Monthly Archives: May 2015

Documentation and Proper Billing of Physical Medicine and Rehabilitation Services

Modalities (e.g., heat, mechanical traction or ultrasound) are generally coded and billed based on the device that is used.

Therapeutic procedures are generally coded and billed on the basis of the intended outcome, not on a device or piece of equipment. For instance therapeutic exercise, 97110, is intended to increase strength, flexibility, and/or endurance while neuromuscular re-education, 97112, is to restore balance, coordination, proprioception, kinesthetic sense etc. The movement or activity can be very similar in these services and as a consequence the proper code to represent the service will depend on the outcome or purpose of the service.

When billing and coding for therapeutic procedures, document the intended clinical outcome, as well as how the procedure is performed. Bear in mind that the documentation should indicate a relationship to a functional improvement and activity as a result of care.

For example: Increase flexibility of the lumbar paraspinal muscles, while activating and stretching the hamstring muscles, to improve the patient’s capacity for walking and standing. This relationship can be easily documented as part of the subjective and objective sections of the chart notes.