Service Specific Post Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy With Therapeutic Exercise – CPT 97113

National Government Services Part B MR Department analyzes national and local data to identify possible improper payment for Medicare services. In an effort to reduce the Part B CERT error rate, the MR Department will be conducting a service specific post payment review of:

CPT code 97113 (Aquatic therapy with therapeutic exercises, 1 or more areas, each 15 minutes)

The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

NGS has randomly selected claims billed for the services mentioned in J6 for Part B providers in the states of Illinois, Wisconsin and Minnesota.

If a claim is selected for review, the provider will receive an ADR letter. Providers with claims selected for review must submit the requested documentation within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in a denial of the billed services.

It is important to submit all documentation which supports the medical necessity of the mentioned services. The medical record must be legible and the name of the beneficiary, the date of service and the signature of the billing provider clearly identified. Please ensure all documentation to support medical necessity of the billed service is submitted for review.

Documentation Requirements

Initial physician order and treatment recommendations
Orders for ongoing therapy
Therapy evaluation/reevaluation which includes treatment plan
Signed and dated certifications and recertifications
Therapy progress notes
Therapy logs
Therapy flow sheets/activity sheets
Abbreviations/acronym key and documentation to support time for each modality
Documentation must clearly support the need for aquatic therapy greater than 8 visits
Justification for use of a water environment
Objective loss of ADLs, mobility, ROM, strength, balance, coordination, posture and effect on function
If used for pain include pain rating, location of pain, effect of pain on function
Specific exercises/activities performed (including progression of the activity), purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills and of a therapist were required.
A copy of any mandatory ABN to the beneficiary
ALL other pertinent documents
Legible signature/sample signature log/signature key/signature page, etc. to affirm the provider signature

Related Content

Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled
- Section 1815 – Payment to Providers of Services Social Security Act, Section 1815
- Section 1833(e) – Payment of Benefits Social Security Act, Section 1833
- Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners. Social Security Act, Section 1861
- Section 1862(a)(1)(A) – Exclusions from Coverage and Medicare as a Secondary Payer and Section 1862(a)(20) Social Security Act, Section 1862
Code of Federal Regulations, Title 42 Public Health
- 42 CFR, Sections 410.59 through 410.61, 410.74, 410.75, 410.76, 419.22, 424.24, 424.27, 424.4, 482.56, 484, 485.705 and 486 Code of Federal Regulations – Title 42
CMS Publications: Internet Only Manuals
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: 220 through 230 Coverage and documentation requirements for physical and occupational therapy services.
- CMS IOM, Publication 100-03, Medicare National Coverage Decisions (NCD) Manual, (multiple sections): provides coverage information on several specific types of therapy services.
- CMS IOM, Publication 100-04, Claims Processing Manual, Chapter 5, Section 10.2 financial limitation for therapy services (therapy cap) and section 20-100 HCPCS coding and therapy billing requirements.
Local Coverage Article: Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566) Local Coverage Article: A56566
Local Coverage Determination: Outpatient Physical and Occupational Therapy Services (L33631) Local Coverage Determination L33631