Use of 97112 for a Non-Neuro Diagnosis

OT Staffing
October 26, 2016
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Lately, there have been some concerns about potential denials for using neuromuscular reeducation (97112) for a non-neuro dx.

Some payers are looking for a neuro diagnosis when 97112 is charged because it makes the connection simple. If you use 97112 for treating a patient who does not have a neurological diagnosis, you must clearly document the connection between the treatment and the description of 97112 which follows: 

The definition of 97112: Therapeutic procedure, one or more areas, each 15 minutes – Neuromuscular Reeducation of movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/or standing activities.   

This is a therapeutic procedure, a manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Requires direct (one-on-one) patient contact.

This procedure is used to improve balance, coordination, kinesthetic sense and proprioception.  This procedure is reasonable and medically necessary for impairments, which affect the body’s neuromuscular system (i.e., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity).  Examples include Proprioceptive Neuromuscular Facilitation (PNF), The Feldenkrais Method, Bobath, Bap’s Boards and Desensitization Techniques, other balance techniques.

Your treatment plan should be specific and describe your clinical rationale for performing 97112.  Your patient history and exam findings should relate to the patient having difficulties and impaired functional capacity with certain movements, balance, coordination, kinesthetic sense, posture and/or proprioception.  The plan of care should also outline what specific parameters will be used for 97112 (e.g., balance board for 10 minutes, PNF stretching to lumbar region, etc.)

Your daily notes do not need to describe the clinical approach and rationale on every visit.  The daily notes should list the anatomic site and the amount of time spent on that area (e.g., PNF stretching to bilateral hamstrings for 15 minutes) and be supported by the evaluation and PN.

While there isn’t one universally accepted definition, neuro-re-ed generally refers to a treatment technique or exercise performed by an individual with the purpose of improving — via the nervous system — the level of communication between the body and the brain. This point could easily be made when attempting to get a patient post TKR to improve gait or perform a quad set.  The NMR process also encompasses proprioceptive training. Proprioception is defined as the sense of the relative position of neighboring parts of the body. Again, this might be an issue that could be described functionally with gait patterns or a patient recovering from a frozen shoulder. The proprioceptive system provides feedback solely on the status of the body internally. It is the sense that indicates whether the body is moving with required effort, as well as where the various parts of the body are located in relation to each other.

It is critical that the notes paint a picture of why the patient needs NMR if the patient does not have a true neuro diagnosis.  Also, the flow sheet should clearly support what activities are included in NMR vs Ther Ex to support the billing on a daily basis.

If a charge for 97112 is denied and the documentation supports the use, the denial should be appealed. Use of codes is not dictated solely by diagnosis, but on the documentation of medical necessity for the condition.