CPT Code 97035 : Description And Reimbursement Examples

CPT Code 97035, while essential for billing therapeutic ultrasound treatments, often brings confusion and potential claim denials due to strict guidelines around documentation, time-based billing, and constant attendance requirements. 

What is CPT Code 97035?

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.

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.

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 highly important. 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.

Common Challenges with CPT Code 97035

• Ensuring Correct Administration and Documentation

The problem with CPT Code 97035 is that direct, one-to-one contact must be maintained throughout the length of the ultrasound therapy treatment. That is to say that contact must be maintained during the treatment session: visual, verbal, or manual. If this occurs not, a denied claim ensues.

Example:

A physical therapist treats a patient with therapeutic ultrasound for a shoulder injury. During the session, the therapist steps away for a few minutes to assist another patient. Even though the ultrasound machine continued working during that time, the lack of constant one-on-one contact renders the session unbillable under CPT 97035. In this case, if the insurance company audits the session and finds the therapist did not maintain uninterrupted attendance, the claim could be denied, or the provider could face a compliance issue.

• Complexity of Billing with Concurrent Modalities

Another challenge is billing for ultrasound therapy when it is administered alongside other modalities, such as electrical stimulation. The rules for billing can be confusing, particularly regarding when to bill both services or only one. According to coding guidelines, if both treatments are provided at the same time, you should only bill for one of the modalities—whichever is the primary focus of the session.

Example:

A clinic administers both therapeutic ultrasound and electrical stimulation simultaneously to treat a patient’s lower back pain. The therapist mistakenly submits claims for both CPT Code 97035 (therapeutic ultrasound) and CPT Code 97014 (electrical stimulation). Since both services were delivered concurrently, the insurance company denies one of the claims. In this case, the clinic should have only billed for the primary modality, depending on the session's goal. Failing to understand these nuances can lead to denials or recoupment during audits.

• Varying Insurance Policies and Reimbursement Challenges

Every different insurance company has different policies and reimbursement rates for CPT Code 97035, which makes it challenging to always receive consistent reimbursement. Some may request more documentation than others, or they may be rather picky when attempting to verify medical necessity. Some may even deny claims on the spot if they feel that therapy isn't warranted for the patient's condition.

Example:

A physical therapist provides therapeutic ultrasound under CPT 97035 for a patient with mild tendinitis. This will be payable by Medicare under its rules but is denied by a private insurance firm because the ultrasound was not medically necessary for the condition. The therapist should appeal the denial with more documentation to support the treatment, which delays reimbursement and places additional burdens on administrative operations.

• Documentation Inconsistencies Leading to Denied Claims

Now-a-days the CPT 97035 claims are most of the times denied due to incomplete and inconsistent documentation. Insurance companies need clear descriptions of ultrasound therapy, right from the specificity of the area covered down to the length of the session, but more importantly, why it's medically necessary.

Example:

A clinic fails to document the exact amount of time the therapist spent administering therapeutic ultrasound and doesn't provide a clear rationale for the treatment. When the claim is submitted, the insurance company denies it due to insufficient documentation. Without the proper justification of medical necessity and time spent, the clinic loses out on reimbursement and may face future audits.

• Audits and Compliance Risks

Because CPT 97035 is a time-based code, where services are billed in 15-minute increments, errors in timing or improper rounding can trigger audits. Insurance companies closely scrutinize time-based services, and discrepancies in timing can result in a deeper investigation into a clinic’s billing practices.

Example:

A therapist rounds up a 12-minute ultrasound to 15 minutes and reports this as CPT 97035. On audit, this is detected by the insurance and they begin to question whether the clinic is actually billing correctly. That claim might not only get denied, but the back-and-forth may also increase an audit of other time-based codes, where more billing errors could be detected.

Solutions and Best Practices for CPT Code 97035

• Thorough Training for Therapists and Billing Staff

The best prevention against claims denials or errors for CPT Code 97035 is proper training given to therapists and billing staff on the proper applications of this code. Such training should include not only the procedural elements of therapeutic ultrasound but also its billing nuances, such as constant one-on-one contact and understanding the difference of this code in conjunction with other modality codes.

Example: A clinic institutes training sessions for its staff wherein they go through case studies in real-time of how common billing errors occur and the correct use of CPT codes. In such training therapists learn that to maintain uninterrupted contact during the procedure the billing staff learns that claims should be filed properly to avoid denials.

• Clear and Consistent Documentation

Standardized templates for documentation can actually reduce the risk of incomplete or inaccurate records, which can lead to claims being denied. Creating these should design templates that address all relevant information-change in the area treated, length, indication for therapy, and type of ultrasound. It will make it easier for a therapist to navigate his workload since the templates will show them how to document without conflicting with other patient records.

Example: A clinic introduces a documentation template in which therapists are challenged to put in particular information about the treatment with ultrasound, such as the time exactly spent and where focused, alongside the medical reason for choosing this modality. There will always be an opportunity for reduced instances of omitted key components in documentation, thus lowering the cases of denied claims.

• Stay Updated on Coding Guidelines and Insurance Policies

Medical billing codes, for example, CPT 97035, change over time. Insurance companies might also evolve their policy on what constitutes medically necessary care. To avert unwarranted claim denials or, worse, problems during audits, clinics must maintain a system where they refresh themselves on the then-current coding rules and insurance reimbursement policies. The clinic may further identify a dedicated team member to track such changes and update staff about them.

Example: A clinic assigns a dedicated billing manager to subscribe to industry newsletters and attend webinars on coding updates. This person routinely reviews coding changes and insurance company announcements and ensures that the clinic’s billing processes are aligned with the most current standards.

• Leverage Technology for Compliance

Implementing EMR systems with built-in prompts for CPT 97035 can enhance compliance with documentation and billing requirements. Advanced EMR systems can be programmed to alert therapists if they have not completed necessary documentation or if any required information is missing before the claim is submitted. This reduces the chances of claims being denied due to incomplete information.

Example: A clinic utilizes an EMR system that flags incomplete entries related to ultrasound therapy before therapists can finalize their notes. For instance, if a therapist forgets to input the treatment duration or rationale for the ultrasound, the system prompts them to complete the missing details, helping ensure the documentation meets insurance requirements before the claim is filed.

Impact on Reimbursement

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.

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.

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.

FAQs:

• How much does Medicare reimburse for CPT Code 97035?
  Medicare reimbursement for CPT Code 97035 varies by region but typically averages around $11.64. It’s important to check local Medicare fee schedules for exact rates in your area.

• Why was my claim for CPT Code 97035 denied by insurance?
  Claims for CPT Code 97035 may be denied if the documentation does not clearly demonstrate medical necessity or if the session lasted less than 8 minutes. Additionally, if the ultrasound was provided without constant one-on-one contact, insurance may reject the claim.

• Can I bill for both CPT Code 97035 and another modality like electrical stimulation?
  No, you cannot bill for CPT Code 97035 and another modality, like electrical stimulation, if they are performed simultaneously. Only one modality should be billed per session unless the treatments are performed separately.

• What documentation is required for reimbursement of CPT Code 97035?
  To ensure reimbursement for CPT Code 97035, documentation should include the diagnosis, the medical necessity for ultrasound therapy, the specific area treated, the duration of the session, and proof that constant one-on-one attendance was maintained throughout the procedure.

• Do private insurance companies reimburse differently for CPT Code 97035?
  Yes, reimbursement rates for CPT Code 97035 vary among private insurers. For example, Aetna may reimburse around $7.40, while Florida Medicare Part B can reimburse up to $20.86. It’s important to verify rates with each insurer and ensure proper documentation to avoid claim denials.

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.