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Coding and Reimbursement Guidelines For Thera-Band and Biofreeze Products
Payors require specific documentation for reimbursement of rehabilitation services and supplies. Clinicians may legally bill for services and supplies based on their state's practice acts. You should contact payors to determine approved provider types, coverage & benefits, authorization requirements, as well as codes allowed and forms necessary to submit a claim.
Codes refer to specific numbers assigned to individual treatments or supplies. These include CPT codes for procedures, and HCPCS Level II codes for supplies. "Local Codes" may also be used in your area, particularly with Workers Compensation. Remember that coding is specific to the payor; therefore, it is important to know which codes are applicable. Be aware that code "modifiers" may be required as well. The Resource-Based Relative Value System (RBRVS)is used to determine the reimbursement rate for Medicare. These rates are generally limited to "usual, reasonable, and customary" charges.
||Therapeutic exercise, one or more areas, each 15 min.
||Therapeutic exercises to develop strength and endurance, range of motion and flexibility.|
||Neuromuscular Re-education, one or more areas, each 15 min.
||Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception (such as stabilization or balance training)|
||Aquatic Therapy, one or more areas, each 15 min.
||Aquatic therapy with therapeutic exercises.|
||Group Therapeutic Exercise (2 or more individuals).
||Therapeutic exercises to develop strength and endurance, range of motion and flexibility for 2 or more individuals.|
||Therapeutic Activities, direct hands-on, each 15 minutes.
||Use of dynamic activities to improve functional performance with direct contact by the provider.|
||Manual Therapy techniques, one or more regions, each 15 minutes.
||Mobilization/manipulation, manual lymphatic drainage, manual traction, and soft tissue mobilization|
||Therapeutic Massage, one or more areas, each 15 minutes.
||Includes effleurage, petrissage, and/or tapotement|
||Paraffin Bath, each 15 minutes.
||Application of paraffin bath to one or more areas|
||Self-care / Home Management Training.
||Instruction in self care at home|
||Education and Training for Patient Self-Management
||Education and training performed by a non-physician using a standardized curriculum|
*NOTE: Therapeutic exercise (97110) and therapeutic activities (97530) both require direct one-on-one provision of service according to Medicare guidelines. Therapeutic Exercise includes activities related to strengthening, endurance training, range of motion, and flexibility. Therapeutic Activities utilize dynamic activities to improve functional performance; these are also referred to as the "-ing" codes, for example, "lifting," "pulling," "pushing," "running," and "jumping."
**Aquatic therapy may require extra documentation. Aquatic therapy has suffered poor reimbursement because of confusion between therapy and exercise. Patients should be appropriately selected for aquatic interventions. Aquatic therapy should be differentiated from aquatic exercise as a skilled intervention by a licensed therapist to improve function. Document a timely plan for transition from water to land and integrate functional land components. Provide specific reasons that aquatic therapy is required, including the special properties of water. The therapist must be present, providing one-on-one contact with the patient, but does not have to be physically in the pool.
Reimbursement for Self-Care Products at Home
Home exercise programs are commonly prescribed in addition to in-clinic rehabilitation. There is no specific CPT code for home exercise instruction. The time spent in educating the patient in a home exercise program for strengthening & stretching activities should be designated as therapeutic exercise, 97110. Training for home exercises involving functional activites should use 97530. Remember that these codes are subject to the 'time' rule.
Medicare and most other insurers do not reimburse for exericse equipment used by the patient at home. The products used to deliver the service in the clinic, such as elastic bands, are considered "bundled" in the fee for service and cannot be billed separately. However, patients using these products for home exercise programs under the supervision of a healthcare professional may be billed for the cost of the items. In the unlikely event that an insurer reimburses for these products, check with the payor for specific coding requirements. Provide a full explanation of the supplies and equipment provided, being as specific as possible in regards to the patients limitations and needs. Letters of medical necessity are particularly helpful.
||CPT Supply Code
||HCPCS II Codes|
|Elastic Bands & Tubing
|Exercise Ball / MiniBall
|Stability Trainers and Discs
|Ankle & Wrist Cuff Weights
|Progressive Hand Trainer
|Aquatic Exercise Equipment
|Paraffin Bath Unit*
|Paraffin Bath Refills (per pound)
*Portable paraffin bath units and supplies may be covered when the patient has undergone a successful trial period of paraffin therapy ordered by a provider and the patient's condition is expected to be relieved by long-term use of this modality.
Thera-Band and Biofreeze products are not sold by the Hygenic Corporation direct to consumers; they are only sold through professionals. Since few insurers reimburse the cost of home-based exericse products, it's best to direct-bill patients for the cost of the products. This can easily be done by collecting cash payment for the product at the time of service. Medicare providers should have the patient complete a Notice of Exculsions from Medicare Benefits (NEMB) and an Advanced Beneficiary Notice (ABN) to bill patients for non-covered services. Be sure to provide a receipt and a letter of medical necessity to the patient (download an example here) from the new Thera-Band Exercise Software). Many patients have Flexible Spending Accounts (FSA) or Health Savings Accounts (HSA) that can reimburse patients for out-of-pocket medical expenses. The amount charged by the professional varies, depending on their cost to inventory the products, as well as the market area.
NOTE: For more information on the ethics of physical therapists selling self-care products to patients, visit these links:
APTA Ethics & Judicial Committee Opinion.
Ethical Considerations for Physical Therapists
CPT Code/Relative Value Search This free search engine gives users of CPT the opportunity to perform CPT code searches and obtain information about Medicare's relative value payment amount associated with the codes (Source: AMA)
2007 Coding and Payment Guide for the Physical Therapist. Published by Ingenix.
Guide to Physical Therapist Practice. American Physical Therapy Association: 2nd Ed. Alexandria, Virginia. 2001.