Medicare Documentation and Proving Medical Necessity

With over 30% of all physical therapy visits involving Medicare, documenting for Medicare is crucial and proving medical necessity is a requirement. We have broken down the Medicare Local Coverage Determination (LCD) for New Jersey to provide you with tips on documentation best practices when dealing with Medicare.

General Medicare guidelines

Clause: “Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist.”

Key finding: To get paid by Medicare, you must treat the patient with direct supervision from a therapist and document why the patient can’t perform the activity without a therapist present.

Clause: “These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”

Key finding: You must document how the services you are providing are improving, maintaining, or preventing deterioration of the patient’s condition.

Medicare requirements for maintaining current condition

Medicare will cover services provided to maintain the patient’s current condition if certain criteria are met. Let’s examine them.

Criteria 1: “The documentation would need to substantiate that the services of skilled personnel are, in fact, required to achieve this goal.”

Key finding 1: You must document why a skilled therapist is needed to achieve the goal (maintain current condition).

Criteria 2: “Regularly documenting the degree to which the program’s treatment goals are being accomplished.”

Key finding 2: You must document the progress towards achieving the treatment goals regularly (i.e. more than once every ten visits).

Medicare coverage guidelines

Medicare clearly state’s in their LCD what the requirements are for a therapy visit to be covered. Here they are.

Therapy services are covered when they are rendered:

1. Under the written treatment plan developed by a physician or therapist;
2. To address specific treatment goals through stated modalities and procedures planned out in terms of frequency and duration; and
3. The patient’s functional limitations are documented in terms that are objective and measurable

Medicare plan of care (POC) requirements

Medicare clearly states their requirements for developing a plan of care, which is required for any therapy visit to be covered:

1. The plan must be reviewed and signed by the referring physician
2. The therapist may not significantly alter the POC without approval by the referring physician
3. The plan must be re-certified by the physician within the duration of the initial POC or within 90 calendar days of the initial treatment, whichever is less
4. The POC must clearly state the frequency and duration of treatment (i.e. 2 times per week for 8 weeks)

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Medicare modality guidelines

Medicare provides guidelines for documentation for certain modalities. Here is an overview of the primary codes used in physical therapy. Over the next few weeks, we will provide more details on what is required for an initial evaluation, re-evaluation, and some of the lesser used CPT codes in physical therapy.

Therapeutic exercises (CPT code: 97110)

One of the core therapy treatment codes, 97110 requires the following documentation to support a billed unit. Medicare notes that often you will bill multiple units of 97110 on one claim.

Requirements:

• Documentation must show objective loss of joint motion (degrees of motion), strength (strength grades), or mobility (levels of assistance)
• Documentation must show how these therapeutic exercises are helping the patient progress towards their stated, objective, and measurable goals
• The exercise is reasonable and necessary if it is performed for the purpose of restoring functional strength, range of motion, endurance training, and flexibility

Checks

Perform these checks when billing 97110

• Does this exercise improve functional strength, range of motion, endurance and/or flexibility?
• Did I document an objective loss of joint motion (in degrees), strength (in a strength grade) or mobility (in a level of assistance)?
• Does my documentation have clear, objective goals that are measurable?
• Did I document how these exercises help reach those states objective goals?

Neuromuscular re-education (CPT Code: 97112)

Medicare notes that this procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception and that the procedure may be reasonable and necessary for impairments that affect the body’s neuromuscular system. Some examples of this are poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity.

Checks:

• Does my patient have a problem with balance, coordination, kinesthetic sense, posture, or proprioception?
• Does the service I provide affect the body’s neuromuscular system?
• Did I document the affect these services have on improving the problem with the neuromuscular system?

Manual therapy (CPT code: 97140)

There are multiple manual therapy techniques that Medicare will cover with proper documentation. Here is a breakdown of each technique and what is required.

Myofascial release/soft tissue mobilization

Medicare states that this treatment may be medically necessary for the treatment of restricted motion of soft tissues involving the extremities, trunk, or neck. Your documentation must clearly state the restriction and what specific techniques you provided. Some examples of techniques Medicare states are acceptable include the facilitation of fluid exchange, the restoration of movement in acutely edematous muscles, and stretching of shortened connective tissue.

Joint mobilization

Medicare states this can be medically necessary when the loss of articular motion and flexibility impedes the therapeutic procedure. You must clearly document the impairment and why joint mobilization is required.

Checks for manual therapy

• Did I clearly document the techniques I used?
• Did I clearly document the region of the body I applied the technique?

Gait training (CPT code: 97116)

Medicare will cover gait therapy for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma. Medicare will not cover this service if it is a repetitive walk-strengthening exercise for feeble/unstable patients or to increase endurance. Medicare will not cover gait therapy in conjunction with orthotic management and training unless the orthotic management and training was performed on an upper extremity.

Checks:

• Does my patient have a walking impairment caused by neurological, muscular, or skeletal abnormalities or trauma?
• Was my treatment to increase endurance? If yes, do not bill 97116
• Was my treatment provided in combination with orthotic management? If yes, do not bill 97116

Therapeutic activities (CPT code: 97530)

Medicare notes that this procedure involves using functional activities to improve functional performance. Some functional activities include bending, lifting, carrying, reaching, catching, and overhead activities. The activities should be targeted at a loss or restriction of mobility, strength, balance, or coordination.

Checks: 

• Does my patient have a clearly documented functional impairment?
• Do I have clearly stated, objective treatment goals to improve this functional impairment?
• Did we perform functional activities to reach this goal?
• NOTE: If you are attempting to bill 97530 in combination with 97140, you must apply modifier 59 to 97530 to get paid. Only apply 97530 if you performed the therapeutic activities in a unique 15-minute window from the manual therapy. See our billing tips article for more coding advice.

Massage therapy (CPT code: 97124)

Medicare has determined that massage therapy may be necessary as adjunctive treatment to another therapeutic procedure on the same day. The therapy must be designed to restore muscle function, reduce edema, improve joint motion, or for relief of muscle spasm.

Electrical stimulation for indications other than wound care (HCPCS codes: G0283) vs. electric stimulation (CPT code: 97032)

This is a common mistake therapists make when billing to Medicare (and United Healthcare).

Use G0283:

G0283 represents unattended electrical stimulation to one or more areas for indications other than wound care. Some of the possible treatments may include:

• Transcutaneous electrical nerve stimulation (TENS)
• Microcurrent e-stimulation (MENS)
• Percutaneous electrical nerve stimulation (PENS)
• Electrogalvanic stimulation (high-voltage pulsed current)
• Functional electrical stimulation
• Interferential current/medium current

These treatments may be necessary during the initial phase of treatment if and only if there is an expectation of improvement in function or to prevent further deterioration.

G0283 is typically billed in conjunction with CPT code 97110. It is expected that G0283 is used in a clearly adjunctive role and not as a major component of the therapeutic encounter.

Checks for G0283:

• Did I use one of the techniques stated above?
• Was the treatment provided in a supervised manner?
• Do I expect my patient’s condition to improve?
• Did I bill CPT code 97110?

Use CPT code 97032

CPT code 97032 also requires direct (one-on-one) patient contact by a qualified professional and clear documentation of the type of electrical stimulation provided, as well as the medical necessity of constant contact. Types of e-stim that might require constant contact include:

• Direct motor point stimulation delivered via a prove
• Instructing a patient on how to use a home TENS unit
• Use of e-stim for walking in patients with spinal cord injury (SCI). This is typically referred to as functional electrical stimulation (FES).

Billing 97032 requires supportive documentation at least every ten visits. The documentation required is:

• Type of electrical stimulation required – Don’t just state whether it was manual or attended
• Area(s) of body being treated
• When used for muscle weakness: objective rating of strength and functional deficits
• When used for pain: pain rating, location of pain, effect of pain on function

Checks for 97032:

• Did I provide electrical stimulation in a one-on-one manner?
• Was the service provided NOT one of the services covered under G0283?
• Did I meet the documentation requirements stated above?

Check back next week for an article on some of the lesser billed CPT codes and the Medicare requirements for them!