CPT CODE, DESCRIPTION AND FEE amount
97760 – Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes – Average Fee amount -$40
97761 – Prosthetic training, upper and/or lower extremity(s), each 15 minutes – Average Fee amount – $35
97762 – Checkout for orthotic/prosthetic use, established patient, each 15 minutes – Average Fee amount – $48
Orthotics Fitting (CPT code 97760)
1. This procedure may be considered reasonable and necessary, if there is an indication for education for the application of orthotics, and the functional use of the orthotic is present and documented.
2. Generally, orthotic training can be completed in three visits; however for modification of the orthotic due to healing of tissue, change in edema, or impairment in skin integrity additional visits may be required.
3. The medical record should document the distinct treatments rendered when orthotic training for upper and lower extremity is done.
4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to apply the device.
Prosthetic Training (CPT code 97761)
1. This procedure and training may be considered reasonable and necessary, if there is an indication for education in the application of the prosthesis, and the functional use of the prosthesis is present and documented.
2. The medical record should document the distinct goals and service rendered when prosthetic training for upper and lower extremity is done.
3. Periodic revisits beyond the third month would require documentation to support medical necessity.
Orthotic/Prosthetic Checkout (CPT Code 97762)
1. These assessments are reasonable and necessary when there is a modification or reissue of a recently issued device or a reassessment of a newly issued device.
2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls).
3. These assessments may be reasonable and necessary for determining “the patients response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient’s need for padding, underwrap, or socks and determining the patient’s tolerance to any dynamic forces being applied.”
Medicare Policy:
Some of the policies implemented in this notification were 1) discussed in the CY 2006 OPPS final rule, or 2) discussed in the CY 2006 MPFS final rule or reflected in its Addendum B. Other policies contained in this notification correct or clarify our previous policy noted in Transmittal 515, CR 3647, issued April 1, 2005 in Pub. 100-04. This CR updates the therapy code list and associated policies for CY 2006, as follows:
1) “Orthotic Management and Prosthetic Management” Services.
In order to create a new category under the section for physical medicine and rehabilitation services, HCPCS/CPT modified the descriptor of one of these codes, CPT 97504 (2005), and renumbered it as well as two other HCPCS/CPT codes. The new therapy code list removes the CY 2005 CPT codes, 97504, 97520 and 97703 and replaces them with CPT codes 97760, 97761 and 97762, respectively, for use in CY 2006.
Constant Attendance Modalities (97010-97039), Therapeutic Procedures (97110-97542), Orthotic Management (97760, 97762), and the unlisted Physical Medicine code (97799) will be limited to a maximum 4 therapeutic modalities per treatment session, not to exceed one hour (4 units) for the combinations of codes submitted.
Generally, CPT code 97116 should not be reported with 97760. However, if a service represented by code 97760 was performed on an upper extremity and a service represented by code 97116© (gait training) was also performed, both codes may be billed with modifier 59 to denote separate anatomic sites.
Orthotic Management and Prosthetic Management:
CPT codes 97760-97762 describe orthotic and prosthetic assessment, management, and training
services. These codes also contain a 15 minute time component
The “Rule of Eight” reporting requirements described in the policy section below apply to all of the 15 minute time-based codes listed above under Modalities, Therapeutic Procedures, Tests and
Measurements, and Orthotic Management and Prosthetic Management. However, this policy focuses
on Constant Attendance Modalities and Therapeutic Procedures
I. “Rule of Eight”
The Health Plan has adopted The Centers for Medicare & Medicaid Services (CMS) reporting guidelines for determining the appropriate number of units to report with respect to physical medicine CPT codes that are subject to a 15-minute time component. The Health Plan refers to this guideline as the “Rule of Eight.”
The “Rule of Eight” addresses the relationship between the direct (one-on-one) time spent with the patient, and the billing and reimbursement of a unit of service. According to the “Rule of Eight”, the provider must spend more than one-half (8 minutes or more) of a given 15-minute time component with the patient in order to properly submit that unit to the Health Plan for reimbursement
II. Reporting Guidelines
The Health Plan requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the performance of procedures that are reported to Health Plan as direct treatment services.
• The time reported should be the time actually spent in the delivery of the modality and/or therapeutic procedure. This means that pre and post-delivery services should not be counted in determining the treatment time.
• The time that the patient spends not being treated, due to resting periods or waiting for a piece of equipment to become available, is not considered treatment time.
• All treatment time, including the beginning and ending time of the direct treatment, must be recorded in the patient’s medical record, along with the note describing the specific modality or procedure.
III. Determining Units
A. A provider should not report a direct treatment service if only one attended modality or therapeutic procedure is provided in a day, and the procedure is performed for less than 8 minutes.
B. A single 15-minute unit of direct treatment service may be billed when the duration of direct treatment is equal to or greater than 8 minutes, and less than 23 minutes. If the duration of a single modality or procedure is between 23 minutes but less than 38 minutes, then two 15-minute units of direct treatment service may be billed.
The following table indicates the appropriate protocol for reporting each additional unit:
Number of units billed: Number of minutes provided in treatment:
1 unit 8 minutes to < 23 minutes
2 units 23 minutes to < 38 minutes
3 units 38 minutes to < 53 minutes
4 units 53 minutes to < 68 minutes
5 units 68 minutes to < 83 minutes
6 units 83 minutes to < 98 minutes
7 units 98 minutes to < 113 minutes
8 units 113 minutes to < 128 minutes*
TMJ Orthotic Adjustments
Adjustments for TMJ orthotics are normally billed under CPT codes 97760 or 97762. These services are not separately covered with a TMJ diagnosis. These adjustments are considered an integral part of the splint therapy and as such will be denied regardless if billed alone or with another service.
Modifier Invalid Combination Special Coding Instructions
G8 QS Modifier G8 should only be used with the following anesthesia codes: 00100, 00160, 00300, 00400, 00532, and 00920. KMAP will deny the service if this modifier is billed with any code other than those listed. G9 Submit this modifier only with anesthesia services (such as codes 00100 – 01999). KMAP will deny services billed with modifier G9 on codes other than the anesthesia series of codes.
GA
GB At this time, there are no special coding instructions applicable to Medicaid claims billing for these modifiers.
GC Modifier GC must be used by the physician for teaching physician services. A teaching physician service billed using this modifier is certifying that he or she has been present during the key portion of the service and was immediately available during the other parts of the service.
GD At this time, there are no special coding instructions applicable to Medicaid claims billing for this modifier.
GE Submit this modifier with services performed by a resident in a teaching facility without the presence of a teaching physician. This modifier is informational and can only be submitted with procedure codes included in the primary care exception. HCPCS code: G0344
CPT® codes: 99201 – 99203, 99211 – 99213, 93005 and 93041
GF For services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA), use this modifier.
GG Modifier GG is used when a diagnostic and a screening mammogram are performed on the same day for the same patient. Modifier GG is added to the diagnostic mammography code only. Both the diagnostic and screening codes must be billed on the same claim form. Submit modifier GG with the diagnostic mammography code. CMS uses this modifier for tracking and data collection purposes. This modifier can be submitted with the following:
CPT® codes: 76082, 76090, 76091, 77051, 77055 and 77056 HCPCS codes: G0204, G0206, and G0236 KMAP will deny the service if this modifier is billed with any code other than those listed.
GH When a screening mammogram indicates a potential problem, the interpreting radiologist can order additional films during the same visit on the same day without an additional order from the treating physician. The radiologist must report to the treating physician the condition of the patient. These additional films, with the report to the treating physician, convert a screening mammogram to a diagnostic mammogram. The procedure code is reported with modifier GH to indicate the radiologist converted the screening mammogram to a diagnostic mammogram.
This modifier can be submitted with CPT® codes: 76090, 76091, 77055 and 77056. KMAP will deny the service if this modifier is billed with any code other than those listed.
GJ This modifier is used specific to Medicare. Medicare rules: Physicians who have opted out of Medicare (also called private contracting) are not permitted to submit services toMedicare; however, the exception to this rule is when services are provided on an emergent or urgent basis. Opt-out physicians and practitioners must submit these services to Medicare with modifier GJ. In order to opt out of Medicare, physicians and practitioners who are permitted to opt out must follow certain procedures and guidelines.
GK
GL At this time, there are no special coding instructions applicable to Medicaid claims billing for these modifiers.
GM This modifier can be submitted only with claims for ambulance transport, A0021 – A0999. KMAP will deny the service if this modifier is billed with any code other than those listed.
GN Submit modifier GN to indicate the services were delivered under an outpatient speech language pathology plan of care. KMAP has determined it is appropriate to use modifier GN on the following codes: 64550, G0281, G0283, G0329, 0019T, 0029T, 0183T, 90901, 92520, 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92607, 92608, 92609, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 96105, 96110, 96111, 96125, 97001, 97002, 97003, 97004, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97597, 97598, 97602, 97605, 97606, 97750, 97755, 97760, 97761, 97762 and 97799.
KMAP will deny the service if this modifier is billed with any code other than those listed
GO Submit modifier GO to indicate services delivered under an outpatient occupational plan of care. KMAP has determined it is appropriate to use modifier GO on the following codes:
• 97010 through 97546; 97760 through 97799
* These codes must be billed separately.
* If you deliver more than one unit of service the number must be recorded in the units field of the CMS 1500 claim form.
* When the same modality is applied to two different locations on the same day, always identify the areas (i.e., right shoulder and left elbow) on claim attachment.
* When two modalities are performed by one machine at the same time only one modality may be billed.
Multiple Concurrent Physical Medicine Procedures and Modalities: “Multiple concurrent physical medicine procedures are subject to the following rules and limitations.
• No more than four physical medicine procedures, modalities or time units will be reimbursed in one visit by each type of medical provider. No more than two of the four CPT code charges can be modality codes (CPT codes 97010-97039). The only exceptions to this are:
1) if injured employee is diagnosed as “catastrophic”
2) 2) CPT codes 97545 and 97546 (see page 12, Physical Medicine Maximum Per Visit and/or Day for more details)
3) CPT code 97750 when used for Functional capacity evaluation (FCE) only with a limit of $600.00
4) CPT code 97750 must be used by physical/occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. Additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI – Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day.
CPT code 99455 or 99456 should be used by the treating physician when performing an impairment rating.
Under the guidelines above, Physical Performance Test/Measurement testing and functional capacity evaluation can be performed on the same day by physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day.
5) CPT Code 97760, Management and training (including assessment and fitting when not otherwise reported) for custom-made orthotics, CPT code 97761, Prosthetic training, and CPT code 97762, Checkout for Orthotic/prosthetic use, established patient. CPT code 97762 is used to checkout the custom-made Orthotic/prosthetic for any medically necessary adjustments
6) by mutual agreement of all parties
CPT Deletion and modification update
The policies implemented in CR10303 were discussed in CY 2018 Medicare Physician Fee Schedule (MPFS) rulemaking. CR10303 updates the therapy code list and associated policies for CY 2018, as follows:
* The Current Procedural Terminology (CPT) Editorial Panel revised the set of codes physical and occupational therapists use to report orthotic and prosthetic management and training services by differentiating between initial and subsequent encounters through the: (a) addition of the term “initial encounter” to the code descriptors for CPT codes 97760 and 97761, (b) creation of CPT code 97763 to describe all subsequent encounters for orthotics and/or prosthetics management and training services, and (c) deletion of CPT code 97762. The new long descriptors for CPT codes 97760 and 97761
– now intended only to be reported for the initial encounter with the patient – are:
o CPT code 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes)
o CPT code 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes)
* The Centers for Medicare & Medicaid Services (CMS) will add CPT code 97763 to the therapy code list and CPT code 97762 will be deleted.
* The panel also created, for CY 2018, CPT code 97127 to replace/delete CPT code 97532. CMS will recognize HCPCS code G0515, instead of CPT code 97127, and add HCPCS code G0515 to the therapy code list. CPT code 97127 will be assigned a Medicare Physician Fee Schedule (MPFS) payment status indicator of “I” to indicate that it is “invalid” for Medicare purposes and that another code is used for reporting and payment for these services.
* Just as its predecessor code was, CPT code 97763 is designated as “always therapy” and must always be reported with the appropriate therapy modifier, GN, GO or GP, to indicate whether it’s under a Speech-language pathology (SLP), Occupational Therapy (OT) or Physical Therapy (PT) plan of care, respectively.
* HCPCS code G0515 is designated as a “sometimes therapy” code, which means that an appropriate therapy modifier – GN, GO or GP, to reflect it’s under an SLP, OT, or PT plan of care – is always required when this service is furnished by therapists; and, when it’s furnished by or incident to physicians and certain Nonphysician Practitioners (NPPs), that is, nurse practitioners, physician assistants, and clinical nurse specialists when the services are integral to an SLP, OT, or PT plan of care. Accordingly, HCPCS code G0515 is sometimes appropriately reported by physicians, NPPs, and psychologists without a therapy modifier when it is appropriately furnished outside an SLP, OT, or PT plan of care. When furnished by psychologists, the services of HCPCS code G0515 are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier.
* The therapy code list is updated with one new “always therapy” code and one new “sometimes therapy” code, using their HCPCS/CPT long descriptors, as follows:
o CPT code 97763 – This “always therapy” code replaces/deletes CPT code 97762.
o CPT code 97763: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
o HCPCS code G0515 – This “sometimes therapy” code replaces/deletes CPT code 97532
o HCPCS code G0515: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
Physical Medicine Maximum per Visit and/or Day:
No more than four charges will be reimbursed per visit/day regardless of medical necessity. No more than two of the charges can be modality codes (CPT codes 97010-97039). Each unit (15 minutes) reported counts as one charge. Exemptions to this rule are as follows:
1) An injured worker has been diagnosed with a catastrophic injury, O.C.G.A. §34-9- 200.1(g).
2) CPT codes 97545 and 97546 report work hardening/work conditioning. CPT code 97545 reports the first two hours and CPT code 97546 reports each additional hour. The total dollar amount reimbursed for work hardening/work conditioning reported with these two CPT codes shall not exceed $267.00 per visit/day.
3) CPT code 97750 – Physical Performance Test/Measurements with Report 15 Minutes. This code must be used for billing functional capacity evaluations (not to exceed $600.00).
CPT code 97750 must be used by physical/occupational therapists when billing for Physical Performance Test/Measurements that are required by the treating physician in preparing an impairment rating. No more than 4 time units per visit per day can be billed. Additional physical medicine treatment can be conducted on the same day, with reimbursement in accordance with Section XI – Physical Medicine Services. Modifier 59 may be used when multiple procedures are performed on the same day.
CPT code 99455 or 99456 should be used by the treating physician when performing an impairment rating.
Under the guidelines above, Physical Performance Test/Measurement testing and functional capacity evaluation can be performed on the same day by physical/occupational therapists. Modifier 59 may be used when multiple procedures are performed on the same day.
4) CPT code 97760, Orthotic management and training (including assessment and fitting when not otherwise reported) for custom-made orthotics, CPT code 97761, Prosthetic training, and CPT code 97762, Checkout for orthotic/prosthetic use, established patient.