Best Practices: Documenting Modalities & Procedures

September 17, 2015   |   Evidence in Integrative Healthcare

Naturopathic and chiropractic physicians need to accurately record clinical information when providing or performing physical therapy modalities and procedures. Standards for “best practices” rely on these records to establish the clinical necessity and effectiveness of any given modality or procedure, aid in the determination of patient outcomes management, help with continuity of patient care, and aid in the reduction of malpractice risk.

These services are broken up into three broad categories:

  • Supervised (CPT codes 97010 – 97028) – these are limited to one unit per patient encounter per day regardless of time or region.
  • Constant Attendance (CPT codes 97032 – 97039) – these are time based and require the provider to be present during the administration, application, or performance of the modality.
  • Therapeutic Procedures (CPT codes 97110 – 97546) – these require direct patient – provider interaction; these are also time based.

Clinical documentation for these services should include a brief explanation of the necessity of the service, the nature of the modality or procedure (ultrasound, interferential electrical stimulation, massage, myofascial release, etc.), settings – if appropriate (e.g. pulsed vs. continuous ultrasound), location of application by region or segment (as specific as possible), duration, and result.

When billing any time-based modality or procedure, certain rules apply. While the AMA CPT Code Book defines time as a 15 minute unit, actual practice does not always fit such rigid parameters. Billing methods for time-based services, including physical therapy modalities and procedures allow for some flexibility. (CMS Physical and Occupational Therapy Billing Manual, Center for Medicare and Medicaid Services, 2010, 2012)

While one unit of time is 15 minutes, the individual service is allowed to vary between 8 minutes (just above the midpoint between 0 and 15) to 22 minutes (just below the midpoint between 15 and 30). Thus a single unit of service may be billed when the involved time reaches 8 minutes.

When more than a single unit is rendered or when other time-based modalities or procedures are performed during the same encounter, the provider must account for the total time involved in rendering these services. If two time-based services are performed sequentially, billing would be dependent on the total time of service. As an example, 8 minutes of ultrasound (CPT code 97035) followed by 8 minutes of attended electrical stimulation (CPT code 97032) totals only 16 minutes of time-based services. While if each were performed separately on different dates of service, one unit of time could be billed for each code. However, since the two procedures are performed in the same visit, only one unit (8 to 22 minutes) can be billed. In such a case, it would be permitted to bill for the modality or procedure with the higher associated fee. If the fees are the same, bill for the one requiring slightly more time than the other. If all aspects are equal, the decision is left to the provider to bill for one or the other; however, the clinical documentation needs to reflect the specific services performed during the patient encounter.

When multiple units of service are billed, only the last unit of service is subject to the range of time adjustment. All other units billed are based on the 15 minute definition. Two units of service would require 15 minutes for the first unit; the second unit could range between 8 and 22 minutes (total time of service would be from a low of 23 to a high of 37 minutes). Three units of service would require 30 minutes for the first two units; the third unit could range between 8 and 22 minutes (total time of service would be from a low of 38 minutes to a high of 52 minutes). The same method of calculation is used as additional units of modalities or procedures are added.

It is incumbent on the provider to document the time elements described above in such a manner that allows easy determination of when threshold parameters are met.