Codes 101: Determining Medical Necessity & Billing CPT Code 97016

In recent years, use of compression therapy has increased in the industry as it has become a popular treatment option for many physical therapy and rehab specialists who want to provide its benefits to patients. While the use of these types of vasopneumatic devices is helpful for many, their application is not always medically necessary. According to Noridian’s 2018 update, “multiple outpatient therapy reviews have had insufficient documentation to support appropriate use and billing for the use of a vasopneumatic device.1 With an increase in popularity comes the need to reevaluate what constitutes as a medical necessity and what is required when billing for these treatments.  

Let’s take a closer look at what CPT code 97016 is, determining medical necessity, and what is needed for billing.

What Is CPT Code 97016?

According to the American Medical Association (AMA), CPT code 97016 is a procedural code that falls under the range of Supervised Physical Medicine and Rehabilitation Modalities. It is used when a vasopneumatic device is applied during treatment to one or more areas. 

What Are Vasopneumatic Devices?

Vasopneumatic devices are a type of specialized equipment, such as compression therapy systems, that provide pressure to an area of the body to help reduce swelling and improve recovery. Often used alongside rest and elevation, vasopneumatic devices can help reduce discomfort while aiding in swelling reduction like in the treatment of lymphedema. This type of treatment can be performed all over, including the back, shoulder, leg, and arm. 

While vasopneumatic devices can provide relief and aid in a patient’s healing, the matter of correct billing and substantiation of medical need becomes an issue.

Guidelines for Determining Medical Necessity 

Determining medical necessity is made on a case-by-case basis and requires strict compliance to the guidelines specified in the Medicare Benefit Policy Manual, CH 15, 220.2 – Reasonable and Necessary Outpatient Rehabilitation Therapy. According to the manual, “Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services.”2 This means services that “promote overall fitness . . . or general motivation do not constitute therapy services for Medicare purposes.”2

Unskilled vs Skilled Services

For the CPT code 97016 to be covered by insurance, the services provided must be “skilled therapy services.”2

Skilled Services
  1. A skilled therapy service may be necessary to do the following:2
    1. “Improve a patient’s current condition.”
    2. “Maintain the patient’s current condition.”
    3. “Prevent or slow further deterioration of the patient’s condition.” 
Unskilled Services

1. A service is considered an unskilled service if it is:

    1. “Provided by professionals or personnel who do not meet the qualification standards” or 
    2. “Not appropriate to the setting or conditions,” even if the person performing the service is qualified.22.

2. A service is not considered a skilled therapy service because it is performed by a therapist or a therapist/therapist assistant under direct or general supervision.2

3. If an unskilled person can self-administer or safely and effectively perform a service with direct or general supervision by a therapist, it is an unskilled service—”even though a therapist actually furnishes the service.”2

4. “The unavailability of a competent person to provide a non-skilled service,” regardless of the “importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.”2

Reasonable & Necessary

To establish medical necessity and be covered by Medicare, the treatment must meet the following criteria to the Medicare Benefit Policy Manual:1

  1. A skilled service is considered “acceptable practices for therapy services” when found in:
    1. “Medicare manuals,
    2. Contractors Local Coverage Determinations, and
    3. Guidelines and literature of the professions of physical therapy, occupational therapy and speech-language pathology.”2
  2. The service “shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist.”2
  3. “Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.”2
  4. “While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by non-skilled personnel.”2
  5. Also, “the amount, frequency, and duration of the services must be reasonable under accepted standards of practice.”2

Guidelines for Billing Code 97016

When billing using CPT 97016, the following guidelines should be considered:

    • Code 97016 is a service-based code, meaning it can only be billed as 1 unit regardless of treatment time length. 
    • If more than one 97016 treatment is performed within a short period of time, the modifier “-59” may be applied.3

Be sure that this additional visit constitutes as a separate treatment.

    • Provide insurers with detailed documentation substantiating the medical necessity, including:
      • Initial evaluation,
      • Pre- and post-treatment measurements of the swelling,
      • “Certified plan of care, 
      • Progress reports, and 
      • Treatment encounter notes.”1
      • The documentation should demonstrate that “the edema is clinically significant, interferes with the patient’s functional abilities, and fully meets the CPT® code descriptor requirements.”1

Check Coverage

As with all treatments, check with insurers to make sure the services are covered. Plus, not all insurers will pay for vasopneumatic devices, so it’s important that the device you use is a device they will pay for when used during treatment.4


Get access to professional pricing when you create an account or contact your account manager at 1.866.528.2144 for more information. 

References

1“Vasopneumatic Modality – CPT 97016.” Noridian Healthcare Solutions, 14 Dec. 2018, med.noridianmedicare.com/web/jea/article-detail/-/view/10521/vasopneumatic-modality-cpt-97016.

2“Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services.” CMS.gov, 12 July 2019, www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf.

3Jannenga, Heidi. “CPT Codes & Physical Therapy: What You Need To Know.” WebPT, 22 Apr. 2019, www.webpt.com/cpt-codes/.

4“Documentation and Payment for Vasopneumatic Devices.” PT Management, 19 May 2015, pt-management.com/compliance/documentation-and-payment-vasopneumatic-devices/.

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