What is Self Care Management CPT Code?

Touseef Riaz

March 10, 2022

Self Care Management CPT Code

Self Care Management CPT Code

The self-care management CPT code is 97535, also known as home management training. This code involves direct one-on-one contact training, for 15 minutes (each training), and is composed of:

– Activities of daily living (ADL)

– Compensatory training

– Meal preparation

– Safety procedures

– Instructions in the use of assistive technology devices/adaptive equipment.

This CPT code lies under the code set of Physical Medicine and Rehabilitation Therapeutic Procedures CPT® Code range 97110 – 97546.

How to bill self-care management?

CPT Code for self-care/home management training is 97535.

This self-care management CPT Code is designed to address the patient’s specific needs. If the professional skills of a healthcare provider are required, only then is this procedure medically necessary. And it must be part of an active treatment plan directed to a particular outcome. The following are the coding guidelines for self-care management CPT code:

Self Care Management CPT Code

CPT Code Self-care Management Description:

As mentioned above, self-care or home management training CPT code comprises training activities of daily living. There are six basic ADLs including:

  •         Eating
  •         Bathing
  •         Dressing
  •         Toileting
  •         Transferring
  •         Continence

If the physician is performing any of the mentioned activities in the exercise program, the services can be billed against the 97535 code.

Reimbursement for 97535 CPT code:

CPT code for self-care or home management typically gets reimbursed at a higher rate than TA, TE, NMR, and MT. Why is this? Because you can’t teach self-care with the “hands-off” technique. In order to perform the tasks required by the CPT code for self-care management., one needs to:

– Actively lecture

– Demonstrate

– Provide literature

Does Self Care Management CPT Code Require Any Modifier?

Self-care or home management training CPT code will require a modifier if two codes are being billed separately to the patient on the same day.

Coding Guidelines:

  1. The patient must have the capacity to learn from the instructions.
  2. Twelve visits in four weeks might be required for the medical treatment. To continue the treatment, documentation supporting the medical necessity might be required – for coverage beyond 12 visits in 4 weeks.
  3. Documentation must relate the training to expected functional goals that are attainable by the patient.
  4. If/when the self-care or home management training is done under the same visit as (conditions mentioned below), the medical record must document the distinct goal and services rendered.
  • Gait Training
  • Orthotics Fitting and Training
  • Prosthetic Training

What are CPT codes?

Current Procedural Terminology (CPT) codes are used for several administrative tasks like claim processing. CPT codes are a distinct language for billing and coding medical procedures performed by healthcare providers and medical professionals. These CPT codes are used by laboratories, hospitals, outpatient facilities, physicians, and allied health professionals. This code set is published and maintained by AMA – American Medical Association. Along with ICD, the CPT code set is one of the major code sets among medical coders.

Surgeries, diagnoses, and evaluations, including any other medical procedure, can be coded using CPT codes. This code set comprises thousands of codes for thousands of medical procedures,  they play a vital role in medical billing and coding. These codes are divided into the following categories:

– Category I:

Most of the time of the medical coders is spent using category I CPT codes. Like the ICD code set, the category I code set comprises six large sections or chapters. This code set is represented with five digits. The sections include:

  •         Evaluation and Management
  •         Anesthesia
  •         Radiology Procedures
  •         Pathology and laboratory procedures
  •         Medicine Services and Procedures
  •         Surgery

–  Category II:

Category II CPT codes are used for performance measurement and are helpful for future patient care. These supplemental tracking codes comprise four digits and an alphabet (F) at the end of the code. Category I and III codes can never replace category II codes. These codes simply just provide extra information to the codes and are not required for coding.

– Category III:

This category code is made up of temporary codes for emerging technology, procedures, and experimental services. Category I code set consists of procedures for unlisted services. But if the procedure is already listed in Category III code set, medical billers are required to use that code.

Category III codes consist of experimental procedures that may get added to the Category I code set. But category III codes do not always meet the criteria to be added to the category I code set.

Like to Category II, this code set also has five characters, four digits, and an alphabet (T) at the end of the code.

CPT Modifiers:

Medical coding also requires being familiar with and using CPT modifiers. Using these modifiers in the right way is essential for medical coding. Using the wrong modifiers can result in claim denials, lower reimbursements, and therefore lost revenues.

The followers are some of the most used modifiers in medical billing:

– Modifier 59:

This CPT modifier is used to report “Distinct Procedural Service.” This is considered to be the most misused modifier of all. Modifier 59 is generally used to report that two or more medical procedures were performed on different sides of the body in the same visit. It separates one code from the other on the same day of service.

– Modifier 25:

“Significant, Separately Identifiable Evaluation and Management (E/M) Service.”

It reports that the significantly separate E/M service was performed on the same day as the procedure or other service by the same physician.

– Modifier 91:

Modifier 91 is defined as:

“Repeat tests performed on the same day by the same provider at different times with separate specimens to get the reportable test values.” Use modifier 91 for medical billing when reporting a repeat test, along with the appropriate procedure code.

Errors in Medical Coding:

Errors in medical coding can be human errors or typing mistakes, but these errors can lead to payments being received or not. Medical billers and coders work to reduce errors in coding. The following are some of the most common medical coding errors:

– Upcoding:

Using or billing a more expensive CPT code than the procedure or service actually rendered is called upcoding. For instance, if a physician did a 15-minute one-on-one session with the patient but bills for 30 minutes or 60 minutes, it is considered upcoding.

– Incorrect procedure codes:

One wrong digit or letter, and there goes an incorrect procedure code! Wrong procedure codes can also be a result of incomplete or inaccurate documentation.

– Unbundling codes:

There are some comprehensive CPT codes used to report complete procedures. However, if multiple codes are used to report every step of such a procedure separately, it is known as unbundling. This type of coding results in higher reimbursement and, therefore, is considered  Medicare abuse. Unbundling can either be a result of a misunderstanding or done intentionally to increase revenues.

– Use of inappropriate modifiers:

Correct modifiers should be used in medical billing. Using the incorrect modifier can result in claim denials.

– Overuse of Modifier 22:

Modifier 22 in medical billing is used for “increased procedural services.” This modifier highlights a physician’s additional time and services due to a medical complexity in that procedure.

For instance, if a surgical procedure gets more difficult due to scar tissue or any other complexity and takes more time than usual. Modifier 22 can be used to report the medical service indicating increased complexity.

Medical Coding with U Control Billing:

U Control Billing is a well-reputed medical billing outsourced services company. With globally renowned credentials and proven accolades in the industry, U Control Billing offers:

– Affordable & Competitive pricing

– Maximizing the reimbursements

– Reduce the overall expenses

The team of medical billing professionals at U Control Billing is highly proficient and qualified in terms of providing medical coding services like:

– Improving your coding accuracy

– ICD 10 CM, CPT, HCPCS, NDC, and Modifiers

– Provider note Audits

– Code Reviews

– Specialty and Payer specific coding requirements

With experienced professionals, U Control Billing ensures reduced errors in medical coding to optimize revenue.

We understand that if claims are not submitted on time and accurately, they result in lost revenues and late payments. Incorrect coding has a direct impact on the healthcare practice’s cash flows. With U Control Billing, you get:

– Improved Quality and Increased revenues

– Billing in 24 hours

– Timely follow-ups

– Patient support and customer services.

We consider ourselves as a “Remote Business Office,” always ready to respond to any queries and needs of our clients.

But why outsource medical coding?

Outsourcing medical billing and coding services to a medical billing company come with several benefits. Some of the major benefits of outsourcing medical billing include:

– Reduced expenses:

It means lesser costs of administrative tasks, computer equipment, medical billing software, and maintenance.

– Lesser coding errors:

A team of highly specialized medical billing and coding professionals ensures to minimize that coding errors and submit clean claims. They ensure the use of updated and right codes following the specific payer’s requirements. Medical coding companies are up to date with all the changes in the CPT codes and payer’s guidelines, avoiding any errors.

– Claim denial management:

In case of a claim denial or rejection, the outsourced team will be managing the claim denials and dealing with the multiple insurance payers.

– More focus on patient care:

In-house medical billing takes a lot of time to monitor and manage the administrative staff. With outsourcing, physicians can focus more on the primary goal of treating patients, therefore increasing patient satisfaction.

– Streamlined workflow and cash flows:

With lesser errors in medical coding and timely submission of the medical claim, healthcare practice’s smooth operations can be ensured. It also results in faster payments, a higher clean claim rate, and an increased reimbursement rate with an improved revenue cycle.

– Timely payments:

Medical billing companies ensure timely submissions of medical claims resulting in faster payments.

Frequently Asked Questions (FAQs)

What is the Self Care Management CPT Code in medical billing?

CPT code for self-care or home management training is 97535 for medical billing and coding physician’s services. This CPT code lies under the code set of Physical Medicine and Rehabilitation Therapeutic Procedures ranging from 97110 – 97546. If the professional skills of a healthcare provider are required, only then is this procedure considered medically necessary.

What are common self-care home management CPT code errors?

Self-care or home management training CPT code must always be coded by following the guidelines for this code. Incomplete documentation use of incorrect codes and modifiers can result in medical claims being denied or rejected. Therefore, impacting the reimbursement rate and revenues.

What is the denial Self Care Management CPT Code?

CPT code for self-care or home management training is 97535. Including (e.g., activities of daily living (ADL), compensatory training, and going over safety procedures/instructions. CPT Code for self-care management also includes meal preparation and Instructions in the use of assistive technology devices/adaptive equipment.




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