97166
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
1.54
Facility
$100.54
Non-Facility
$100.54
Documentation Required
- An updated and completed OASIS M2200 for the billing period must be in the patient's medical record and made available to the Medicare Administrative Contractor upon request to support medical necessity for therapy services.
- Medical records must document which modalities and specific procedures were performed for each therapy visit and be available to the MAC upon request.
- When multiple heating modalities are provided the same date of service, documentation of the medical necessity for multiple modalities must be present in the medical record.
- For CPT 97032 include the type of electrical stimulation (manual/attended), treatment area(s), objective strength ratings and functional deficits if used for muscle weakness, and pain rating/location/effect on function if used for pain.
Key Coverage Criteria
- Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
- Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
- Wheelchair management training (CPT 97542) is covered for patient and/or caregiver training in transfers and propulsion when documentation ties the training to attainable functional goals.
- Therapeutic exercise (CPT 97110) is covered when used to address impairments of exercise tolerance due to cardiopulmonary impairments.
- Range of motion testing (CPT 95851) may be used for extremity ROM when every joint of the extremity is tested and documentation explains why such comprehensive assessment was warranted.
- Occupational therapists may recertify home health patients under a plan of care if services meet CMS occupational therapy definitions and the patient's home health eligibility is established by prior need for skilled nursing (not solely venipuncture), speech-language pathology, or physical therapy in the current or prior certification period.
19 Active Policies
L33631 — Outpatient Physical and Occupational Therapy Services
J06
A56566 — Billing and Coding: Outpatient Physical and Occupational Therapy Services
J06
A53304 — Billing and Coding: Medical Necessity of Therapy Services
A57021 — Billing and Coding: Cervical Disc Replacement
A57067 — Billing and Coding: Outpatient Physical and Occupational Therapy Services
Related Codes
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