| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Therapies: Physical, Occupational, and Speech and Language Pathology | | 04/26/2024 | Covered and Noncovered Services : CodesTopic #2753 Modifiers
Allowable modifiers for PT, OT, and SLP services are listed in the following table.
| Therapy Discipline |
Modifier |
Description |
Notes |
| OT |
GO |
Services delivered personally by an occupational therapist or under an outpatient OT POC |
Modifier GO should only be indicated when submitting PA requests or claims for services rendered by a licensed occupational therapist, a certified OT assistant, or an OT student. (All relevant supervision requirements must be met for services rendered by assistants or students.) |
| PT |
GP |
Services delivered personally by a physical therapist or under an outpatient PT POC |
Modifier GP should only be indicated when submitting PA requests or claims for services rendered by a licensed physical therapist, a physical therapist assistant, a PT aide, or a PT student. (All relevant supervision requirements must be met for services rendered by assistants, aides, or students.) |
| SLP |
GN |
Services delivered personally by a speech and language pathologist or under an outpatient SLP POC |
Modifier GN should only be indicated when submitting PA requests or claims for services rendered by a licensed speech and language pathologist, an SLP provider assistant, or an SLP student. (All relevant supervision requirements must be met for services rendered by assistants or students.) |
| PT and OT |
TF |
Intermediate level of care |
Modifier TF should be indicated when submitting claims for services provided by physical therapist assistants or certified OT assistants under general supervision. TF should not be indicated on PA requests. |
| PT, OT, and SLP |
TL |
Early intervention/IFSP |
Modifier TL should be indicated when submitting claims for Birth to 3 services provided in the natural environment of a Birth to 3 member. TL should not be indicated on PA requests. |
Providers are required to indicate modifier TL when submitting claims for natural environment-enhanced reimbursement when providing services to members in the Birth to 3 Program. Providers are required to indicate the TL modifier for each detail line that they wish the reimbursement to be considered.
Providers are required to indicate modifier TF when submitting claims for services provided by an assistant therapist. Topic #2796 Occupational Therapy Birth to 3 Procedure Codes
Allowable OT Birth to 3 services are identified by the CPT procedure codes listed in the following table.
Note: All codes listed in this chart, if billed with an applicable place of service code, are eligible for natural environment enhanced reimbursement.
| Procedure Code |
Description |
| 97110 |
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
| 97112 |
Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities |
| 97113 |
Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises |
| 97129 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes |
| 97130 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure) |
| 97140 |
Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes |
| 97150 |
Therapeutic procedure(s), group (2 or more individuals) (Report 97150 for each member of the group) (Group therapy procedures involve constant attendance of the physician or therapist, but by definition do not require one-on-one member contact by the physician or therapist) |
| 97165 |
Occupational therapy evaluation, low complexity, requiring these components:
- An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;
- An assessment[s] that identifies 1–3 performance deficits [ie, relating to physical, cognitive, or psychosocial skills] that result in activity limitations and/or participation restrictions; and
- Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment[s], and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance [eg, physical or verbal] with assessment[s] is not necessary to enable completion of evaluation component.
Typically, 30 minutes are spent face to face with the patient and/or family.
|
| 97166 |
Occupational therapy evaluation, moderate complexity, requiring these components:
- An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
- An assessment[s] that identifies 3–5 performance deficits [ie, relating to physical, cognitive, or psychosocial skills] that result in activity limitations and/or participation restrictions; and
- Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment[s], and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance [eg, physical or verbal] with assessment[s] is necessary to enable patient to complete evaluation component.
Typically, 45 minutes are spent face to face with the patient and/or family.
|
| 97167 |
Occupational therapy evaluation, high complexity, requiring these components:
- An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive review of physical, cognitive, or psychosocial history related to current functional performance;
- An assessment[s] that identifies 5 or more performance deficits [ie, relating to physical, cognitive, or psychosocial skills] that result in activity limitations and/or participation restrictions; and
- Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment[s], and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance [eg, physical or verbal] with assessment[s] is necessary to enable patient to complete evaluation component.
Typically, 60 minutes are spent face to face with the patient and/or family.
|
| 97168 |
Re-evaluation of occupational therapy established plan of care, requiring these components:
- An assessment of changes in patient functional or medical status with revised plan of care;
- An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
- A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.
Typically, 30 minutes are spent face to face with the patient and/or family.
|
| 97530 |
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes |
| 97533 |
Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes |
| 97535 |
Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes |
Topic #2793 Occupational Therapy Procedure Codes
Covered OT services are identified by the allowable CPT and HCPCS procedures codes listed in the following table.
Note: Procedure codes for many OT services are defined as
15 minutes. One unit of these codes = 15 minutes. If less than 15 minutes is
used, bill in decimals. For example, 7.5 minutes = .5 units. All other
procedure codes for OT services do not have a time increment indicated in
their description. For these procedure codes, a quantity of "1" indicates a
complete service.
| General Casting |
| Procedure Code |
Description |
| 29065 |
Application, cast; shoulder to hand (long arm) |
| 29075 |
elbow to finger (short arm) |
| 29085 |
hand and lower forearm (gauntlet) |
| 29086 |
finger (eg, contracture) |
| 29345 |
Application of long leg cast (thighs to toes) |
| 29355 |
walker or ambulatory type |
| 29365 |
Application of cylinder cast (thigh to ankle) |
| 29405 |
Application of short leg cast (below knee to toes); |
| 29425 |
walker or ambulatory type |
| 29445 |
Application of rigid total contact leg cast |
| Casting Supply |
| Procedure Code |
Description |
| Q4003 |
Cast supplies, shoulder cast, adult (11 years +), plaster |
| Q4004 |
Cast supplies, shoulder cast, adult (11 years +), fiberglass |
| Q4005 |
Cast supplies, long arm cast, adult (11 years +), plaster |
| Q4006 |
Cast supplies, long arm cast, adult (11 years +), fiberglass |
| Q4007 |
Cast supplies, long arm cast, pediatric (0–10 years), plaster |
| Q4008 |
Cast supplies, long arm cast, pediatric (0–10 years), fiberglass |
| Q4009 |
Cast supplies, short arm cast, adult (11 years +), plaster |
| Q4010 |
Cast supplies, short arm cast, adult (11 years +), fiberglass |
| Q4011 |
Cast supplies, short arm cast, pediatric (0–10 years), plaster |
| Q4012 |
Cast supplies, short arm cast, pediatric (0–10 years), fiberglass |
| Q4013 |
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster |
| Q4014 |
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), fiberglass |
| Q4015 |
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0–10 years), plaster |
| Q4016 |
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0–10 years), fiberglass |
| Q4025 |
Cast supplies, hip spica (one or both legs), adult (11 years +), plaster |
| Q4026 |
Cast supplies, hip spica (one or both legs), adult (11 years +), fiberglass |
| Q4027 |
Cast supplies, hip spica (one or both legs), pediatric (0–10 years), plaster |
| Q4028 |
Cast supplies, hip spica (one or both legs), pediatric (0–10 years), fiberglass |
| Q4029 |
Cast supplies, long leg cast, adult (11 years +), plaster |
| Q4030 |
Cast supplies, long leg cast, adult (11 years +), fiberglass |
| Q4031 |
Cast supplies, long leg cast, pediatric (0–10 years), plaster |
| Q4032 |
Cast supplies, long leg cast, pediatric (0–10 years), fiberglass |
| Q4033 |
Cast supplies, long leg cylinder cast, adult (11 years +), plaster |
| Q4034 |
Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass |
| Q4035 |
Cast supplies, long leg cylinder cast, pediatric (0–10 years), plaster |
| Q4036 |
Cast supplies, long leg cylinder cast, pediatric (0–10 years), fiberglass |
| Q4037 |
Cast supplies, short leg cast, adult (11 years +), plaster |
| Q4038 |
Cast supplies, short leg cast, adult (11 years +), fiberglass |
| Q4039 |
Cast supplies, short leg cast, pediatric (0–10 years), plaster |
| Q4040 |
Cast supplies, short leg cast, pediatric (0–10 years), fiberglass |
| Evaluations |
| Procedure Code |
Description |
| 97165* |
Occupational therapy evaluation, low complexity, requiring these components:
- An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;
- An assessment[s] that identifies one to three performance deficits [eg, relating to physical, cognitive, or psychosocial skills] that result in activity limitations and/or participation restrictions; and
- Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment[s], and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance [eg, physical or verbal] with assessment[s] is not necessary to enable completion of evaluation component.
Typically, 30 minutes are spent face to face with the patient and/or family.
|
| 97166* |
Occupational therapy evaluation, moderate complexity, requiring these components:
- An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
- An assessment[s] that identifies three to five performance deficits [eg, relating to physical, cognitive, or psychosocial skills] that result in activity limitations and/or participation restrictions; and
- Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment[s], and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance [eg, physical or verbal] with assessment[s] is necessary to enable patient to complete evaluation component.
Typically, 45 minutes are spent face to face with the patient and/or family.
|
| 97167* |
Occupational therapy evaluation, high complexity, requiring these components:
- An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive review of physical, cognitive, or psychosocial history related to current functional performance;
- An assessment[s] that identifies five or more performance deficits [eg, relating to physical, cognitive, or psychosocial skills] that result in activity limitations and/or participation restrictions; and
- Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment[s], and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance [eg, physical or verbal] with assessment[s] is necessary to enable patient to complete evaluation component.
Typically, 60 minutes are spent face to face with the patient and/or family.
|
| 97168* |
Re-evaluation of occupational therapy established plan of care, requiring these components:
- An assessment of changes in patient functional or medical status with revised plan of care;
- An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
- A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.
Typically, 30 minutes are spent face to face with the patient and/or family.
|
| Therapeutic Procedures |
| Procedure Code |
Description |
| 97110 |
Therapeutic procedure, one or more areas,
each 15 minutes; therapeutic exercises to develop strength and endurance,
range of motion and flexibility |
| 97112 |
neuromuscular reeducation of movement,
balance, coordination, kinesthetic sense, posture, and/or proprioception for
sitting and/or standing activities |
| 97113 |
Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises |
| 97124 |
massage, including effleurage, petrissage
and/or tapotement (stroking, compression, percussion) |
| 97129 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes |
| 97130 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure) |
| 97139 |
Unlisted therapeutic procedure (specify) |
| 97140 |
Manual therapy techniques (eg,
mobilization/manipulation, manual lymphatic drainage, manual traction), one
or more regions, each 15 minutes |
| 97150 |
Therapeutic procedure(s), group (2 or more
individuals) |
| 97530 |
Therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve
functional performance), each 15 minutes |
| 97533 |
Sensory integrative techniques to enhance
sensory processing and promote adaptive responses to environmental demands,
direct (one-on-one) patient contact, each 15 minutes |
| 97535 |
Self-care/home management training (eg,
activities of daily living (ADL) and compensatory training, meal
preparation, safety procedures, and instructions in use of assistive
technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes |
| 97542 |
Wheelchair management (eg, assessment,
fitting, training), each 15 minutes |
| 97597* |
Removal of devitalized tissue from wound(s),
selective debridement, without anesthesia (eg, high pressure waterjet
with/without suction, sharp selective debridement with scissors, scalpel and
forceps), with or without topical application(s), wound assessment, and
instruction(s) for ongoing care, may include use of a whirlpool, per
session; total wound(s) surface area less than or equal to 20 square
centimeters |
| 97598* |
Total wound(s) surface area greater than 20
square centimeters |
| 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 |
| 97761 |
Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes |
| 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 |
| Modalities |
| Procedure Code |
Description |
| 90901 |
Biofeedback training by any modality |
| 97016 |
Application of modality to one or more areas;
vasopneumatic devices |
| 97018 |
paraffin bath |
| 97022 |
whirlpool |
| 97032 |
Application of a modality to one or more
areas; electrical stimulation (manual), each 15 minutes |
| 97033 |
iontophoresis, each 15 minutes |
| 97034 |
contrast baths, each 15 minutes |
| 97035 |
ultrasound, each 15 minutes |
* Procedure may not be provided by an occupational therapist assistant.
A unit of time is attained when the mid-point is passed. Providers should refer to the CPT guidelines for direction on reporting units on time-based and non-time-based procedures.
The same modality may not be reimbursed as
a PT service and an OT service on the same date of service for the same
member.
| E-Visits and Virtual Check-Ins |
| Procedure Code |
Description |
| G2250 |
Remote assessment of recorded video and/or images submitted by an established patient (eg, store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment |
| G2251 |
Brief communication technology-based service (eg, virtual check-in), by a qualified health care professional who cannot report Evaluation and Management services, provided to an established patient, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of clinical discussion |
| 98970 |
Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; 5–10 minutes |
| 98971 |
Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 11–20 minutes |
| 98972 |
Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes |
Topic #2797 Physical Therapy Birth to 3 Procedure Codes
Allowable PT Birth to 3 Program services are identified by the CPT procedure codes listed in the following table.
Note: All codes listed in this chart, if billed with an applicable place of service code, are eligible for natural environment enhanced reimbursement.
| Procedure Code |
Description |
| 97110 |
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
| 97112 |
neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities |
| 97113 |
aquatic therapy with therapeutic exercises |
| 97116 |
gait training (includes stair climbing) |
| 97140 |
Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes |
| 97150 |
Therapeutic procedure(s), group (2 or more individuals) |
| 97161 |
Physical therapy evaluation: low complexity, requiring these components:
- A history with no personal factors and/or comorbidities that impact the plan of care;
- An examination of body system[s] using standardized tests and measures addressing 1–2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
- A clinical presentation with stable and/or uncomplicated characteristics; and
- Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face to face with the patient and/or family.
|
| 97162 |
Physical therapy evaluation: moderate complexity, requiring these components:
- A history of present problem with 1–2 personal factors and/or comorbidities that impact the plan of care;
- An examination of body system[s] using standardized tests and measures addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
- An evolving clinical presentation with changing characteristics; and
- Clinical decision making of moderate complexity using measurable assessment of functional outcome.
Typically, 30 minutes are spent face to face with the patient and/or family.
|
| 97163 |
Physical therapy evaluation: high complexity, requiring these components:
- A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;
- An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
- A clinical presentation with unstable and unpredictable characteristics; and
- Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face to face with the patient and/or family.
|
| 97164 |
Re-evaluation of physical therapy established plan of care, requiring these components:
- An examination including a review of history and use of standardized tests and measures is required; and
- Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face to face with the patient and/or family.
|
| 97530 |
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes |
| 97533 |
Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes |
| 97535 |
Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes |
Topic #2792 Physical Therapy Procedure Codes
Covered PT services are identified by the allowable CPT and HCPCS procedures codes listed in the following table.
| General Casting |
| Procedure Code |
Description |
| 29065 |
Application, cast; shoulder to hand (long arm) |
| 29075 |
elbow to finger (short arm) |
| 29085 |
hand and lower forearm (gauntlet) |
| 29086 |
finger (eg, contracture) |
| 29345 |
Application of long leg cast (thighs to toes) |
| 29355 |
walker or ambulatory type |
| 29365 |
Application of cylinder cast (thigh to ankle) |
| 29405 |
Application of short leg cast (below knee to toes); |
| 29425 |
walker or ambulatory type |
| 29445 |
Application of rigid total contact leg cast |
| Casting Supply |
| Procedure Code |
Description |
| Q4003 |
Cast supplies, shoulder cast, adult (11 years +), plaster |
| Q4004 |
Cast supplies, shoulder cast, adult (11 years +), fiberglass |
| Q4005 |
Cast supplies, long arm cast, adult (11 years +), plaster |
| Q4006 |
Cast supplies, long arm cast, adult (11 years +), fiberglass |
| Q4007 |
Cast supplies, long arm cast, pediatric (0–10 years), plaster |
| Q4008 |
Cast supplies, long arm cast, pediatric (0–10 years), fiberglass |
| Q4009 |
Cast supplies, short arm cast, adult (11 years +), plaster |
| Q4010 |
Cast supplies, short arm cast, adult (11 years +), fiberglass |
| Q4011 |
Cast supplies, short arm cast, pediatric (0–10 years), plaster |
| Q4012 |
Cast supplies, short arm cast, pediatric (0–10 years), fiberglass |
| Q4013 |
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster |
| Q4014 |
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), fiberglass |
| Q4015 |
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0–10 years), plaster |
| Q4016 |
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0–10 years), fiberglass |
| Q4025 |
Cast supplies, hip spica (one or both legs), adult (11 years +), plaster |
| Q4026 |
Cast supplies, hip spica (one or both legs), adult (11 years +), fiberglass |
| Q4027 |
Cast supplies, hip spica (one or both legs), pediatric (0–10 years), plaster |
| Q4028 |
Cast supplies, hip spica (one or both legs), pediatric (0–10 years), fiberglass |
| Q4029 |
Cast supplies, long leg cast, adult (11 years +), plaster |
| Q4030 |
Cast supplies, long leg cast, adult (11 years +), fiberglass |
| Q4031 |
Cast supplies, long leg cast, pediatric (0–10 years), plaster |
| Q4032 |
Cast supplies, long leg cast, pediatric (0–10 years), fiberglass |
| Q4033 |
Cast supplies, long leg cylinder cast, adult (11 years +), plaster |
| Q4034 |
Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass |
| Q4035 |
Cast supplies, long leg cylinder cast, pediatric (0–10 years), plaster |
| Q4036 |
Cast supplies, long leg cylinder cast, pediatric (0–10 years), fiberglass |
| Q4037 |
Cast supplies, short leg cast, adult (11 years +), plaster |
| Q4038 |
Cast supplies, short leg cast, adult (11 years +), fiberglass |
| Q4039 |
Cast supplies, short leg cast, pediatric (0–10 years), plaster |
| Q4040 |
Cast supplies, short leg cast, pediatric (0–10 years), fiberglass |
| Evaluations |
| Procedure Code |
Description |
| 97161 |
Physical therapy evaluation: low complexity, requiring these components:
- A history with no personal factors and/or comorbidities that impact the plan of care;
- An examination of body system[s] using standardized tests and measures addressing one to two elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
- A clinical presentation with stable and/or uncomplicated characteristics; and
- Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face to face with the patient and/or family. |
| 97162 |
Physical therapy evaluation: moderate complexity, requiring these components:
- A history of present problem with one to two personal factors and/or comorbidities that impact the plan of care;
- An examination of body system[s] using standardized tests and measures addressing a total of three or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
- An evolving clinical presentation with changing characteristics; and
- Clinical decision making of moderate complexity using measurable assessment of functional outcome.
Typically, 30 minutes are spent face to face with the patient and/or family.
|
| 97163 |
Physical therapy evaluation: high complexity, requiring these components:
- A history of present problem with three or more personal factors and/or comorbidities that impact the plan of care;
- An examination of body systems using standardized tests and measures addressing a total of four or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
- A clinical presentation with unstable and unpredictable characteristics; and
- Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face to face with the patient and/or family.
|
| 97164 |
Re-evaluation of physical therapy established plan of care, requiring these components:
- An examination including a review of history and use of standardized tests and measures is required; and
- Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face to face with the patient and/or family.
|
| Modalities |
| Procedure Code |
Description |
| G0281 |
Electrical stimulation, (unattended), to one
or more areas, for chronic stage iii and stage iv pressure ulcers, arterial
ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating
measurable signs of healing after 30 days of conventional care, as part of a
therapy plan of care |
| G0282 |
Electrical stimulation, (unattended), to one
or more areas, for wound care other than described in G0281 |
| G0283 |
Electrical stimulation (unattended), to one
or more areas for indication(s) other than wound care, as part of a therapy
plan of care |
| 90901 |
Biofeedback training by any
modality |
| 97012 |
Application of a modality to one
or more areas; traction, mechanical |
| 97016 |
vasopneumatic devices |
| 97018 |
paraffin bath |
| 97022 |
whirlpool |
| 97024 |
diathermy (eg, microwave) |
| 97026 |
infrared |
| 97028 |
ultraviolet |
| 97032 |
Application of a modality to one
or more areas; electrical stimulation (manual), each 15 minutes |
| 97033 |
iontophoresis, each 15 minutes |
| 97034 |
contrast baths, each 15 minutes |
| 97035 |
ultrasound, each 15 minutes |
| 97036 |
Hubbard tank, each 15 minutes |
| 97039 |
Unlisted modality (specify type
and time if constant attendance) |
| Therapeutic Procedures |
| Procedure Code |
Description |
| 97110 |
Therapeutic procedure, one or more areas,
each 15 minutes; therapeutic exercises to develop strength and endurance,
range of motion and flexibility |
| 97112 |
neuromuscular reeducation of movement,
balance, coordination, kinesthetic sense, posture, and/or proprioception for
sitting and/or standing activities |
| 97113 |
aquatic therapy with therapeutic exercises |
| 97116 |
gait training (includes stair climbing) |
| 97124 |
massage, including effleurage, petrissage
and/or tapotement (stroking, compression, percussion) |
| 97139 |
Unlisted therapeutic procedure (specify) |
| 97140 |
Manual therapy techniques (eg,
mobilization/manipulation, manual lymphatic drainage, manual traction), one
or more regions, each 15 minutes |
| 97150 |
Therapeutic procedure(s), group (two or more individuals) (Report 97150 for each member of the group) (Group Therapy procedures involve constant attendance of the physician or therapist, but by definition do not require one-on-one member contact by the physician or therapist) |
| 97530 |
Therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve
functional performance), each 15 minutes |
| 97533 |
Sensory integrative techniques to enhance
sensory processing and promote adaptive responses to environmental demands,
direct (one-on-one) patient contact, each 15 minutes |
| 97535 |
Self-care/home management training (eg,
activities of daily living (ADL) and compensatory training, meal
preparation, safety procedures, and instructions in use of assistive
technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes |
| 97542 |
Wheelchair management (eg, assessment,
fitting, training), each 15 minutes |
| 97597 |
Removal of devitalized tissue from wound(s),
selective debridement, without anesthesia (eg, high pressure waterjet
with/without suction, sharp selective debridement with scissors, scalpel and
forceps), with or without topical application(s), wound assessment, and
instruction(s) for ongoing care, may include use of a whirlpool, per
session; total wound(s) surface area less than or equal to 20 square
centimeters |
| 97598 |
total wound(s) surface area greater than 20
square centimeters |
| 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 |
| 97761 |
Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes |
| 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 |
| E-Visits and Virtual Check-ins |
| Procedure Code |
Description |
| 98970 |
Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; 5–10 minutes |
| 98971 |
Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 11–20 minutes |
| 98972 |
Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes |
| G2250 |
Remote assessment of recorded video and/or images submitted by an established patient (eg, store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment |
| G2251 |
Brief communication technology-based service (eg, virtual check-in) by a qualified health care professional who cannot report Evaluation and Management services, provided to an established patient, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of clinical discussion |
| Other Procedures |
| Procedure Code |
Description |
| 93797 |
Physician services for outpatient cardiac
rehabilitation; without continuous ECG monitoring (per session) |
| 93798 |
with continuous ECG monitoring (per session) |
| 94667 |
Manipulation chest wall, such as cupping,
percussing, and vibration to facilitate lung function; initial demonstration
and/or evaluation |
| 94668 |
subsequent |
A unit of time is attained when the mid-point is passed. Providers should refer to the CPT guidelines for direction on reporting units on time-based and non-time-based procedures.
The same modality may not be reimbursed as a PT service and an OT service on the same DOS for the same member. Topic #2752 Place of Service Codes
Allowable POS codes for PT, OT, and SLP are listed in the following table.
| POS Code |
Description |
| 02 |
Telehealth Provided Other Than in Patient's Home |
| 04* |
Homeless Shelter |
| 05 |
Indian Health Service Free-Standing Facility |
| 06 |
Indian Health Service Provider-Based Facility |
| 07 |
Tribal 638 Free-Standing Facility |
| 08 |
Tribal 638 Provider-Based Facility |
| 10 |
Telehealth Provided in Patient's Home |
| 11 |
Office |
| 12* |
Home |
| 15 |
Mobile Unit |
| 19 |
Off Campus—Outpatient Hospital |
| 20 |
Urgent Care Facility |
| 21 |
Inpatient Hospital |
| 22 |
On Campus—Outpatient Hospital |
| 31 |
Skilled Nursing Facility |
| 32 |
Nursing Facility |
| 33 |
Custodial Care Facility |
| 34 |
Hospice |
| 50 |
Federally Qualified Health Center |
| 54 |
Intermediate Care Facility/Individuals With Intellectual Disabilities |
| 71 |
Public Health Clinic |
| 72 |
Rural Health Clinic |
| 99* |
Other Place of Service |
* POS codes 04, 12, and 99 are eligible for the natural environment enhanced reimbursement when providing services to members who participate in the Birth to 3 Program when the natural environment modifier is indicated on the claim. Topic #2798 Speech and Language Pathology Birth to 3 Procedure Codes
Allowable SLP Birth to 3 services are identified by the CPT procedure codes listed in the following table.
Note: All codes listed in this chart, if billed with an applicable POS code, are eligible for natural environment enhanced reimbursement. As with Medicare, providers may not submit a claim for services for less than eight minutes. Most procedure codes for SLP services do not have a time increment indicated in their description. Except as noted above, a quantity of "1" indicates a complete service. The daily service limitation for these codes is one.
| Procedure Code |
Description |
Billing Limitations |
ForwardHealth Coverage Criteria |
| 92507 |
Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual |
Cannot use on the same DOS as 92507 UC. |
Therapy addressing communication/cognitive impairments and voice prosthetics should use this code. If treatment focus is aural rehabilitation as a result of a cochlear implant, submit a PA request using the PA/TA, to request code 92507 UC. |
| 92508 |
group, two or more individuals |
|
Group is limited to two to four individuals. |
| 92521 |
Evaluation of speech fluency (e.g., stuttering, cluttering) |
|
Evaluation must provide a quantitative and/or qualitative description of the member's fluency level and/or evaluation must provide a measurement of speaking rate such as SPM. Member's fluency may be documented through results of a commercial stuttering severity instrument and/or description of frequency and severity, types of dysfluencies, secondary characteristics, and self-awareness/perception/self-correction. |
| 92522 |
Evaluation of speech sound productions (e.g., articulation, phonological process, apraxia, dysarthria) |
Not allowed on the same DOS as 92523. |
Evaluation must provide a quantitative and/or qualitative description of member's speech intelligibility. Member's speech sound production may be documented using results of standardized tests, reporting percent of intelligibility by familiar and unfamiliar listeners when context is known and unknown, and/or describing signs and symptoms of disordered sound production. |
| 92523 |
with evaluation of language comprehension and expression (e.g., receptive and expressive language) |
Not allowed on the same DOS as 92522.
If the member is evaluated only for language, procedure code 92523 should be billed with modifier 52. |
Evaluation must provide a quantitative and/or qualitative description of member's speech intelligibility. Member's abilities may be documented using results of standardized tests, reporting percent of intelligibility by familiar and unfamiliar listeners when context is known and unknown, and/or reporting signs and symptoms of disordered sound production and report of member's receptive and expressive language abilities using standardized test results, norm referenced data, developmental levels, and/or estimate of language age-equivalent levels if formal testing is unable to be completed. |
| 92524 |
Behavioral and qualitative analysis of voice and resonance |
|
Evaluation must provide a quantitative and/or qualitative measurement of the member's voice and resonance including but not limited to perceptual ratings of voice quality, pitch, and loudness, and description of member's awareness of vocal problem, and phonatory behaviors.
This procedure does not include instrumental assessment. |
| 92526 |
Treatment of swallowing dysfunction and/or oral function for feeding |
|
The member must have an identified physiological swallowing and/or feeding problem. This is to be documented using professional standards of practice such as identifying oral phase, esophageal phase or pharyngeal phase dysphagia, baseline of current swallowing and feeding skills not limited to signs of aspiration, an oral mechanism exam, report of how nutrition is met, current diet restrictions, compensation strategies used, and level of assistance needed. |
| 92597 |
Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech |
Cannot use on the same DOS as 96105. |
This code describes the services to evaluate a patient for the use of a voice prosthetic device (for example, electrolarynx, tracheostomy-speaking valve). Evaluation of picture communication books, manual picture boards, sign language, the Picture Exchange Communication System, picture cards, gestures, etc., are not included in the reimbursement for this code. Instead, use code 92506. |
| 92607* |
Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour |
Cannot use on the same DOS as 96105. |
This code describes the services to evaluate a patient to specify the speech-generating device recommended to meet the member's needs and capacity. This can also be used for re-evaluations. Evaluation of picture communication books, manual picture boards, sign language, the Picture Exchange Communication System, picture cards, gestures, etc., are not included in the reimbursement for this code. Instead, use code 92506. |
| 92608** |
each additional 30 minutes |
This code can only be billed in conjunction with 92607. |
A maximum of 90 minutes is allowable. The maximum allowable number of units for this service is one unit of 92607 and one unit of 92608. |
| 92609 |
Therapeutic services for the use of speech-generating device, including programming and modification |
|
This code describes the face-to-face services delivered to the member to adapt the device to the member and train him or her in its use. |
| 92610 |
Evaluation of oral and pharyngeal swallowing function |
|
|
| 97129 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes |
|
|
| 97130 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure) |
|
|
* The procedure code description defines this code as one hour. One unit of this code equals 1 hour. If less than one hour is used, bill in decimals to the nearest quarter hour. For example, 45 minutes equals .75 units and 30 minutes equals .5 units. If more than one hour of service is provided, up to one unit of code 92608 can be used in combination with this code.
** The procedure code description defines this code as 30 minutes. One unit of this code equals 30 minutes. If less than 30 minutes is used, bill in decimals to the nearest quarter hour. For example, 15 minutes equals .5 units. Topic #2794 Speech and Language Pathology Procedure Codes
Allowable SLP services are identified by the allowable CPT procedure codes listed in the following table.
Note: All codes listed in this chart, if billed with an applicable POS code, are eligible for natural environment enhanced reimbursement. Providers may not submit claims for services for less than eight minutes. Most procedure codes for SLP services do not have a time increment indicated in their description. Except as previously noted, a quantity of "1" indicates a complete service. The daily service limitation for these codes is one.
| Procedure Code |
Description |
Billing Limitations |
ForwardHealth Coverage Criteria |
| G2250 |
Remote assessment of recorded video and/or images submitted by an established patient (eg, store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment |
- Cannot take place during an in-person visit.
- Cannot take place within seven days after an in-person visit furnished by the same provider.
- Cannot trigger an in-person visit within 24 hours or the soonest available appointment.
- Do not have sufficient information from the remote evaluation of an image or video (store and forward) for the provider to complete the service.
Only the relevant in-person procedure code that was rendered would be reimbursed if any of the above conditions apply. |
These services do not require prior authorization and are patient-initiated by established patients of the provider's practice. |
| G2251 |
Brief communication technology-based service (eg, virtual check-in), by a qualified health care professional who cannot report Evaluation and Management services, provided to an established patient, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of clinical discussion |
- Cannot take place during an in-person visit.
- Cannot take place within seven days after an in-person visit furnished by the same provider.
- Cannot trigger an in-person visit within 24 hours or the soonest available appointment.
- Do not have sufficient information from the remote evaluation of an image or video (store and forward) for the provider to complete the service.
Only the relevant in-person procedure code that was rendered would be reimbursed if any of the above conditions apply. |
These services do not require prior authorization and are patient-initiated by established patients of the provider's practice. |
| 31575 |
Laryngoscopy, flexible; diagnostic |
|
Use this code if the speech-language pathologist actually inserts a laryngoscope. Do not use this code if the speech-language pathologist is providing an analysis and does not insert the laryngoscope; instead, use code 92506 or 92610, as appropriate. For treatment, use 92507 or 92526, as appropriate. This service is to be performed according to the ASHA Code of Ethics and ASHA Training Guidelines for Laryngeal Videoendoscopy/Stroboscopy. |
| 31579 |
Laryngoscopy, flexible or rigid telescopic, with stroboscopy |
|
Use this code if the speech-language pathologist actually inserts a laryngoscope. Do not use this code if the speech-language pathologist is providing an analysis and does not insert the laryngoscope; instead, use code 92506 or 92610, as appropriate. This service is to be performed according to the ASHA Code of Ethics and ASHA Training Guidelines for Laryngeal Videoendoscopy/Stroboscopy. |
| 92507 |
Treatment of speech, language, voice, communication, and/or auditory processing disorder |
|
This code should be used for therapy services that address communication/cognitive impairments, voice prosthetics, and auditory rehabilitation. |
| 92507 + UC* |
Treatment of speech, language, voice, communication, and/or auditory processing disorder |
|
Use this code for aural rehabilitation following a cochlear implant. |
| 92508 |
group, two or more individuals |
|
"Group speech/language pathology treatment" means the delivery of SLP treatment procedures limited to the areas of expressive language, receptive language, and hearing/auditory training (auditory training, lip reading, and hearing-aid orientation), in a group setting for up to four BadgerCare Plus members (per Wis. Admin. Code § DHS 101.03[69]). |
| 92511 |
Nasopharyngoscopy with endoscope (separate procedure) |
|
Use this code if the speech-language pathologist actually inserts an endoscope. Do not use this code if the speech-language pathologist is providing an analysis and does not insert the scope; instead, use code 92506 or 92610, as appropriate. Use this code for evaluation of dysphagia or assessment of velopharyngeal insufficiency or incompetence. This service is to be performed according to the ASHA Code of Ethics and ASHA Training Guidelines for Laryngeal Videoendoscopy/Stroboscopy. |
| 92512 |
Nasal function studies (eg, rhinomanometry) |
|
Use this code if completing aerodynamic studies, oral pressure/nasal airflow, flow/flow studies, or pressure/pressure studies. |
| 92520 |
Laryngeal function studies (eg, aerodynamic testing and acoustic testing) |
|
Use this code for laryngeal airflow studies, subglottic air pressure studies, acoustic analysis, EGG laryngeal resistance. |
| 92521 |
Evaluation of speech fluency (eg, stuttering, cluttering) |
|
Evaluation must provide a quantitative and/or qualitative description of the member's fluency level and/or evaluation must provide a measurement of speaking rate such as SPM. Member's fluency may be documented through results of a commercial stuttering severity instrument and/or description of frequency and severity, types of dysfluencies, secondary characteristics, and self-awareness/perception/self-correction. |
| 92522 |
Evaluation of speech sound productions (eg, articulation, phonological process, apraxia, dysarthria) |
Not allowed on the same DOS as 92523. |
Evaluation must provide a quantitative and/or qualitative description of member's speech intelligibility. Member's speech sound production may be documented using results of standardized tests, reporting percent of intelligibility by familiar and unfamiliar listeners when context is known and unknown, and/or describing signs and symptoms of disordered sound production. |
| 92523 |
with evaluation of language comprehension and expression (eg, receptive and expressive language) |
Not allowed on the same DOS as 92522.
If the member is evaluated only for language, procedure code 92523 should be billed with modifier 52. |
Evaluation must provide a quantitative and/or qualitative description of member's speech intelligibility. Member's abilities may be documented using results of standardized tests, reporting percent of intelligibility by familiar and unfamiliar listeners when context is known and unknown, and/or reporting signs and symptoms of disordered sound production and report of member's receptive and expressive language abilities using standardized test results, norm referenced data, developmental levels, and/or estimate of language age-equivalent levels if formal testing is unable to be completed. |
| 92524 |
Behavioral and qualitative analysis of voice and resonance |
|
Evaluation must provide a quantitative and/or qualitative measurement of the member's voice and resonance including but not limited to perceptual ratings of voice quality, pitch, and loudness, and description of member's awareness of vocal problem, and phonatory behaviors.
This procedure does not include instrumental assessment. |
| 92526 |
Treatment of swallowing dysfunction and/or oral function for feeding |
|
The member must have an identified physiological swallowing and/or feeding problem. This is to be documented using professional standards of practice such as identifying oral phase, esophageal phase, or pharyngeal phase dysphagia, baseline of current swallowing and feeding skills not limited to signs of aspiration, an oral mechanism exam, report of how nutrition is met, current diet restrictions, compensation strategies used, and level of assistance needed. |
| 92597 |
Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech |
Cannot use on the same DOS as 96105. |
This code describes the services to evaluate a member for the use of a voice prosthetic device (eg, electrolarynx, tracheostomy-speaking valve). Evaluation of picture communication books, manual picture boards, sign language, the Picture Exchange Communication System, picture cards, gestures, etc., are not included in the reimbursement for this code. Instead, use code 92506. |
| 92607** |
Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour |
Cannot use on the same DOS as 96105. |
This code describes the services to evaluate a member to specify the speech-generating device recommended to meet the member's needs and capacity. This can also be used for re-evaluations. Evaluation of picture communication books, manual picture boards, sign language, the Picture Exchange Communication System, picture cards, gestures, etc., are not included in the reimbursement for this code. Instead, use code 92506. |
| 92608*** |
each additional 30 minutes (List separately in addition to code for primary procedure) |
This code can be billed only in conjunction with 92607. |
The maximum allowable number of units for this service is one unit of 92607 and one unit of 92608 (that is, a maximum of 90 minutes). |
| 92609 |
Therapeutic services for the use of speech-generating device, including programming and modification |
|
This code describes the face-to-face services delivered to the member to adapt the device to the member and train him or her in its use. |
| 92610 |
Evaluation of oral and pharyngeal swallowing function |
|
|
| 92611 |
Motion fluoroscopic evaluation of swallowing function by cine or video recording |
|
Accompanying a member to a swallow study is not reimbursable. This code involves participation and interpretation of results from the dynamic observation of the member swallowing materials of various consistencies. It is observed fluoroscopically and typically recorded on video. The evaluation involves using the information to assess the member's swallowing function and to develop a treatment. |
| 92612 |
Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; |
|
|
| 92614 |
Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; |
Only allowable when used in conjunction with 92612. |
|
| 92626 |
Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour |
|
|
| 92627 |
Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (List separately in addition to code for primary procedure) |
|
|
| 92700 |
Unlisted otorhinolaryngological service or procedure |
|
PA is always required to use this code. Use this code when no other CPT code description appropriately describes the evaluation or treatment. |
| 96105** |
Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing [eg, by Boston Diagnostic Aphasia Examination]) with interpretation and report, per hour |
Cannot use on the same DOS as 92506, 92597, 92607, or 92608. |
|
| 97129 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes |
|
|
| 97130 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure) |
|
|
| 98970 |
Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; 5–10 minutes |
- Cannot take place during an in-person visit.
- Cannot take place within seven days after an in-person visit furnished by the same provider.
- Cannot trigger an in-person visit within 24 hours or the soonest available appointment.
- Do not have sufficient information from the remote evaluation of an image or video (store and forward) for the provider to complete the service.
Only the relevant in-person procedure code that was rendered would be reimbursed if any of the above conditions apply. |
These services do not require prior authorization and are patient-initiated by established patients of the provider's practice. |
| 98971 |
Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 11–20 minutes |
- Cannot take place during an in-person visit.
- Cannot take place within seven days after an in-person visit furnished by the same provider.
- Cannot trigger an in-person visit within 24 hours or the soonest available appointment.
- Do not have sufficient information from the remote evaluation of an image or video (store and forward) for the provider to complete the service.
Only the relevant in-person procedure code that was rendered would be reimbursed if any of the above conditions apply. |
These services do not require prior authorization and are patient-initiated by established patients of the provider's practice. |
| 98972 |
Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes |
- Cannot take place during an in-person visit.
- Cannot take place within seven days after an in-person visit furnished by the same provider.
- Cannot trigger an in-person visit within 24 hours or the soonest available appointment.
- Do not have sufficient information from the remote evaluation of an image or video (store and forward) for the provider to complete the service.
Only the relevant in-person procedure code that was rendered would be reimbursed if any of the above conditions apply. |
These services do not require prior authorization and are patient-initiated by established patients of the provider's practice. |
* Use 92507 with modifier "UC" for therapy following a cochlear implant.
** The procedure code description defines this code as one hour. One unit of this code = 1 hour. If less than one hour is used, bill in decimals to the nearest quarter hour. For example, 45 minutes = .75 units and 30 minutes = .5 units. If more than one hour of service is provided, up to one unit of code 92608 can be used in combination with this code.
*** The procedure code description defines this code as 30 minutes. One unit of this code = 30 minutes. If less than 30 minutes is used, bill in decimals to the nearest quarter hour. For example, 15 minutes = .5 units. Topic #2751 Unit of Service
Some procedure code descriptions do not specify a unit of time. When an amount of time is not specified, the entire service, for each DOS, equals one unit. For example, descriptions for 94667 (for PT and OT services) and 92612 (for SLP services) do not specify the duration of the service; therefore, one unit indicates the complete service.
Some procedure code descriptions specify a unit of time. When an amount of time is specified, that amount of time equals one unit. For example, the description for 97032 (for PT and OT services) indicates "each 15 minutes;" therefore, 15 minutes are equal to one unit. The description for 92607 (for SLP services) indicates "first hour;" therefore, one hour is equal to one unit.
In addition, part of a unit may be indicated by using a number with a decimal point. For example, in the case of 97140, 7.5 minutes are equal to .5 units. In the case of 92607, 30 minutes are equal to .5 units. (As with Medicare, SLP providers may not submit a claim for services provided for less than eight minutes.) Topic #643 Unlisted Procedure Codes
According to the HCPCS codebook, if a service is provided that is not accurately described by other HCPCS CPT procedure codes, the service should be reported using an unlisted procedure code.
Before considering using an unlisted, or NOC, procedure code, a provider should determine if there is another more specific code that could be indicated to describe the procedure or service being performed/provided. If there is no more specific code available, the provider is required to submit the appropriate documentation, which could include a PA request, to justify use of the unlisted procedure code and to describe the procedure or service rendered. Submitting the proper documentation, which could include a PA request, may result in more timely claims processing.
Unlisted procedure codes should not be used to request adjusted reimbursement for a procedure for which there is a more specific code available.
Unlisted Codes That Do Not Require Prior Authorization or Additional Supporting Documentation
For a limited group of unlisted procedure codes, ForwardHealth has established specific policies for their use and associated reimbursement. These codes do not require PA or additional documentation to be submitted with the claim. Providers should refer to their service-specific area of the Online Handbook on the ForwardHealth Portal for details about these unlisted codes.
For most unlisted codes, ForwardHealth requires additional documentation.
Unlisted Codes That Require Prior Authorization
Certain unlisted procedure codes require PA. Providers should follow their service-specific PA instructions and documentation requirements for requesting PA. For a list of procedure codes for which ForwardHealth requires PA, refer to the service-specific interactive maximum allowable fee schedule.
In addition to a properly completed PA request, documentation submitted on the service-specific PA attachment or as additional supporting documentation with the PA request should provide the following information:
- Specifically identify or describe the name of the procedure/service being performed or billed under the unlisted code.
- List/justify why other codes are not appropriate.
- Include only relevant documentation.
- Include all required clinical/supporting documentation.
For most situations, once the provider has an approved PA request for the unlisted procedure code, there is no need to submit additional documentation along with the claim.
Unlisted Codes That Do Not Require Prior Authorization
If an unlisted procedure code does not require PA, documentation submitted with the claim to justify use of the unlisted code and to describe the procedure/service rendered must be sufficient to allow ForwardHealth to determine the nature and scope of the procedure and to determine whether or not the procedure is covered and was medically necessary, as defined in Wisconsin Administrative Code.
The documentation submitted should provide the following information related to the unlisted code:
- Specifically identify or describe the name of the procedure/service being performed or billed under the unlisted code.
- List/justify why other codes are not appropriate.
- Include only relevant documentation.
How to Submit Claims and Related Documentation
Claims including an unlisted procedure code and supporting documentation may be submitted to ForwardHealth in the following ways:
- If submitting on paper using the 1500 Health Insurance Claim Form, the provider may do either of the following:
- Include supporting information/description in Item Number 19 of the claim form.
- Include supporting documentation on a separate paper attachment. This option should be used if Item Number 19 on the 1500 Health Insurance Claim Form does not allow enough space for the description or when billing multiple unlisted procedure codes. Providers should indicate "See Attachment" in Item Number 19 of the claim form and send the supporting documentation along with the claim form.
- If submitting electronically using DDE on the Portal, PES software, or 837 electronic transactions, the provider may do one of the following:
- Include supporting documentation in the Notes field. The Notes field is limited to 80 characters.
- Indicate that supporting documentation will be submitted separately on paper. This option should be used if the Notes field does not allow enough space for the description or when billing multiple unlisted procedure codes. Providers should indicate "See Attachment" in the Notes field of the electronic transaction and submit the supporting documentation on paper.
- Upload claim attachments via the secure Provider area of the Portal.
Topic #830 Valid Codes Required on Claims
ForwardHealth requires that all codes indicated on claims and PA requests, including diagnosis codes, revenue codes, HCPCS codes, HIPPS codes, and CPT codes be valid codes. Claims received without valid diagnosis codes, revenue codes, and HCPCS, HIPPS, or CPT codes will be denied; PA requests received without valid codes will be returned to the provider. Providers should refer to current national coding and billing manuals for information on valid code sets.
Code Validity
In order for a code to be valid, it must reflect the highest number of required characters as indicated by its national coding and billing manual. If a stakeholder uses a code that is not valid, ForwardHealth will deny the claim or return the PA request, and it will need to be resubmitted with a valid code.
Code Specificity for Diagnosis
All codes allow a high level of detail for a condition. The level of detail for ICD diagnosis codes is expressed as the level of specificity. In order for a code to be valid, it must reflect the highest level of specificity (that is, contain the highest number of characters) required by the code set. For some codes, this could be as few as three characters. If a stakeholder uses an ICD diagnosis code that is not valid (that is, not to the specific number of characters required), ForwardHealth will deny the claim or return the PA request, and it will need to be resubmitted with a valid ICD diagnosis code. |