Physical/Occupational and Chiro Therapy (Aug 2017)
Utilization & Treatment Guidelines (U&T)
DLI adopted the U&T Guidelines in 2009 and they have been in effect since July 1, 2011. These Guidelines give recommendations for treatment types and limits based on injury type. They also indicate treatment types that are not generally recommended such as SEMG, Thermography, VaxD etc or treatment types that are only recommended for certain types of injuries such as low level laser. Prior approval should be sought before using treatment types that are not recommended in the Guidelines to prevent denials or refund requests or if a treatment plan goes over the maximum threshold. If you are unsure, it is a good idea to get authorization from the Claim Examiner assigned to the claim. The U&T Guidelines can be found at http://www.mtguidelines.com/. For questions regarding these Guidelines, please contact Maralyn Lytle at DLI at 406-444-6604.
Many of the Medicine codes in the Physical Medicine and Rehabilitation have a time element. The actual time spent for each of the timed codes need to be recorded in the submitted documentation. DLI adopted Rule of 8 for the purposes of calculating the total number of modalities/therapeutic procedures that can be billed. The total number of minutes is divided by 15 (one unit of service = 15 minutes) for the total number of units of services that may be billed.
Services of less than 8 minutes when that is the only service performed during a visit is not billable. Time intervals are incremented in 15 minute units (base is 8 minutes):
8-22 minutes = 1 unit
23-37 minutes =2 units
38-52 minutes = 3 unit
53-67 minutes = 4 units etc
See the Instruction Set on the DLI website in the Montana Professional Fee Schedule or Montana Facility Fee Schedule sections.
Passive/Active Modalities/Therapeutic Procedures Limits
DLI adopted limits to the number of passive and active services that may be billed in a single visit:
- A total of 8 units of active and passive therapy may be billed per visit. If active therapy is being applied, only one unit of a passive modality may be included in the 8 units.
- Passive therapies will be limited to 4 units per visit, if only passive therapy is being applied. Note: Only 2 units may be billed if active therapy is being applied after 7/1/2016.
|97010||Hot or cold packs – one or more regions|
|97012||Traction – mechanical|
|97014||Electrical stimulation (unattended)|
|97024||Diathermy (e.g. microwave)|
|97032||Electrical stimulation (manual) one or more areas, ea 15 minutes|
|97033||Iontophoresis, ea 15 minutes|
|97034||Contrast Baths, ea 15 minutes|
|97035||Ultrasound, ea 15 minutes|
|97036||Hubbard tank, ea 15 minutes|
|97039||Unlisted modality, specify type and time if constant attendance|
Active/Passive Therapeutic Procedures:
|CPT Code||Description||Passive or Active|
|97110||Therapeutic Procedure, 1 or more areas, each 15 minutes. Therapeutic exercises to develop strength, endurance, range of motion and flexibility.||Active|
|97113||Aquatic therapy with therapeutic exercises||Active|
|97116||Gait training (includes stair climbing)||Active|
|97139||Unlisted therapeutic procedure. ** Passive or Active will depend upon the procedure.||Passive or Active**|
|97140||Manual therapy, ea 15 minutes||Passive|
|97150||Therapeutic procedure(s), group (2 or more individuals)||Active|
|97530||Therapeutic activities, direct (one-on-one) pt contact, ea 15 minutes.||Active|
|97532||Development of cognitive skills to improve attention, memory, problem solving, direct (one-on-one) pt contact, ea 15 minutes.||Active|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) pat contact, ea 15 minutes.||Active|
|97535||Self-care/home management training, direct (one-on-one) pt contact, ea 15 minutes.||Active|
|97537||Community/Work reintegration training, direct (one-on-one) pt contact, ea 15 minutes.||Active|
|97542||Wheelchair management ea 15 minutes||Active|
|97545||Work hardening/conditioning, initial 2 hours||Active|
|97546||Work hardening/conditioning, ea addl hour||Active|
|97799||97799 Unlisted physical medicine/rehabilitation service or procedure. **Passive or Active will depend upon the procedure.||Passive or Active**|
|98940||Chiropractic manipulative treatment, spinal 1-2 regions||Passive|
|98941||Chiropractic manipulative treatment, spinal 3-4 regions||Passive|
|98942||Chiropractic manipulative treatment, spinal 5 regions||Passive|
|98943||Extraspinal, 1 or more regions||Passive|
All timed codes must have the time documented (in minutes) in the office notes submitted for each code billed for reimbursement.
Therapy codes billed must have part of body documented or it must be clearly identified in a flow sheet or other attached documentation. If the procedures are clearly documented in the notes, a flow sheet is unnecessary. If the notes do not support the procedures billed but refers to a flow sheet then the flow sheet must be attached.
Massage Therapy services also fall under the Physical/Occupational therapy rules. For MSF codes 97124 (massage) and 97010 (hot and cold packs) can be used to bill massage therapy services. As these are both passive services, only a total of 4 units of service may be billed per visit. U&T Guidelines include recommendations for the use of massage but it is a good idea to contact the Claim Examiner assigned to the claim to verify the number of visits approved as the injured worker’s treating physician may prescribe a specific number of visits.