Work Hardening Fee Schedule

Work hardening programs are authorized for up to 4 weeks. You can only bill for the time that services are provided in the presence of the client. Current Procedure Terminology (CPT™) codes 97545 and 97546 take into consideration that some work will occur when the client is not present (team conference, plan development, etc).

Time spent in treatment conferences is not covered as a separate procedure regardless of the presence of the patient at the conference.

Forms used to bill L&I

• CMS 1500 (F245‑127‑000) - For physical therapists.
• Statement for Miscellaneous Services (F245‑072‑000) - For occupational therapist.
• UB04 (F245‑367‑000) - For hospitals.

Fee schedule

Effective July 1, 2009.

Fee Schedule — Reimbursement of services for 4 week program

Fee Schedule — Reimbursement of services for 4 week program
Code	Description	Unit limit	Unit price	Max price
Local 1001M	Evaluation	6 units (1 unit = 1 hour)	$117.02 /1 hr	$702.12.
CPT™ 97545	Initial first 2 hours per day (if less than 2 hours, see example below)	20 units (1 unit = 2 hours) 1 unit per day, per claimant	$128.60 /2 hr	$2,572.00.
CPT™ 97546	Each additional hour on the same day (if less than 1 hour, see example below)	70 units (1 unit = 1 hour)	$60.30 /1 hr	$4,221.00.
Total	Maximum total — 4 weeks			$7,495.12.

Extending the work hardening program

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.

Fee Schedule — Additional two week program with prior approval

Fee Schedule — Additional two week program with prior approval
CPT™ code	Description	Additional unit limit	Additional unit price	Max price
97545	Initial first 2 hours/day	10 units (1 unit = 2 hours)	$128.60 /2 hr	$1,286.00.
97546	Each additional hour on the same day	50 units (1 unit = 1 hour)	$60.30 /1 hr	$3,015.00.
Total	Maximum total - 2 weeks			$4,301.00.

Billing examples

Less than 2 hours per day

Less than 2 hours per day does not meet the work hardening program standards and must be billed outside of the work hardening program codes. Use the CPT™ code that appropriately reflects the services provided.

Example of less than 2 hours per day:

Less than 1 hour of CPT™ 97546

After the first 2 hours of service on any day (CPT™ 97545), if less than 38 minutes of service is provided.

• The Procedure code CPT™ 97546 must be billed as a separate line item with a -52 modifier.
  AND
• The charged amount is pro-rated to reflect the reduced level of service.

Example of less than 1 hour of CPT™ 97546:

Billing for services in multi-disciplinary programs

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

Only one unit of CPT™ 97545 (first 2 hours) will be paid per day, per claimant. The total number of hours billed should not exceed the hours that the direct services was provided.

Example of billing in multi-disciplinary programs:

Billing for additonal services

The work hardening provider can only bill for work hardening services (1001M, CPT™ 97545, 97546) per day, per claimant unless they get prior authorization from the claim manager. Documentation must support the billing of additional services.

Example of billing for additional services:

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Work conditioning

L&I does not recognize work conditioning as a special program. Work conditioning is paid according to the rules for outpatient physical and occupational therapy.

Unlike work hardening, L&I has not established standards or a reimbursement schedule unique to work conditioning programs. "Work conditioning" programs are reimbursed as outpatient occupational and physical therapy (OT/PT) under the daily fee cap.

"Work conditioning" programs may be used to bridge a gap between acute outpatient therapy and a structured work hardening program or return-to-work. Other key differences between the 2 programs are compared below.

Differences between work hardening and work conditioning

Differences between work hardening and work conditioning
Work hardening	OT/PT ("work conditioning")
Requires a specific return to work goal.	No specific return to work goal required.
Recognized as a specific treatment program by L&I — program standards have been established.	Not recognized as a specific treatment program by L&I — specific standards have not been established.
Reimbursed according to the work hardening fee schedule.	Reimbursed according to the physical and occupational therapy WAC in the medical aid rules and fee schedule.
Addresses physical, functional, behavioral, and vocational needs of the worker.	Addresses physical and functional needs of the worker.
Multi-disciplinary.	May be provided by 1 discipline.
Uses real or simulated work activities with some physical conditioning.	Uses physical conditioning and functional activities related to work.
Includes education (for example, body mechanics, work pacing, safety, injury prevention).	May or may not include an educational component.
Begins at 4 hours/day and builds to 8 hours/day over the course of 4 weeks.	4 hours or less/day. Note: Reimbursement for outpatient occupational and physical therapy do not typically cover 4 hours/day.