physical therapy evaluation
Physical therapy re-evaluation
Occupational therapy evaluation
Occupational therapy re-evaluation
Athletic training evaluation
Athletic training re-evaluation
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
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;  traction, mechanical
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;  electrical stimulation (unattended)
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;  electrical stimulation for Stage ¾ wounds 
MEDICARE ONLY (unattended)
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;  electrical stimulation MEDICARE ONLY
(unattended)
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  vasopneumatic devices
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  paraffin bath
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  whirlpool
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  diathermy (e.g., microwave)
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  infrared
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  ultraviolet
The application of a modality that requires direct (one on one)
patient contact by the provider: application of a modality to one or
more areas  electrical stimulation (manual), each 15 minutes
The application of a modality that requires direct (one on one)
patient contact by the provider: application of a modality to one or
more areas  iontophoresis, each 15 minutes
The application of a modality that requires direct (one on one)
patient contact by the provider: application of a modality to one or
more areas  contrast baths, each 15 minutes
February 24, 2012 / Page 1 of 11
15.63 / 8.82
38.05 / 20.21
83.51 / 44.58
Non-Timed
Non-Timed
64550
90901
$
$
Non-Timed
Non-Timed
Non-Timed
Non-Timed
Non-Timed
Non-Timed
Non-Timed
Non-Timed
90911
97001
97002
97003
97004
97005
97006
97010
$
$
$
$
$
$
$
$
72.46
40.17
80.90
49.58
-0-0-0-
Non-Timed
97012
$
15.42
Non-Timed
97014
Non-Timed
G0281
(Medicare
ONLY)
Medicare uses
G0281 & G0283
for 97014
$
13.03
Non-Timed
G0283
(Medicare
ONLY)
$
13.03
Non-Timed
97016
$
17.90
Non-Timed
97018
$
9.92
Non-Timed
97022
$
21.45
Non-Timed
97024
$
6.35
Non-Timed
97026
$
5.71
Non-Timed
97028
$
7.04
Timed
97032
$
18.01
Timed
97033
$
29.71
Timed
97034
$
16.65
DEFINITION
Ultrasound
Hubbard Tank
Unlisted Modality
Therapeutic Exercise
Neuromuscular Re-Ed,
Balance, Coordination
Aquatic Therapy
Gait Training
Massage
Unlisted Therapeutic
Procedure
Manual Therapy
GROUP (2+ people)
Therapeutic Activities
Cognitive Training
Sensory Integration
DESCRIPTION
The application of a modality that requires direct (one on one)
patient contact by the provider: application of a modality to one or
more areas  ultrasound, each 15 minutes
The application of a modality that requires direct (one on one)
patient contact by the provider: application of a modality to one or
more areas  Hubbard tank, each 15 minutes
The application of a modality that requires direct (one on one)
patient contact by the provider:  Unlisted modality (specify type
and time if constant attendance)
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact:
therapeutic procedure, one or more areas, each 15 minutes 
therapeutic exercises to develop strength and endurance, range of
motion and flexibility
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact:
therapeutic procedure, one or more areas, each 15 minutes 
neuromuscular re-education of movement, balance, coordination,
kinesthetic sense, posture, and/or proprioception for sitting and/or
standing activities
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact:
therapeutic procedure, one or more areas, each 15 minutes 
aquatic therapy with therapeutic exercises
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact:
therapeutic procedure, one or more areas, each 15 minutes  gait
training (includes stair climbing)
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact:
therapeutic procedure, one or more areas, each 15 minutes 
massage, including effleurage, petrissage and/or tapotement
(stroking, compression, percussion)
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact: 
Unlisted therapeutic procedure (specify)
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Manual therapy techniques (e.g., mobilization/manipulation, manual
lymphatic drainage, manual traction), 1 or more regions, each 15
minutes.
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Therapeutic procedure(s), GROUP (2 or more individuals). Group
therapy procedures involve constant attendance of the physician or
therapist, but by definition do not require one-on-one patient contact
by the physician or therapist.
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Therapeutic activities, direct (one on one) patient contact by the
provider (use of dynamic activities to improve functional
performance), each 15 minutes
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Development of cognitive skills to improve attention, memory,
problem solving, (includes compensatory training), direct (one-onone) patient contact by the provider, each 15 minutes.
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Sensory integrative techniques to enhance sensory processing and
promote adaptive responses to environmental demands, direct
(one-on-one) patient contact by the provider, each 15 minutes.
February 24, 2012 / Page 2 of 11
MPFS
TIMED?
Timed
CPT 4
97035
$
12.11
Timed
97036
$
30.06
Non-Timed
97039
Timed
97110
$
30.01
Timed
97112
$
31.31
Timed
97113
$
39.72
Timed
97116
$
26.69
Timed
97124
$
24.66
Non-Timed
97139
Timed
97140
$
28.03
Non-Timed
97150
$
19.34
Timed
97530
$
32.91
Timed
97532
$
25.13
Timed
97533
$
27.72
Non-Facility / Facility
Not in MPFS
Not in MPFS
DEFINITION
Self Care Management
Training (ADL Training)
Community/Work
Reintegration
Wheelchair Management
Work Hardening/
Conditioning
Work Hardening/
Conditioning Each Add’l
Hour
Debridement-Selective
First 20cm2 or less
Debridement-Selective
>20cm2
Debridement – NonSelective
Negative Pressure
Wound Therapy (Wound
Vac) <=50cm2
Negative Pressure
Wound Therapy (Wound
Vac) >50cm2
DESCRIPTION
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Self-care/home management training (e.g., activities of daily living
(ADL) and compensatory training, meal preparation, safety
procedures, and instructions in use of assistive technology
devices/adaptive equipment) direct one-on-one contact by provider,
each 15 minutes
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Community/work reintegration training (e.g., shopping,
transportation, money management, avocational activities and/or
work environment/modification analysis, work task analysis, use of
assistive technology device/adaptive equipment)), direct one on one
contact by provider, each 15 minutes
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Wheelchair management (e.g., assessment, fitting, training), each
15 minutes
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Work hardening/conditioning; initial 2 hours
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function. Physician or
therapist required to have direct (one on one) patient contact.
Work hardening/conditioning; each additional hour (list separately in
addition to code for primary procedure)
Active wound care procedures are performed to remove devitalized
and/or necrotic tissue and promote healing. Provider is required to
have direct (one-on-one) patient contact.
Debridement (eg., high pressure waterjet with/without suction,
sharp selective debridement with scissors, scalpel and forceps),
open wound (eg., fibrin, devitalized epidermis and/or dermis,
exudate, debris, biofilm), including topical application(s), wound
assessment, use of a whirlpool, when performed and instruction(s)
for ongoing care, per session, total wound(s) surface area; first 20
sq cm or less
Active wound care procedures are performed to remove devitalized
and/or necrotic tissue and promote healing. Provider is required to
have direct (one-on-one) patient contact.
Debridement (eg., high pressure waterjet with/without suction,
sharp selective debridement with scissors, scalpel and forceps),
open wound (eg., fibrin, devitalized epidermis and/or dermis,
exudate, debris, biofilm), including topical application(s), wound
assessment, use of a whirlpool, when performed and instruction(s)
for ongoing care, per session, total wound(s) surface area; each
additional 20 sq cm, or part thereof (List separately in addition to
code for primary procedure)
Active wound care procedures are performed to remove devitalized
and/or necrotic tissue and promote healing. Provider is required to
have direct (one-on-one) patient contact.
Removal of devitalized tissue from wound(s); non-selective
debridement, without anesthesia (e.g., wet-to-moist dressings,
enzymatic, abrasion), including topical application(s), wound
assessment, and instruction(s) for ongoing care, per session
Active wound care procedures are performed to remove devitalized
and/or necrotic tissue and promote healing. Provider is required to
have direct (one-on-one) patient contact.
Negative pressure wound therapy (e.g., vacuum assisted drainage
collection), including topical application(s), wound assessment, and
instruction(s) for ongoing care, per session; total wound(s) surface
area less than or equal to 50 square centimeters
Active wound care procedures are performed to remove devitalized
and/or necrotic tissue and promote healing. Provider is required to
have direct (one-on-one) patient contact.
Negative pressure wound therapy (e.g., vacuum assisted drainage
collection), including topical application(s), wound assessment, and
instruction(s) for ongoing care, per session; total wound(s) surface
area greater than 50 square centimeters
February 24, 2012 / Page 3 of 11
MPFS
TIMED?
Timed
CPT 4
97535
$
32.60
Timed
97537
$
28.39
Timed
97542
$
29.04
Initial 2
hours
97545
$
-0-
Add’l 1
hour
97546
$
-0-
Non-Timed
97597
$
72.98 / 24.00
Non-Timed
97598
$
24.35 / 11.37
Non-Timed
97602
Non-Timed
97605
$
40.57 / 27.27
Non-Timed
97606
$
43.43 / 30.13
Non-Facility / Facility
Not in MPFS
DEFINITION
Physical Performance
Test
Assistive Technology
Assessment
Orthotic Mgmt & Training
Prosthetic Training
Orthotic/Prosthetic
Checkout
Unlisted Physical
Medicine/Rehab
Procedure
Education & Training;
Individual Patient
Education & Training;
2-4 Patients
Education & Training;
5-8 patients
DESCRIPTION
Requires direct one-on-one patient contact.
Physical performance test or measurement (e.g., musculoskeletal,
functional capacity), with written report, each 15 minutes
Requires direct one-on-one patient contact.
Assistive technology assessment (e.g., to restore, augment or
compensate for existing function, optimize functional tasks and/or
maximize environmental accessibility), direct one-on-one contact by
provider, with written report, each 15 minutes
Orthotic(s) management and training (including assessment and
fitting when not otherwise reported), upper extremity(s), lower
extremity(s) and/or trunk, each 15 minutes
Prosthetic training, upper and/or lower extremity(s), each 15
minutes
Checkout for orthotic/prosthetic use, established patient, each 15
minutes
Unlisted physical medicine/rehabilitation service or procedure
Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient
Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 2-4 patients
Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 5-8 patients
MPFS
TIMED?
Timed
CPT 4
97750
$
31.82
Timed
97755
$
34.69
Timed
97760
$
36.04
Timed
97761
$
31.50
Timed
97762
$
42.66
Non-Timed
97799
Not in MPFS
Timed
98960
Not in MPFS
Timed
98961
Not in MPFS
Timed
98962
Not in MPFS
Non-Facility / Facility
Non-Facility /
Facility
The Medicare non-facility allowable reimbursement applies when the professional service is
performed in a physician’s office or any place of service other than those listed above (PT
private practice).
The Medicare facility allowable reimbursement applies when the professional service is
performed in a hospital (inpatient, outpatient, and emergency room), ambulatory surgical
center, and/or skilled nursing facility setting.
Sources: CPT codes and definitions  American Medical Association (AMA) Current Procedural Terminology (CPT)
Manual, 2012
Medicare Physician Fee Schedule (MPFS)  http://www.cms.hhs.gov/PFSlookup/
Current codes not being paid by K.C. area insurers, usually due their being deemed “experimental” or “investigational”:
I. 97010 = Hot/Cold Pack
A. Health Access
TriCare also does not pay for any services
B. TriCare
provided by Physical Therapist Assistants
II. 97014 = Unattended Electrical Stimulation
(PTA’s).
A. Blue Cross Blue Shield of K.C.
III. 97033 = Iontophoresis
Medicare does not pay for any services
A. Aetna
provided by techs/aides in the outpatient
B. Blue Cross Blue Shield of K.C.
setting.
IV. 97113 = Aquatic Therapy
A. Firstguard
V. 97124 = Massage
A. Coventry
VI. 90901 = Biofeedback and 90911 = Biofeedback – Urogenital
A. Coventry
February 24, 2012 / Page 4 of 11
SPEECH LANGUAGE PATHOLOGY CODES
DEFINITION
Evaluation – ST
Treatment of Speech
GROUP (Treatment of
Speech)
Treatment of Swallow
Eval Oral/Pharyngeal
Swallow (Bedside)
Fluoro Video Swallow
Evaluation
FEES Evaluation of
Swallow
Aphasia Assessment
Per HR
Development Testing –
Limited
Development Testing –
Extensive
Education & Training;
Individual Patient
Education & Training;
2-4 Patients
Education & Training;
5-8 patients
DESCRIPTION
Evaluation of speech, language, voice, communication, and/or
auditory processing
Treatment of speech, language, voice, communication, and/or
auditory processing disorder; individual
Treatment of speech, language, voice, communication, and/or
auditory processing disorder; group, 2 or more individuals
Treatment of swallowing dysfunction and/or oral function for feeding
Evaluation of oral and pharyngeal swallowing function
Motion fluoroscopic evaluation for swallowing function by cine or
video recording
Flexible fiberoptic endoscopic evaluation of swallowing by cine or
video recording
Assessment of aphasia (includes assessment of expressive and
receptive speech and language function, language comprehension,
speech production ability, reading, spelling, writing, e.g., by Boston
Diagnostic Aphasia Examination) with interpretation and report, per
hour
Developmental testing; limited (e.g., Developmental Screening Test
2, Early Language Milestone Screen), with interpretation and report
Developmental testing; extended (includes assessment of motor,
language, social, adaptive and/or cognitive functioning by
standardized developmental instruments) with interpretation and
report
Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient
Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 2-4 patients
Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 5-8 patients
MPFS
TIMED?
CPT 4
Non-Timed
92506
$
159.50
Non-Timed
92507
$
74.11
Non-Timed
Non-Timed
92508
92526
$
$
22.03
81.96
Non-Timed
92610
$
88.06 / 66.65
Non-Timed
92611
$
96.65
Non-Timed
92612
$
164.56 / 66.93
Per HOUR
96105
$
100.17
Non-Timed
96110
Non-Timed
Timed
96111
98960
Timed
98961
Not in MPFS
Timed
98962
Not in MPFS
Non-Facility / Facility
Not in MPFS
$
124.08 / 118.89
Not in MPFS
Non-Facility /
Facility
Sources: CPT codes and definitions  American Medical Association (AMA) Current Procedural Terminology (CPT)
Manual, 2012
Medicare Physician Fee Schedule (MPFS)  http://www.cms.hhs.gov/PFSlookup/
February 24, 2012 / Page 5 of 11
National Correct Coding Initiative Edits
CPT Code
92507
Description
Timed?
Treatment of Speech
GROUP (Treatment of
Speech)
N
Treatment of swallow
Developmental Testing –
Extensive
PT Eval
PT Re-eval
OT Eval
OT Re-Eval
Hot / Cold Pack
Mechanical Traction
Electrical Stimulation
Vasopneumatic device
Paraffin Bath
Microwave
Whirlpool
Diathermy
Infrared
Ultraviolet
Electrical Stimulation
Iontophoresis
Contrast Bath
Ultrasound
Hubbard Tank
Physical Therapy
Treatment
Therapeutic Exercises
Neuromuscular Re
Education
Aquatic
Therapy/Exercises
Gait Training
Massage
Physical Medicine
Procedure
Manual Therapy
N
97150
Group Therapeutic
Procedures
N
97530
Therapeutic Activities
Y
97532
Cognitive Skills
Development
Sensory Integration
Self Care Management
Training
Community/work
Reintegration
Y
92508
92526
92611
97001
97002
97003
97004
97010
97012
97014
97016
97018
97020
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97533
97535
97537
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Effective 1/1/2012 - 3/31/2012
Mutually Exclusive
Column1/Column2
m=modifier possible; n=modifier NOT possible
97110m, 97112m, 97150m, 97530m,
97532m, 97533m
97110m, 97112m, 97150m, 97530m,
92507m
97532m, 97533m
97032m, 97110m, 97112m, 97150m,
97530m, 97532m
97003n
92610m
97750n; 97755n; 97762n
97750n; 97755n; 97762n
97750n; 97755n; 97762n
97750n; 97755n; 97762n
97140m
97002m; 97004m; 97018m
97022m
97002m; 97004m; 97018m; 97026m
97002m; 97004m
97001n
97018m; 97022m
97022m
97002m; 97004m, 97602m
97002m; 97004m; 97018m; 97026m
97002m; 97004m
97002m; 97004m; 97018m; 97026m
97002m; 97004m
97002m; 97004m
97002m; 97004m
97002m; 97004m
97002m; 97004m
97002m; 97004m
97002m; 97004m
Y
Y
97002m; 97004m; 97022m; 97036m
97002m; 97004m; 97022m; 97036n;
97110m
97002m; 97004m
97002m; 97004m
Y
Y
Y
Y
Y
97530m
97110m; 97112m;
97113m; 97116m;
97140m; 97530m
Y
Y
97002m; 97004m
97002m; 97004m; 97018m; 97124n;
97750m
97002m; 97004m; 97124m; 97532m;
97533m; 97535m; 97537m; 97542m;
97760m; 97761m
97002m; 97004m; 97113m; 97116m;
97532m; 97533m; 97535m; 97537m;
97542m; 97750m
97002m; 97004m
97002m; 97004m
97002m; 97004m
Y
97002m; 97004m
February 24, 2012 / Page 6 of 11
National Correct Coding Initiative Edits
Description
97542
97545
97597
97598
97601
97602
97605
97606
97750
97755
Wheelchair Management
Training
Work Hardening
Debridement-Selective
<=20cm2
Debridement-Selective
>20cm2
Wound Care Selective
Debridement – NonSelective
Negative Pressure
Wound Therapy (Wound
Vac) <=50cm2
Negative Pressure
Wound Therapy (Wound
Vac) >50cm2
Physical Performance
Test
Assistive Technology
Assessment
Timed?
Y
Y
N
N
97002m; 97004m
97002m; 97004m; 97140n
97602n, 97605m,
97606m
97602n, 97605m,
97606m
97761
97002m; 97022m
97002m
N
97602n
97002m
97602n
97002m; 97605n
N
Y
Y
Orthotic Management &
Training
Prosthetic Training
Y
Development of
Cognitive Skills
Y
97762m
Y
97762m
97770
97002m; 97022m
N
N
97762n
97760
Effective 1/1/2012 - 3/31/2012
Mutually Exclusive
Column1/Column2
m=modifier possible; n=modifier NOT possible
97150n
97035m, 97110m, 97112m, 97140m,
97530m, 97532m, 97533m, 97535m,
97537m, 97542m, 97545m, 97750n,
97760m, 97761m
97002m; 97004m; 97016m; 97110m;
97112m; 97116m; 97124m; 97140m
97002m; 97004m; 97016m; 97110m;
97112m; 97116m; 97124m; 97140m;
97760m
Source: http://www.cms.hhs.gov/NationalCorrectCodInitEd/ then choose “NCCI Edits - Hospital Outpatient PPS” at top left. On next
page, at bottom choose the link titled, “Medicine Evaluation and Management Services
90000-99999”.
n = cannot bill these codes together and cannot use a modifier
m = can use a modifier to bill these codes together. Should document in medical record in sequential language if using a modifier.
Example: After performing gait training we then performed re-evaluation.
Mutually Exclusive
If you use one (primary, on the left), it precludes you from using the other (secondary, on the right) if the code on the right has a “n”.
Column 1/Column 2
The Column 2 code is considered to be a component of the column 1 code. Cannot bill them on same day if an “n” but can bill
together if followed by a “m”.
Example: Notice that 97002 (Re-Eval) is in almost every line. That means that while you are performing gait training with a patient, you
cannot bill for gait training (97012) and re-eval (97002) with your argument being that while performing gait training you are constantly
reassessing their gait pattern. However, if you perform gait training for 15 minutes, THEN perform a 15 minute re-evaluation of whole
body strength, ROM, coordination, balance, etc. with thorough documentation that the re-eval occurred and that it occurred after the
gait training, and you use the -59 modifier, then you can bill for both of them.
These NCCI edits are now applicable to all facilities that bill for Part B Medicare services, including rehab agencies, CORF's
(Certified Outpatient Rehabilitation Facilities), etc.
February 24, 2012 / Page 7 of 11
MEDICARE BILLING, 97150 (GROUP), & STUDENTS
Sources:
Medicare Claims Processing Manual (Pub. 104), Chapter 5, Section 20
Medicare Benefit Policy Manual (Pub. 102), Chapter 15, Sections 220 and 230
2012 Current Procedural Terminology (CPT) Manual; American Medical Association
BILLING FOR MEDICARE OUTPATIENTS
1. "When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes.
For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for
treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or
procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be
billed. Time intervals for 1 through 8 units are as follows:" Pub. 104, Chapter 5, Section 20.2, subsection C
2. For timed codes, the following scale is used to determine number of units to bill:
a. 1 unit: ≥ 8 minutes through 22 minutes
b. 2 units: ≥ 23 minutes through 37 minutes
c. 3 units: ≥ 38 minutes through 52 minutes
d. 4 units: ≥ 53 minutes through 67 minutes
e. 5 units: ≥ 68 minutes through 82 minutes
f. 6 units: ≥ 83 minutes through 97 minutes
g. 7 units: ≥ 98 minutes through 112 minutes
h. 8 units: ≥ 113 minutes through 127 minutes
3. “When more than one service represented by 15 minute timed codes is performed in a single day, the total
number of minutes of service (as noted on the chart above) determines the number of timed units billed.”
Pub. 104, Chapter 5, Section 20.2, subsection C
a. Examples (from Pub. 104, Chapter 5, Section 20.2, subsection C)
1. Example 1
i.
24 minutes of neuromuscular reeducation, code 97112
ii.
23 minutes of therapeutic exercise, code 97110
iii.
Total timed code treatment time was 47 minutes.
iv.
The 47 minutes falls within the range for 3 units = 38 to 52 minutes.
v.
Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than
15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and
one unit of code 97110, assigning more timed units to the service that took the most time.
2. Example 2
i.
20 minutes of neuromuscular reeducation (97112)
ii.
20 minutes therapeutic exercise (97110),
iii.
40 Total timed code minutes.
iv.
Appropriate billing for 40 minutes is 3 units. Each service was done at least 15 minutes and should be
billed for at least one unit, but the total allows 3 units. Since the time for each service is the same,
choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the
codes.
3. Example 3
i.
33 minutes of therapeutic exercise (97110),
ii.
7 minutes of manual therapy (97140),
iii.
40 Total timed minutes
iv.
Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the
first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes)
to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.
4. Example 4
i.
18 minutes of therapeutic exercise (97110),
ii.
13 minutes of manual therapy (97140),
iii.
10 minutes of gait training (97116),
iv.
8 minutes of ultrasound (97035),
v.
49 Total timed minutes
vi.
Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each
of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed
units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill
4 units for less than 53 minutes regardless of how many services were performed). You would still
document the ultrasound in the treatment notes.
February 24, 2012 / Page 8 of 11
4.
5.
6.
7.
8.
5. Example 5
i.
7 minutes of neuromuscular reeducation (97112)
ii.
7 minutes therapeutic exercise (97110)
iii.
7 minutes manual therapy (97140)
iv.
21 Total timed minutes
v.
Appropriate billing is for one unit. The qualified professional ( See definition in Pub 100-02/15, sec.
220) shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was
performed for the same amount of time and only one unit is allowed.
b. The above examples of times “is intended to provide assistance in rounding time into 15-minute increments. It
does not imply that any minute until the eighth should be excluded from the total count. The total minutes
of active treatment counted for all 15 minute timed codes includes all direct treatment time for the timed codes.”
Documentation requirements in the medical record:
a. Total timed minutes = only minutes from timed codes  is what 8-23 minute scale will apply to
b. Total treatment minutes = timed minutes + untimed minutes
Only active treatment time can be billed for.
“Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and
therapy services. Pre- and post-delivery services are not to be counted in determining the treatment service time. In
other words, the time counted as “intra-service care” begins when the therapist or physician (or an assistant under the
supervision of a physician or therapist) is directly working with the patient to deliver treatment services. The time the
patient spends not being treated because of the need for toileting or resting should not be billed. In addition, the time
spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time.” Pub. 104,
Chapter 5, Section 20.3
“If a single patient is treated simultaneously by two practitioners (therapist, therapy assistant, or a physician), then
only a single unit of another procedure, modality, or test and measurement code can be billed for each 15 minute
unit." In other words, if co-treating with an OT for 30 minutes, the most that can be billed by both disciplines is 2
units. Typically PT bills one unit and OT bills one unit.
Providers are required to report one of the following modifiers to distinguish who performed the outpatient treatment:
a. GN ==> service delivered personally by a speech language pathologist under an outpatient SLP plan of care.
b. GO ==> service delivered personally by an occupational therapist or under and outpatient OT plan of care.
c. GP ==> service delivered personally by a physical therapist or under an outpatient PT plan of care.
PAYMENT
1. The Medicare allowed charge for the services is the lower of the actual charge or the MPFS (Medicare Physician Fee
Schedule) amount. “Allowable” is defined as that which Medicare (or any other payor) will pay for a service.
2. The Medicare payment for the services is 80% of the allowed charge (fee schedule amount) after the Part B
deductible is met.
3. Co-insurance (patient responsibility) is made at 20% of the lower of the actual charge or the MPFS amount.
4. The general coinsurance rule (20% of the actual charges) does not apply when making payment under the MPFS.
WHO CAN BILL
Only PT’s and PTA’s can bill for physical therapy, including when it is incident-to a physician’s service.
Only OT’s and OTA’s can bill for occupational therapy, including when it is incident-to a physician’s service.
Only SLP’s can bill for speech language pathology, including when it is incident-to a physician’s service.
Anyone other than a PT/PTA, OT/OTA, SLP, MD, DO, NP (Nurse Practitioner), CNS (Clinical Nurse Specialist), or PA
(Physician Assistant) is considered an aide and those PT/OT/SLP services cannot be billed to Medicare.
Services delegated by a PT/PTA, OT/OTA, SLP, MD, DO, NP, CNS, or PA to someone classified as an aide cannot
be billed to Medicare.
A physical therapist in Medicare’s eyes is someone who graduated from an accredited PT education program. No one
else can claim to be a PT when billing Medicare.
MD = Medical Doctor
DO = Doctor of Osteophathy
PA = Physician Assistant
CNS = Clinical Nurse Specialist
NP = Nurse Practitioner
February 24, 2012 / Page 9 of 11
GROUP CHARGE
Applies to ALL patients, not just Medicare since definition below is out of the CPT manual and not Medicare documents.
97150 = Therapeutic procedure(s), GROUP (2 or more individuals). This is a non-timed code.
1. “Group Therapy Services. Contractors pay for outpatient physical therapy services (which includes outpatient speechlanguage pathology services) and outpatient occupational therapy services provided simultaneously to two or more
individuals by a practitioner as group therapy services (97150). The individuals can be, but need not be performing
the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but
one-on-one patient contact is not required.” Section 230, subsection A, www.cms.hhs.gov/manuals/downloads/bp102c15.pdf
2. Charge group when performing timed codes on 2 or more patients at the same time (simultaneously), such as gait
training, aquatics, therapeutic exercise, manual therapy, therapeutic activities, etc.
a. Patient 1 arrived at 0900 and from 0900 – 0915 the physical therapist performed manual therapy. From 0915 –
0930 the PT supervised patient 1 performing therapeutic exercise in the gym. From 0915 – 0930 the PT also
supervised patient 2 performing therapeutic exercise in the gym, then from 0930 – 0945 the PT performed
therapeutic activities with patient 2, and from 0945 – 1000 performed neuromuscular re-education with patient 2.
Patient 1
Patient 2
0900 – 0915
97140 (Manual Therapy)
0915 – 0930
97110 (Ther. Ex. on mat supervised by PT)
97110 (Ther. Ex. on mat supervised by PT)
0930 – 0945
97116 (Gait Training)
0945 – 1000
97112 (Neuromuscular Re-Education…)
Patient 1 is billed 1 unit of 97150 (group)
and 1 unit of 97140 (manual therapy – 59
modifier needed)
Patient 2 is billed 1 unit of 97150 (group) +
1 unit of 97116 (gait training – 59 modifier
needed) + 1 unit of 97112 (neuromusc. reed – 59 modifier needed)
b. If the therapist had seen both patients for a full half hour and supervised therapeutic exercise simultaneously for
the entire half hour, then the therapist would have billed Patient #1 one unit of group (97150) and Patient #2 one
unit of group (97150) and nothing else.
c.
If you do a one hour aquatics class with 5 people and bill using CPT codes, each patient would be billed one (1)
unit of 97150 (group) and nothing else.
3. If performing a timed code on one patient (e.g., manual therapy) and non-timed code on another (e.g., mechanical
traction), you can bill each patient for each individual code  manual therapy (97140) for one and mechanical traction
(97012) for the other.
4. The Group Therapy code (97150) should NOT be used if simultaneous supervision is not being provided.
a. Example: In a 45-minute period, a therapist works with 3 patients - A, B, and C, providing therapeutic exercises
to each patient with direct one-on-one contact in the following sequence:
1. Patient A receives 8 minutes, patient B receives 8 minutes and patient C receives 8 minutes.
2. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18
minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional
minutes (14 minutes total).
3. During the times the patients are not receiving direct one-on-one contact with the therapist, they are each
exercising independently.
b. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise (97110) corresponding to
the time of the skilled intervention with each patient.
1. The therapist does NOT bill for the time when the patients were exercising independently since there was
no therapist supervision.
5. Medicare  "…group activities led by personnel who are not therapists, therapy assistants, or physicians should not
be billed as group therapy." When any service is provided by a non-PT, PTA, or physician then it cannot be billed to
Medicare.
February 24, 2012 / Page 10 of 11
THERAPY STUDENTS
Medicare Benefit Policy Manual 100-02, Chapter 15, Section 230, subsection B, 1;
www.cms.hhs.gov/manuals/downloads/bp102c15.pdf
“Only the services of the therapist can be billed and paid under Medicare Part B. The services performed by a student are
not reimbursed even if provided under “line of sight” supervision of the therapist; however, the presence of the student “in
the room” does not make the service unbillable. Pay for the direct (one-to-one) patient contact services of the physician or
therapist provided to Medicare Part B patients. Group therapy services performed by a therapist or physician may be
billed when a student is also present ‘in the room’.”
EXAMPLES:
Therapists may bill and be paid for the provision of services in the following scenarios:
 The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of
services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the
assessment and treatment.
 The qualified practitioner is present in the room guiding the student in service delivery when the therapy student and
the therapy assistant student are participating in the provision of services, and the practitioner is not engaged in
treating another patient or doing other tasks at the same time.
 The qualified practitioner is responsible for the services and as such, signs all documentation. (A student may, of
course, also sign but it is not necessary since the Part B payment is for the clinician’s service, not for the student’s
services).
DIAGNOSIS CODING
ICD-9  International Classification of Diagnoses, Version 9 is the international standard for classifying and documenting
diagnoses. This is what private insurers and Medicare/Medicaid use for diagnosis documentation and reporting.
 http://icd9.chrisendres.com/  online ICD-9 code definitions
 In hospital or facility settings usually are assigned by Certified Coders, but sometimes therapists will do so, especially
in smaller private practices.
ICD-10 will be implemented in the United States on October 1, 2013.
listed below:
ISSUE
ICD-9
Volume of Codes
Approximately 13,600
Composition of Codes
Mostly numeric, with E and V codes
alphanumeric.
Valid codes of 3, 4, or 5 digits.
Duplication of Code Sets
Currently, only ICD-9 codes are
required. No mapping is necessary.
The differences between ICD-9 and ICD-10 are
ICD-10
Approximately 69,000
All codes are alphanumeric, beginning with a letter
and with a mix of numbers and letters thereafter.
Valid codes may have 3, 4, 5, 6, or 7 digits.
For a period of up to two (2) years, systems will
need to access both ICD-9 codes and ICD-10
codes as the country transitions from ICD-9 to ICD10.
Mapping will be necessary so that equivalent codes
can be found for issues of disease tracking,
medical necessity edits, and outcomes studies.
Source: www.aapc.com/ICD-10/faq.aspx#different
February 24, 2012 / Page 11 of 11