CPT Code 97535: Coverage, Compliance, and Use-Cases

Are you getting your claims denied because of incorrectly using the CPT code 97535? We have covered this blog for you that covers everything there is to know about this code. We have explained its coverage criteria and use cases in detail.

The blog also discusses how you can ensure compliance and conduct occupational therapy services with it. 

What Is CPT Code 97535?

This code comes under the range of Physical Medicine and Rehabilitation Therapeutic Procedures. It is assigned whenever healthcare providers have to provide proper instructions to patients. This code is especially appropriate in cases of recovery from acute diseases.

Those instructions are primarily based on self-care and home management training. The CPT code 97535 is common among occupational therapists who assign it to relevant activities. Assigning this code requires one-on-one interactions between providers and patients.

The full form of CPT in medical coding is Current Procedural Terminology. This name is associated with specific numeric codes that are assigned to medical services. Healthcare providers and insurance companies use CPT codes to identify those services while billing them.

Coverage Criteria for CPT Code 97535

There are some key factors that you must follow to ensure full coverage of the medical services associated with this code. Let’s take a look at them in detail:

• Level of Function and Outcome Measures

You must document the prior level of function of your patients. This involves their daily living activities before the current injury, illness, or disability. Compare them with the current outcome measures of those patients.

These measures are standardized assessments that you can conduct for this comparison. They identify the decline in your patients’ ability to perform common daily life activities. The comparison establishes a baseline and justifies the medical necessity for intervention.

It highlights the functional decline of patients due to their illness, injury, or disability. As a result, you can conclude the need for skilled therapy to make up for that decline.

• Increase Participation Through Intervention

Consider a patient who is currently receiving assistance from you for ADLs. ADLs are common daily life activities like dressing, bathing, and feeding. You must document details about the potential of your patients to increase their independence. Those details should also include whether their reliance on you can be reduced through therapy.

This factor focuses on the level of expected functional improvement from patients. In most cases, insurers demand evidence that your therapy will yield progress. Therapy should not only be a medium for maintaining their current level of function.

• Compensatory Training Requirement

Your documents should also cover the requirement of compensatory training. Patients must undergo this training to complete their ADLs and self-management activities. Consider a patient who has had back surgery.

Compensatory training would be covered for them as they have to perform ADLs. While performing them, they have to take specific precautions as well. This ensures that the therapy provided is customized to the patient’s needs.

You have to teach new ways to your patients to perform tasks due to limitations. This is considered a skilled intervention and, thus, eligible for coverage.

• Repetition of Techniques

There does come a point when a patient is able to perform their ADLs and home management tasks independently. They may also require some minimal assistance using modified techniques. For such patients, the repetition of the same therapy techniques is not considered a skilled service.

At one point, your patient may achieve a modified independent status. A further repetition of their therapy will be viewed as maintenance instead of skilled therapy. Insurance companies typically do not cover maintenance therapy. Their reason is that it does not provide skilled care to patients.

• Learn from Instructions

Healthcare providers also have to document whether their patients have the capacity to learn. Those patients should be able to benefit from the instructions of their therapists. These details ensure that those patients undergo and improve from training. Insurance companies deny coverage for patients who cannot retain information or follow instructions.

Ensuring Compliance Using CPT Code 97535

There are various guidelines that you can follow to ensure compliance using the CPT code 97535. Here are some details about them:

• Prioritize performance-based intervention to directly incorporate ADLs into the treatments of your patients.
• Record details about the limited ADLs performed by patients and their cognitive capacity to benefit from their intervention.
• Deploy hands-on approach by actively assisting and providing education to your patients during their treatments.
• Intervention should be relevant to your in-treatment plans for increased independence of patients during their sessions.
• A licensed therapist with the necessary qualifications and expertise should provide clinical services to patients.
• Therapists should conduct one-to-one sessions with their patients for personalized attention and treatment.
• Avoid charging for unskilled treatments that do not require the advanced skills and expertise of a licensed therapist.
• All relevant details about patients and their relevant therapies should be accurately documented for compliance.

Occupational Therapy Using Code 97535

Occupational therapy services include a wide range of interventions. These interventions usually comprise ADLs, self-management, and home management activities. Occupational therapists focus on their performance to improve the overall functioning of patients.

Self-management comprises organization and planning, medication management, and financial management. The tasks of home management maintain a safe and functional living environment. Occupational therapists empower patients to perform these activities independently.

They directly address the functional deficits and limitations that their patients may face. Interventions can be customized to the specific needs and goals of each patient. This enables greater independence and self-efficacy by occupational therapists.

The usage of modalities is billed separately from the CPT code 97535. This code specifically addresses the skilled interventions provided by occupational therapists. Those therapists enhance the ability of their patients to engage in necessary daily activities.

Use-Cases of Code 97535 Services

The CPT code 97535 is assigned to several occupational therapy services. Here are some of those use cases that provide effective care:

• Memory Support: This code can be assigned to provide memory support to patients who have traumatic brain injuries.
• Energy Conservation Techniques: You can also assign this code to energy conservation techniques for multiple sclerosis patients. These techniques include appropriate pacing, planning activities, and energy-saving methods.
• Independent Meal Preparation: You can apply 97535 to elderly patients as well to prepare their independent meals. For this, you have to utilize assistive devices and implement adaptive techniques.
• Cervical Radiculopathy: This code applies to patients who use cervical pillows to maintain their neutral cervical spine positions while sleeping.
• Returning to Running: It is also appropriate for those patients who have to manage tissue responses in response to the progressive loads experienced.
• Training for Safety Procedures: You can assign 97535 when you have to conduct safety procedures of joint protection as well.

Modifier 59 for CPT Code 97535

Healthcare providers have to assign an appropriate modifier as well along with the 97535 code. A modifier helps them distinguish their relevant services from the other procedures conducted on the same day.

Modifier 59 is the appropriate one for the services associated with this code. You can use this modifier to prevent denials caused due to bundling issues. This modifier provides unique details about therapeutic activities.

It is specifically assigned to differentiate procedures that are not typically reported together. You have to append this modifier to the code 97535 to overcome potential coding issues. This way, your therapeutic activities can receive appropriate recognition and reimbursement.

Consider a patient who receives therapeutic activities and another service on the same day. You may mistakenly bundle those services together if you do not use the modifier. This can result in claim denials or incomplete payments from insurance companies.

You can prevent that by appending modifier 59 to CPT code 97535. This way, you can clearly communicate that those two services are distinct. As a result, you should bill them separately in order to receive complete payments.

The Bottom Line

This blog covered the CPT code 97535 in detail. We explored its coverage criteria along with the ways to ensure compliance while assigning it. We also discussed how this code can be assigned to occupational therapy services.

There were some common use-cases mentioned as well that involved the code 97535. Finally, we saw how modifier 59 can be appended to it and which benefits come out of that. Contact Health Quest Billing and get a chance to work with a highly qualified medical coding team.