It takes a lot of time, presence of mind, and patience to provide rehabilitation services and teach patients self-care and home management techniques. In these situations, if occupational therapists are preoccupied with the intricacies of invoicing, it results in subpar service and unhappy patients. But then, how will they manage medical billing and collect reimbursement for their services? With the aid of our thorough guides!
CPT code 97535 is used by occupational therapists to bill for training patients in self-care and home management skills. In this blog, we will explain the correct uses of this code, helping medical professionals to bill for their services accurately.
CPT Code 97535 – Description
CPT code 97535 commonly refers to self-care/home management training. The American Medical Association has listed this code under the category of “Physical Medicine and Rehabilitation Therapeutic Procedures”.
It covers the services of a healthcare professional when he properly advises a patient, particularly when the patient is recovering from an acute illness.
This training consists of activities designed to promote independence and reintegrate patients into home environments. To help patients become more independent in their everyday lives, this code covers instructions on instrumental activities of daily living (IADLs), activities of daily living (ADLs), and the appropriate use of adaptive equipment.
Scenarios Where CPT Code 97535 is Applicable
Occupational therapists commonly use this code to address self-care and home management activities. But how do they utilize this code, and when should they bill their services with CPT code 97535? The following scenarios will provide explanations.
Injury Rehab
A 40-year-old man met with an accident while on his way to the office. While crossing the road, he was hit by a car and fractured his right wrist. As a result, he now struggles with daily activities like buttoning his shirt, brushing his teeth, and writing. He contacts an occupational therapist to preserve his independence. The therapist asks him about his recovery goals and plans exercises and the movement patterns to achieve that goal. The occupational therapist provides self-care training sessions, teaching adaptive strategies and exercises to restore hand coordination and strength. To bill these services, the occupational therapist can use the CPT code 97535.
Post-Surgical Recovery
A 60-year-old woman undergoes a knee replacement surgery. She stays under the care of physicians on the first day. After being released from the hospital, she is put in the care of an occupational therapist who helps her regain mobility and independence to live on her own. The therapist instructs her on exercises and precautions to promote a safe recovery, prevent post-surgical complications, and enable her to resume daily self-care routines independently at home. Since the therapist is providing instructions on self-care services, he can use the CPT code 97535 to bill for his services.
Chronic Arthritis Management
A 65-year-old woman who is an osteoarthritis patient experiences stiffness, reduced hand mobility, and pain that interferes with her daily household chores. The occupational therapist plans her training and therapy according to the intensity of her daily work. The therapist provides training to improve joint function, strength, and flexibility, provides pain relief through techniques, and modifies household tasks to reduce joint stress. To bill this training session, the therapist can use CPT code 97535.
Applicable Modifiers for CPT Code 97535
If you are providing other services than those primarily mentioned in the CPT code 97535, only then can you use the following modifier.
Modifier 59
Modifier 59 is used to communicate distinct procedural services. So, if the therapist rendered another service to the same patient on the same day along with instructions on self-care and home management, modifier 59 should be appended to CPT code 97535 for separate payment collection.
CPT Code 97535 – Billing & Reimbursement Guidelines
The following are some useful tips when billing CPT code 97535.
Provide Documentation
Precise documentation is crucial when submitting claims for CPT code 97535. If your records do not adequately demonstrate the medical necessity of the procedure, include thorough progress notes or provide clear goals for the sessions, your claim is likely to be denied.
Below is the information that must be included in your documentation to establish medical necessity and outline the full procedure.
- Measurements of the client’s activities of daily living (ADL) abilities.
- A note of the patient’s initial functional level.
- A mention of the improvements after the services.
- Details about the compensatory services given.
- Any equipment used during the treatment session.
- An answer to how the treatment plan aligned with patient-centered goals.
Calculate Time
The question that arises here is what is the minimum duration to qualify for a one-unit billing? To bill for one unit of CPT code 97535, you must follow the 8-minute rule. This means you need to provide at least 8 minutes of direct care. The structure for billing units is as follows:
- 8-22 minutes: If you provide services under this bracket, then you will qualify for 1 unit per session.
- 23-37 minutes: If your service exceeds 22 minutes and lasts till 37 minutes, then you are allowed to bill 2 units per session.
- 38-52 minutes: If your service exceeds 37 minutes but lasts until 52 minutes, then you can bill 3 units.
Furthermore, if you conduct self-care training in distinct portions within a session, you may combine the durations to fulfill the 8-minute minimum requirement. For example, 5 minutes dedicated to safety protocols and 3 minutes focused on adaptive equipment training can be billed as a single unit. In short, you must provide at least 8 minutes of direct training to bill one unit.
Follow Payer-Specific Guidelines
Last but not least, it is vital to cross-check with the insurance payers before submitting medical claims. Medicare covers CPT code 97535. But what if some private insurance payers do not cover these services? Furthermore, some insurance payers require proof of prior authorization from the billing party. This will lead to unnecessary denials. So, it is better that you check the payer’s guidelines beforehand.
Final Word
In conclusion, CPT code 97535 reports training of patients on self-care, activities of daily living, and integration into the home life, particularly when the patient is recovering from an acute illness. However, proper billing and coding play a vital role in the reimbursement of code 97535. By following proper billing practices, using appropriate modifiers, and ensuring thorough documentation, healthcare providers can maximize reimbursement while delivering impactful care.
We believe that we have touched every important billing aspect of the CPT code 97535. However, if you still think that this information was not enough and you need more guidance, you can always opt for professional occupational therapy billing services.
