CPT code 97139
CPT code 97139 bills for specific therapeutic procedures not found in the current CPT code set that is maintained by the American Medical Association. There are instances when an occupational therapist creates a specific and custom intervention for the client that may not fall into any other designated codes for physical medicine and rehabilitation, allowing the therapist to charge for their skilled service under this code.
Although unspecified, there are still requirements and suggested information you should include in your documentation to specify why this procedure code is necessary. This article will outline standard information required when using procedure codes to ensure compliance and accurate reimbursement for your services.
Understanding CPT code 97139
CPT code 97139 is a current procedural terminology code to classify unlisted therapeutic procedures. This code is distinctly used by therapists for procedures. Therapists will bill unlisted modalities as CPT® code 97139. Therapists are required to specify what this procedure was, why it was necessary, and justify its therapeutic benefit. Therapists will also need to document quality and safety measures when using new equipment for a procedure that is FDA-cleared or if there is supporting evidence to prove its therapeutic benefit.
Procedures included within this code include use of modalities or interventions that cannot be defined by existing CPT codes. Justifying medical necessity looks like other codes in that you need to include the following information:
Medical necessity and coverage criteria:
- Documentation must include disease or condition that qualifies for skilled service
- Documentation of objective measurements that show decreased participation or independence during ADLs and IADLs due to performance limitations, pain, or environmental limitations
- Document how evidence supports the procedure's benefit for client diagnosis or condition and clinical rationale for using specific procedure
- Document that procedure is consistent with the chief complaint/clinical findings, and conditions included in the treatment plan
In addition to documentation required for medical necessity, therapists should include the following information in their documentation.
- Document clear link from how specific procedure billed will help clients meet their treatment goals
- Document how direct clinical skill was required by describing the amount and what type of assistance was required
- Clearly document how direct treatment time was used including start and end times to accompany units billed
- Include signature of supervising therapist in documentation for each date of service
- Document specificity for either modality or procedure including type, rationale, location being treated, settings or frequency as applicable, and actual time service was provided
- Document client education and why additional units are required if planning to use this code during multiple visits
- Document how therapy is adapting to client progress and how the procedure is supporting clients in meeting goals reported in their treatment plan
CPT code 97139 and occupational therapy
The Centers for Medicare and Medicaid Services, CMS, states on their website that this code should be used infrequently and be submitted with sufficient information to justify its use.
CPT code 97139 will require additional information for reimbursement including evidence-based resources to justify clinical rationale. New treatment techniques or modalities may fall within this code, requiring current research to support clinical decisions linking procedure used to client impairment requiring skilled services. Occupational therapy treatment plans are specific and may be customized to meet a client’s need to the extent that an unlisted code may be appropriate in helping a client meet their goals.
Maximizing reimbursement for CPT code 97139
Because this code is for unlisted procedures, it may be susceptible to an audit. Therapists should include strong justification when billing for unlisted procedures. Supportive evidence cited, medical necessity justified, and therapeutic benefit recorded, such as frequent pain ratings or objective measures to show improvement of documented impairments and improving participation.
Coding and billing tips for CPT code 97139
The Centers for Medicare and Medicaid Services provides an annual list of coding updates with qualifications and restrictions for each code called the Medicare National Correct Coding Initiative (NCII edits).
Current guidance for using CPT code 97139 include modifiers to distinguish which provider administered the service.
- Modifier 59 is required per CMS guidelines when billed with codes 97164 (Physical Therapy Evaluation) and 97168 (Occupational Therapy Evaluation) when used for the same date of service.
- Coding restrictions include that procedure code 97139 cannot be billed on the same date of service with codes for IV access, infusion services, or blood specimen codes.
Review the CMS website for further guidelines and NCII edits about using this code for more information. Clear and supportive documentation is key for reimbursement when using this code in your practice. Ensure your medical necessity is well justified and that your documentation is complete to increase your chances of timely and accurate reimbursement for your services when billing CPT code 97139.
CPT code 97139 and compliance
CPT code 97139 is a timed code, meaning providers will follow the eight-minute rule, charging per 15-minute increments and constant attendance by the provider during the procedure. This code also requires direct care by a qualified professional with documentation recording the involvement of the supervising therapist in the provision of care.
Potential compliance risks associated with CPT code 97139 include not providing enough supportive information in your documentation or not using a procedure supported by evidence when utilizing this code. As this code is for unlisted procedures, strong justification is required to support that the unlisted procedure is medically necessary and beneficial for the claim to be considered for reimbursement.
Strategies for ensuring compliance include discussing the exact procedure you plan to use with the client’s care team, including the referring physician and a representative from the insurance provider, ensuring no other procedure codes will qualify for the specific procedure you intend to bill and making sure you include required modifiers as needed.
Some insurance payors may require you to notify them before using this procedure code, so due diligence is necessary to ensure you provide sufficient information for accurate and prompt reimbursement.
Although infrequent, you may need to bill for an unlisted procedure when working through a treatment plan. All parties involved, including the client, referring physician, and insurance payor, should be aware when using an unlisted procedure to communicate what to expect once the claim is submitted. Provide supporting documentation to justify why this procedure is necessary. Healthcare is constantly evolving, with new ideas, and techniques continually created that may require the use of this CPT code 97139.
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