Rehabilitation Documentation and Proper Coding Guidelines Purpose: 1) Develop a guide for doctors in South Dakota to follow when performing reviews on rehabilitation cases. 2) Provide doctors in South Dakota a reference guide to follow when performing and billing for rehabilitative services. What is Rehabilitation? Rehabilitation is a progressive program that takes a dysfunctional unit and attempts to make it function properly. It includes cardiovascular, flexibility, proprioception and strengthening. It involves one on one contact with a health care provider and the exercises performed are complex and require the supervision and assistance by a health care provider. Many times patients are shown simple exercises in the office and are instructed to perform the exercises at home. It is appropriate for the provider to bill for the exercises. When the patient returns to the clinic the exercises are reviewed by the health care provider and once again bills for the service. Again this is appropriate. But if the patient continues to perform the simple exercises at home and when they come in the office there is no advancement of the exercises and they are just performing the exercises already performed then this is not appropriate to bill. Rehabilitation is a progressive process of exercises that need to be performed in the office, not exercises that the patient understands well and can easily perform at home. This is always difficult to determine but we need to determine if the patient requires continued in office rehabilitation or can they be sent home to perform the exercises. Rehabilitation vs. Exercise: 1) Rehabilitation is taking an injured or weakened region of the body and returning it to a normal
state. 2) Exercise is taking a normal person or body part and making it stronger. Determining the Need for Rehabilitation: 1) Most if not all cases of musculoskeletal injuries require some form of rehabilitation. 2) The more complex the case the more complex the rehabilitation will be. 3) When the condition is chronic, severe, or recurrent these are typical scenarios that would require prolonged rehabilitation in the clinic. 4) When rehabilitation is being considered by a doctor the doctor will typically do some sort of evaluation to determine if the patient is a candidate for rehabilitation. This evaluation can include any of the following; functional evaluation, muscle testing, postural evaluation, one leg standing, cardiovascular testing (step test), flexibility testing, limits in activities of daily living or demands of employment, and also clinical knowledge of typical patterns of weakness and tightness for specific conditions. Setting up a Rehabilitation Program and Billing for It: 1) If during the initial evaluation a deficit in cardiovascular fitness is discovered, the rehabilitation would include a cardiovascular component. If there is no cardiovascular fitness deficit, the initial portion of the rehabilitation program would consist of a short warm up. The time needed to perform the cardiovascular portion of the rehabilitation must be documented. The typical time needed for a warm up would be 5 to 10 minutes. The time for cardiovascular training for a deficit will vary depending on the goals of the rehabilitation. Commonly, a cool down using cardiovascular equipment will be performed following the rehabilitation session. The typical amount of time for this would be 5 to 10 minutes. Effective July 1, 2005: *Cardio Warm-up and Cool-down Do not require one-on-one supervision and are considered
non-covered services *Med-X Testing Typically Billed as Physical Performance Testing or Measurement (e.g., Musculoskeletal, functional capacity) with written report each 15 Minutes: The following rules will apply: 2 units of 97750 will be allowed if documentation supports 1 region of the body is being evaluated and the time needed to perform the service is 30 minutes. 3 units of 97750 will be allowed if documentation supports 2 regions of the body are being evaluated and the time needed to perform the service is 45 minutes. (A written report must be included in the documentation and it must support the necessity of testing. Further rehab must be based on the patient s subjective complaints, effects on Activities of Daily Living (ADL s) and Demands of Employment (DE s), objective findings, the doctor s interpretation of findings, updated diagnosis and future treatment plan and goals.) 2) If deficits were found in flexibility then the muscles will be stretched. The time to perform a stretch on a specific muscle is typically one minute. The specific muscles stretched must be documented. It would be helpful to include the technique as well. Many times doctors document that stretches were performed to the lumbar spine. It would be helpful if they were more specific. However, if the time documented is for a short period of time (5 minutes), then it is often accepted. If a doctor performs prolonged stretching to a muscle, the documentation must include the duration and the reason(s) why it took that amount of time. It will be assumed by the reviewing doctor that each stretch takes one minute to perform. Each stretch performed must have a correlation to the patient s complaint. If the stretches take longer than this amount of time, the documentation must state why. Also, if muscles are stretched that do not correlate to the chief complaint, the documentation must explain why. 3) If muscles were found to be weak, strengthening or stabilization exercises would be prescribed. Specific exercises must be documented along with repetitions and sets of the exercise that were performed. It is always difficult to review cases that involve strengthening exercises when a great deal of time is documented to perform just a few exercises. It will be assumed that a set of 10 exercises including rest time will take the patient 2 minutes to perform. So each set of 10 exercises will be added up to determine if the time billed corresponds to the number of exercises performed. If a patient needs prolonged time it must be documented as to why it took so long. If
strengthening exercises are performed that do not have a direct relationship to the chief complaint, the documentation must state why it was performed. 4) If poor balance or proprioception is found on the evaluation, proprioceptive exercises will be performed. The time to perform the proprioceptive exercises must be documented along with a description of the exercise. Billing: When billing for rehabilitation the codes are all timed codes per 15 minutes. Time must be documented in the chart or on the flow chart. Each exercise must be documented and the time, as stated above, must correlate with the amount of exercises that are performed. The codes used for the evaluation are also time based codes. The time must be documented and must correlate to the level of the evaluation that is performed. Common codes used for rehabilitation are: 97110, 97530, and 97112. The code for evaluation is: 97750. When performing a time based service it is important to recognize that 15 minutes must be spent in performing the pre-, intra, and post-service work. If less than 15 minutes is spent performing the service, the modifier 52 should be appended to the code, and the fee must be reduced to the appropriate fee. For example; If the time needed to perform the service is 5 minutes, the amount billed should be 1/3 of the billing for a full unit. Special Note: The 8 minute rule is a Medicare rule and does not apply to CHIROPRACTIC ASSOCIATES policies.
CPT Descriptions 97110 Therapeutic exercises to develop strength and endurance, range of motion an flexibility. Therapeutic exercises incorporates one parameter (strength, endurance, and range of motion or flexibility). Examples include treadmill, isokinetic exercise, lumbar stabilization exercise and gymnastic ball. 97112 Neuromuscular reeducation of movement, balance, coordination, kisesthetic sense, posture, and/or proprioception for sitting and/or standing activities. Examples include Proprioceptive Neuromuscular Facilitation (PNF), Feldenkreis, Bobath, Bap s Boards, and Desensitization Techniques. PNF definitions (2): 1. What is Proprioceptive Neuromuscular Facilitation (PNF)? Based on functional human anatomy and neurophysiology, Proprioceptive Neuromuscular Facilitation (PNF) uses proprioceptive (sensory receptors found in muscles, tendons and inner ear that detects body/limb motion or position)input to improve motor functionability. Proprioceptive Neuromuscular Facilitation (PNF) is best used to increase flexibility, range of motion and strength. In therapeutic sessions, Proprioceptive Neuromuscular Facilitation (PNF), patients are shown its patterns of sequenced movements through visual means and feedback, manual pressure and body positioning, and other therapeutic modalities. Proprioceptive Neuromuscular Facilitation (PNF) is good for muscle strength development, increasing endurance and improving coordination. Correcting imbalances, increasing holding power and promoting relaxation, Proprioceptive Neuromuscular Facilitation (PNF)can be helpful in improving overall health and well-being. This form of PNF would appropriately be billed with either 97112 or 97110 since the goal of the procedure is to improve muscle strength, increase endurance and improve coordination. 2. Proprioceptive Neuromuscular Facilitation (PNF) is a more advanced form of flexibility training that involves both the stretching and contraction of the muscle group being targeted. PNF
stretching was originally developed as a form of rehabilitation, and to that effect it is very effective. It is also excellent for targeting specific muscle groups, and as well as increasing flexibility, (and range of movement) it also improves muscular strength. This form or PNF would be appropriately billed with 97110 since the goal of the procedure is to improve muscle strength, increase flexibility and range of motion. 97150 Group therapeutic procedures including CPT codes 97110-97139. If any of these procedures are performed with two or more individuals, then only 97150 is reported. Do not code the specific type of therapy in addition to the group therapy code. 97530 Direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance). Dynamic activities include the use of multiple parameters, such as balance, strength and range of motion, for a functional activity. Examples include lifting stations, closed kinetic chain activity, hand assembly activity, transfers (chair to bed, lying to sitting, etc.), and throwing catching and swinging. PROPER USE OF, AND BILLING FOR, MUSCLE ENERGY TECHNIQUES Muscle Energy Techniques to restore flexibility / ROM (objective findings must include limited flexibility and or ROM): It is appropriate to bill 97110. Muscle Energy Techniques to reduce adhesions / trigger points, etc.: It is appropriate to bill 97140. It may be appropriate to use CPT code 97112; Neuromuscular reeducation: Therapeutic Procedure, one or more areas, each 15 minutes; if the goal of care is Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting or standing activities; would be appropriate as long as medical necessity was established at the initiation of care. A description of the procedure(s) should also be included in the treatment plan.
As with all active care services, in addition to the progression of the active care, patients should be educated on self care procedures. If muscle energy techniques are performed on multiple visits, the medical necessity must be established. In most cases 2 to 4 visits of muscle energy techniques only, without the addition of other active care exercises, would be appropriate. Muscle energy techniques beyond this must clearly show medical necessity. SAMPLE DOCUMENTATION FOR REHABILITATION SERVICES S: Patient continues to suffer with low back pain. The condition has been present for 6 months with 50% reduction of symptoms since beginning care. Pain is present with transition movements, lifting and prolonged walking/standing. Dull pain in lower back, VAS best 2 worst 7. No radiation of pain. Feels best with very short periods of light activity, ice and using proper postures. O: Patient functions well when presenting to office, after sitting for a short period discussing history patient is in moderate discomfort with sit to stand activity and for a minute is in a flexed posture. When standing the patient continues with some pain on flexion, extension and right lateral flexion. Compression is negative, kemps causes some pain on the right lower back region. Tenderness and fixation noted right SI with tightness palpated in the right glutmedius, piriformis. Hip ROM is normal but there is tightness in right hamstring at 60 degree SLR, tight right illiopsoas with 20 degrees hip flexion on modified Thompson test. Trendelenburgs is positive on the right with a dropped left hip on right leg one leg standing. Muscle testing reveals weakness in right hip extension and abduction. Poor pelvic control is noted with pelvic tilts and attempting abdominal hollow and brace. Abdominal (25 seconds/average 50 seconds) and Sorensen s (30 seconds/60 seconds average) endurance tests are 50% of normal for age. A: 50% improved but continues with some pain due to SI dysfunction on the right and functional deficits. P: We will begin a more active component of care for a 2 times per week basis in addition to spinal and pelvic manipulation. Treatment manipulation right SI.
Rehab: Patient had no contraindications to cardiovascular exercise and was placed on the exercise bike for 10 minutes to warm up for the rehabilitation. Patient was instructed on proper use of the exercise bike and was monitored for the initial period. On future visits the patient will not require supervision on the exercise bike. Flexibility: Right Hamstring 3/10 Right Piriformis 3/10, Right Gluteus Medius 3/10, Right Illiopsoas 3/10. 4 minutes Proprioception: Swiss Ball Sitting posture, sit to stand activity, marches, rolls and bounces 8 minutes Strengthening: Core stabilization proper respiration, hallow, multifidi, pelvic floor and brace 5 minutes Right hip abduction 2/15 Right hip extension 2/15, Supermans 3 X 20 seconds, Dead Bugs 3 X 10. 10 minutes Return 2 times per week for 2 weeks. Appropriate to Bill 2 units of 97110 (on future visits cardio warm up would not be billable) If you have any questions please contact the CHIROPRACTIC ASSOCIATES Utilization Review Department at 1-800-658-2214.