97535 CPT Code (2023) Description, Guidelines, Reimbursement, Modifiers & Example
97535 CPT code describes self-care/home management training. It is necessary when someone requires professional skills from a physiotherapist. CPT code 97535 is a medical procedural code that comes under the range – Of physical Medicine and Rehabilitation Therapeutic Procedures.
97535 CPT Code | Description
97535 CPT code requires the time component when the patient is in contact with the therapist.
According to CMS guidelines, a single is billed when;
The patient has been in direct contact with the therapist for the last eight minutes.
CPT code 97535 can be used for ;
- ADL (Activities of daily life)
- Safety procedures
- Meal preparations
- Assistive technology device
- Compensatory training
Following are the codes that medicare covers
These are the CPT codes that can be billed with MEDICARE.
Activities of daily life (ADL) :
ADL means activities that are related to living independently in the community but are not limited to diet and preparation, managing finances, shopping for food, clothing, and other essential items, performing basic household chores, communicating by phone or other media, and traveling around and participating in the community.
For example, let’s look for an initial program of Total hip arthroplasty (THA). This patient is educated on lower extremities techniques for proper dressing due to limited range of motion and increased pain.
The occupational therapist will diagnose the patient to determine the appropriate approach to be taught based on the individual patient assessment and will instruct the patient or caregiver in the unique technique in a pain-free range when the patient develops the skills of proper dressing and how he can dress and how to manage his movements in a pain-free range.
The techniques the patient cannot do are documented and need to be noted in the treatment file. When the patient feels that he has a better command of everything and he can do whatever he wants, this means not that the therapist does not support or continue therapy.
Documentation that demonstrates a progression in the technique to more complex or less patient dependence will assist in establishing that the method remains skilled.
Who Is A Physiotherapist?
A physiotherapist is a health care professional who is an expert in treating injuries and conditions that can affect movements. Physiotherapy helps restore movement and function. He can diagnose, assess, treats, and work on the target treatment plan to improve the disability and immobility.
A physiotherapist is a degree-based profession, so physiotherapists can use their knowledge and skills to assess such as:
Neuromusculoskeletal – low back pain, neck pain, tennis elbow, frozen shoulder, sciatica, muscle spasm, soft tissue injuries,
Neurological – it includes Guillain-Barré syndrome (GBS), stroke, Bell’s palsy, facial palsy, and Cerebral palsy.
Cardiovascular -commonly includes Congestive heart failure, Ischemic heart disease, and Cardiopulmonary distress.
Respiratory -respiratory illnesses include pulmonary distress, pulmonary edema, Asthma, Acute bronchitis, and Tuberculosis.
97535 CPT Code | Billing Guidelines
It is billed when the patient needs active treatment from the provider for a practical outcome.
Services are provided by the therapist, physician, optometrist, and occupational therapist and may be covered if distinct and separate goals are mentioned in the treatment.
The patients are advised to follow the proper treatment plan for better recovery from the disease and improve their daily activities.
Medical treatment commonly is required up to 12 visits in 4 weeks coverage beyond 12 trips in 4 weeks may require documentation that supports the medical necessity of continued treatment.
Documents will be on the file for the expected functional goals. For example, the medical record should document the distinct purposes and services performed when self-care/home management training is performed during the same visit as gait training (CPT 97116), orthotics fitting, and training (CPT 97504), or prosthetic training (CPT 97520).
97535 CPT Code | Modifiers
Modifiers that are used with 97535 CPT code are 59, 25, 91, 22, 53, 23, 78.
Modifier 59
Modifier 59 can be used when two CPT codes are billed separately on the same day. For example, the 97535 CPT code (ADL) and the 97530 CPT Code.
This modifier is also used for the distinct procedures; for example, if CPT 76801 and CPT 76817 are billed together on the same date, then Modifier 59 will be used with 76801, which shows this is a separate procedure. Without this modifier, this cannot be billed.
Modifier 22
Modifier 22 tells us about the Unusual Increased procedural services
It is commonly used when the physician has gone above the time framework that he was needed for the procedure.
Does Insurance Medicare Pay For Modifier 22?
MEDICARE will pay for modifier 22 as forwarded to carrier medical staff for coding, review, and pricing. As a result, they will increase the payment if the claim meets the medical necessity.
For example:
If a patient has a scar that requires extra time and works for the treatment, then the expected time.
If the patient comes for the debridement of a wound and while he is coming, he is injured and needs urgent treatment for that injury, the total timeframe for the target will be increased.
Modifier 23
In short, this modifier indicates (Unusual Anesthesia).
If a patient goes through a procedure and while having this procedure, he needs urgent anesthesia due to unusual circumstances. Then 23 modifiers will be added to bill the service.
Uses:
- Pregnancy-related procedures
- Dental procedures
- Road traffic accidents
- Natural disasters
- Unusual circumstances
For example:
- A child needs a BAEP, but he needs to be sedated for an unknown reason.
- A patient went through a Dentist’s procedure and unfortunately slept due to extreme anxiety and tiredness.
- A mentally ill patient who abuses and beats the provider and the provider cannot complete the course.
Modifier 53
It describes (Discontinued procedures). They indicate that the physician or qualified health care professional terminated a surgical or diagnostic procedure due to unusual circumstances or threatening the patient’s well-being.
Do not use modifier 53 for their effective cancellation of a procedure.
Modifier 53 cannot be appended to a code like E/M.
Modifier 53 cannot be used when the laparoscopic approach is converted into an open system.
For example:
If the patient is going through an open procedure and sudden blood pressure drops, this is the best time to stop or terminate the process.
If the patient is not fit enough to tolerate the procedure
Modifier 25
“Separately identifiable evaluation and management. And other qualified health care professionals.
It reports that the significantly separate E/M service was performed on the same day as the Procedure or Other Service by the Same physician and other qualified healthcare professionals.
Uses:
- Suppose the patient comes back for an injection in the left eye. The Ocular examination confirms the need for the injection. Then, in this case, we don’t append the modifier 25.
Exemptions:
Patient Dialysis service- E/M same day as dialysis is denied UNLESS
- Use related to the treatment of ESRD.
- Was not finished during dialysis
Critical care visits- Use modifier 25 WHEN:
- Critically ill, requires constant attention
- Unrelated to specific injury/procedure
Modifier 78
The unplanned patient returns to an operating room or surgical room by the same physician when following an initial procedure for a related course.
Uses:
- For modifier 78, the reimbursement criteria were reduced to the operative portion.
- Do not use the code for the original procedure.
- For all the surgical procedures, modifiers 78, 79, 50, 54, 55, RT, and LT are used.
For example:
If the patient has a bypass ( 90 days global period) in June and the patient returns for the repair of a hiatal hernia and goes to the operating room for that repair. Add modifier 78 to hernia repair.
Modifier 91
Modifier 91 is defined by CPT as representative of repeat clinical diagnostic laboratory tests and is used to;
When repeated lab tests are performed on the same patient.
And on the same day for obtaining new test data throughout the treatment.
Under What Circumstances Should CPT Modifier 91 Not Be Used?
Per CPT® guidelines, you should not append modifier 91 for lab tests: These are repeated to confirm the initial results; They are repeated due to malfunctions of either the testing equipment or the specimen; or when another appropriate one-time code is all that is needed to report the service.
97535 CPT Code Reimbursement
The multiple procedure payment reduction policy has been applied to the 97535 CPT code.
Under MPPR, when multiple “always therapy” procedures are rendered to the same patient on the same service date (even in separate sessions), 100% expense of practice will be paid, and the second and subsequent therapy service will be paid for 50% percent.
Therapy service payment will not be reduced. If the insurance is other than medicare, the amount of reduction may differ by the players and the insurance plan.
The reimbursement rate is higher than TA, TE, NMR, and MT.
Does CPT Code 97535 Need A Modifier?
Yes, CPT 97535 requires Modifier 59 when two codes are billed individually on the same day. For example the 97535 CPT Code (ADL) and the 97530 CPT Code.
CPT 97535 is usually reimbursed after a rate higher than TA, TE, NMR & MT.
