What is manual therapy?
Manual therapy techniques are skilled hand movements and skilled passive movements of joints and soft tissue that are intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling, inflammation or restriction. These techniques may include manual lymphatic drainage, manual traction, massage, mobilization/manipulation, and passive range of motion.
The therapist selects, prescribes, and implements manual therapy techniques when the examination findings, diagnosis, and prognosis indicate use of these techniques to decrease edema, pain, spasm or swelling; enhance health, wellness and fitness; enhance or maintain physical performance; increase the ability to move; or prevent or remediate impairment in body functions and structures, activity limitations, or participation restrictions to improve physical function.
Manual Therapy Techniques using CPT code 97140
1. Joint Mobilization (Peripheral or Spinal)
This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.
2. Soft Tissue Mobilization
This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue.
Myofascial release/soft tissue mobilization can be considered reasonable and necessary if at least one of the following conditions is present and documented:
- The patient having restricted joint or soft tissue motion in an extremity, neck or trunk
- Treatment being a necessary adjunct to other occupational therapy interventions such as 97110, 97112 or 97530
This procedure may be considered reasonable and necessary for treatment of painful spasms, the loss of articular motion, or restricted motion of soft tissues or joints. It may also be used as an adjunct to other therapeutic procedures such as 97110, 97112 or 97530.
4. Manual Lymphatic Drainage/Complex Decongestive Physiotherapy
The goal of this type of therapy is to reduce lymphedema by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain the reduction after therapy is complete. This therapy involves intensive treatment to reduce the size by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program.
- It is expected that during these sessions, education is being provided to the patient and/or caregiver on the correct application of the compression bandage;
- It is also expected that after the completion of the therapy, the patient and/or caregiver can perform these activities without supervision
- Evaluation/and plan of care including any other pertinent characteristics of the beneficiary
- Certifications and recertifications
- The history and physical exam pertinent to the patient’s care (including the response or changes in behavior to previously administered skilled services)
- The skilled services provided
- A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
- The complexity of the service to be performed
- Progress reports written by the clinician
- Services related to progress reports are to be furnished on or before every 10th treatment day
- Treatment notes for each visit detailing the patient’s response to the skilled services provided (may also serve as progress notes)
- When appropriate, a separate justification statement for services that are more extensive than is typical for the condition treated
- Payment and coverage conditions require that the plan must be reviewed as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. It is not required that the same physician/NPP who participated initially in recommending or planning the patient's care certify and/or recertify the plans.
Therapy services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient's response to treatment. Such visits would be considered covered therapy services when the skills of a therapist are required to perform the services. The patient’s needs, course of therapy and response to therapy must be documented for each date of service.
The use of modifier 59
There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes per hour). If two timed services are provided in time periods that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins), modifier 59 may be used to identify the services.
- CPT Code 97140 – Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
- CPT Code 97530 – Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy. Alternatively, the therapy time blocks may be split.
Another example: manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block. Modifier 59 is used appropriately when two timed procedures are performed in different blocks of time on the same day.
Denials that are being seen for Manual Therapy 97140
No Valid Plan of Care (5D162/5H162) — A plan of care must be submitted, signed by the physician, dated, include goals.
No Documentation of Medical Necessity (5D164/5H164) — This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.
No Physician Certification/ReCertification (5D165/5H165) — A signed and dated certification/recertification must be submitted.
Services Not Documented (5D169/5H169) — This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.
The Recommended Protocol Was Not Ordered and/or Followed (5D920/5H920) — Medicare cannot pay for this service because one or more requirements for coverage were not met.
Billing Error (5D199/5H199) — The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.
Units Billed More Than Ordered (5D151/5H151) — The physician’s orders submitted did not cover all of the units billed.
Auto Deny — Requested Records Not Submitted Timely (56900) — The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Documentation Request (ADR). When an ADR is generated, the provider has 45 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied or an overpayment will be collected.
Question: This provider is under TPE for HBO error code 12058 regarding documentation addressing the patient’s nutritional status for diabetic wound management via HBO. Can nutritional documentation be from a consult and treatment by a Registered Dietitian or a biochemical assessment using laboratory measures to identify specific nutritional deficiencies and treatment by a medical doctor be used?
Answer: Yes, you should include all documentation that is related to the HBO treatment being provided as well as any consults, lab results, and what measures were taken if any.