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October 9, 2018

Targeted Probe and Education Program to Focus on Physical Therapy (PT) and Occupational Therapy (OT) Claims

In October 2018, the CGS Targeted Probe and Education program will begin review of claims associated with physical and occupational therapies. Guidance for PT/OT service provision and documentation may be found in the CGS Administrators "Outpatient and Occupational Therapy (LCD L34049) Fact Sheet"PDF

Medical record documentation is required for every treatment day, and for every therapy service to justify the use of codes and units on the claim.

The treatment note must include the following required information:

  • date of treatment;
  • identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;
  • record of the total time spent in services, represented by timed codes under timed code treatment minutes;
  • record of the total treatment time in minutes, which is a sum of the timed and untimed services;
  • signature and credentials of each individual(s) that provided skilled interventions.

In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:

  • patient comments regarding pain, function, completion of self management/home exercise program (HEP), etc.;
  • significant improvement or adverse reaction to treatment;
  • significant, unusual, or unexpected changes in clinical status;
  • parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;
  • description of the skilled components of the specific exercises, training, or activities;
  • instructions given for the home exercise program (HEP), restorative or self/caregiver managed program, including updates and revisions;
  • communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);
  • communication with patient, family, caregiver;
  • equipment provided
  • any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.

For additional documentation requirements, please reference the CGS LCD for Outpatient & Occupational Therapy (# L34049) LCDExternal Website

CPT codes initially under review will include:

  • 97110- Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
  • 97112-Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
  • 97113-Aquatic therapy with therapeutic exercises
  • 97116-Gait Training Therapy (includes stair climbing)
  • 97140-Manual therapy techniques (eg mobilization/manipulation, manual lymphatic drainage, manual traction) to 1 or more regions, each 15 minutes
  • 97530- Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

For more information on Targeted Probe and Education, please see the following links:

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