CPT Code 97035

Description of the Procedure or Service

CPT Code 97035 refers to a therapeutic ultrasound treatment administered by licensed physical therapists. This procedure is used to treat patients with various injuries and medical conditions by applying sound waves to the targeted area, which promotes healing in tissues. The primary goals of this therapy include reducing inflammation, alleviating pain, improving circulation, and enhancing muscle and joint flexibility.

Therapeutic ultrasound under CPT 97035 is a time-based code, typically billed in 15-minute increments. It's important to note that this code is designated as a "constant attendance" code, meaning that the provider must maintain direct one-on-one contact with the patient throughout the procedure. This contact can be visual, verbal, or manual, ensuring that the therapy is administered correctly and effectively.

When to Use CPT Code 97035

CPT Code 97035 is used in various clinical scenarios where therapeutic ultrasound is deemed medically necessary. It is commonly employed in treating musculoskeletal conditions, such as tendinitis, bursitis, and sprains. The code is also applicable in postoperative care to reduce scar tissue formation and improve tissue healing.

However, it's crucial to understand that this code should only be used when the ultrasound is provided via direct contact by the therapist. If the ultrasound is administered using a hands-free device or without constant attendance, this service should not be billed under CPT 97035. Instead, it should be coded as an unlisted modality using CPT 97039.

1. Common Misconceptions

A common misconception surrounding CPT Code 97035 is that it can be billed for any ultrasound therapy, regardless of the method of delivery. However, as previously mentioned, this code is strictly for ultrasound services that require direct one-on-one contact. Additionally, some providers may mistakenly believe that they can bill for both ultrasound and concurrent electrical stimulation. According to coding guidelines, only one of these modalities should be billed if they are performed simultaneously.

2. Associated Codes

When dealing with therapeutic ultrasound, several other CPT codes might come into play:

• CPT 97014: Electrical stimulation (unattended). This code is used when electrical stimulation is applied without direct supervision.
• CPT 97039: Unlisted modality. This code is used when the ultrasound is administered without direct patient contact or via hands-free devices.
• CPT 97110: Therapeutic exercises. This may be used in conjunction with ultrasound therapy to further enhance rehabilitation.

3. Practical Application

Step-by-Step Guide to Using CPT Code 97035

1. Assessment and Diagnosis: Begin by assessing the patient's condition to determine if therapeutic ultrasound is medically necessary. Ensure that the therapy aligns with the patient's diagnosis and treatment plan.
2. Preparation: Prepare the area to be treated by applying ultrasound gel, which facilitates the transmission of sound waves.
3. Administration: Using an ultrasound device, apply sound waves to the targeted area. Maintain direct one-on-one contact with the patient throughout the procedure. The session should last at least 15 minutes to meet the billing requirements for CPT 97035.
4. Concurrent Treatments: If electrical stimulation is also part of the treatment plan, administer it simultaneously if necessary. However, remember to only bill for the ultrasound if both modalities are provided concurrently under constant attendance.
5. Documentation: Thoroughly document the procedure, including the area treated, the duration of the treatment, and the rationale for using therapeutic ultrasound. Ensure that the documentation clearly justifies the medical necessity of the therapy.
6. Billing: Submit the claim using CPT 97035, ensuring that all required modifiers (such as GP) are appended if necessary. Only bill for the time spent in direct contact with the patient.

Compliance Considerations

When using CPT 97035, compliance is paramount. Therapists must adhere to several guidelines to ensure proper use:

• Time-Based Billing: Only bill for the time the therapist is in direct contact with the patient. If the session lasts less than 8 minutes, it should not be billed.
• Medical Necessity: Ensure that each ultrasound session is medically necessary and supported by the patient's diagnosis and treatment plan.
• Documentation: Properly document each session, including the type of modality, area treated, and time spent. Incomplete or inaccurate documentation can lead to claim denials or audits.
• Modifier Use: Append appropriate modifiers, such as GP, when billing to specific payors like BCBSNC or NC State Health Plan.

4. Challenges and Solutions

Common Challenges with CPT Code 97035

One of the primary challenges associated with CPT Code 97035 is ensuring correct administration and documentation. The requirement for direct one-on-one contact throughout the procedure means that there is little room for error. If the therapy is administered incorrectly or the documentation is incomplete, the claim may be denied or lead to an audit.

Another challenge is the complexity of billing when ultrasound is provided concurrently with other modalities like electrical stimulation. The coding rules can be confusing, especially regarding when to bill for both services or just one.

Finally, obtaining reimbursement for CPT 97035 can be challenging. Insurance companies may have different policies regarding the coverage of therapeutic ultrasound, and some may deny claims if they believe the treatment is not medically necessary.

Solutions and Best Practices

• Thorough Training: Ensure that all therapists and billing staff are thoroughly trained in the correct use of CPT 97035, including the documentation and billing requirements.
• Clear Documentation: Develop standardized documentation templates to ensure that all necessary information is captured consistently. This can help prevent claim denials due to incomplete or inaccurate records.
• Stay Updated: Regularly review and stay updated on coding guidelines and insurance policies. This can help prevent issues related to claim denials or audits.
• Use Technology: Implement electronic health record (EHR) systems that prompt therapists to document all required information for CPT 97035. This can help ensure compliance with documentation standards.

5. Impact on Reimbursement

Reimbursement Rates for CPT Code 97035 Across Different Insurance Companies

The reimbursement rates for CPT Code 97035 can vary significantly depending on the insurance company and the region. Some insurance providers may have higher reimbursement rates, while others may be more stringent in their criteria for approving claims. It is important for healthcare providers to be aware of these differences and adjust their billing practices accordingly.

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Insurance Considerations

When billing for CPT 97035, it is essential to consider the specific requirements of each insurance company. Some insurers may have stricter guidelines regarding the medical necessity of therapeutic ultrasound, while others may require additional documentation. Providers should be proactive in understanding these requirements to avoid claim denials.

Additionally, healthcare providers should be aware of the limitations on the number of modalities that can be billed per visit. During the initial phase of care, no more than two therapies or modalities per visit are considered usual and customary. Providers should reduce the use of therapies as the patient's condition improves.

Maximizing Revenue

To maximize revenue when using CPT 97035, healthcare providers should:

• Ensure Accurate Documentation: Proper documentation is key to securing reimbursement. Make sure all necessary details, including the rationale for therapy and the duration of the session, are thoroughly documented.
• Use Appropriate Modifiers: As mentioned earlier, always append the required modifiers when billing to specific insurance plans. This can prevent claim denials and ensure proper reimbursement.
• Monitor Insurance Policies: Stay informed about the reimbursement rates and policies of the insurance companies you work with. This can help you adjust your billing practices to maximize revenue.
• Educate Patients: Educate patients about the importance of therapeutic ultrasound and its role in their treatment plan. This can help them understand the value of the therapy and may reduce the likelihood of them questioning the necessity of the treatment.

6. Conclusion

CPT Code 97035 is a critical code in physical therapy rehabilitation treatment, particularly for those involved in therapeutic ultrasound. Understanding the intricacies of this code, including when and how to use it, is essential for therapists and healthcare providers. By following best practices in documentation, compliance, and billing, providers can overcome the challenges associated with CPT 97035 and maximize their revenue.

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