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Chapter 24: Physical Medicine Services


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



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Effective July 1, 2013

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

Table of contents

Definitions

Payment policies:
Electrical stimulators (including TENS)
Massage therapy
Osteopathic manipulative treatment
Physical capacities evaluation
Physical medicine CPT® codes billing guidance
Physical therapy (PT) and occupational therapy (OT)
Powered traction therapy
Work hardening
Wound care

More info:
Related topics

 

Definitions

Body regions:

For osteopathic manipulation treatment (OMT) services, body regions are defined as:

  • Head,
  • Cervical,
  • Thoracic,
  • Lumbar,
  • Sacral,
  • Pelvic,
  • Rib cage,
  • Abdomen and viscera regions,
  • Lower and upper extremities.

Bundled codes:

Services and supplies that are considered bundled into the cost of other services (associated office visits or procedures) and won’t be paid separately.

CPT® and local code modifiers mentioned in this chapter:

–1S

Surgical dressings for home use

Bill the appropriate HCPCS code for each dressing item using this modifier –1S for each item.  Use this modifier to bill for surgical dressing supplies dispensed for home use.

–25

Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure

Payment is made at 100% of the fee schedule level or billed charge, whichever is less.

–52

Reduced services

Payment is made at the fee schedule level or billed charge, whichever is less.

Work conditioning:

An intensive, work-related, goal-oriented conditioning program designed specifically to restore function for work.

Work hardening:

An interdisciplinary, individualized, job specific program of activity with the goal of return to work. Work hardening programs use real or simulated work tasks and progressively graded conditioning exercises that are based on the individual’s measured tolerances. Work hardening provides a transition between acute care and successful return to work and is designed to improve the biomechanical, neuromuscular, cardiovascular, and psychosocial functioning of the worker.

Link: More information about L&I’s work hardening program, including a list of approved work hardening providers, criteria for admission into a work hardening program, and other work hardening program standards is available on L&I’s website at www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/RTW/WorkHard/.

This information is also available by calling the work hardening program reviewer at 360-902-4480.

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Payment policy: Electrical stimulators (including TENS)

Prior authorization

These HCPCS codes for electrical stimulator devices for home use or surgical implantation require prior authorization:

HCPCS code Brief description Additional coverage information
E0745 Neuromuscular stimulator for shock This code is covered for muscle denervation only.
E0747 Electrical osteogenesis stimulator, not spine
E0748 Electrical osteogenesis stimulator, spinal
E0749 Electrical osteogenesis stimulator, implanted Authorization for this code is subject to utilization review.
E0760 Osteogenesis ultrasound, stimulator This code is covered for appendicular skeleton only (not the spine).
E0764 Functional neuromuscular stimulator

Services that can be billed

For electrical stimulator devices used in the office setting:

  • When it is within the provider’s scope of practice, a provider may bill professional services for application of stimulators with the CPT® physical medicine codes.
  • Attending providers who aren’t board qualified or certified in physical medicine and rehabilitation must bill local code 1044M.

For electrical stimulator devices and supplies for home use or surgical implantation, HCPCS code E0761 (Nonthermal electromagnetic device) is covered.


Services that aren’t covered

For use outside of medically supervised facility settings (including home use and purchase or rental of durable medical equipment and supplies), the insurer doesn’t cover:

  • Transcutaneous Electrical Nerve Stimulators (TENS) units and supplies, or
  • Interferential current therapy (IFC) devices, or
  • Percutaneous neuromodulation therapy (PNT) devices.  

Note: Use of these therapies will continue to be covered during hospitalization and in supervised facility settings.

For home use or surgical implantation, these HCPCS codes aren’t covered:

  • E0731 (Conductive garment for TENS),
  • E0740 (Incontinence treatment system),
  • E0744 (Neuromuscular stimulator for scoliosis),
  • E0755 (Electronic salivary reflex stimulator),
  • E0762 (Transcutaneous electrical joint stimulation device system),
  • E0765 (Nerve stimulator for treatment of nausea and vomiting),
  • E0769 (Electric wound treatment device, not otherwise classified),
  • L8680 (Implantable neurostimulator electrode).

For home use or in medically supervised facility settings, CPT® code 64555 (Peripheral nerve neurostimulator) isn't covered.

Payment limits

These supplies are bundled and not payable separately for office use:

  • A4365 (Adhesive remover wipes),
  • A4455 (Adhesive remover per ounce),
  • A4556 (Electrodes, pair),
  • A4557 (Lead wires, pair),
  • A4558 (Conductive paste or gel),
  • A5120 (Skin barrier wipes box per 50),
  • A6250 (Skin seal protect moisturizer).

Additional information: Why the insurer doesn’t cover TENS

On October 30, 2009, the State Health Technology Clinical Committee (HTCC) met in an open public meeting to review the evidence for Electrical Nerve Stimulation (ENS), including TENS, interferential current therapy (IFC), and percutaneous neuromodulation therapy (PNT), as treatments for acute and chronic pain

Based on a review of the best available evidence of safety, efficacy, and cost effectiveness, the committee determined that ENS is noncovered for use outside of medically supervised facilities. Purchase or rental of TENS, IFC, and PNT equipment and supplies isn’t covered.

The determination was made final by the HTCC on November 20, 2009.

Link: Complete information on this HTCC determination is available at: www.hta.hca.wa.gov.


 

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Payment policy: Massage therapy

Who must perform massage therapy services to qualify for payment

To qualify for payment, massage therapy services must be performed by:

  • A licensed massage therapist, or
  • Other covered provider whose scope of practice includes massage techniques.

Link: For more information, see WAC 296-23-250.

Services that can be billed

Massage therapists must bill CPT® code 97124 for all forms of massage therapy, regardless of the technique used. The insurer won’t pay massage therapists for additional codes.

Requirements for billing

Massage therapists must bill CPT® code 97124 for all forms of massage therapy, regardless of the technique used. Massage therapists must also use CPT® code 97124 for evaluations and reevaluations.

Massage therapists must bill their usual and customary fee and designate the duration of the massage therapy treatment.

Documentation must support the units of service billed. Document the amount of time spent performing evaluations and reevaluations as well as the treatment.

Payment limits

Massage therapy is paid at 75% of the maximum daily rate for PT and OT services, and

The daily maximum allowable amount is $89.97.

These are bundled into the massage therapy service and aren’t separately payable:

  • Application of hot or cold packs,
  • Anti-friction devices,
  • Lubricants (for example, oils, lotions, emollients).

Link: For more information, see WAC 296-23-250.

Payment policy: Osteopathic manipulative treatment (OMT)

Who must perform these services to qualify for payment

Only osteopathic physicians may bill for OMT services.

Services that aren’t covered

CPT® code 97140 isn’t covered for osteopathic physicians.

Requirements for billing

OMT includes pre- and postservice work (for example, cursory history and palpatory examination). E/M office visit service may be billed in conjunction with OMT only when all of the following conditions are met:

  • When the E/M service constitutes a significant separately identifiable service that exceeds the usual pre- and post-service work included with OMT, and
  • The worker’s record contains documentation supporting the level of E/M service billed, and
  • The E/M service is billed using modifier –25. Without modifier –25, the insurer won’t pay for E/M codes billed on the same day as OMT.

Note:  The E/M service may be caused or prompted by the same diagnosis as the OMT service. A separate diagnosis isn’t required for payment of E/M in addition to OMT services on the same day.

Payment limits

The insurer may reduce payments or process recoupments when E/M services aren’t documented sufficiently to support the level of service billed. The CPT® book describes the key components that must be present for each level of service.

For OMT services, only one code is payable per treatment codes. This is because codes for body regions ascend in value to accommodate the additional body regions involved.

Example: If three body regions were manipulated, one unit of the correct CPT® code would be payable.

(See definition of body regions in “Definitions” at the beginning of this chapter.)

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Payment policy: Physical capacities evaluation

Who must perform these services to qualify for payment

To qualify for payment, a physical capacities evaluation must be performed by:

  • Physicians who are board qualified or certified in physical medicine and rehabilitation, or
  • Physical and occupational therapists.

Services that can be billed

Qualified providers can bill local code 1045M which has a maximum fee of $717.12.

Documentation must include a report with a detailed summary of capacities.

Requirements for billing

The evaluation must be provided as a one on one service.

Payment limits

Local code 1045M is payable only once per 30 days per worker.

 

Payment policy: Physical medicine CPT® codes billing guidance

Timed codes

Some physical medicine services (such as ultrasound and therapeutic exercises) are billed based the number of minutes spent performing the service. These services are referred to as “timed services” and are billed using “timed codes.”

Timed codes can be identified in CPT®  by the code description. The definition will include words such as “each 15 minutes.”

Providers must document in the daily medical record (chart note and flow sheet, if used):

  • The amount of time spent for each time based service performed, and
  • The specific interventions or techniques performed, including:
    • Frequency and intensity (if appropriate), and
    • Intended purpose of each intervention or technique.

Simply documenting the procedure code and the amount of time the service is performed is insufficient and may result in denial of the bill or recoupment of payment. All documentation must be submitted to support your billing (for example, flow sheets, chart notes, and reports).

Note: Documenting a range of time (for example, 8-22 minutes) for a timed service isn‘t acceptable. Providers must document the actual amount of minutes spent performing the service.

The number of units you can bill is:

  • Determined by the time spent performing each “timed service,” and
  • Constrained by the total minutes spent performing these services on a given day.

To obtain the total minutes spent performing time based services, add together the minutes spent performing each individual time based service.

To obtain the number of units that can be billed for these services, use the table below.

If the combined duration of
all time based services is at least…
and less than… Then, when billing, report:
8 minutes 23 minutes 1 unit
23 minutes

38 minutes

2 units

38 minutes

53 minutes

3 units

53 minutes

68 minutes

4 units

68 minutes

83 minutes

5 units

83 minutes

98 minutes

6 units

98 minutes

113 minutes

7 units

113 minutes

128 minutes

8 units

Note: The above schedule of times doesn‘t imply that any of the first eight minutes should be excluded from the total count. The timing of active treatment counted includes all direct treatment time.

For example, if you perform:

  • 10 minutes of CPT® 97110 (therapeutic exercises), and
  • 12 minutes of CPT® 97140 (manual therapy),

… you have performed 22 minutes of timed code services. This equates to one unit of service that can be billed. Since the most time was spent performing manual therapy, bill one unit of 97140.

Examples of how to document and bill timed codes

The following examples show how the required elements of interventions can be documented and billed. These examples aren’t reflective of a complete medical record for the patient’s visit. The other elements of reporting (SOAP) also must be documented.

Example 1:

Procedural intervention Specific intervention Purpose Treatment time
Therapeutic exercise Left leg straight leg
raises x 4 directions;
3 lbs. each direction. 
10 reps x 2 sets
Strength and
endurance training for lifting
20 minutes
Neuromuscular reeducation One leg stance,
45 seconds left;
110 seconds on right using
balance board x 2 sets each
Normalize balance
for reaching overhead
15 minutes
Cold pack Applied to left knee Decrease edema 10 minutes

Total treatment time = 45 minutes
Total timed intervention (treatment time spent performing timed services) = 35 minutes

A maximum of two units of timed services can be billed. Correct billing for the services documented is:

  • 97110 (Therapeutic exercise) x 1 unit, and
  • 97112 (Neuromuscular reeducation) x 1 unit.

Example 2:

Procedural intervention Specific intervention Purpose Treatment time
Attended E-Stim and
Ultrasound performed
simultaneously
5mA right forearm
1.5 W/cm2 ; 100% right forearm
Increase joint mobility

8 minutes
Whirlpool Heat bath to right forearm and hand Facilitate movement;
reduce inflammation
8 minutes
Therapeutic exercise Active assisted ROM to right wrist;
flexion/extension; 15 reps x 2 sets
Increase motion and
strength for gripping
10 minutes

Total treatment time = 26 minutes
Total timed intervention (treatment time spent performing timed services) = 18 minutes

A maximum of one unit of timed services can be billed. Correct billing for the services documented is:

  • 97110 (Therapeutic exercise) x 1 unit, and
  • 97022 (Whirlpool) x 1 unit.

Prohibited pairs: What CPT® codes can’t be billed together

A therapist can’t bill any of the following pairs of CPT® codes for outpatient therapy services provided simultaneously to one or more patients for the same time period:

  • Any two codes for “therapeutic procedures” requiring direct, one on one patient contact, or
  • Any two codes for modalities requiring “constant attendance” and direct, one on one patient contact, or
  • Any two codes requiring either constant attendance or direct, one on one patient contact, as described above (for example, any CPT® codes for a therapeutic procedure with any attended modality CPT® code), or
  • Any code for therapeutic procedures requiring direct, one on one patient contact with the group therapy code (for example, CPT® code 97150 with CPT® code 97112), or
  • Any code for modalities requiring constant attendance with the group therapy code (for example, CPT® code 97150 with CPT® code 97035), or
  • An untimed evaluation or reevaluation code with any other timed or untimed codes, including constant attendance modalities, therapeutic procedures, and group therapy.

Determining what time counts towards timed codes

Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services:

  • Pre and post delivery services aren’t counted in determining the treatment service time. In other words, the time counted as “intraservice care” begins when the therapist or physician (or a PT or OT assistant under the supervision of a physician or therapist) is working directly with the patient to deliver treatment services.
  • The patient should already be in the treatment area (for example, on the treatment table or mat or in the gym) and prepared to begin treatment.
  • The time counted is the time the patient is treated.
  • The time the patient spends not being treated because of the need for toileting or resting shouldn’t be billed. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin isn’t considered treatment time.

Regardless of the number of units billed, the daily maximum fee for services won’t be exceeded.

Note: For more information about L&I’s PT, OT, and massage therapy policies, see www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/RTW/Therapy/.

 

Payment policy: Physical therapy (PT) and occupational therapy (OT)

Who must perform PT and OT services to qualify for payment

PT services

PT services must be ordered by the worker’s attending doctor, nurse practitioner, or the physician’s assistant for the attending doctor. The services must be provided by a:

  • Licensed physical therapist, or
  • Physical therapist assistant serving under a licensed physical therapist’s direction.

Link: For more information, see WAC 296-23-220.

OT services

OT services must be ordered by the worker’s attending doctor, nurse practitioner, or the physician’s assistant for the attending doctor. The services must be provided by a:

  • Licensed occupational therapist, or
  • Occupational therapy assistant serving under a licensed occupational therapists direction.

Link: For more information, see WAC 296-23-230.

Physical medicine services

Physical medicine services may be provided by:

  • Medical or osteopathic physicians who are board qualified or board certified in physical medicine and rehabilitation (physiatry), or
  • Attending doctors who aren’t board qualified or certified in physical medicine and rehabilitation. For nonboard certified/qualified providers, special payment policies apply. (See “Requirements for billing” and “Payment limits,” below.)

Link: For more information, see WAC 296-21-290.

Who won’t be paid for physical medicine services

  • Physical or occupational therapist students, or
  • Physical or occupational therapist assistant students, or
  • Physical or occupational therapist aides, or
  • Athletic trainers.

Services that can be billed

Physical and occupational therapists must use the appropriate CPT® and HCPCS codes 64550, 95831-95852, 95992, 97001-97799, and G0283.

Note: Some of these codes aren’t covered or are bundled. See these exceptions noted in the “Services that aren’t covered” and “Payment limits” (“Bundled items or services”), below.

For information on “Surgical dressings dispensed for home use,” see the Supplies, Materials, and Bundled Services chapter.

If more than one patient is treated at the same time, use CPT® code 97150.  

Note: For more information, see “Billing guidance for physical medicine CPT® codes” earlier in this chapter.

For PT and OT evaluations and reevaluations, bill using CPT® codes 97001 through 97004.

To report the evaluation by the physician or therapist to establish a plan of care, use CPT® codes 97001 and 97003.

To revise the plan of care by reporting the evaluation of a patient who has been under a plan of care established by the physician or therapist, use CPT® codes 97002 and 97004.

Note: CPT® codes 97002 and 97004 have no limit on how often they can be billed. 


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Services that aren’t covered

Physical medicine CPT® codes 97005, 97006, and 97033 aren’t covered.

Note: For a complete list of noncovered codes, see Appendix D: Noncovered Codes and Modifiers.

Requirements for billing

Physical medicine services

Board qualified and board certified physiatrists bill for services using:

  • CPT® codes 97001 through 97799, and 95831 through 95852, or
  • CPT® code 64550 (payable only once per claim).

Nonboard certified/qualified physical medicine providers may perform physical medicine modalities and procedures described in CPT® codes 97001-97750 if their scopes of practice and training permit it, but for these services must bill local code 1044M.  (See “Payment limits” for local code 1044M, below.)

Note: The description for local code 1044M is “Physical medicine modality(ies) and/or procedure(s) by attending doctor who isn’t board qualified or certified in physical medicine and rehabilitation.”  The maximum fee for the code is $43.75.

Payment limits

Physical medicine services

CPT® code 64550 is payable only once per claim, and is payable only to board certified/qualified physiatrists.

Nonboard certified/qualified physical medicine providers won’t be paid for CPT® codes 97001-97799.

Local code 1044M is limited to six units per claim.  After six units, the patient must be referred to a licensed physical or occupational therapist or physiatrist except when the attending doctor practices in a remote location where no licensed physical or occupational therapist or physiatrists is available.

Bundled items or services

  • Activity supplies used in work hardening, such as leather and wood,
  • Application of hot or cold packs,
  • Electrodes and gel,
  • Exercise balls,
  • Ice packs, ice caps, and ice collars,
  • Thera-taping,
  • Wound dressing materials used during an office visit and/or PT treatment.

Note:  For complete lists of bundled codes, see Appendix B: Bundled Services and Appendix C: Bundled Supplies.

Daily maximum for services

The daily maximum allowable fee for PT and OT services is $119.96.

Note:  For more information, see WAC 296-23-220 and WAC 296-23-230.

The daily maximum allowable fee doesn’t apply to:

  • Physicians board certified in Physical Medicine, or

  • Performance-based physical capacities examinations (PCEs), or

  • Work hardening services, or

  • Work evaluations, or

  • Job modification/prejob accommodation consultation services.

When performed for the same claim for the same date of service, the daily maximum applies to CPT® codes 64550, 95831-95852, and 97001-97799, and HCPCS code G0283.

Work conditioning programs are reimbursed as outpatient PT and OT under the daily fee cap.

If PT, OT, and massage therapy services are provided on the same day, the daily maximum applies once for each provider type.

If the worker is treated for two separate claims with different allowed conditions on the same date, the daily maximum will apply for each claim.

If part of the visit is for a condition unrelated to an accepted claim and part is for the accepted condition:

  • Therapists must apportion their usual and customary charges equally between the insurer and the other payer based on the level of service provided during the visit.
  • In this case, separate chart notes for the accepted condition should be sent to the insurer since the employer doesn’t have the right to see information about an unrelated condition.

Untimed services

Supervised modalities and therapeutic procedures that don’t list a specific time increment in their description are limited to one unit per day. This applies to these CPT® and HCPCS codes:

  • 97001-97004,
  • 97012,
  • 97014,
  • 97016,
  • 97018,
  • 97022,
  • 97024,
  • 97026,
  • 97028,
  • 97150
  • G0283.

Work conditioning: Guidelines

See definintion of work conditioning in "Definitions" at the beginning of this chapter.)

  • Frequency: At least three times per week and no more than 5 times per week.
  • Duration: No more than 8 weeks for one set. One set equals up to 20 visits.
    • An additional 10 visits may be approved upon review of progress.
  • Plan of Care: Goals are related to:
    • Increasing physical capacities, and
    • Return to work function, and
    • Establishing a home program allowing the worker to progress and/or maintain function after discharge.
  • Documentation: Includes return to work capacities, which may include lifting, carrying, pushing, pulling, sitting, standing, and walking tolerances.
  • Treatment: May be provided by a single therapy discipline (PT or OT) or combination of both (PT or OT).
    • PT and OT visits accumulate separately and both are allowed on the same date of service.
    • Biling reflects active treatment. Examples include CPT® 97110, 97112, 97530, 97535, and 97537.

     

Payment policy: Powered traction therapy

Services that can be billed

Powered traction devices are covered as a physical medicine modality.

Payment limits

The insurer won’t pay any additional cost when powered devices are used.

Additional information: Why the insurer won’t pay additional cost when powered devices are used

Published literature hasn’t substantially shown that powered devices are more effective than other forms of traction, other conservative treatments or surgery. This policy applies to all FDA-approved powered traction devices.

For more information go to:
www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Pwdtractiondevices.asp


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Payment policy: Work hardening

Note: See definition of work hardening in “Definitions" at the beginning of this chapter.

Prior authorization

Work hardening programs require:

  • Prior approval by the worker’s attending physician, and
  • Prior authorization by the claim manager.

Providing additional services during a work hardening program is atypical and must be authorized in advance by the claim manager.

Note:  Documentation must support the billing of additional services.

Program extensions must be authorized in advance by the claim manager and are based on:

  • Documentation of progress, and
  • The worker’s ability to benefit from the program extension up to two additional weeks.

Who must perform work hardening services to qualify for payment

Only L&I-approved work hardening providers will be paid for work hardening services.

Services that can be billed

Work hardening

  • For the evaluation, bill using local code 1001M.
  • For treatment, bill using CPT® codes 97545 and 97546.

Services that aren’t covered

Billing for less than two hours of service in one day (CPT® code 97545)

Services provided for less than two hours on any day don’t meet the work hardening program standards. Therefore, the services must be billed outside of the work hardening program codes. This should be conisdered as an absence in determining worker compliance with the program.

Example: The worker arrives for work hardening, but isn’t able to participate fully that day.

Requirements for billing

Work hardening

CPT® codes should be billed that appropriately reflect the services provided.

A worker typically starts at four hours per day and gradually increases to 7-8 hours per day by week four.

 

Billing less than one hour of CPT® code 97546

Modifier –52 must be billed:

After the first two hours of service on any day, If less than 38 minutes of service are provided modifier –52 must be billed. For that increment of time:

  • CPT® code 97546 must be billed as a separate line item with modifier –52, and
  • The charged amount prorated to reflect the reduced level of service.

Example: Worker completes 4 hours and 20 minutes of treatment. Billing for that date of service would include three lines:

Code Modifier Charged amount Units
97545   Usual and customary 1
97546   Usual and customary 2
97546 –52 33% of usual and customary (completed 20 of 60 minutes)

1

Billing for services in multidisciplinary programs

Each provider must bill for the services that they are responsible for each day.  Both occupational and physical therapists may bill for the same date of service.

 

Billing for evaluation and treatment on the same day (multiple disciplines)

If both the occupational therapist (OT) and the physical therapist (PT) need to bill for one hour of evaluation and one hour of treatment on the same date of service, the services must be billed as follows:

If the provider type is… and the service provided is… Then bill as:
OT 1 hour of evaluation 1 unit of 1001M
PT 1 hour of evaluation 1 unit of 1001M
OT (or PT) 1 hour of treatment 1 unit of 97545 with modifier –52 (billed amount proportionate to 1 hour)
PT (or OT) 1 hour of treatment 1 unit of 97546

Examples of billing options for services in multidisciplinary programs

Scenari: The occupational therapist (OT) is responsible for the work stimulation portion of the worker's program, which lasted four hours. On the same day, the worker performed two hours of conditioning/aerobic activity for which the physical therapist (PT) is responsible.

The providers could bill for the six hours of service in either one of two ways:

Billing option 1   Billing option 2
PT: 1 unit 97545 2 hours   OT: 1 unit 97545
+
2 units 97546
2 hours

2 additional hours
OT: 4 units 97546 4 hours   PT: 2 units 97546 2 hours
Total hours billed: 6 hours   Total hours billed: 6 hours

Payment limits

Work hardening

Work hardening programs are authorized for up to four weeks. Only one unit of 97545 (first two hours) will be paid per day per worker and the toatl number of hours billed shouldn't exceed the number of direct services provided.

These codes are subject to the following limits:

Code Description Unit limit (four-week program) Unit price
1001M Work hardening evaluation 6 units (1 unit = 1 hour) $118.90
97545 Initial two hours per day 20 units per program;
Maximum of one unit per day
per worker
(1 unit = 2 hours)
$138.90
97546 Each additional hour 70 units per program
Add-on, won’t be paid as a
stand-alone procedure per
worker per day.
(1 unit = 1 hour)
$66.41

 

Providers may only bill for the time that services are provided in the presence of the client. The payment value of procedure codes 97545 and 97546 takes into consideration that some work occurs outside of the time the client is present (for example, team conference, plan development).

Time spent in treatment conferences isn’t covered as a separate procedure regardless of the presence of the patient at the conference. Job coaching and education are provided as part of the work hardening program. These services must be billed using CPT® codes 97545 and 97546.

Program extensions

Additional units available for extended programs:

Code Description Six-week program limit
1001M Work hardening evaluation no additional units
97545 Initial two hours per day 10 units (20 hours)
97546 Each additional hour 50 units (50 hours)

 

Additional information: L&I’s work hardening program

More information about L&I’s work hardening program, including a list of approved work hardening providers, criteria for admission into a work hardening program, and other work hardening program standards is available:


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Payment policy: Wound care

Prior authorization

Electrical stimulation for chronic wounds

If electrical stimulation for chronic wounds is requested for use on an outpatient basis, prior authorization is required using the following criteria:

  • Electrical stimulation will be authorized if the wound hasn’t improved following 30 days of standard wound therapy, and
  • In addition to electrical stimulation, standard wound care must continue.

Note: In order to pay for electrical stimulation beyond 30 days, licensed medical personnel must document improved wound measurements within the past 30 days. (See “Requirements for billing,” below.)

Services that can be billed

Debridement

Therapists must bill CPT® 97597, 97598, or 97602 when performing wound debridement that exceeds what is incidental to a therapy (for example, whirlpool).

Wound dressings and supplies sent home with the patient for self-care can be billed with HCPCS codes appended with local modifier –1S.

Note: For wound dressings and supplies used in the office, see “Payment limits,” below.

Link: For more information on billing with local modifier –1S, see the “Surgical dressings for home use” section (“Requirements for billing” and “Payment limits”) of the Supplies, Materials, and Bundled Services chapter.


Electrical stimulation for chronic wounds

Electrical stimulation passes electric currents through a wound to accelerate wound healing. Electrical stimulation is covered for the following chronic wound indications:

  • Stage III and IV pressure ulcers,
  • Arterial ulcers,
  • Diabetic ulcers,
  • Venous stasis ulcers.

To bill for electrical stimulation for chronic wounds, use HCPCS code G0281.  

Link: For more information on electrical stimulation for chronic wounds, go to www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/elecStimofChronicWounds.asp

Requirements for billing

Debridement

When performing wound debridement that exceeds what is incidental to a therapy (for example, whirlpool), therapists must bill CPT® 97597, 97598, or 97602.

Electrical stimulation for chronic wounds

In order to pay for electrical stimulation beyond 30 days, licensed medical personnel must document improved wound measurements within the past 30 days.

 

Payment limits

Debridement

Wound dressings and supplies used in the office are bundled and aren’t payable separately.

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If you’re looking for more information about… Then go here:
Administrative rules
for physical medicine
Washington Administrative Code (WAC) 296-21-290:
http://app.leg.wa.gov/wac/default.aspx?cite=296-21-290
Becoming an L&I Provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/
Billing instructions and forms Chapter 2:
Information for All Providers
Electrical stimulation of chronic wounds L&I website:
www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/elecStimofChronicWounds.asp
L&I’s general policies and rules for
PT, OT, and massage therapy
L&I website:
www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/RTW/Therapy/
Massage therapy administrative rules Washington Administrative Code (WAC) 296-23-250:
http://app.leg.wa.gov/wac/default.aspx?cite=296-23-250
Occupational therapy administrative rules Washington Administrative Code (WAC) 296-23-230:
http://app.leg.wa.gov/wac/default.aspx?cite=296-23-230
Physical therapy administrative rules Washington Administrative Code (WAC) 296-23-220:
http://app.leg.wa.gov/wac/default.aspx?cite=296-23-220
Powered traction devices
for intervertebral decompression
L&I website:
www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/ByCondition/Pwdtractiondevices.asp
Fee schedules for all
healthcare professional services
L&I’s website:
www.Lni.wa.gov/ClaimsIns/Files/ProviderPay/FeeSchedules/2013FS/fsAll.xls
Payment policies for
bundled and noncovered codes
General appendices:
Appendix A: Bundled Services
Appendix C: Bundled Supplies
Appendix F: Noncovered Codes and Modifiers
Payment policies for supplies,
materials, and bundled services
Chapter 28:
Supplies, Materials, and Bundled Services
TENS coverage decision State Health Technology Clinical Committee (HTCC) website:
www.hta.hca.wa.gov
Work hardening program at L&I Program reviewer:
360-902-4480
L&I website:
www.Lni.wa.gov/ClaimsIns/Providers/TreatingPatients/RTW/WorkHard/

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2012 American Medical Association


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