Corporate Compliance

CPT code 97001

Compliance Monitor, December 1, 2006

Q: Is it appropriate to report CPT code 97001 when a physical therapist does an inpatient consult that has been ordered by the patient's physician? Would it be appropriate to report 92506 for a speech therapy consult that has been ordered by a physician?

A: No, consults are not billable. Review the following Medicare benefit policy:

To be covered PT, OT or speech-language pathology services, the services must relate directly and specifically to an active written treatment regimen established by the physician or non-physician practitioner after any needed consultation with the qualified PT, OT, or speech-language pathologist and must be reasonable and necessary to the treatment of the individual's illness or injury. The physician, non-physician practitioner or the qualified therapist providing such services may establish a plan of treatment for outpatient PT, OT, or speech-language pathology services.

Reasonable and Necessary

To be considered reasonable and necessary the following conditions must be met:

The services must be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition; The services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified PT, OT, or speech language pathologist or under the therapist's supervision. Services which do not require the performance or supervision of a therapist are not considered reasonable or necessary PT, OT or speech-language pathology services, even if they are performed or supervised by a therapist. (When the carrier determines the services furnished were of a type that could have been safely and related to the maintenance of function (see subsection D) do not require the skills of a qualified physical therapist.

Thanks to Jodee E. Collins, charge description master director at UCLA Healthcare, for answering this question.

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