The 97110 CPT code, often referred to as Therapeutic Exercise, is a crucial billing component for physical therapists. This common CPT code is employed to bill for exercises devised to strengthen, improve endurance, expand range of motion, or augment flexibility. This article provides a comprehensive understanding of the 97110 CPT code, vital for physical therapists to ensure accurate billing and documentation.
What is the 97110 CPT Code?
The 97110 CPT code is a physical therapy procedure used to denote therapeutic exercises aimed at enhancing or maintaining strength, endurance, flexibility, or range of motion in one or several body parts. This therapeutic interventions essential for physical therapists aiming to incorporate foundational exercises while assisting individuals with physical impairments in improving their daily routine independence.
Detailed Description of the 97110 CPT Code
The American Medical Association (AMA) defines the CPT code 97110 as exercises designed to improve a patient's strength, motion range, endurance, or flexibility. These exercises address problems such as muscle weakness, stiffness, or restricted range of motion.
To bill using the 97110 CPT code, the exercises prescribed must be medically necessary to enhance a patient's mobility and strength, thus increasing participation in daily activities like feeding, dressing, bathing, and various other functional tasks.
What is the 8 minute rule for 97110?
The 97110 CPT code is a timed code, with each unit lasting 15 minutes. Physical therapists must actively work with the client one-on-one during the entire session. This rule, commonly known as the 8-minute rule, is a method employed to calculate how many units of time-based services a patient can bill for Medicare. The rule stipulates that a service must be performed for at least eight minutes to count for one full unit.
EMR Software like PatientStudio will automatically calculate units based on the CMS or AMA 8-minute rule.
Documentation Requirements for the 97110 CPT Code
Clear and comprehensive documentation is vital when billing using the 97110 CPT code. The documentation should underline the single deficit area you're focusing on for treatment, establishing a clear connection between the deficit and the patient's quality of life.
The documentation should also substantiate how the exercises are designed for the patient's needs, reflecting the type, quantity, and purpose of exercises performed during your occupational therapy sessions.
As the patient progresses, any changes to their exercise program, including any new exercises added, should be clearly documented.
When documenting CPT 97110, remember to include a few essential details. Specify the body parts treated, particularly the muscles and/or joints. It's also necessary to note the specific exercises performed. For instance, activities under CPT 97110 may encompass:
Active, active assistive, or passive range of motion exercises to enhance joint motion
Active, resistive exercises to boost muscle strength and endurance (specify if it's isometric, isokinetic, or isotonic)
Stretches to increase flexibility (indicate the type of stretch, such as active, ballistic, pre-contraction, etc.)
Exercises to improve cardio-pulmonary endurance, like walking on a treadmill or using an upper extremity ergometer
In your documentation, it is important to explain the purpose of each exercise in relation to achieving a specific functional goal. Therapeutic exercises are designed to target specific parameters, such as improving range of motion (ROM) or increasing strength. These exercises ultimately aim to enhance the ability to perform real-life movements, such as activities of daily living (ADLs). However, it is worth noting that ADLs, work tasks, sport tasks, and similar activities fall under the category of CPT 97530 Therapeutic Activities, which will be discussed in more detail later on.
What is the difference between CPT code 97110 and 97530?
The main difference between CPT code 97110 and 97530 lies in the type of treatment they represent. While both codes fall under the umbrella of therapeutic interventions, they focus on different aspects of rehabilitation. CPT code 97110 is used for therapeutic exercises, which aim to improve strength, flexibility, and range of motion. These exercises typically involve repetitive movements and are designed to target specific muscle groups. On the other hand, CPT code 97530 covers therapeutic activities, which involve purposeful and dynamic activities. These activities are aimed at improving functional performance, such as coordination, balance, and endurance.
Commonly Linked Services and the 97110 CPT Code
The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together, known as "edit pairs". For instance, if you bill CPT code 97140 (manual therapy techniques) with 97124 (Therapeutic Massage), you will only receive payment for 97140 as these are considered linked services.
The complete list is available on the CMS website. Major government payers such as Medicare, Tricare, and Medicaid typically use this list. However, private payers frequently establish their own edit pairs, so payment is not guaranteed, even if modifier 59 is applied.
Does 97110 need a 59 modifier?
The 59 modifier is an essential component when billing with the 97110 CPT code. This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. When billing 97110 and any of its pairs for the same session or date, modifier 59 is only appropriate if the two procedures are performed in distinctly different 15-minute intervals.
Per 2021 NCCI edits, 97110 will need the 59 modifier if billed with any of the following CPT codes; 36591, 36592, 96523.
Medicare complies with NCCI edits, however, not all commercial insurances do the same—at least not entirely. Private payers use a mix of NCCI/CCI edits and proprietary edits to identify 'covered services' in line with payer benefit plans. Therefore, to avoid denials due to incorrect usage of modifier 59, it's crucial to review the list of edit pairs for each specific carrier.
Can you bill 97110 and 97530 together?
Short answer, Yes. Per CMS, "CPT codes 97110, ... 97530, ... describe different types of therapeutic interventions. The expected goals documented in the treatment plan, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of these procedures may be used in a treatment plan, documentation must support the use of each procedure as it relates to a specific therapeutic goal."
The challenge arises with private payers. As mentioned above, medicare adheres to NCCI edits, but not all commercial insurances follow suit. The 59 Modifier might be required for specific private payers.
What is the reimbursement rate for CPT code 97110?
Based on the 2023 CMS Physician Fee Schedule (PFS) the National Payment amount for CPT code 97110 was $29.82 per unit.
The proposed CY 2024 PFS conversion factor is $32.75, a decrease of $1.14 (or 3.34%) from the current CY 2023 conversion factor of $33.89.
Based on the proposed 2024 conversion the National Payment amount for CPT code 97110 will be $28.82 per unit.
Wrapping Up
The 97110 CPT code plays a crucial role in the billing process for physical therapists. Understanding the ins and outs of this code, from the 8-minute rule to the correct use of the 59 modifier, can help ensure accurate billing, reduce the chance of reimbursement claim denials, and ultimately, lead to more effective patient care. As healthcare continues to evolve, physical therapists must stay updated on changes in CPT codes, including the introduction of new codes for remote therapeutic monitoring services.