97112 heads up in florida - denial

[Guest guest]

Hello everyone,

Our facility is completing ADR's for First Coast, an Intermediary for

Medicare in the Florida and Connecticut region. I spoke with the

representative

for the subcontractor reviewing the charts and she stated that there is a

problem with the usage of the 97112 code, Neuromuscular reeducation. We had

used

the code to describe balance activities involving sensory organization

techniques for coordination and neuromuscular control for patients

disproportionately weighting their somatosensroy system that results in

multiple falls.

She stated that was incorrect usage of the code and that the patient had to

fit into what they interpret of the definition in the LMRP for Physical

Medicine and rehabilitation. In it it states:

CPT 97112 - Neuromuscular ucation

* This therapeutic procedure is provided for the purpose of restoring

balance, coordination, kinesthetic sense, posture, and proprioception (e.g.,

proprioceptive neuromuscular facilitation (PNF), Feldenkreis, Bobath, BAP's

boards, and desensitization techniques).

* This procedure may be reasonable and necessary for impairments which

affect the body's neuromuscular system such as:

* documented loss of deep tendon reflexes and vibration sense

accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs,

and/or

fingers;

* documented nerve palsy, such as peroneal nerve injury causing foot

drop;

* documented muscular weakness or flaccidity as result of a cerebral

dysfunction, a nerve injury or disease or having had a spinal cord disease or

trauma;

She stated that patient must have one of the above conditions to qualify for

this CPT code. They interpret the third condition to mean:

Documented muscular weakness or flaccidity as result of a cerebral

dysfunction, a nerve injury or [a nerve disease] disease or having had a spinal

cord

disease or [spinal cord ] trauma;

Thus significantly restricting this code to a) Peripheral neuropathy

nerve palsy or c) Central nervous system lesion

Other intermediaries define the code correctly and elaborate further as well:

CPT 97112 - Neuromuscular ucation

* This therapeutic procedure is provided for the purpose of restoring

balance, coordination, kinesthetic sense, posture, and proprioception (e.g.,

proprioceptive neuromuscular facilitation (PNF), Feldenkreis, Bobath, BAP's

boards, and desensitization techniques).

* This procedure may be reasonable and necessary for impairments which

affect the body's neuromuscular system such as:

* documented loss of deep tendon reflexes and vibration sense

accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs,

and/or

fingers;

* documented nerve palsy, such as peroneal nerve injury causing foot

drop;

* documented muscular weakness or flaccidity as result of a cerebral

dysfunction, a nerve injury or disease or having had a spinal cord disease or

trauma;

* documented poor static or dynamic sitting/standing balance;

* documented loss of gross and fine motor coordination;

* documented hypo/hypertonicity.

* Documentation for neuromuscular reeducation must show impairments

which affect the neuromuscular system as listed above. Documentation must

contain objective measurements/ratings of loss of motion, strength, balance,

coordination, and/or mobility, e.g., degrees of motion, strength grades, assist

for balance and mobility, specific tests for balance and coordination.

* If an exercise is instructed to the patient and performed for the

purpose of restoring functional balance, motor coordination, kinesthetic sense,

posture, or proprioception for sitting or standing activities, CPT 97112 is

the appropriate code. For example, a gym ball exercise used for the purpose

of improving balance should be considered as neuromuscular reeducation when

coding for billing.

* This code is generally not covered for greater than 12-18 visits

within a 4-6 week period. Documentation must support the need for continued

treatment beyond this frequency and duration. No greater than 1-2

services/units

of this code should be used on each visit date. If this code is used in

conjunction with CPT 97110 or CPT 97530 on any given visit date, only 1-2

services/units of CPT 97112 are generally covered. Documentation must support

the

number of services/units for each visit date.

Additional Documentation Requirements

* Objective measurements of strength and range of motion (with

comparison to the uninvolved side) and mobility, balance, and coordination

deficits

to support the use of this code.

* Specific exercises performed, purpose of exercises as related to

function, instruction given, and/or assistance needed.

* Documentation to support that the skills and expertise of the

therapist were required.

The understanding by myself and most practitioners is that any disease or

trauma causing coordination, proprioceptive, neuromuscular deficits would use

this code. But the reviewers interpret it differently in Florida.

Here is the CMS FAQ on the CPT coide 97112;

The Medicare Part B frequently asked question (FAQ) dated June 28, 2004

states:

5Q Does a disease with the symptoms of muscle weakness or flaccidity meet

the medical necessity requirements for neuromuscular reeducation procedure

97112 (revised 09-11-03)

5A Yes, however, the documentation must support the patient not only having

the condition, but also currently experiencing the symptoms that represent

medical necessity as described in the Physical Medicine and Rehabilitation

Local Medical Review Policy

Any input would be helpful. I am battling with them now to change their

opinion, even using their own FAQ's to provide evidence that they are incorrect

in their interpretation:

Thanks

Kunkel MSPT