CPT Code 97110: 8 Minute Rule, Modifier, and Scenarios
Are you getting denials over the CPT code 97110? We will help you turn those denials into approvals through this detailed blog. We have covered the procedures relevant to this code along with the modifier that you can use.
You will also find key documentation essentials and coding considerations that will ensure approved claims for you. Contact Health Quest Billing to learn more about coding medical services with perfection.
What Is CPT Code 97110?
The CPT code 97110 is maintained by the American Medical Association (AMA) and falls under the Physical Medicine and Rehabilitation Therapeutic Procedures category. It is commonly used in medical coding services for therapeutic exercise, a key component of physical therapy.
Therapeutic exercises involve structured activities and movements designed to enhance mobility, strength, and flexibility. Healthcare providers use CPT 97110 to treat injury-related disabilities, assist in post-surgical recovery, and improve overall physical health. This procedure is also beneficial for pregnant patients, osteoporosis management, and general fitness enhancement.
Accurate medical billing and coding services ensure proper modifier application, adherence to payer guidelines, and compliance with the 8-minute rule, reducing claim denials and optimizing reimbursement.
Importance of CPT Code 97110 in Therapy
CPT 97110 is crucial in various therapeutic settings. It addresses muscle imbalances, limited mobility, or joint stiffness through individualized exercise programs. It’s commonly used after surgeries, injuries, or to manage chronic conditions. Those conditions affect muscle strength and joint function.
Conditions Treated Using CPT 97110
Many conditions are treated using the CPT code 97110. This code is frequently used alongside other therapy modalities to provide holistic patient care. Here is a list of the common ones involved:
- Post-surgical rehabilitation (e.g., after knee replacement).
- Conditions like arthritis or osteoarthritis.
- Sports injuries and musculoskeletal dysfunctions.
- Neurological conditions such as stroke.
What is the 8 Minute Rule?
The 8-minute rule is a guideline used for billing time-based CPT codes. It includes the 97110 code as well which represents therapeutic exercises. The rule states that you can bill one unit of a time-based CPT code.
For one unit, you have to provide at least 8 minutes of direct and one-on-one therapy time to patients. A unit of 97110 represents 15 minutes of therapeutic exercise. The 8-minute rule helps determine how many units to bill based on the actual time spent. Here’s how it works:
- 8 to 22 Minutes: 1 unit can be billed.
- 23 to 37 Minutes: 2 units can be billed.
- 38 to 52 Minutes: 3 units can be billed.
- 53 to 67 Minutes: 4 units can be billed.
Modifier Used For CPT Code 97110
The modifier used alongside the CPT code 97110 is 59. It is an essential component for assigning 97110 to your services. It indicates whether those services were distinct or independent from the other ones performed on the same day. You may assign 97110 and its pairs to bill the same session or date.
In this case, the modifier 59 is appropriate. But those two procedures have to be performed in distinctly different 15-minute intervals. The 2021 NCCI edits state that you must use the 59 modifier while billing 97110 with 3 specific codes. Those codes are 36591, 36592, and 96523. Although Medicare follows NCCI edits, not every commercial insurance does the same.
Private insurance companies follow a mix of proprietary and NCCI/CCI edits. This way, they identify ‘covered services’ in line with payer benefit plans. You must review the list of edit pairs for each specific carrier. Failure to do so might lead to denials caused by incorrectly using 59.
Documentation Essentials for CPT Code 97110
Proper documentation for CPT 97110 is necessary to ensure accurate billing and compliance. Here are key aspects to include in the documentation:
- Patient’s Baseline Condition: Document the patient’s initial functional status such as muscle strength and range of motion. Also, record the specific deficits targeted through therapeutic exercises.
- Treatment Goals: Clearly outline the goals of the exercise program. They can be targeted towards increasing muscle strength, improving flexibility, or reducing pain.
- Specific Exercises Performed: List each exercise along with the number of sets, repetitions, and any equipment used.
- Duration and Frequency: Record the time spent on each exercise session. Remember that 97110 is a timed CPT code. The total number of units billed should correspond with the total therapy minutes provided.
- Patient Response and Progress: Document how the patient responded to the exercises and any changes in their condition. An example would be increased strength or reduced pain.
Coding Considerations for CPT 97110
Billing CPT 97110 correctly is critical for healthcare providers. Here are some considerations to keep in mind:
Reporting Service Units
You may have to report service units for CPT codes defined by a specific timeframe. It’s essential to accurately count the total time of direct patient contact. This ensures compliance and proper reimbursement for the therapy services provided.
Combining with Other CPT Codes
Multiple therapy services may be provided in a single session. The total minutes for all services should be counted together to determine the number of units billed. Be careful not to double-bill for overlapping periods.
Comparing CPT 97110 With Other Therapy Codes
CPT 97110 is often used in conjunction with other therapeutic procedure codes such as:
- CPT 97112: This code is used for neuromuscular re-education techniques. They involve movement, balance, coordination, and proprioception training.
- CPT 97140: This code represents manual therapy techniques. They include joint mobilization, manipulation, and massage. These techniques differ significantly from 97110 therapeutic exercises.
The choice between these codes depends on the specific therapeutic intervention provided. The goals of the treatment plan are also important. For instance, the CPT code 97110 focuses on muscle strengthening and flexibility. Whereas, 97112 and 97140 are for restoring joint and muscle function.
Can 97110 and 97530 Be Billed Together?
These CPT codes describe different types of therapeutic interventions. The expected goals documented in the treatment plan define the reasonability and necessity of procedures. The use of each of these procedures affects those goals. Any one or a combination of these procedures may be used in a treatment plan.
Documentation must support the use of each procedure as it relates to a specific therapeutic goal. The challenge arises with private payers. As mentioned above, Medicare does follow NCCI edits but not every commercial insurance. The 59 modifiers might be required for specific private payers.
Practical Scenarios for Using CPT 97110
We have outlined some key scenarios to give you an idea about using CPT 97110. Let’s take a look at them in detail:
Post-Operative Recovery
A patient recovering from knee surgery might undergo therapeutic exercises. Those exercises may target quadriceps and hamstring strengthening. In this case, CPT 97110 would be billed based on the time spent. The time is spent on performing these exercises under the therapist’s supervision.
Chronic Pain Management
A patient with chronic low back pain might be assigned core strengthening. They can also be assigned flexibility exercises as part of their therapy program. Each session would be documented with specific exercises, duration, and patient response.
Rehabilitation After Stroke
Some stroke patients experience muscle weakness or limited mobility. For them, therapeutic exercises can help regain muscle function and improve range of motion. In such cases, you can assign the CPT code 97110 as a vital part of rehabilitation.
Coding Challenges and Solutions
Coding CPT 97110 can present several challenges. Let’s take a look at the major ones along with their solutions:
Determining Accurate Time Units
It’s essential to track the total minutes spent on direct patient care. This ensures correct billing for time-based codes. An effective solution is the usage of software tools. It automatically calculates time spent based on therapist inputs.
Justifying Medical Necessity
Payers often require evidence of the medical necessity of therapeutic exercises. Your services should be medically necessary for your patient’s condition. Documented evidence can support this justification. It can include patient deficits, therapy goals, and progress notes
Avoiding Overlapping Time Units
You may have to bill multiple therapy codes on the same day. It’s crucial to ensure that time units do not overlap. Detailed scheduling and clear documentation of start and end times for each service are important. It can help you prevent this issue.
Conclusion
CPT code 97110 is essential in rehabilitation and therapy for billing therapeutic exercises that enhance muscle function, flexibility, and patient recovery. Accurate coding ensures compliance and maximizes reimbursement while supporting better patient outcomes.
Staying updated on medical coding changes, payer policies, and proper documentation is crucial for reducing claim denials and optimizing revenue. For expert guidance on CPT 97110 and other medical coding services, contact Health Quest Billing at (415) 508-6537 today!