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Supporting Medical Necessity of CPT Code 97016

January 07, 2019
Documentation, Billing, & Coding By Deborah Alexander, Director

On December 14, 2018, Noridian provided an update within their “Fees and News Update,” which was published on December 17, 2018 regarding billing of CPT code 97016 for Vasopnuematic devices. Noridian reported multiple outpatient reviews have noted insufficient documentation to support use and billing for the use of vasopnuematic devices to apply pressure to an extremity to reduce swelling.

MedicalNecessity_97016


Noridian provided informational guidelines and documentation expectations to meet Medicare’s coverage to support 97016.  Here are the findings/guidelines from the update:

  • CPT Code 97016 is an “always therapy,” service-based code and as such can only be billed as 1 unit regardless of treatment time provided;
  • The services must be provided by a qualified clinician, i.e., physician, non-physician practitioner, licensed therapist and/or therapy assistant;
  • The services must be supported in the medical record initial evaluation, certified plan of care, progress reports and treatment encounter notes; and
  • The documentation must demonstrate the edema is significant, interferes with the patient’s functional abilities and fully meets the CPT descriptor.

What are some of the key takeaways!

  • It is important to establish the medical necessity of vasopnuematic treatment on the date of the Initial Evaluation (IE). This is typically captured by taking bilateral volumetric or circumferential measurements.
  • When an edema discrepancy is determined during the IE physical examination AND this discrepancy is having a negative impact on the patient’s function, it is important to document this relevance within the clinical assessment summary. Documenting the relevance improves medical necessity support when establishing the treatment plan interventions.
  • Create a goal specifically addressing how edema treatment will create a functional gain.
  • Noridian stated the use of CPT 97016 is to be supported in the IE, Certified POC, Progress Reports and Treatment Encounter notes.
  • Documenting pre and post-treatment edema measurements while capturing an improvement in the patient’s function further supports medical necessity of the edema treatment.

It is important to recognize this is an update provided by Noridian, a Medicare Administrative Contractor, and as such, may not apply to all payers.  Providers should be familiar with various payer medical and payment policies regarding use and billing of CPT 97016.

LW Consulting, Inc.’s rehabilitation consultants provide on-site or remote coding and billing training, therapy documentation auditing and compliance consulting. Contact Deborah Alexander, CHC, CHPC, DPT, MED, ATC, CSCS by calling 215-907-8740 or email DAlexander@LW-Consult.com.

Need additional help with documentation compliance? Don't miss our 3-part webinar series beginning January 23, 2019, "Documenting Skilled, Reasonable and Medically Necessary Care in Outpatient Therapy."

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