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It is time to explore the depths of CPT code 97750, which has rightly become a coding conundrum across several medical specialties. Stay with us as we tell you why 97750 is often called the FCE CPT code and when and how to bill it for maximum reimbursement.
97750 CPT Code – Description
The current procedural terminology (CPT) code 97750 reports a physical performance test, such as musculoskeletal and functional capacity evaluation (FCE), for patients who suffered work-related injuries, physical traumas, or disabilities and might be in the process of rehabilitation or post-surgery care. For this reason, it is also known as a FCE CPT code.
You can find the 97750 code specifically in the Physical Medicine and Rehabilitation Tests and Measurements code set, as maintained by the American Medical Association (AMA).
CPT code 97750 is used when the provider evaluates the patient’s physical performance in 15-minute increments and records the results to prepare a comprehensive report, which may then be used to determine if the patient is fit to resume work after an illness or injury.
In the case of Functional Capacity Evaluation CPT Code 97750, the series of tests and measurements must target the patient’s ability to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs), both of which are crucial to a human’s normal functioning and readiness for work.
Medical specialties that are more inclined to report FCE CPT code 97750 are:
- Physical Therapy
- Physical Medicine & Rehabilitation (PM&R) or Physiatry
- Occupational Therapy
- Chiropractic
Please note that the current Medicare reimbursement rate for the 97750 CPT code is between $31 and $48, depending on the MAC locality and medical facility.
What Performance Measurement Tests are Covered By CPT Code 97750?
The primary purpose of a physical performance test is to assess the patient’s ability to handle day-to-day and work-related tasks after he has recovered from an injury, surgery, or illness that impacted his physical and cognitive functions. The 15-minute session is used to assess the patient’s performance in the following areas:
- Activities of daily living (ADLs)
- Instrumental activities of daily living (IADLs)
- Occupational performance
- Dexterity
- Cognition
- Functional mobility
- Equilibrium and balance
- Aerobic capacity
| Activities of Daily Living (ADLs) | Instrumental Activities of Daily Living (IADLs) |
|---|---|
| Eating | Managing money |
| Bathing | Managing health |
| Toileting | Managing household (cooking, laundry, child-rearing, etc.) |
| Dressing | Managing transportation |
| Grooming | Maintaining communication |
| Mobility | Making complex decisions |
What Should You Expect During a Functional Capacity Evaluation Session?
A comprehensive functional capacity evaluation, reported by CPT code 97750, includes the following manual and equipment-based tests and measurements:
- A 6-minute walk test
- Manual muscle testing
- Balance evaluation like the Timed Up and Go (TUG) test
- Evaluation of functional capacity
- Special musculoskeletal tests for one or more body region
- Range of Motion (ROM) testing
Scenarios Where CPT Code 97750 is Applicable
So, now that you know that CPT code 97750 refers to a complete and objective physical performance test to evaluate the patient’s functional and musculoskeletal capacity, let’s try to understand why these tests are performed and in what instances you can bill this FCE CPT code. Look at the real-world scenarios below for details.
Pre-Employment Screening
Employers across various industries may request a pre-employment physical performance test as part of medical screening from new or potential hires to assess if they are physically fit for what the job demands. For example, truck drivers, firefighters, law enforcement personnel, and even frontline healthcare workers like paramedics may be asked to undergo a comprehensive physical performance exam, denoted by CPT code 97750.
Workers’ Compensation Cases
A functional capacity evaluation is ordered after treatment/surgery and recovery in Workers’ Compensation cases, where the patient was injured or fell ill because of his work, to gauge if the patient can return to work and perform the tasks assigned to him. The test results of FCEs also help identify the worker’s functional limitations, paving the way for special considerations, e.g., assisted living (accommodation), reduced work hours, and restricted physical labor. After the evaluation, the provider can use the 97750 CPT code to bill the service under Workers’ Compensation insurance.
Disability Assessments
The U.S. federal government provides Social Security Disability Insurance (SSDI) or disability benefits to people who are unable to work and earn an income because of their disability. The monthly payments are deposited in the beneficiary’s account. However, to claim this benefit, the person must submit objective data or reports on his disability. This is where disability evaluations come in. The detailed screening, reported by CPT code 97750, substantiates the patient’s disability claim as several tests prove his functional decline and inability to perform efficiently at work.
Rehabilitation Progress Evaluation
CPT code 97750 can also be used for performance testing conducted in physical rehabilitation centers. The provider performs a functional capacity evaluation to see if there are any improvements after the patient undergoes physical rehabilitation therapies. If the patient’s natural functionality remains unrestored, the provider will adjust the treatment plan to enhance the effects of physical rehab therapies.
Other CPT Codes Related to 97750
CPT code 97750 is not the only code that reports a specialized physical assessment performed on a patient. Some other CPT codes are also used for billing physical tests and measurements in an outpatient physical or occupational therapy center. Hence, they have come to be known as related codes.
Before we dive into the descriptions of these related codes, please note that the Centers for Medicare and Medicaid Services (CMS) has strict rules for billing CPT code 97750 and its related formal testing codes. We will touch upon these do’s and don’ts later in the guide.
CPT Code 95851
A range of motion (ROM) is an equipment-based test that measures the degree of movement of a joint. A device called a goniometer measures the angle at a joint between 0 to 180 or 360 degrees, assessing the movement and flexibility of bones, joints, muscles, ligaments, and tendons. However, CPT code 95851 specifically reports a ROM test to measure the range of motion in one section of the spine or one extremity (excluding the hand). It is a separately billable code under the ‘range of motion testing’ code set.
CPT Code 95852
95852 is also a ROM testing code and bills the measurement of movement in the patient’s hand. The provider uses a goniometer to see the range of motion in a hand that was previously injured or affected by disability. He may compare the findings of the other (normal functioning) hand with the injured one.
CPT Code 97755
CPT codes 97750 and 97755 are part of the same code range. However, code 97755 denotes a one-on-one assessment to measure the patient’s degree of disability and decide which assistive technology will be the best compensation for the patient’s lost function(s). Hence, CPT code 97755 is an assistive technology assessment and involves the preparation of a detailed report to document the test findings.
CPT Code 96112
Can you recall playing a game called ‘Find The Odd One Out’ in your childhood? It is a lot like that when we come to CPT code 96112. Although 96112 is a related code, it is unique from the other four formal testing codes because of the category it falls under, the age range of patients it targets, and the aspect of human care it tests. Basically, CPT code 96112 is used when the provider performs a series of tests (e.g., BOT-2) on a child to diagnose developmental problems and prepare a detailed report on the findings. The tests last an hour, and this code specifically reports the first hour of testing.
97750 CPT Code – Reimbursement Guidelines
Survey results obtained from over 17,461 clinicians representing more than 30 specialties across the nation’s healthcare landscape have shown that Physical Medicine and Rehabilitation has one of the highest denial rates. Around 19% of the medical claims submitted by physical medicine and rehabilitation specialists are denied, even though the average denial rate across all specialties is between 5% and 10%.
After looking at the grim stats above, how can you ensure a first-pass claim submission for your 97750 CPT code? The answer is simple – follow billing best practices to nip denials in the bud. Here are some carefully thought out, tried & tested reimbursement guidelines for CPT code 97750 to help you collect better.
Ensure Coding Accuracy
When billing a thorough physical performance test or functional capacity evaluation, you must ensure that you are using the correct FCE CPT code and it accurately captures a range of musculoskeletal, endurance, balance, and mobility assessments. Moreover, you must follow the insurance payer’s specific coding guidelines, such as appending appropriate modifiers and unit-based billing, when reporting CPT code 97750 to avoid claim denials.
Maintain Complete Documentation
Your supporting documents should prove the medical necessity of a physical performance test. For example, if you are filing a workers’ compensation insurance claim, you must submit all the required documents to the payer with the 97750 claim form to explain that a complete physical performance test was necessary to prove that the patient has recovered from a work-related injury and can resume work on the natural level of his functionality.
Educate and Train Your Staff
To secure a high and timely reimbursement for CPT code 97750, you must provide regular training to your staff on coding best practices and educate them on the updates in coding systems, government regulations, and payer policies. They should be familiar with all challenges that may arise when billing code 97750 and must know effective strategies to overcome them.
Confirm Direct Provider-Patient Contact
Functional Capacity Evaluation CPT Code 97750 can only be reported for face-to-face testing in which the provider spends at least 15 minutes with the patient, evaluating his ability to perform various functions, such as balancing, walking, bending, communicating, holding, dodging, etc. So, before entering the code, you must check the physical therapy notes (clinical notes) to confirm if the patient received service directly from a qualified healthcare provider (therapist, chiropractor, or physical/occupational therapy assistant) or if a telehealth service is wrongly being reported by CPT code 97750.
Bill in 15-Minute Increments
97750 is a timed CPT code and is billed in 15-minute blocks. You must report 1 unit of CPT code 97750 when the performance test lasts up to 22 minutes. You can add more units depending on the total time the provider spends with the patient testing his functional capabilities. Refer to the table below for clarity.
| Billing Units | Test Duration | Details |
|---|---|---|
| 1 unit | 15 minutes | The provider-patient direct contact testing lasts at least 8 minutes and up to 22 minutes |
| 2 units | 30 minutes | The provider-patient direct contact testing lasts at least 23 minutes and up to 37 minutes |
| 3 units | 45 minutes | The provider-patient direct contact testing lasts at least 38 minutes and up to 52 minutes |
| 4 units | 60 minutes | The provider-patient direct contact testing lasts at least 53 minutes and up to 67 minutes |
| 5 units | 75 minutes | The provider-patient direct contact testing lasts at least 68 minutes and up to 82 minutes |
| 6 units | 90 minutes | The provider-patient direct contact testing lasts at least 83 minutes and up to 97 minutes |
| 7 units | 105 minutes | The provider-patient direct contact testing lasts at least 98 minutes and up to 112 minutes |
| 8 units | 120 minutes | The provider-patient direct contact testing lasts at least 113 minutes and up to 127 minutes |
Follow CMS’ 8-Minute Rule
Medicare’s 8-minute Rule, or the Rule of 8’s, states that if you want to bill 1 unit of a physical therapy service, the provider should perform that service or procedure for at least 8 minutes. That’s why the unit-based billing starts at 8 minutes and goes up to 127 minutes, depending on the total time spent with the patient. So, even if the physical performance test lasted less than 15 minutes but longer than 8, you can report 1 unit of CPT code 97750 to bill the service and collect reimbursement accordingly.
Don’t Bill 97750 CPT Code On the Same Day as An Initial Evaluation
Another directive that Medicare has given in regard to billing the 97750 CPT code for FCE is that you cannot claim separate reimbursements if an initial therapy evaluation and a physical performance test were conducted on the same day. It is because, as per the Correct Coding Initiative (CCI) edits, the initial evaluation for physical therapy covers performance, ROM, and manual muscle tests, denoted by CPT codes 97750, 95851-95852, and 97755, respectively.
Append Appropriate Physical Therapy Modifiers
Modifiers are 2-digit alphanumerical, standardized codes used with CPT and Healthcare Common Procedure Coding System (HCPCS) codes to offer more explanation about the billable service, product, or procedure. For example, modifier 59 can be appended with CPT code 97750 if another service was performed on the same day, on the same patient, by the same provider, in the same outpatient physical therapy center, but was distinct and billed separately. Some other modifiers that you can append with code 97750 are:
- GO – Service delivered at an outpatient occupational therapy center.
- GP – Service delivered at an outpatient physical therapy center.
- 76 – The procedure was repeated by the same physician.
- 77 – The procedure was repeated by another physician.
- KX – The specific therapy or service was medically necessary and exceeds the annual threshold amounts set by Medicare ($2,330 for CY 2024).
Final Word
CPT code 97750 is commonly reported by physical, occupational, and rehabilitation therapists to indicate an objective yet detailed physical performance test that is billed in 15-minute increments and assesses a patient’s musculoskeletal and functional capacities. The test may be performed for several reasons. For example, to chart the patient’s recovery after a work-related injury, surgery, or illness that impacted his body’s normal functioning.
Today, we covered the 97750 CPT code’s description, correct application, related codes, and reimbursement guidelines to help you master coding accuracy for physical therapy.
However, if you have reached a state of “information overload, situation lost control”, send an SOS to us at MediBill MD. Our physical therapy billing services include precise CPT coding and detailed documentation, helping you achieve a 97% claim first-pass ratio.
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