CPT code 97535
Introduction
CPT code 97535 is used by occupational therapists to indicate billing for training for self-care, home management, ADLs, compensatory training, safety procedures, and incorporating assistive devices into a routine.
This is a timed code requiring the use of the 8-minute rule and direct one-to-one service delivery by the provider. Occupational therapists use this code frequently as they specialize in participation and help clients with treatments directly applied to self-care and home management activities. This article will explore details to consider when using this code in your practice.
Understanding CPT Code 97535
The American Medical Association defines CPT code 97535 as Self-care/home management training (e.g., activities of daily living [ADLs] and compensatory training, meal preparation, safety procedures, and instructions in the use of assistive technology devices/adaptive equipment), direct one-on-one contact, every 15 minutes.
Procedures included in this procedure code include:
- Training a client in using adaptive dressing strategies following a surgery with safety precautions
- Using energy conservation strategies to maintain a home independently
- Training a client how to use compensatory strategies after a stroke
- Additional procedures include training for ADLs, compensatory training for ADLs, safety procedures, adaptive equipment training and assistive technology for use in the home environment. This code is not used for all home instruction, however. The code for the activity that best describes the self-management activity pertaining to your service such as using procedure code 97535 to bill for teaching a client safety strategies during meal preparation versus home instruction of a home program for a balance and coordination which may fall under procedure code 97112.
Medical necessity and coverage criteria:
The following elements must be included in your documentation to support medical necessity and coverage of CPT code 97535.
- Prior level of function documented along with current outcome measures that report the client has experienced a decline in self-care, ADLs, or home management due to an injury, illness, or disability.
- If a client is currently receiving assistance from a caregiver for ADLs and has the potential to increase participation through intervention.
- If a client requires compensatory training to safely complete ADLs, self-management, or home maintenance while adhering to new movement limitations such as training a client to perform ADL’s while adhering to back precautions after a surgery.
- Repetition of same techniques for ADLs and home management after modified independent status has been achieved by the client, will not be considered skilled and therefore not billable.
- It must be documented that the client must have the capacity to learn from instructions.
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Documentation requirements
Supportive documentation is required every ten visits to document current objective measures to illustrate improvement and impairments addressed through intervention.
Standard documentation requirements include:
- Objective measurements of the client’s ADL abilities that have improved and what needs continued intervention.
- Detailed ADL and/or compensatory training provided, specific safety procedures instructed, specific adaptive equipment or technology used, type of assistance still required (verbal or physical), and the client’s response to the intervention.
- Why the client needs continued skilled services to meet goals stated in-treatment plan.
- Intervention billed must directly relate to goals listed in-treatment plan with clear documentation linking treatment to goals.
- Goals listed in-treatment plan should be client centered, strengths based and include a goal of supporting the client to return to the highest level of independence attainable.
CPT code 97535 and occupational therapy
Occupational therapy services covered by CPT code 97535 include a variety of interventions where the therapist is helping the client with direct ADL, self-management, and home management activities. Therapists often use a performance-based approach to analyze strengths and impairments, with interventions applied directly to goal activities. Modalities are generally billed separately from CPT code 97535, as this code is specific to self and home management. Modalities are billed during a separate time, per device, and with supporting documentation to detail why modalities were necessary during the same session.
Examples of how CPT code 97535 fits into occupational therapy treatment plans:
- A client with a traumatic brain injury requires memory support and use of assistive technology for memory impairment to support ADL independence.
- An individual with multiple sclerosis needs assistance with energy conservation techniques to complete all necessary ADLs successfully.
- An elderly client experiencing limited strength working on using compensatory strategies and use of assistive devices to complete meal preparation independently.
Maximizing reimbursement for CPT code 97535
For reimbursement, the client must meet the medical necessity criteria with good rehab potential for improving self-management/home management abilities with treatment. Services must document medical necessity and be directly related to their qualifying condition requiring your services. Common reimbursement issues include incomplete documentation, not documenting the skill of the therapist, or if treatment time was shared with a concurrent session.
Coding and billing tips for CPT code 97535
Some billing considerations when using CPT code 97535 include:
- Adhere to the 8-minute rule with documentation to support why additional time and units were needed of procedure code 97535. For example, if a therapist required 45 minutes, or 3 units of procedure code 97535 due to energy conservation, environmental modification or the client requiring additional time to complete activity, the therapist would document the context to justify why additional units were required.
- Ensure medical necessity criteria is met and documentation requirements such as appropriate objective measurements are included in your medical record.
- Ensure key documentation elements are included in your notes for reimbursement success including documentation of clients progress or continued limitations to meeting goals, signed treatment notes, and necessary modifications to treatment plan to reflect clients amount of progress.
CPT code 97535 compliance
Compliance regulations include that clinical service must be delivered by a licensed therapist, or a physician through direct, one-to-one contact with the client. If an assistant is providing the service, a modifier may be required to distinguish which type of provider delivered the service, and collaboration with a supervising therapist must be documented. Potential compliance risks associated with procedure code 97535 include charging for unskilled treatment and incomplete documentation.
Strategies for ensuring compliance
Document your steps to ensure compliance by reflecting the following strategies into your medical documentation:
- Use performance-based intervention, directly incorporating the ADL, home management, self-care, or compensatory strategy into your treatment.
- Include documentation that the client is experiencing limited ADL, self-care or home management participation that will benefit from intervention and that the client has cognitive capacity to benefit from intervention.
- Use a hands-on approach by actively demonstrating, assisting, and providing education during treatment.
- Intervention must relate to goals in-treatment plan for increased independence in activities practiced during the session.
Conclusion
Key considerations for using this code include ensuring that your treatment time respects the 8-minute rule, is one-to-one care with the client, and is directly related to ADL, compensatory training, meal preparation, home management, safety procedures, or instructions for the use of assistive devices, for your treatment to align with CPT code 97535.
Occupational therapists emphasize the whole picture with a top-down approach, emphasizing the actual performance of self-care and home management to help clients achieve greater independence.
Resources
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More resources
- Activities for daily living
- Occupational therapy billing units
- Occupational therapy ICD codes
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
