Appropriate Use and Documentation of Therapeutic Activities (97530)

August 30, 2018
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The following discussion is intended to help PT/OT providers choose when using 97530 is appropriate with documentation examples.
The CPT definition of 97530 is “[t]herapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.”
More detailed guidance can be found in local coverage determinations which provide that therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques involving movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a therapist and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active written plan of care and be directed at a specific outcome.

When using 97530, you should focus on tasks ending in “ing” such as carrying, lifting, handling, reaching, transferring and transporting to improve overall function. Specific examples include hand assembly activities, transfers (chair to bed, lying to sitting, etc.), swinging, catching, lunging and throwing. (In contrast to therapeutic exercise which uses one parameter-strength, ROM, flexibility). Choosing 97530 or 97110 depends on the intent of the task. For example, squatting can be used for strengthening and billed under therapeutic exercise; however, if the patient is squatting for item retrieval from floor level, then you can code as therapeutic activity.
Best practice is to determine what functional outcome is expected from the task. Your documentation needs to include the specific focus of the functional task and/or activity and should be clearly identified in the goals for 97530. Examples of 97530 documentation (with key words in italics) include:

1. PT facilitated forward reaching activities at 90 degrees of shoulder flexion. Patient was given a 4 lb. on B wrists simulating item retrieval from shelves, placing the item on the floor and returning to the shelf. Patient performed the activity 10 x 1 set with reports of right anterior shoulder discomfort by the 7th attempt. Patient required 25% verbal and tactile cues to perform proper lifting technique following rotator cuff injury. PT graded the task after a 5-minute therapeutic rest break to then retrieve items at a 125 degree of shoulder flexion reaching. Similar discomfort was reported by the 4th trial. Patient educated on various pain relief techniques that patient could perform at home. Patient verbalized understanding.

2. PT facilitated vestibular training for patient to return to driving independently. Patient instructed in simulated neck rotation tasks mimicking skills needed to operate a vehicle. Patient completed x 15 each side with no signs of dizziness or nystagmus. Patient was then instructed in item retrieval tasks from floor level to further assess any increased report in dizziness. Patient able to retrieve a total of 5 items (1 item at a time) and return to erect postural alignment in sitting without complaints of dizziness.

3. Patient has been followed by skilled PT post R ACL reconstruction in prep to return to work as a truck delivery driver requiring high level stepping and transporting skills. Pt initially instructed in side stepping tasks x 10 with no reports of pain. PT graded the task to step up training using 4-inch step, 8-inch, and 12-inch steps x 10 trials each height with rest as needed. Patient reporting minimal pain after 12-inch step, but pain subsided with rest. Task was graded again to include 12-inch stepping while transporting a 15# box from floor height to chest height (no UE support to step). By end of session, patient very fatigued. Next session to focus on 12+ inch steps with carrying 15-20# to continue to progress patient to return to work.

4. Patient instructed in ladder climbing x 5 trials ascending and descending with work boots donned to increase functional use of quads needed to return to work as a firefighter. Patient required min vc to engage in pursed lipped breathing as patient was becoming easily fatigued and straining causing a physical response (increased redness, shortness of breath). BP, HR, and O2 as follows 165/80-baseline was 120/75, HR 100 bpm, and O2 93%. PT instructed patient to rest despite resistance from patient. With education, patient agreed requiring 5-minute therapeutic rest. After incorporating learned strategies, patient was able to complete with increased independence and safety.

5. In unsupported seated position, patient was instructed in dynamic reaching tasks to facilitate increased ability and improved balance to independently reach in her kitchen cabinets from w/c level. OT facilitated task to incorporate functional reaching in all planes using BUE to retrieve objects. Patient required min verbal cues and visual demo to initiate, CGA at times needed to maintain sitting balance. Most difficulty noted when reaching above 140 degrees in B shoulder flexion as muscles fatigued easily. OT provided tactile guiding to maximize performance and decrease substitution (lateral trunk flexion) to achieve optimal performance.

6. Patient directed in functional standing task incorporating functional reach outside base of support/all planes to increase ability to reach for items in closet while reducing risk of falls. PT provided pelvic stabilization as well as minimal verbal cues to decrease substitution methods and promote safety awareness. Task graded to incorporate standing tasks on uneven surface. On uneven surface, patient with loss of balance requiring mod A for proper weight shifting, all 4 trials. Will continue to require dynamic standing/reaching interventions to reduce fall risks and maximize balance recovery strategies.

7. Patient instructed in multiple squatting activities in attempt to improve functional mobility and safety, ability to retrieve items from floor level, reduce falls, and improve independence at home. PT facilitated mobility tasks without use of assistive device to retrieve multiple items from floor level. Patient required CGA and mod verbal cues to get closer to object, hold object closer to the body to reduce lumbar strain as well as cues for posture, and technique to facilitate quad contraction. Patient educated on the need to reduce excessive lumbar flexion during task to reduce injury and promote proper lifting techniques.

8. Patient arrived at skilled OT complaining of 4/10 R shoulder pain limiting UE dressing tasks. Upon assessment, patient unable to raise RUE against gravity. Patient instructed in gravity eliminated reaching task on table top to increase R shoulder flexion, extension, horizontal abduction/adduction to improve ability for dressing tasks. OT provided intermittent tactile cues to reduce compensatory strategies and isolate targeted muscle groups needed for functional task. As patient’s pain subsides, progress to against gravity reaching tasks next session.

9. Patient instructed in table top task incorporating L wrist flexion/extension, radial/ulnar deviation, finger flex/extension, opposition movements to increase ROM, decrease stiffness, reduce pain to utilize L hand in functional tasks s/p wrist fx. Patient is L hand dominant. Patient instructed in familiar household tasks (lifting coffee cup, transporting small, light objects from one location to another). Tasks incorporated the need for patient to stabilize wrist against gravity, engage in L wrist flex/ext, radial/ulnar deviation, opposition movements with therapeutic rest as needed. Min tactile, verbal, and visual cues needed to isolate targeted muscle groups. Patient with difficulty noted for radial/ulnar deviation, thus, OT stabilized patient at the wrist joint to perform accurately and patient was able to complete with overall less pain.

10. Patient arrived at therapy with 5/10 R hip pain reporting most difficulty when getting in and out of her car. Patient instructed in dynamic standing tasks mimicking R hip abd/add movements in order to increase ability to transfer in and out of the car in a pain free zone. Patient then instructed in car transfers x 3 separate trials (in and out) with mod vc to modify technique for less reports of pain. Patient also required visual demonstration and min A to lift RLE into car all trials. Adjusted and modified seat to allow for more room to maneuver RLE. Will need further time to address and perfect technique to increase to independent level. Next session to also focus on core stability.

11. Patient instructed in proper technique to get up off the ground, as patient wants to be able to get down on her knees for gardening. She required max A first trial. PT provided further instruction on technique and visual demonstration and by 2nd trial was able to complete with min A. PT progressed task for improved biofeedback with using mirror for patient to increase understanding of learned technique. After this intervention, patient was able to complete the last trial with supervision only. Patient requires further time to increase to independent level but is progressing well with adapted interventions.

12. OT educated patient in B hand manipulation tasks post estim to improve overall grip/pincer grasps needed for ADLs/IADLs. Patient trained in fine motor tasks involving various sized objects (coins, buttons, paper clips) to increase various pinches and functional use. Patient required mod vc and visual demo to perform correctly as patient had difficulty isolating digits. Post functional task: OT assessed and measured R and L lateral and tip pinch lateral: 12# R and 11# L and tip pinch 5# bilaterally (an improvement of 1# each hand for tip pinch from last session). Patient denied pain, just complained of overall stiffness. Patient reported overall functional progress with ability to button and manipulate coins during IADLs since her last session which is helping with dressing and shopping tasks.

13. Patient presents to skilled PT following CHF exacerbation with reports of feeling breathlessness with community ambulation. Patient educated on use of functional activity tolerance training techniques to increase overall pulmonary function. O2 and RR levels were closely monitored throughout task with no abnormal response from baseline when patient was assessed (O2 95%-97%, RR 18-22). PT facilitated patient in performing activity tolerance task incorporating 10 minutes of dynamic standing without rest on various surface heights. PT further graded task to engage in overhead reaching in one leg stance. Patient with noted difficulty during this task requiring min A to maintain balance while reaching.

14. Patient presents to skilled PT s/p fall in patient’s bedroom resulting in L sided hip pain and overall weakness. Without PT, patient is at risk for further decline as patient lives alone and was I with all tasks. Due to L sided hip pain, patient having noted difficulty getting off low surface heights of bed. Patient instructed in variety of sit to stands, stands to sits from multiple surface heights to increase overall function. Patient required min A initially and was provided cues for technique including hand, feet, and trunk placement. By the 4th trial, patient was able to complete with supervision. Patient was also provided with pictorial handout providing adaptive equipment (bed risers) recommendations as a resource to heighten the bed to allow for smoother and less difficult transitions from his low bed if this continues to be an issue for him. Will require follow up next session to ensure independence.

15. Patient instructed in 6-minute walk test to increase overall functional activity tolerance for improved community integration. Patient provided with verbal cues for pacing as well as energy conservation techniques and to keep RW closer to him particularly over threshold transitions to reduce falls. Patient was educated on results of assessment, discussed norms, and its overall effect on community ambulation. Patient educated on the plan for the following next 3 PT sessions in order to increase overall ability to safely ambulate in the community. The patient’s number one goal is to be able to sustain long enough to complete her grocery shopping with modified independence (use of RW). Patient in agreeance with the plan and determined to utilize learned energy conservation techniques to improve overall functional performance.

16. In standing, with unilateral upper UE support as needed, patient instructed in single stance tasks to facilitate improved standing balance while reaching for overhead items. Patient instructed in single leg raise while reaching for overhead items with initial max vc and tactile cues to illicit appropriate muscles to maintain balance as well as cues to maintain hips in neutral. Progressed patient this session to standing with no UE support; however, did require min A for proper balance recovery techniques when engaging in functional reaching (simulating reaching for grooming items in bathroom). Patient with min cues for posture to reduce trunk sway with standing tasks.

17. Patient arrived at OT with R UE weakness s/p CVA. Post estim to facilitate muscle contraction, patient was instructed in the following to facilitate improved voluntary muscle movement. Patient instructed in manipulation tasks (transporting small objects of paper clip size) incorporating all R hand digits to increase functional use of R hand needed for ADLs with assistance of LUE as needed; however, OT facilitated constraint therapy to increase RUE movement. Patient frustrated at times, but OT provided hand over hand as needed and patient with resultant improved performance.

18. Patient is at risk for increased back pain without training to stabilize core muscles. PT instructed patient in functional mobility tasks while engaging core strength when carrying 10-pound items from one location to another (30 feet apart) using both hands x 3 trials. Patient required mod vc for proper body mechanics during lifting and carrying to reduce further injury and reports of pain. With recommendations, patient completed task without pain. PT graded task to perform using only one hand to carry items another 5 trials. Patient was able to do this with 2/10 back pain. Patient reports overall improvement at home when carrying items of less weight from refrigerator to kitchen table (i.e. gallon of milk) with less reports of pain; however, larger items (needed for yard work) with increased pain. Continue to progress with heavier weight next session and continue to address proper body mechanics and technique.

19. Patient instructed in obstacle negotiation task to reduce falls during in home mobility item retrieval. PT facilitated weight shifting tasks in standing providing tactile guiding when needed (approx. 25% of the time). PT graded the task by incorporating distraction for scanning for items in environment. Patient had one instance of LOB requiring min A, but overall improvement noted. Continue to focus on high level mobility/standing tasks with scanning to reduce falls in the home during functional tasks.