Section 10: Physical Medicine
Note: Please see the ADDENDUM at the end of this document.
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Physical medicine is an integral part of the healing process for a variety of injured workers. Recognizing this, this schedule includes codes for physical medicine, i.e., those modalities, procedures, tests, and measurements in the physical medicine section, codes 97001 through 97750, also unlisted code (97799) representing specific therapeutic procedures performed by licensed physicians, licensed physical therapists, licensed occupational therapists, a licensed PT assistant under the direction of a licensed physical therapist, a certified occupational therapist assistant under the direction of a licensed occupational therapists or by support personnel under direct supervision of a licensed provider. The following criteria must be met in all cases where physical medicine is rendered in order for a service to quality for reimbursement.
A. PHYSICAL MEDICAL ASSESSMENT
- An assessment must be performed to determine if a patient will benefit from physical medicine therapy.
- When a physician examines a patient and an assessment for physical medicine is performed, the billing for the office visit includes the physical medicine assessment.
B. QUALIFICATIONS FOR REIMBURSEMENT
- The patient’s condition must have the potential for restoration of function.
- The treatment must be specific to the injury and have the potential to improve the patient’s condition.
C. PLAN OF CARE
- An initial plan of care must be developed and filed with the payer regardless of whether therapy is provided by a physician or practicing therapist. The content of the plan of care, at the minimum, should contact:
- The potential degree of restoration and measurable goals (i.e., potential restoration is good, poor, low, guarded)
- The specific therapists to be provided, including the frequency and duration of each
- The estimated duration of the therapeutic regimen
- Preparation of care plan does not warrant a separate fee
- A plan of care must be updated at least every 30 days, and the revised plan must be signed by the physician or therapist and submitted to the payer.
- Visits for therapy may not exceed one visit per day without prior approval from the payer.
- Therapy exceeding 30 visits must have preauthorization from the payer for continuing care. It must meet the following guidelines:
- The treatment must be medically necessary
- Telephone approval is appropriate. Documentation should be made by the provider in the patient’s medical record indicating the date and name of the payer representative giving authorization for the continued therapy.
- Modalities are now divided into two groups: “supervised” and “constant attendance.” Supervised modalities will be reimbursed as billed for only one unit per visit. Constant attendance modalities will be reimbursed as billed in units of 15 minutes. Appropriate rounding up or down is expected through professional judgment. Excess in units will be subject to utilization review
E. FOLLOW-UP EXAMINATION OF AN ESTABLISHED PATIENT
- A physician, physical therapists, or occupational therapist may charge and be reimbursed for a follow-up examination for physical therapy only if new symptoms present the need for reexamination and evaluation as follows:
- There is a definitive change in the patient’s condition
- The patient fails to respond to treatment and there is a need to change the treatment plan
- The patient has completed the therapy regimen and is ready to receive discharge instructions
F. TESTS AND MEASUREMENTS
- Reimbursement for extremity testing, muscle testing, and range of motion measurements (95831, 95832, 95834, 95851, 95852 (97750) will not be made more than once in a 30-day period for the same body area.
- When two or more procedures from 95831 through 95852 are performed on the same day, reimbursement may not exceed the maximum reimbursement allowance (MRA) for the procedure code 95834, total evaluation of the body, including hands.
- Procedure code 97750 must be used when testing is performed by means of mechanical equipment.
- Procedure code 97750 includes a printout of test results and separate reimbursement must not be made under CPT code 99090.
- Functional capacity testing must have preauthorization from the carrier before scheduling the tests. Reimbursement will be per your agreement with the insurance carrier or self insurer. CPT code EV100 must be used. See industrial Rehabilitation Section for additional information on evaluations.
G. FABRICATION OF ORTHOTICS
- Procedure code 97760 must be billed for the professional services of a physician or therapists to fabricate orthotics.
- Orthotics, prosthetics, and related supplies used may be billed under code 99070 and may not exceed a 20 percent mark-up of the provider’s cost. An invoice may be required by the carrier before reimbursement is made.
H. TENS UNITS
- TENS (transcutaneous electrical nerve simulation) must be provided and under the attending or treating physician’s prescription.
- Authorization from the payer must be sought before purchase or rental arrangements are made for TENs. The payer has sole right of selection of vendors for rental or purchase of equipment, supplies, etc.
I. SUPPLIES, EQUIPMENT, ORTHOTICS, AND PROSTHETICS
- Physicians and therapists must obtain authorization from the payer before purchase/rental of supplies, equipment, orthotics, and prosthetics.
- The payer has sole right of selection of vendors.
- Reimbursement for supplies and equipment must not exceed 20 percent above the provider’s costs. An invoice may be required by the carrier before reimbursement is made.
J. OTHER INSTRUCTIONS
- Charges will not be reimbursed for publications, books, or video cassettes unless by prior approval of the payer.
- All charges for services must be clearly itemized by CPT code. State professional license number must be on the bill.
- Documentation may be required by the payer to substantiate the necessity for treatment rendered. Documentation to substantiate charges and reports of tests and measurements are included in the fee for the service and do not warrant additional reimbursement.
- When patients do not show measurable progress, the payer may request the physician to discontinue the treatment or provide documentation to substantiate medical necessity.
K. CHRONIC PAIN PROGRAM AND BACK SCHOOLS
All chronic paid programs or back schools shall require preauthorization from the payer. The payer and the chronic paid program or back school program may agree upon the daily, weekly, or other time-based payment to be made for services provided to the injured/ill worker. This agreement shall supersede the use of this physical medicine section when calculating reimbursement but shall not exceed the usual and customary fee. These charges may be paid by insurance carrier or self insured per agreement.
- Transcutaneous Electrical Nerve Stimulation (TENS) units, neuromuscular units, and continuous passive units are billed using the Industrial Commission assigned codes. The codes are listed in the Physical Medicine Section of the N.C. Medical Fee Schedule. Rental Codes are for daily, weekly, and monthly use.
- The CPT Code BT100, which the Commission used in the past for back testing, has been eliminated; and you should advise the Providers to use CPT Code 97750 and this code requires time. We have received inquiries regarding approvals of CPT Code 97750 for Physical Therapy. CPT Code 97750 is used to represent physical performance testing or measurements in units of 15 minutes. More than one unit may be allowed for this code. 97750 replaced former codes 97720, 97721, and 97752. These codes were replaced per the 1995 edition of Current Procedural Terminology. The N.C. Industrial Commission Medical Fee Schedule, Physical Medicine Section F, states that 97720, 97721, and 97752 are to be used only once for the same body area within a 30-day period. The same applies for code 97750. However, there may be a reason testing has to be done twice in 30-day period (e.g., when such testing was ordered by the treating physician). When billing for Functional Capacity, the Medical Provider must use the Code EV100 and this is to be paid per agreement. These bills are not to be sent to the Industrial Commission for calculation, because they are to be paid per agreement.
- For physical therapy, you must enter a time in total minutes for most CPT codes. The provider must be a licensed physical therapist or occupational therapist. Codes 97010 through 97028 will not require the time to be entered and only one of each of the above codes will be allowed per day. You can allow more than one of these codes per visit, but not the same code more than once during the same visit. OHT01 has been eliminated and occupational therapists must use physical therapist codes. (See new 1996 Medical Fee Schedule for changes in time). Billing an extra fee for electrodes is allowed for iontophoresis code 97033 only.
SMT01—Sport Therapy—approved in full.
YM100—Y membership—approved in full.
- Physical Therapy Providers may use CPT codes 97001-97799, 95831-95852, 64550, and HCPCS and Commission Assigned Codes to bill supplies/equipment. See Master File.
- Custom prosthetics/orthotics require pre-authorization and agreement for fees.
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