Documentation to support Therapeutic Activities and Neuromuscular Reeducation

Tips on How to avoid denials in a PT & OT audit:

Documentation to support Therapeutic Activities and Neuromuscular Reeducation

Insufficient documentation to support billing Therapeutic Activities and Neuromuscular Reeducation is common in a Medicare audit.  Medicare and Managed Care providers are reviewing the billing and documentation of specific CPT codes more frequently to identify potential billing errors.

Would your documentation make the grade?  Many providers thought theirs would, but after going through an audit, they learned they were wrong, as identified in a publication by the Office of Inspector General (OIG) called “MANY MEDICARE CLAIMS FOR OUTPATIENT PHYSICAL

THERAPY SERVICES DID NOT COMPLY WITH MEDICARE REQUIREMENTS”. 

97530 and 97112 are the focus of at least one Medicare administrative contractor (MAC) under Targeted Probe and Educate (TPE), and they’re an example of why rexperts say that rehab providers should track utilization.

Let’s dive into the specifics needed for billing 97530 (Therapeutic Activities) and 97112 (Neuromuscular reeducation) that should help you avoid or successfully pass an audit.

Therapeutic Activities – 97530

This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance.

The activities are usually directed at a loss or restriction of mobility, strength, balance or coordination. They require the professional skills of a qualified professional and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.

Often seen incorrectly in the support documentation are examples included here:

Step ups 3×10

Side step ups 3×10

Squats with 20# kettlebell 3×15

Overhead lift with 20# kettlebell 3×8

Those “actions” alone support therapeutic exercise (97110), but do not contain enough supportive documentation for therapeutic activities (97530).  While those exercises are working toward something functional, to be documented as a therapeutic activity you should consider “ing” within the verbiage as the “specific outcome it is being directed toward”.  Additionally, whereas even active therapeutic exercises involve one parameter being measured at most (such as strength, flexibility, or endurance), therapeutic activities involve multiple. Instead of performing a single, specific, physical movement, the patient will be engaging in a functional task such as throwing a ball, pushing a cart, or even activities like cooking.

To become supportive toward therapeutic exercise, it should sound something like this: Squat with overhead lift using a 20# kettlebell to simulate good posture and form for picking up her 20# Grandchild, 3×8

The simulation for picking or lifting her Grandchild allows this to support billing 97530 instead of 97110.

By identifying the intent of your treatment, it helps to clarify which code you should be billing under.  For example:

Therapeutic Exercise = Intent to strengthen the quads

Therapeutic Activity = Intent to improve sit to stand transfers

You must identify your intent within your supportive documentation; this will allow you to bill the appropriate code.  You should also consider the complexity of the activity.  Therapeutic exercise is a lower complexity activity for the patient, whereas neuromuscular reeducation and therapeutic activities is a higher complexity activity and requires the documentation to support it as such.

97112 – Neuromuscular Reeducation is one of the most commonly misused codes in outpatient rehab.  97112 means “neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.” Like therapeutic activity, neuromuscular reeducation also applies to one or multiple body parts and requires direct contact with the proper provider.

A common reason for denial in an audit is not properly establishing the need for performing neuro reed in your initial evaluation.

Neuromuscular Re-ed is used to address:

  • Poor motor control and sequencing
  • Decreased balance and stability
  • Lack of coordination
  • Poor ability to recruit muscle with motion (facilitation)
  • Difficulty with timing of muscle recruitment
  • Nerve palsy resulting in muscle flaccidity or weakness (L4-5 impingement/compression; Radial n. palsy)
  • Posture and proprioception in sitting and standing

If you’re going to include Neuromuscular Reeducation in your POC, your objective measures and observation should identify at least one of these areas that is impaired and needs to be addressed in order to achieve the identified long-term goals.  Lack of doing so when 97112 was billed was a reason for denial.

Appropriate documentation for neuromuscular reeducation (97112) may include the following:

• Proprioceptive Neuromuscular Facilitation (PNF)

• Feldenkrais

• Bobath (NDT)

• BAPS (for balance, position sense and motor control; not for ROM and strengthening)

• Clinical Test for Sensory Interaction in Balance (CTSIB)

• Tinetti Balance Assessment

• Berg Balance Test

• Timed Up and Go Test (TUG)

• Romberg’s Test

• Functional Reach

• Developmental motor learning and sequencing tasks

• Spatial awareness

• Kinesthetic sense

• Postural training

• Stabilization programs

• Desensitization

• Development of Gross Motor Coordination

• Development of Fine Motor Coordination

For example, any open chain shoulder exercises without additional documentation would be appropriate under therapeutic exercises.  If you use manual and/or tactile cues and have a patient perform open-chain shoulder exercises with closed eyes, then this procedure will facilitate proper scapulohumeral rhythm and position sense and can be billed as 97112.

Does your EMR help you with functionality that helps to support these codes?  Even in some of the best it’s still the clinical decision of the therapist of when the interventions are appropriate and providing the necessary supportive documentation throughout the episode of care to support continued medical necessity.  Let us help!  Schedule a demo so we can show you how OptimisPT and our embedded compliance features help you provide documentation that supports medical necessity throughout the episode of care.