CPT 97535 - Self-Care Home Management Training

 

CPT 97535 - Self-Care/Home Management Training

 

(Time-based Code)

 

CPT Code 97535:  Self-Care/Home Management Training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment), direct one-on-one contact by provider, each 15 minutes.

 

If the service is provided for less than 8 minutes, it should not be billed to the payor.

 

This is a therapeutic procedure, a manner of effecting change through the application of clinical skills and/or services that attempt to improve function. This procedure requires direct (one-on-one) patient contact by a physician or licensed therapist.

 

Self-Care/Home Management Training (97535) involves the use of ADL and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment, with direct one-on-one contact by the provider. The patient must have the capacity to learn from instructions.

 

Documentation Requirements Specific to this CPT Code:

  • The documentation must relate the training to the patient's expected functional goals, and the procedure must be part of an active treatment plan directed at a specific goal.

     

  • The overall goal should be to get the patient to return to the highest level of function realistically attainable and within the context of the presenting problem.

     

  • The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency, and duration. There must be an expectation the condition will improve significantly in a reasonable and generally predictable time period, based on the assessment of the patient's rehabilitation potential.

     

    (AAPC Knowledge Center July 1, 2021)
    https://www.aapc.com/blog/22462-document-chiropractic-group-and-individual-therapy-differences/

 

HNS Policies: Documentation/Billing
When performed and billed to a payor, modalities/therapies must be properly documented in the health care record and accurately reported using the most appropriate code.

 

When performed and billed to a payor, modalities/therapies must be medically necessary and consistent with the chief complaint/clinical findings, diagnoses and treatment plan.

 

Documentation in the health care record must include the rationale for each therapy and must clearly establish the medical necessity for each therapy billed to the payor.

 

For ALL modalities and therapies, documentation must include:

  • Type of modality

     

  • Rationale

     

  • Area of application (specific region treated)

     

  • Setting and frequency (as applicable)

     

  • If time based code, actual time service performed

  

During the initial phase of care, no more than two therapies or modalities per visit are considered usual and customary.

 

There should be a reduction in the use of therapies as the patient's condition improves.

 

Modifiers Needed:
Importantly, when reporting 97535 to BCBSNC, NC State Health Plan (SHP), MedCost, or any plan which utilizes Zelis edits, you must append 97535 with modifier GP.

 

Please click here
for the HNS NCCI Edit - Modifier Help Sheet,
which is a list of therapy codes requiring special modifiers.