CPT code 97535 is medically necessary only when it requires the professional skills of a therapist, is designed to address specific needs of the patient, and is part of an active treatment plan directed at a specific outcome.
CPT Code 97535 Description
Self-care/home management training. Direct one-on-one contact, each 15 minutes.
Examples of CPT Code 97535 are:
- meal preparations;
- ADL (activities of daily living);
- compensatory training;
- safety procedures;
- instructions in use of assistive technology devices/adaptive equipment.
CPT Code 97535 – Usage & Reimbursement
- Services provided concurrently by physicians, optometrists, physical therapists, and occupational therapists may be covered if separate and distinct goals are documented in the treatment plans.
- This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific outcome.
- The patient must have the capacity to learn from instructions. The patient must have a condition for which training in activities of daily living is medically reasonable and necessary, and such training must be reasonably expected to restore or improve the functioning of the patient.
- Medical treatment may generally require up to 12 visits in 4 weeks. Coverage beyond 12 visits in 4 weeks may require documentation supporting the medical necessity of continued treatment.
- Documentation must relate the training to expected functional goals that are attainable by the patient.
- The medical record should document the distinct goals and service rendered when self-care/home management training is done during the same visit as gait training (97116), orthotics fitting and training (97504) or prosthetic training (97520).
Does CPT Code 97535 Need a Modifier?
The CPT code combinations 97530 (Therapeutic Activity) and 97535 (ADL) requires Modifier 59 to enable the codes to be billed individually on the same day.
Note: CPT code 97535 is usually reimbursed after a rate higher than TA, TE, NMR & MT.
For more information: check the AAPC website.