Ultimate Guide to CPT Code 97537

Did you know that every 40 seconds, someone in the USA experiences a stroke? That’s around 800,000 people in a year! Strokes or brain attacks are one of the most common medical conditions in the country. Those who survive may be left with permanent brain damage, affecting their performance at work and conduct in social settings.

Thankfully, CPT code 97537 reports a community/work reintegration training session, helping survivors return to the workplace and their daily lives with renewed confidence. Let’s explore the description, real-world applications, and billing best practices for CPT 97537.  

Understanding Community/Work Reintegration

Anyone who has experienced a major health setback after a brain injury or stroke will require some form of therapeutic intervention to return to his community or workplace and resume his normal functions. It is because brain injuries and strokes damage a portion of the brain, causing numerous problems like a lack of motor skills, cognitive issues, speech disorders, decreased coordination, and even partial paralysis. It significantly impacts the patient’s performance and behavior in personal and professional settings. 

However, to boost patients’ confidence and enable their return to normal life, physical, occupational, and rehabilitation therapists collaborate to offer community/work reintegration training. These tailored training sessions comprise exercises and activities like using assistive technology, balancing, communicating, and analyzing to expedite the patient’s recovery and return to normalcy. 

97537 CPT Code – Description 

The Current Procedural Terminology (CPT) code 97537 is listed under the Physical Medicine and Rehabilitation Therapeutic Procedures code set, which the American Medical Association (AMA) maintains and revises annually. The 97537 CPT code reports to the insurance payer that the provider and patient had an in-person community/work reintegration training lasting at least 15 minutes. The training session aims to help an injured or ill patient resume work and integrate confidently into the community.  

Physical, occupational, and rehabilitation therapists (PTs, OTs, and RTs) can bill 1 unit of CPT 97537 for every 15 minutes of direct contact with the patient. The one-on-one community/work reintegration training can take place at the patient’s home and an outpatient physical therapy center, including rehab.  

Scenarios Where CPT Code 97537 is Applicable

Billing physical medicine and rehabilitation therapies is challenging as it requires choosing the most accurate CPT code from a pool of dozens, highlighting a range of services with minor differences. 

CPT code 97537 is often reported in conjunction with other therapeutic procedures like self-care/home management training (97535) and gait training (97116) for the patient’s comprehensive recovery. In this case, CPT 97537 is not separately billable. Instead, it should be bundled with other therapeutic procedures performed on the same day for combined payment. 

Here are some real-world examples where CPT code 97537 is applicable for rightful reimbursements. 

Training a Partially Paralyzed Patient in the Use of an Electric Wheelchair

According to the Centers for Medicare and Medicaid Service (CMS)’s billing and coding guidelines for outpatient physical therapy, providers should report CPT code 97537 when the patient receives training in the use of assistive technology for assistance with “mobility, seating systems, and environmental control systems”. 

Hence, code 97537 can be used when a partially paralyzed patient (due to a stroke) gets training on using an electric wheelchair for mobility at home, work, or within the community. However, the provider must directly train the patient and follow CMS’s 8-Minute Rule for accurate code usage.  

Helping a Stroke Survivor Learn Communication Skills 

Around one-third of stroke survivors experience speech and language disorders like aphasia, dysarthria, and apraxia of speech because of brain damage, especially in the left hemisphere. They require speech therapy services to cope with these disorders and ensure effective verbal and written communication. 

So, to help stroke survivors reintegrate into the community and workplaces, healthcare providers render speech therapies, including exercises for improved communication, speech, and thinking. CPT code 97537 will be used to report this training. 

Neuromuscular Reeducation for a Patient Recovering from TBI

Traumatic brain injuries (TBI) are caused when an external force is applied to the head and affects the skull and brain. For example, these injuries can occur as a result of a fall, a car accident, hitting the head on the pavement, an assault, etc. TBIs can have a serious impact on brain functioning, causing a communication delay between the brain, nerves, and muscles. As a result, the patient faces difficulty in movement, balancing, hand and eye coordination, and reflex action. 

To help the patient recover and reassimilate in society, therapists arrange neuromuscular reeducation training. These involve exercises for improved balance, enhanced coordination, muscle control, postural training, and more. All the exercises and therapeutic techniques are customized to support the patient’s community/work reintegration and hence reported by CPT code 97537.  

Helping a Patient with Dynamic Performance Tasks After Brain Tumor Removal 

According to the American Brain Tumor Association, over 1.3 million people in the USA have a primary or secondary brain tumor. Benign or non-cancerous brain tumors can be successfully removed with brain surgery. However, this procedure impairs the normal functioning of the brain and body, affecting the patient’s ability to think, act, and react properly. They require extensive education and training to relearn dynamic performance tasks, like managing money, traveling by public transportation, shopping, driving, and mentoring, for effective reassimilation into the community. 

Healthcare providers arrange timed sessions, reported by CPT code 97537, to help the patient with these tasks and equip him with the skills needed to resume work and daily activities. 

Things to Consider While Billing CPT Code 97537

More than 50 million Americans seek physical therapy services each year, but, unfortunately, the claim denial rate for physical medicine and rehabilitation is one of the highest among all medical specialties. Nearly 19% of the medical claims submitted by physical and rehabilitation therapists are denied, whereas the average claim denial rate in the healthcare industry is between 5% and 10%. 

So, what are the PTs, RTs, and OTs doing wrong when it comes to billing and claim filing? The answer lies in the failure to implement billing and coding best practices. If you are a physical, occupational, or rehabilitation therapist, you must consider the following guidelines for effectively billing CPT code 97537 and capitalizing your high patient inflow for revenue uptick.  

Follow CMS’s 8-Minute Rule

CMS billing guideline for physical therapy services states that the provider must deliver at least 8 minutes of direct service to the patient if he wants to bill for 1 unit. So, it is essential that you provide at least 8 minutes of one-on-one training to the patient to bill 1 unit of CPT 97537.  

Ensure Direct Contact Between Provider and Patient 

Again, following the CMS 8-Minute Rule, you must ensure that direct contact occurs between you and the patient. This in-person or face-to-face training can take place at the patient’s home, a rehab facility, or in your office/training room. 

Please note that CPT code 97537 will not be valid if you supervised the community/work reintegration training over an online medium. You must be physically present on the site and personally direct the therapeutic exercises/activities. 

Apply Unit-Based Billing 

You must bill CPT code 97537 in 15-minute increments, where 1 unit equals 15 minutes of one-on-one training. You can add more units if the session stretches longer. For example, if the community/work reintegration training lasts 40 minutes, you can bill 3 units of CPT 97537 (15+15+15). 

Note that CMS allows you to bill up to 6 units of a service per day. So, the training session should not last longer than 1 hour and 30 minutes. 

Don’t Bill CPT 97537 Separately when Bundled with Other Therapeutic Procedures 

Often, reintegration training is part of the patient’s holistic rehabilitation and is provided on the same day as other therapeutic services. In such cases, you cannot bill CPT 97537 separately. All the services, like gait training, home management, and language training, must be bundled and billed together for a combined reimbursement.  

Follow State/Payer-Specific Billing Guidelines 

Billing rules and regulations for CPT code 97537 vary across states and insurance payers. You must follow your state’s current rules for physical therapy billing when reporting code 97537. Similarly, you should re-read the insurance payer’s contract to confirm if you are meeting all the requirements specified for billing a community/work reintegration training. Complying with the state and payer-specific billing guidelines will help you avoid denials. 

Submit Complete Documentation 

You must maintain and provide complete documentation with the claim form to prove the medical necessity of the training and prevent denials. For example, the patient’s CT scan should show the damage to the brain after a stroke or injury, while your physical therapy notes should highlight the patient’s condition and gradual improvement after continuous training. 

Append the Correct Physical Therapy Modifier

CPT modifiers can make or break your physical therapy billing. Modifiers provide extra information to the insurance payer, often explaining the procedure’s complexity and the circumstances in which the service was performed. For example, physical therapy modifiers like GO, GP, and GN explain who delivered the training. While payment modifier 59 indicates that the service or procedure is distinct from other services performed on the same day. 

Therefore, consider appending the following modifiers with CPT code 97537 for accurate reimbursement.  

• GP – Indicates that the training was provided at an outpatient physical therapy. 
• GO – Indicates that the training was provided at an outpatient occupational therapy.
• GN – Indicates that the training was provided at an outpatient speech/language therapy.
• KX – Indicates that the training was medically necessary but exceeded Medicare’s threshold amount. 
• 59 – Indicates that the training is separate and distinct from another therapeutic service rendered on the same day. 

Final Word 

Now that you know CPT code 97537 specifically reports a training session for the patient’s reintegration into the community and workplace, bill it in 15-minute increments to seek reimbursement for your language training, assistive technology training, dynamic performance task training, or neuromuscular reeducation. Don’t forget to implement the above-stated billing best practices to prevent denials. 

However, a surefire way around denials is to outsource physical therapy billing services to a professional medical billing company like MediBill MD. Our AAPC-certified coders know when to report CPT 97537 and ensure the claim’s first pass.