• HelloNote CPT CODES Library
CPT Code Reference for PT, OT, SLP & DC
Clinically accurate, always up to date. Search any procedure code — find the full description, time requirements, documentation tips, and billing guidance in seconds.
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FY 2026
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97010
PTOTDC
Full code
97010
Type
Supervised — untimed
Medicare
Bundled — not separately payable
CPT pairs
97035 · 97032 · 97140
When to use: Apply 97010 for superficial hot or cold pack application. Hot packs increase tissue extensibility and promote muscle relaxation prior to manual therapy or exercise. Cold packs reduce acute inflammation and pain. Document treatment area, duration, and clinical rationale.
DC application: Commonly used before CMT to relax paraspinal musculature. Note: Medicare bundles 97010 — do not bill separately for Medicare patients.
Do not bill 97010 when: Medicare is the payer — it is bundled and will be denied as a separate line item. Applied to an area with impaired sensation, open wounds, or compromised circulation.
"Hot pack applied to lumbar paraspinals, 20 min, moist heat. Patient supine. Skin check pre and post — no adverse response. Used to reduce muscle guarding prior to manual therapy."
Medicare bundling: 97010 is a "sometimes therapy" code bundled under Medicare Part B — cannot be billed separately. Many commercial payers also bundle it. Always verify payer policy.
Can I bill 97010 and 97035 on the same day?
Yes — they are different modalities. Document each separately. Note: 97010 remains bundled by Medicare regardless of what other codes are billed.
97012
PTDC
Full code
97012
Type
Supervised — untimed
Common ICD-10
M54.12 · M54.16 · M50.10
Medicare
Separately billable
When to use: Apply 97012 for mechanical traction — intermittent or sustained distraction of the cervical or lumbar spine using a mechanical device. Evidence-based for cervical radiculopathy and lumbar disc pathology. Relieves nerve root compression, reduces intradiscal pressure, and promotes joint mobility.
Do not use 97012 for: Manual (hands-on) traction — bill 97140 (manual therapy) instead. Patients with osteoporosis, cord compression, fracture, or severe neurological deficit without physician clearance.
"Mechanical cervical traction: intermittent, 15 lbs, 20 min. Patient reports centralization of right arm symptoms. Pain reduced 7/10 → 3/10 post-treatment."
97012 vs 97140: 97012 = mechanical device traction. 97140 = manual (hands-on) traction/therapy. Both may be billed same day if genuinely both were performed. Document which type of traction was applied.
Can I bill 97012 and 97140 same day?
Yes — if both mechanical traction and manual therapy were performed. Document each separately: 97012 = the mechanical device session; 97140 = hands-on manual therapy.
97014
PTOT
Full code
97014
Type
Supervised — untimed
Attended version
97032 (timed, attended)
Medicare
Bundled — not separately payable
When to use: Apply 97014 when electrical stimulation is applied and the clinician is NOT in constant attendance — the patient is set up with electrodes and the device runs unmonitored. Used for muscle re-education, pain modulation, edema reduction, and muscle strengthening.
Do not use 97014 when: The clinician is in constant attendance throughout — use 97032 instead. Medicare is the payer — it is bundled. Metal implants at electrode sites, pacemakers, pregnancy.
"TENS applied bilateral lumbar paraspinals, 4-electrode setup, 80 Hz, 200μs pulse width, 30 min. Patient set up and left unattended. Pre-treatment pain 7/10 → post-treatment 4/10."
97014 vs 97032: 97014 = unattended (therapist sets up and leaves). 97032 = attended (therapist monitors and adjusts throughout). Medicare bundles 97014. Use 97032 when clinician attendance is required.
Can 97014 and 97032 be billed same day?
Generally no — they represent the same service at different attendance levels. Bill the one that accurately reflects the service rendered.
97016
PTOT
Full code
97016
Common use
Lymphedema · Post-surgical edema · Venous insufficiency
ICD-10 pairs
I89.0 · I87.2 · L89.x
Medicare
Bundled — check payer policy
When to use: Apply 97016 for pneumatic compression device therapy — sequential compression applied to an extremity to reduce edema, improve lymphatic circulation, and manage lymphedema. Document limb circumference measurements at each session to demonstrate edema reduction.
"Vasopneumatic compression right LE: 45 mmHg sequential, 30 min. Pre-treatment ankle circumference: 32cm. Post-treatment: 30.5cm (1.5cm reduction). Skin intact, no adverse response."
Coverage: Medicare typically bundles 97016. Commercial payers may cover separately for documented lymphedema. Document limb measurements at every session to demonstrate functional benefit.
Is 97016 covered for lymphedema?
Coverage varies. Medicare typically bundles 97016. Commercial payers may cover separately for documented lymphedema (I89.0). Always verify payer policy and obtain authorization when required.
97018
PTOT
Full code
97018
Common use
RA · OA hand · Scleroderma · Post-surgical hand
ICD-10 pairs
M06.9 · M15.0 · M79.641
Medicare
Bundled — not separately payable
When to use: Apply 97018 for paraffin bath therapy — deep superficial heating using warm paraffin wax applied to hands, wrists, or feet. Increases tissue temperature, improves joint mobility, reduces morning stiffness, and prepares the hand for exercise. Most commonly used in OT hand therapy for RA, OA, and post-surgical rehab.
Contraindications: Active RA flare (hot, swollen joints). Open wounds or skin infections. Decreased sensation or impaired circulation. Document absence of contraindications in every note.
"Paraffin bath right hand and wrist, 15 min. Pre: morning stiffness 7/10. Post: 3/10. Wrist flexion: 30° → 45°. No adverse skin response."
Can paraffin bath be billed for foot treatments?
Yes — 97018 applies to any extremity treated with paraffin wax. Document the treatment area, duration, and therapeutic rationale.
97022
PTOT
Full code
97022
Common use
Burns · Edema · Pain management
Medicare
Separately billable
ICD-10 pairs
L89.x · T31 · M25.x
When to use: Apply 97022 for whirlpool therapy — partial or full body immersion in agitated warm/cool water for burns, edema reduction, and pain management. Note: pulsed lavage (97602) has largely replaced whirlpool for wound care due to infection control concerns.
Do not use 97022 when: Infection control cannot be maintained (cross-contamination risk). Severe cardiac conditions. Open infected wounds where pulsed lavage is more appropriate.
"Whirlpool right LE, 38°C, 20 min. Post ankle ORIF — edema management. Ankle circumference: 30cm → 29cm. ROM: DF 0° → 5°. No adverse response."
Is whirlpool still used for wound care?
Less commonly — pulsed lavage (97602) has largely replaced it for wound debridement. Whirlpool remains appropriate for burns, edema, and pain management where infection control can be maintained.
97024
PT
Full code
97024
Types
Microwave · Shortwave · Pulsed shortwave
Medicare
Bundled — check payer policy
Depth
Deeper than hot packs or ultrasound
When to use: Apply 97024 for diathermy — deep heating using electromagnetic energy (microwave or shortwave). Penetrates deeper than hot packs or ultrasound. Used for deep muscle relaxation, joint stiffness, and tissue extensibility prior to manual therapy. Less commonly used in modern PT practice.
Contraindications: Metal implants near treatment area (severe burn risk). Pacemakers or implanted electronic devices. Pregnancy. Malignancy in treatment area. Impaired sensation. Active bleeding.
"Shortwave diathermy right hip, continuous mode, 20 min. Pre: hip IR 15°→ post: 25°. Muscle guarding reduced. No adverse response. No metal implants confirmed."
Is diathermy safe around joint replacements?
No — diathermy is contraindicated with metal implants, including joint replacements. The electromagnetic energy heats metal, causing severe tissue damage. Always screen for metal implants before applying diathermy.
97026
PTOT
Full code
97026
Type
Superficial heating via infrared radiation
Medicare
Bundled — not separately payable
Note
LLLT billed as 97039, not 97026
When to use: Apply 97026 for infrared therapy — superficial heating using infrared radiation. Promotes blood flow, reduces muscle spasm, and decreases pain. Used prior to exercise or manual therapy to warm superficial tissues.
Note: Low-level laser therapy (LLLT/photobiomodulation) is NOT billed as 97026 — use 97039 (unlisted modality).
"Infrared lamp applied to right shoulder, 15 min, 45cm distance. Mild warmth reported. Preparatory use prior to manual therapy. No adverse skin response."
Is LLLT billed as 97026?
No — LLLT/photobiomodulation is billed under 97039 (unlisted therapeutic modality). Attach a special report with each 97039 claim for laser therapy and check payer coverage.
97028
PTOT
Full code
97028
Uses
Wound healing · Bactericidal · Skin conditions
Medicare
Separately billable for wound care
Setting
Primarily wound care and burn centers
When to use: Apply 97028 for ultraviolet (UV) light therapy — UV-C has bactericidal properties effective against wound biofilm. Used in wound care and burn rehabilitation. Requires specific UV equipment and clinical training in dosimetry.
Contraindications: Photosensitive skin conditions. Photosensitizing medications (tetracyclines). Active TB. History of skin cancer in treatment area. Eye protection mandatory for patient and clinician.
"UV-C therapy to sacral PI (L89.153), 30-second exposure at 10cm. Eye protection applied to patient and clinician. Wound: slough 30% → 20% over 3 sessions."
What documentation is required for UV therapy billing?
Document: UV wavelength, dosage (joules/cm²), exposure time, distance from source, treatment area, skin response, wound measurements if applicable, and absence of contraindications.
97032
PTOT
Full code
97032
Billing unit
15-minute timed units
Unattended version
97014 (untimed, bundled)
Medicare
Separately billable
When to use: Apply 97032 when electrical stimulation requires constant clinician attendance — adjusting parameters, monitoring patient response, or applying FES. Includes NMES for muscle re-education post-stroke, FES for foot drop, and attended TENS with parameter adjustments throughout treatment.
Do not use 97032 when: The clinician is not in constant attendance — use 97014 instead. Same contraindications: metal implants over electrodes, pacemakers, pregnancy.
"NMES attended, right quadriceps, 30 min (2 units). Parameters adjusted ×3 during session to optimize muscle contraction. 6 mA peak, 35 Hz, 300μs. Visible quad contraction. Clinician in constant attendance."
8-minute rule: 1 unit = 8–22 min · 2 units = 23–37 min. Document start/end time of attendance. Must document constant attendance and specific parameter adjustments made.
What makes e-stim 'attended' vs 'unattended'?
Attended (97032) = clinician monitors and actively adjusts parameters throughout the entire session. Unattended (97014) = clinician sets up and leaves. Document specific adjustments made during attendance.
97033
PTOT
Full code
97033
Common agents
Dexamethasone · Lidocaine · Acetic acid
ICD-10 pairs
M77.1 · M65.4 · M76.61 · M72.2
Medicare
Separately billable
When to use: Apply 97033 for iontophoresis — transdermal delivery of ionized medications using direct electrical current. Most commonly used with dexamethasone for tendinopathies, bursitis, and plantar fasciitis. Acetic acid for calcific tendinitis. Requires a physician order.
Do not use 97033 when: No physician order on file. Broken/irritated skin at electrode sites. Known allergy to the medication. Metal implants beneath electrode site. Impaired sensation in treatment area.
"Iontophoresis right lateral epicondyle, dexamethasone 4mg/mL (negative pole), 40 mA·min dose, 4.0 mA, 10 min. Physician order on file. No skin irritation. Patient reports reduced local tenderness post-session."
Physician order required: The order must specify medication, concentration, dosage, frequency, and body area. Document the order reference in every treatment note.
Does iontophoresis require a physician order?
Yes — the medication is prescription-only. A physician order is required specifying medication, concentration, dosage, frequency, and body area. Document the order reference in every treatment note.
97034
PTOT
Full code
97034
Uses
CRPS · Post-surgical edema · Ankle sprain · Hand rehab
Medicare
Bundled — check payer policy
Protocol
4 min warm / 1 min cold · 4–5 cycles · End warm
When to use: Apply 97034 for contrast bath therapy — alternating immersion of a distal extremity in warm and cold water. Promotes vascular pumping, reduces edema, decreases pain, and improves ROM. Commonly used for CRPS, post-surgical hand/foot edema, and subacute ankle sprains.
"Contrast bath right hand, 5 cycles (4 min warm 40°C / 1 min cold 15°C), ending warm. Pre: wrist circumference 18cm → post: 17.2cm. Patient reports decreased stiffness after treatment."
Coverage note: Medicare typically bundles 97034. Check commercial payer policies. Document temperature of each bath, duration, number of cycles, and pre/post edema measurements.
Why end contrast bath in warm water?
Ending in warm water produces net vasodilation — promoting circulation and nutrient delivery to the treated area. Ending in cold would leave tissue vasoconstricted, which is less desirable for most conditions treated with contrast bath.
97035
PTOT
Full code
97035
Billing unit
15-minute timed units
Modes
Continuous (thermal) · Pulsed (non-thermal)
Phonophoresis
Same code — document medication used
Medicare
Separately billable
When to use: Apply 97035 for therapeutic ultrasound. Continuous mode (thermal): increases tissue temperature, promotes extensibility, reduces pain and spasm. Pulsed mode (non-thermal): promotes tissue healing, reduces acute inflammation. Also used for phonophoresis — transdermal delivery of topical medications via ultrasound.
Contraindications: Over epiphyseal plates in growing children. Over pacemakers, laminectomy sites, or spinal cord. Over malignancy. Over thrombophlebitis. Areas with impaired sensation.
"Therapeutic US: right supraspinatus, 1.0 MHz, 1.5 W/cm², continuous, 5 min, 10cm² area. ROM: ER 20° → 35° post. Thermal effect confirmed. No adverse response."
Always document: Frequency (MHz), intensity (W/cm²), duty cycle, treatment area (cm²), coupling medium, and duration. Generic "ultrasound to shoulder" without parameters is a common audit finding.
1 MHz vs 3 MHz — when do I use each?
1 MHz penetrates deeper (2–5cm) — preferred for hip, spine, shoulder. 3 MHz shallower (~1–2cm) — preferred for wrist tendons, plantar fascia, metacarpals. Document your frequency selection rationale.
97036
PTOT
Full code
97036
Use
Burns · Severe wounds · Full body ROM
Medicare
Separately billable
vs 97022
97036 = full body · 97022 = partial immersion
When to use: Apply 97036 for full-body hydrotherapy — Hubbard tank or therapeutic pool immersion. Used in burn centers and acute rehab for wound care, ROM, and early functional mobility. Buoyancy reduces gravitational stress, allowing movement in patients who cannot tolerate full weight bearing.
Note: 97036 = full-body immersion as a modality. Active therapeutic exercise in water = 97113.
"Hubbard tank immersion, 38°C, 25 min. Post-burn bilateral LE scar management. ROM: bilateral knee flexion 45° → 65° in water. Patient tolerated without adverse response."
Is aquatic therapy the same as 97036?
No — aquatic therapy (97113) = active therapeutic exercise in water under skilled supervision. 97036 = full-body hydrotherapy immersion as a passive modality. 97036 = passive; 97113 = active exercise.
97039
PTOT
Full code
97039
Common uses
LLLT/laser · Dry needling · PEMF · Biofeedback
Requires
Special report with every claim
Medicare
Often denied — verify coverage first
When to use: Apply 97039 for therapeutic modalities without a specific CPT code — including LLLT/photobiomodulation, PEMF, and other emerging modalities. A special report describing the modality, equipment, parameters, and clinical rationale must accompany every claim.
Do not use 97039 when: A specific CPT code exists for the modality — always use the most specific code. Without attaching a special report. When the payer excludes coverage for the specific modality.
"LLLT (photobiomodulation): LiteCure LightForce Pro, 810nm/980nm, 8 J/cm², right Achilles tendon, 3 min. For chronic tendinopathy unresponsive to standard modalities. Special report attached."
Coverage highly variable: 97039 is frequently denied by Medicare and many commercial payers. Always verify coverage and obtain prior authorization when required. A detailed special report is mandatory.
Is dry needling billed as 97039?
Some payers accept 97039; others use 20560/20561 (needle insertion). Check each payer policy. Always attach a special report. Verify state practice act permissions for dry needling by PTs.
97110
PTOT
Full code
97110
Billing unit
15-minute timed units
Clinician
Constant attendance required
Modifier
GP (PT) · GO (OT)
CPT pairs
97530 · 97112 · 97116 · 97140
Medicare
Separately billable
When to use: Apply 97110 for therapeutic exercises developing strength, endurance, ROM, or flexibility. The most commonly billed PT/OT code. Requires one-on-one skilled clinician supervision throughout.
PT application: Resisted strengthening, ROM exercises, stretching, cardiovascular conditioning.
OT application: Upper extremity exercise, fine motor strengthening, hand therapy exercise.
Do not bill 97110 for: HEP instruction alone — patient must exercise under your supervision. Functional tasks (sit-to-stand) — use 97530. Group exercise — use 97150. Neuromuscular/balance training — consider 97112.
"Therapeutic exercise ×2 units (30 min): (1) Quad sets 3×15, TKE 3×15, SLR 3×15 — right knee. (2) Hip abductor strengthening band 3×12, clamshells 3×15. Correct form demonstrated. Appropriate fatigue at final set."
8-minute rule: 1 unit = 8–22 min · 2 units = 23–37 min · 3 units = 38–52 min.
97110 vs 97530: 97110 = isolated exercises. 97530 = functional task activities. Both may be billed same day for different goals.
Can I bill 97110 for home exercise instruction?
No — 97110 requires direct one-on-one skilled supervision during the exercise.
Can 97110 and 97530 be billed same day?
Yes — when addressing different therapeutic goals. Each needs separate time documentation.
97112
PTOT
Full code
97112
Billing unit
15-minute timed units
Includes
Balance · Proprioception · PNF · Coordination
ICD-10 pairs
R26.81 · R27.0 · G35 · I63.9
Medicare
Separately billable
When to use: Apply 97112 for neuromuscular reeducation — interventions targeting movement, balance, coordination, kinesthetic sense, posture, and proprioception. Distinct from 97110 (strength/ROM). Use when the primary goal is neuromotor function: balance retraining post-stroke, proprioception after ankle sprain, PNF patterns.
Do not use 97112 when: The primary goal is strength or ROM — use 97110. The activity is purely functional task training — use 97530.
"Neuromuscular reeducation ×2 units (30 min): (1) Single-leg balance on foam, BAPS board level 3, perturbation training — 80% appropriate response. (2) PNF D2 flexion/extension right UE ×3×10. Berg Balance: 32 → 35."
97112 vs 97110: 97112 = neuromotor focus (balance, coordination, proprioception). 97110 = musculoskeletal focus (strength, ROM). Both may be billed same day for different goals.
Can 97112 and 97110 be billed together?
Yes — when addressing different therapeutic goals. Each needs its own time documentation.
97113
PTOT
Full code
97113
Billing unit
15-minute timed units
vs 97036
97113 = active exercise · 97036 = passive modality
Clinician
Constant attendance required
Medicare
Separately billable
When to use: Apply 97113 for aquatic therapy — therapeutic exercise in a pool under skilled clinician supervision. Water buoyancy reduces gravitational load, allowing pain-free movement when land-based exercise is not tolerated. Used for OA, post-surgical rehab, fibromyalgia, and neurological conditions.
Do not use 97113 when: Clinician is not in constant attendance. Open wounds contaminating pool. Incontinence without appropriate protection. Cardiovascular instability.
"Aquatic therapy ×3 units (45 min). Chest-high water (T9). (1) Walking forward/backward 10 min. (2) Hip abductor strengthening, noodle resistance 3×15. (3) Single-leg balance 3×30sec. Clinician in water, constant attendance."
Constant attendance required: The therapist must be in constant attendance (at poolside or in water). Group aquatic exercise = 97150. Document attendance was maintained throughout.
Does the clinician need to be in the water?
Not necessarily — constant attendance means at poolside or in water. Document clinician attendance and specific therapeutic exercises performed in the pool.
97116
PT
Full code
97116
Billing unit
15-minute timed units
Includes
Device training · Stair training · Pre-gait activities
ICD-10 pairs
R26.2 · R26.81 · S72.141A
Medicare
Separately billable
When to use: Apply 97116 for gait training — skilled instruction and supervision of ambulation with assistive devices, over varied surfaces, and on stairs. Includes pre-gait activities, device fitting/training (walker, cane, crutches), and stair negotiation. One of the most commonly billed PT codes post-acute.
Do not use 97116 when: Walking is part of a broader functional task (community navigation) — use 97530. Treadmill walking for cardiovascular conditioning — use 97110. Primary focus is neuromotor coordination — consider 97112.
"Gait training ×2 units (30 min): Ambulation 150 ft rolling walker, min A×2. Stairs: 4 steps step-to, bilateral rail, mod A. WBAT right LE — 85% WB observed. Deviation: decreased right knee extension mid-stance — cueing 70% success."
97116 vs 97530: 97116 = specific gait training focused on ambulation mechanics and device instruction. 97530 = walking as part of broader functional task training.
Can I bill 97116 and 97112 same day?
Yes — 97116 for ambulation/device training and 97112 for balance/proprioception training address different therapeutic goals. Document each separately.
97124
PTOT
Full code
97124
Billing unit
15-minute timed units
Techniques
Effleurage · Petrissage · Tapotement · Compression
vs 97140
97140 for joint mobilization/IASTM
Medicare
Separately billable
When to use: Apply 97124 for massage — manual soft tissue techniques including effleurage, petrissage, compression, and tapotement. Goals: reduce muscle tension, improve circulation, decrease edema, prepare tissue for exercise. Requires skilled clinical judgment — not a standalone relaxation massage.
Do not use 97124 for: Joint mobilization or manipulation — use 97140. IASTM/Graston technique — use 97140. Myofascial release with joint mobilization — use 97140.
"Massage therapy ×1 unit (15 min): Effleurage and petrissage right lumbar paraspinals and piriformis. Pre: muscle tone firm and tender. Post: soft, 50% reduction in aching. Preparatory for manual therapy."
97124 vs 97140: 97124 = massage (effleurage, petrissage). 97140 = joint mobilization, MFR, IASTM. Both may be billed same day for different areas/techniques — document separately.
Can 97124 and 97140 be billed same day?
Yes — when distinct techniques on different areas. Example: 97124 for lumbar effleurage + 97140 for lumbar joint mobilization. Document area, technique, and rationale for each.
97129
PTOTSLP
Full code
97129
Add-on code
97130 for each additional 15 min
ICD-10 pairs
R41.3 · S06.30xA · F03.90 · G31.84
Added
2019 — cross-disciplinary cognitive rehab
Medicare
Separately billable
When to use: Apply 97129 for therapeutic interventions focused on cognitive function — attention, memory, executive function, problem-solving. Added in 2019. Used for TBI cognitive rehab, stroke cognitive-communication treatment, dementia maintenance, and MCI intervention. PT, OT, and SLP may all bill this code within their scope.
Do not use 97129 when: The intervention is primarily physical/motor and cognitive training is incidental. For sessions longer than 15 min without adding 97130 — 97129 = first 15 min only.
"Cognitive rehab ×45 min (97129 + 97130 ×2): (1) Sustained attention task (Trails A) 15 min. (2) Divided attention dual-task 15 min. (3) Prospective memory strategy (calendar system) 15 min. RBANS attention index: +5 points from baseline."
Structure: 97129 = first 15 min. 97130 = each additional 15 min. 45-min session = 97129 ×1 + 97130 ×2.
Modifier by discipline: GP = PT · GO = OT · GN = SLP. Required for Medicare.
Which disciplines can bill 97129?
PT, OT, and SLP can all bill 97129 when providing cognitive rehab within their scope. Use GP (PT), GO (OT), or GN (SLP) modifier for Medicare.
97130
PTOTSLP
Full code
97130
Type
Add-on — requires 97129 on same claim
Billing example
60-min session = 97129 ×1 + 97130 ×3
Medicare
Separately billable (with 97129)
When to use: Apply 97130 for each additional 15-minute block of cognitive rehabilitation beyond the first 15 minutes. Always paired with 97129. Cannot be billed as a standalone code.
No cap on units: Bill as many units as needed to reflect actual time, always with one unit of 97129. A 90-minute session = 97129 ×1 + 97130 ×5. Documentation must support the total treatment time billed.
How many units of 97130 can I bill per session?
As many as needed to reflect actual time — always with one 97129. Document all activities performed and start/end times.
97139
PTOT
Full code
97139
Common uses
Dry needling · Cupping · Specific manual techniques
Requires
Special report submitted with every claim
Medicare
Often denied — verify coverage first
When to use: Apply 97139 for physical medicine procedures without a specific CPT code. A special report must accompany every claim describing the procedure, technique, equipment, and clinical rationale.
Do not use 97139 when: A specific CPT code exists for the procedure. Without a detailed special report attached. When the payer has a specific policy excluding the procedure.
"Dry needling right upper trapezius trigger point, 3 needles, 10 min. Patient reports referred pain pattern abolished post-treatment. Cervicogenic headache indication. Special report attached."
Is 97139 appropriate for dry needling?
Some payers accept 97139; others prefer 20560/20561. Check each payer policy. Always attach a special report. Verify state practice act permissions for dry needling by PTs.
97140
PTOTDC
Full code
97140
Billing unit
15-minute timed units
Includes
Joint mob · HVLA · MFR · IASTM · Neural mob
Modifier
GP (PT) · GO (OT) · AT (DC)
CPT pairs
97110 · 97124 · 97530 · 98940
DC note
Use 98940–98942 for spinal CMT
When to use: Apply 97140 for manual therapy — hands-on techniques directed at joints and soft tissues. The second most commonly billed PT code. Includes joint mobilization/manipulation, myofascial release, IASTM, and neural mobilization. Requires specialized training and direct hands-on contact throughout.
DC application: Use 97140 for extremity joint mobilization only. For spinal chiropractic manipulation, use 98940–98942.
Do not use 97140 for: Massage (effleurage, petrissage) — use 97124. Spinal CMT by a DC — use 98940–98942. Basic stretching alone — use 97110.
"Manual therapy ×2 units (30 min): (1) Left shoulder GH — posterior glide Grade III ×3 sets. ER ROM: 20° → 35°. (2) Cervical C4–C5 PA glide Grade III. Pain: 6/10 → 3/10. Maitland Grade III technique."
Audit tip: Document specific technique, segment/joint treated, sets, pre/post ROM or pain scores, and rationale. Generic "manual therapy to lumbar spine" is insufficient for audit defense.
Can 97140 and 97124 be billed same day?
Yes — distinct techniques on different areas. Example: 97124 for effleurage + 97140 for joint mobilization. Document each separately.
Should a DC bill 97140 or 98940 for spinal manipulation?
Use 98940–98942 for spinal CMT by a DC. Use 97140 for extremity joint mobilization.
97150
PTOT
Full code
97150
Billing
Once per patient per session — untimed
Group size
2+ patients
Medicare
Separately billable
When to use: Apply 97150 when a therapist simultaneously treats 2+ patients. The therapist divides attention among multiple patients. Common in cardiac rehab group exercise, post-surgical class, and lymphedema group education.
Do not use 97150 when: Only one patient is being treated. Individual timed codes cannot be billed for the same time period that 97150 is billed to the same patient.
"Group therapeutic exercise class 9:00–9:45 (97150). 4 patients. Patient X: rotator cuff program. Clinician monitored all 4 patients, providing individual cues to patient X ×3 for shoulder form."
Group vs individual: 97150 is untimed — billed once per patient per session. If one-on-one time occurs within a group session, that time can be separately billed as individual treatment with clear time documentation.
Can I bill 97150 and 97110 same day for the same patient?
Yes — if patient received both group therapy (97150) and individual one-on-one therapy (97110). Document time clearly: "Group 9:00–9:45. Individual manual therapy 9:45–10:00."
97161
PT
Full code
97161
Complexity
1–2 deficits · No comorbidities
Typical time
20 minutes
Modifier
GP required on all Medicare PT claims
When to use: Apply 97161 for low-complexity PT evaluations — 1–2 performance deficits, stable uncomplicated condition, straightforward POC. Examples: isolated ankle sprain, single-joint OA, uncomplicated post-surgical case with no comorbidities affecting the POC.
Upgrade to 97162 when: More than 2 performance deficits are found. Comorbidities are present that affect the POC. More than standard clinical guidelines needed.
Select the code matching actual complexity found during the eval — not what you anticipated. If more complex than expected, upgrade and document the factors that increased complexity.
Criteria: History — no comorbidities affecting POC. Exam — 1–2 deficits. CDM — established guidelines apply. Typical time: 20 min. GP modifier required for Medicare.
Can I change the complexity level after the eval?
Yes — select the code matching actual complexity found. If more complex than anticipated, bill 97162 or 97163 and document the factors that increased complexity.
97162
PT
Full code
97162
Complexity
3+ deficits · Comorbidities present
Typical time
30 minutes
Most common
~60% of outpatient PT evaluations
When to use: Apply 97162 for moderate-complexity PT evaluations — the most common level in outpatient PT. Characterized by 3+ performance deficits and comorbidities that impact the POC. Most post-surgical, neurological, and multijoint presentations qualify as moderate complexity.
Criteria: Comorbidities with identifiable impact on POC. Multiple body structure/function deficits. Guidelines applicable with modifications. Examples: post-TKA, lumbar disc herniation, rotator cuff repair.
Most common trigger for 97162 over 97161: Comorbidities affecting POC — diabetes, cardiovascular disease, obesity. Document which comorbidities affect the POC and how they modify the standard treatment approach.
What is the most common reason to use 97162 over 97161?
The presence of comorbidities that affect the plan of care — diabetes, cardiovascular disease, obesity. When personal factors require modification of typical clinical guidelines, moderate complexity is appropriate.
97163
PT
Full code
97163
Complexity
Multisystem · Complex CDM · No standard guidelines
Typical time
45 minutes
Common cases
Stroke · SCI · Complex TBI · Multi-trauma
When to use: Apply 97163 for high-complexity PT evaluations — multisystem involvement, significant comorbidities, and complex CDM where standard guidelines do not apply. Typical: acute stroke, SCI, complex TBI, multiple trauma, advanced neurological disease.
Audit risk: 97163 carries higher scrutiny. Document thoroughly: specific comorbidities, CDM rationale, and why standard guidelines were insufficient. Upgrade from 97162 to 97163 only when genuinely warranted.
Requirements: Significant comorbidities with major POC impact. Multisystem impairments. No applicable clinical guidelines. Novel or unpredictable POC required. Significant diagnostic uncertainty.
Will auditors question 97163 more?
Yes — 97163 carries higher scrutiny. Document specific comorbidities, CDM rationale, and why standard guidelines were insufficient. A well-documented 97163 is defensible.
97164
PT
Full code
97164
Triggers
New findings · Failure to progress · Significant change
When NOT to use
Routine progress note · Admin recertification
Medicare
Requires POC change justification
When to use: Apply 97164 when formal re-evaluation is warranted — new clinical findings requiring a POC change, failure to progress, significant functional change, or return after a treatment gap. Not a routine progress note — it requires formal reassessment that changes the clinical direction.
Not appropriate for: Routine monthly progress notes. Standard goal updates without clinical change. Administrative recertification without new findings. Each 97164 must document the specific clinical reason requiring POC reassessment.
Valid triggers: New diagnosis affecting POC · Unexpected functional decline · Plateau requiring goal revision · Return after 30+ day gap · Post-surgical phase transition · Payer-requested reassessment.
How often can I bill 97164?
As often as clinically warranted — no fixed frequency limit. Each must document the specific reason requiring POC reassessment. Frequent re-evals without clear justification attract audit scrutiny.
97530
PTOT
Full code
97530
Billing unit
15-minute timed units
vs 97110
97530 = functional tasks · 97110 = isolated exercise
CPT pairs
97110 · 97116 · 97535
Medicare
Separately billable
When to use: Apply 97530 for therapeutic activities — dynamic activities improving functional performance in real-world tasks. Uses functional movements (sit-to-stand, carrying, stair negotiation, dressing simulation) rather than isolated exercise. One of the most commonly billed OT codes.
OT application: ADL training, functional transfers, meal preparation, and task-specific upper extremity training.
Do not use 97530 when: The exercise targets isolated strength/ROM — use 97110. Gait training specifically — use 97116. Home management/ADL in OT — 97535 may be more specific.
"Therapeutic activities ×2 units (30 min): (1) Sit-to-stand ×10 from 16" surface — bilateral LE loading, knee extension control cued. (2) Stair negotiation 8 steps, alternating, single rail — 90% safety compliance."
97530 vs 97110: 97110 = isolated exercises. 97530 = functional tasks resembling real-life activities. Both may be billed same day for different goals — document separately.
Can 97530 be used for ADL training?
Yes — ADL training (dressing, bathing, grooming) is a classic 97530 application. Document specific task, assist level, strategy, and patient performance. Generic "ADL training" is insufficient.
Can 97530 and 97110 be billed same day?
Yes — when addressing different goals. Document separately with distinct time and rationale.
97545
PTOT
Full code
97545
Add-on
97546 for each additional hour
Goal
Return to specific work tasks and job demands
Medicare
Separately billable
When to use: Apply 97545 for work hardening programs — structured, work-specific conditioning for return to work. Uses real or simulated work tasks, progressively graded to match the physical demands of the specific job. Typically 2–4 hour daily sessions over weeks.
97545 + 97546 structure: 97545 = initial 2 hours. 97546 = each additional hour. A 4-hour session = 97545 ×1 + 97546 ×2.
Work hardening vs work conditioning: Work hardening = multidisciplinary, work-specific program using real/simulated tasks (physical and behavioral). Work conditioning = single-discipline physical restoration. Work hardening requires OT, PT, and often psychology/vocational rehab.
Requirements: Job description and physical demands analysis. Specific work tasks simulated. Patient performance metrics (lift capacity, standing tolerance). Progress toward job-specific physical demands.
What is the difference between work hardening and work conditioning?
Work hardening (97545) = multidisciplinary, work-specific program with physical and behavioral components. Work conditioning = single-discipline physical restoration. Work hardening is more comprehensive and typically requires multiple disciplines.
97550
PTOTSLP
Full code
97550
Patient present
No — caregiver-only session
Added
2020 — new caregiver training code set
With patient
97551 · Group: 97552
Medicare
Separately billable
When to use: Apply 97550 when training a caregiver without the patient present. Added 2020 to recognize skilled caregiver education. Use for family training on transfer techniques, positioning, HEP facilitation, dysphagia diet management, or fall prevention — when patient is not in the room.
97550 vs 97551: 97550 = patient NOT present. 97551 = patient IS present and participating. 97552 = group caregiver training (2+ caregivers). Select the code accurately reflecting whether the patient was in the room.
"Caregiver training without patient, 30 min (2 units). Caregiver: wife. Topics: (1) Safe stand-pivot transfer with gait belt — return demo competent. (2) Walker adjustment and safety. (3) HEP facilitation for hip precautions."
Same-day billing: May be billed same day as patient treatment. Document timing clearly — patient treatment time and caregiver training time must be documented separately without overlap.
Can caregiver training and patient treatment be billed same day?
Yes — document timing clearly. Patient treatment time and caregiver training time must be documented separately without overlap.
97551
PTOTSLP
Full code
97551
Patient present
Yes — patient participates
Most common
Most caregiver training occurs with patient
Medicare
Separately billable
When to use: Apply 97551 when training a caregiver with the patient present — the most common caregiver training scenario. Typical: caregiver-assisted transfer training, cueing strategies for dementia, dysphagia diet, or positioning techniques practiced with the patient.
"Caregiver training, patient present, 30 min. Caregiver: daughter. (1) Sit-to-stand transfer assist with gait belt — practiced ×5, caregiver demonstrates safe technique. (2) Cueing strategies for dressing sequence."
Time documentation: Caregiver training (97551) is a separate service. Patient treatment codes reflect direct treatment time only. Document caregiver training time separately.
Should caregiver training time be added to patient treatment time?
No — bill caregiver training (97551) as a separate service. Patient treatment codes reflect direct treatment time only. Document times separately to avoid overlap.
97597
PTOT
Full code
97597
Add-on
97598 for each additional 20cm²
Type
Selective — sharp / autolytic / enzymatic
ICD-10 pairs
L89.x · T31 · E11.621
Certification
CWS or CWOCN often required
When to use: Apply 97597 for selective debridement of open wounds up to 20cm² — removal of devitalized tissue using methods that preserve healthy tissue: sharp debridement, autolytic, or enzymatic. Requires clinical judgment and scope-of-practice compliance.
Area calculation: Measure wound bed (length × width cm). 97597 = first 20cm². Add 97598 for each additional 20cm². Example: 35cm² wound = 97597 ×1 + 97598 ×1. Many payers require wound care certification — verify credentialing requirements.
"Selective sharp debridement right heel PI (L89.314): 4×3cm = 12cm². Yellow slough removed — granulation tissue exposed. Undermining 1cm at 6 o'clock. Irrigated with NS. Collagen dressing applied."
Certification note: Many payers require wound care certification (CWS, CWOCN) for therapist-performed debridement. Check payer credentialing requirements and state practice act guidance.
Can PTs and OTs perform wound debridement?
Yes — within state practice act scope. Specialty wound care certification is typically required by payers. Always verify state requirements and payer credentialing before billing.
97598
PTOT
Full code
97598
Type
Add-on — requires 97597
Billing example
45cm² = 97597 ×1 + 97598 ×1
Large wound
100cm² = 97597 ×1 + 97598 ×4
When to use: Apply 97598 for each additional 20cm² of selective debridement beyond the first 20cm² covered by 97597. Always requires 97597 as the primary code.
Document wound measurements precisely: length × width in cm. Calculate total wound bed area clearly. Example: "Wound: 8×5cm = 40cm². 97597 ×1 (first 20cm²) + 97598 ×1 (additional 20cm²)."
How do I calculate 97598 units for a large wound?
97597 covers the first 20cm². Each 97598 covers an additional 20cm². 100cm² wound = 97597 ×1 + 97598 ×4. Always document measurements and calculated area in your note.
97602
PTOT
Full code
97602
Methods
Wet-to-dry · Pulsed lavage with suction · Mechanical
vs 97597
97597 = selective (preserves healthy tissue)
Medicare
Separately billable
When to use: Apply 97602 for non-selective debridement — methods that remove both viable and non-viable tissue without clinical discrimination. Includes wet-to-dry dressings, pulsed lavage with suction, and wound irrigation. Appropriate for heavily contaminated wounds requiring mechanical cleansing.
97597 vs 97602: 97597 (selective) = preserves healthy tissue, removes only devitalized tissue. 97602 (non-selective) = removes both viable and non-viable tissue. Use 97597 when precision is required. Use 97602 for mechanical cleansing.
"Non-selective debridement via pulsed lavage with suction, right diabetic foot ulcer (E11.621), 150mL NS at 8 psi. Post-irrigation: wound bed 70% granulation, 30% fibrin."
When is non-selective debridement preferred over selective?
Use non-selective (97602) for heavily contaminated wounds needing irrigation/cleansing. Use selective (97597) when preserving specific healthy tissue structures is clinically important.
97605
PTOT
Full code
97605
Device
Non-disposable (reusable) NPWT device
Size
≤50cm² · Use 97606 for >50cm²
Disposable versions
97607 (≤50cm²) · 97608 (>50cm²)
When to use: Apply 97605 for NPWT using a non-disposable device on wounds ≤50cm². NPWT applies controlled negative pressure to remove exudate, reduce edema, promote granulation tissue, and draw wound edges together. Used for chronic wounds, pressure injuries, diabetic foot ulcers, and post-surgical wounds.
NPWT contraindications: Malignancy in the wound. Untreated osteomyelitis. Necrotic tissue with eschar (debride first). Exposed vessels, nerves, or organs. Fistulas to body cavities. Always document absence of contraindications.
"NPWT (97605): right sacral PI. Wound: 9×5cm = 45cm² (≤50cm²). KCI V.A.C., continuous −125 mmHg. Foam dressing. Exudate: moderate serous. Granulation: 60%. Dressing change every 48 hrs."
Code selection: 97605 = non-disposable, ≤50cm². 97606 = non-disposable, >50cm². 97607 = disposable, ≤50cm². 97608 = disposable, >50cm². Select based on device type and wound area.
How often can NPWT be billed?
Per dressing change — typically every 48–72 hours. Document wound measurements, exudate characteristics, granulation tissue %, and wound edge response at each change.
97606
PTOT
Full code
97606
Device
Non-disposable (reusable) NPWT device
Size
>50cm²
Smaller version
97605 (≤50cm²)
When to use: Apply 97606 for NPWT using a non-disposable device on wounds >50cm². Same clinical application as 97605 but for larger wound areas. Document wound measurements clearly to support the >50cm² area billed.
"NPWT (97606): right sacral/gluteal PI. Wound: 9×7cm = 63cm² (>50cm²). KCI V.A.C., continuous −125 mmHg. Exudate: moderate serous. Granulation: 60%."
What if a wound spans exactly 50cm²?
Use 97605 (≤50cm²). The threshold is >50cm² for 97606. If exactly 50cm², bill 97605. Document precise measurements.
97607
PTOT
Full code
97607
Device
Disposable (single-use) NPWT device
Size
≤50cm²
Examples
PICO · KCI SNAP · Single-use VAC devices
When to use: Apply 97607 for NPWT using a disposable (single-use) device on wounds ≤50cm². Disposable NPWT devices (e.g., PICO, SNAP) are increasingly common for outpatient and home wound care. The entire device is discarded after use, distinguishing it from 97605 (reusable device).
Disposable vs non-disposable: Disposable = entire device discarded after use. Non-disposable = permanent pump with replaceable canisters. Select 97605/97606 for reusable, 97607/97608 for disposable based on actual device used.
What makes a device "disposable" for NPWT coding?
A disposable NPWT device is a single-use system where the entire device (not just the dressing) is discarded after use. Select your code based on whether the device itself is reusable or single-use.
97610
PTOT
Full code
97610
Device
MIST Therapy System (40 kHz non-contact)
vs 97035
97035 = therapeutic US (1–3 MHz) · 97610 = wound US (40 kHz)
Medicare
Covered for chronic wounds — requires documentation
When to use: Apply 97610 for low-frequency (40 kHz) non-thermal ultrasound — specifically the MIST Therapy System. Delivered via saline mist, it gently debrides the wound surface and promotes cellular healing without contact. Used for chronic non-healing wounds including diabetic foot ulcers, venous leg ulcers, and pressure injuries that have failed conventional wound care.
Do NOT confuse with 97035: 97035 = therapeutic ultrasound (1–3 MHz, contact, musculoskeletal). 97610 = low-frequency non-contact wound healing ultrasound (40 kHz, saline mist). Completely different technology, frequency, and clinical application.
Medicare requires documentation that conventional wound care has been attempted and failed. Document wound measurements, wound bed characteristics pre/post, number of passes, and patient tolerance.
Is 97610 the same as regular therapeutic ultrasound (97035)?
No — completely different. 97035 = therapeutic ultrasound (1–3 MHz, contact, musculoskeletal). 97610 = low-frequency non-contact wound healing ultrasound (40 kHz, saline mist).
97750
PTOT
Full code
97750
Billing unit
15-minute timed units
Common uses
FCE · Isokinetic testing · Formal Berg · 6MWT
Written report
Required — separate written report
Medicare
Separately billable
When to use: Apply 97750 for standardized physical performance testing generating a separate written report. Common: FCE, isokinetic strength testing, formal standardized balance assessments, 6MWT. Not for routine outcome measures in a progress note — requires a formal standalone written report with normative comparisons.
Do not bill 97750 for: Routine outcome measures (PSFS, LEFS, NDI) documented in a progress note. Informal functional tests performed as part of a standard treatment session. The distinction is whether a separate formal written report with normative data is generated.
Written report must include: Specific tests performed, normative comparison data, clinical interpretation, functional implications, and recommendations. Bill 15-min units for total testing AND report-writing time.
FCE note: For comprehensive FCE, may span multiple hours. Bill 97750 in 15-min units for total evaluation and report time. Pre-authorization often required by workers' comp and commercial payers.
Is 97750 appropriate for a Berg Balance Scale in a progress note?
No — routine Berg administration in a progress note does not qualify. 97750 is for formal standardized testing generating a separate written report with normative comparisons.
97760
PTOT
Full code
97760
Billing unit
15-minute timed units
Common devices
AFO · Knee brace · Thumb spica · Wrist splint · KAFO
Subsequent visits
97763
Medicare
Separately billable
When to use: Apply 97760 for the initial encounter of orthotic management — fitting, checking, and training in orthosis use. Includes device fit evaluation, skin inspection training, donning/doffing instruction, wearing schedule education, and initial function training. Use 97763 for all subsequent sessions.
97760 vs 97763: 97760 = initial fitting and training (first session only). 97763 = all subsequent sessions. Use 97760 only once — all follow-up sessions use 97763.
"Orthotic management initial ×2 units: AFO fit check right LE — trim lines adjusted at medial malleolus. No pressure areas. Donning/doffing: independent with verbal cues for strap sequence. Gait with AFO: improved right dorsiflexion clearance."
Custom splint fabrication (OT): 97760 covers orthotic management including custom splint fabrication when fitting and training are involved. Fabrication labor is included in 97760 billing time. Materials may be separately billable with HCPCS codes.
Can I bill 97760 for custom OT splint fabrication?
Yes — fabrication labor is included in 97760. Materials may be separately billable with HCPCS codes depending on payer policy.
97761
PTOT
Full code
97761
Billing unit
15-minute timed units
Common cases
BKA · AKA · Bilateral · UE amputee
Subsequent visits
97763
ICD-10 pairs
Z89.511 · Z89.611 · Z89.221
When to use: Apply 97761 for the initial encounter of prosthetic training — first fitting and functional training with a prosthetic device. PT focus: LE gait training. OT focus: UE prosthesis functional use (terminal device operation, myoelectric control, ADL integration). Requires specialized prosthetic training knowledge.
"Prosthetic training initial ×3 units: Right BKA — preparatory prosthesis first fitting. Residual limb: no skin breakdown. WB parallel bars 5 min. Gait: step-to pattern, 15 feet. Education: skin inspection, donning/doffing, wearing schedule 2 hrs day 1."
PT vs OT roles: PT = LE prosthetic gait training, transfers, stairs. OT = UE prosthetic training, myoelectric control, ADL integration. Both use 97761 for initial and 97763 for subsequent. Coordinate with the prosthetist.
Who provides prosthetic training — PT or OT?
PT = lower extremity (gait, transfers, stairs). OT = upper extremity (myoelectric control, terminal device, ADL integration). Both use 97761 for initial and 97763 for subsequent sessions.
97763
PTOT
Full code
97763
Billing unit
15-minute timed units
Covers
All follow-up orth/prosth sessions
Initial codes
97760 (orthotic) · 97761 (prosthetic)
Medicare
Separately billable
When to use: Apply 97763 for all subsequent orthotic and prosthetic management after the initial visit (97760 or 97761). Includes progressive gait training with prosthesis, orthotic adjustments, advancing functional activities, problem-solving device issues, and graduating to community-level use.
When 97763 ends: Use 97763 when the primary session focus is the orthosis/prosthesis. When the device becomes secondary to overall functional training, transition to 97110 or 97530. Document the rationale for the code used at each session.
How long should I keep billing 97763?
Continue 97763 as long as the primary focus is the prosthesis/orthosis. As the patient progresses and the device becomes secondary to overall functional training, transition to 97110 or 97530.
97799
PTOT
Full code
97799
Requires
Special report with every claim
Medicare
Almost always denied — use sparingly
When to use
Last resort when no other code applies
When to use: Apply 97799 as a last resort for PT/rehab services that cannot be described by any existing CPT code. A special report must accompany every claim. Medicare almost always denies 97799 — use only when no other code applies and the service is medically necessary and well-documented.
Always check first: Most PT/rehab services have a specific CPT code. Before using 97799, confirm no existing code applies. Overuse of 97799 is an audit red flag.
When is 97799 the right choice?
Rarely — use only when a genuinely novel service has no established code. Always attach a detailed special report. Consider requesting a specific CPT code be established for commonly performed but unlisted services.
97165
OT
Full code
97165
Complexity
1–3 performance areas · No comorbidities
Typical time
30 minutes
Modifier
GO required on all Medicare OT claims
When to use: Apply 97165 for low-complexity OT evaluations — fewer than 3 performance areas affected, minimal comorbidities, straightforward intervention. Examples: isolated hand injury, single ADL deficit after minor injury, simple pediatric fine motor concern without comorbidities.
Upgrade to 97166 when: 3–4 performance areas are affected. Comorbidities are present that impact the OT POC. Upgrade to 97167 when 5+ areas and significant comorbidities.
OT performance areas: ADL (bathing, dressing, grooming, eating, toileting), IADL (meal prep, home management, finances), work/education, leisure, and social participation.
GO modifier: Required on every CPT code on every Medicare OT claim. Without GO, Medicare OT claims will be denied.
What are OT "performance areas"?
ADL, IADL, work/education, leisure, and social participation. Number of affected areas + comorbidities = complexity level: low = 1–3 areas, no comorbidities.
97166
OT
Full code
97166
Complexity
3–4 performance areas · Identified comorbidities
Typical time
45 minutes
Most common
~65% of outpatient OT evaluations
When to use: Apply 97166 for moderate-complexity OT evaluations — the most common level in outpatient OT. Multiple performance areas affected, comorbidities impacting the POC, and moderate CDM required. Most adult neurological, pediatric developmental, and hand therapy cases qualify.
Criteria: Comorbidities with identifiable impact on OT POC. Multiple performance area deficits. Guidelines applicable with modifications. Examples: stroke with hemiplegia, pediatric developmental delay, complex hand injury.
97165 vs 97166 — how do I decide?
Count performance areas and assess comorbidity impact. 1–3 areas, no comorbidities → 97165. 3–4 areas with comorbidities affecting POC → 97166. Complexity is determined by what you find and document.
97167
OT
Full code
97167
Complexity
5+ performance areas · Complex comorbidities
Typical time
60 minutes
Common cases
Stroke · TBI · SCI · Severe burns · Complex pediatric
When to use: Apply 97167 for high-complexity OT evaluations — 5+ performance areas affected, significant comorbidities, complex CDM, multiple standardized assessments required. Common: acute stroke with hemiplegia and cognitive deficits, TBI, SCI, severe burns, or complex pediatric with multiple developmental domains affected.
Standardized assessments supporting 97167: FIM, COPM, KELS, AMPS, or domain-specific tools. Breadth and depth of standardized assessment, combined with scope of occupational performance analysis, supports high complexity billing.
What assessments support 97167?
Use multiple validated assessments across domains — FIM, COPM, KELS, AMPS, or domain-specific tools. Breadth of standardized assessment combined with occupational performance analysis supports high complexity billing.
97168
OT
Full code
97168
Triggers
New findings · Unexpected change · POC revision
PT parallel
97164 (PT re-eval)
Modifier
GO required on all Medicare OT claims
When to use: Apply 97168 when formal OT re-evaluation is warranted — unexpected functional change, new diagnosis affecting occupational performance, plateau requiring POC revision, or return after a significant treatment gap. Not a routine progress note — requires POC modification based on new clinical findings.
Not appropriate for: Routine monthly progress notes. Standard goal updates without clinical change. Administrative recertification without new findings. Each 97168 must document the specific clinical reason requiring POC reassessment.
Is 97168 for a standard progress note?
No — 97168 is a formal re-evaluation requiring POC modification based on new clinical findings. A progress note documents ongoing treatment. 97168 is for when the clinical direction must formally change.
97533
OT
Full code
97533
Billing unit
15-minute timed units
Common diagnoses
F84.0 (ASD) · F82 (DCD) · F90.x (ADHD)
Coverage
Variable — always verify payer policy
When to use: Apply 97533 for sensory integration therapy — structured sensory experiences improving sensory processing and adaptive responses. Used in pediatric OT for ASD, sensory processing disorder, DCD, and ADHD. Involves vestibular, proprioceptive, and tactile activities in a sensory-enriched environment.
Coverage varies significantly: Some payers limit or exclude 97533. Always verify coverage and obtain prior authorization when required. When 97533 is not covered, activities with sensory components may be billed under 97530.
"Sensory integration ×3 units (45 min): (1) Vestibular: platform swing, linear movement, 10 min. (2) Proprioception: joint compression, weighted vest, 15 min. (3) Tactile: textured surface exploration, 20 min. Adaptive responses improved throughout session."
Is sensory integration covered by insurance?
Inconsistently. Many Medicaid plans cover 97533 for ASD with authorization. Commercial payers vary widely. Always check payer-specific policies and obtain authorization before initiating.
97535
OTPT
Full code
97535
Billing unit
15-minute timed units
Includes
ADL training · Adaptive equipment · Energy conservation
vs 97530
97535 = self-care/home · 97530 = broader functional
Medicare
Separately billable
When to use: Apply 97535 for self-care and home management training — direct skilled training in ADL and IADL tasks. Includes adaptive equipment instruction, compensatory technique training, energy conservation, and home modification recommendations. The most characteristic OT CPT code — closely aligned with OT's core domain of occupational performance.
97535 vs 97530: 97535 = specifically self-care/home management tasks (bathing, dressing, meal prep). 97530 = broader functional activities (transfers, stair training, functional mobility). Use 97535 when the focus is specifically ADL/IADL performance.
"Self-care training ×2 units (30 min): (1) Upper body dressing with right hemiplegia — one-handed technique. Modified independence with 1 verbal cue. (2) Adaptive equipment: long-handled shoe horn, elastic laces — patient demonstrates independence."
Can 97535 and 97530 be billed same day?
Yes — when distinct goals are addressed. 97535 = self-care/home tasks. 97530 = broader functional activities. Document each separately with distinct goals, tasks, and time.
97537
OTPT
Full code
97537
Billing unit
15-minute timed units
Includes
Shopping · Banking · Transportation · Work simulation
Setting
In-clinic simulation or community outing
Medicare
Separately billable
When to use: Apply 97537 for community and work reintegration training — skill training for community-level activities including shopping, banking, public transit use, and work simulation tasks. Can be in-clinic (simulated grocery task, cash management) or community outings with the therapist. Documents the transition from clinic to real-world performance.
"Community reintegration training ×2 units (30 min). In-clinic simulation: (1) Grocery shopping task — navigates mock store, selects 10 items from list, 80% accuracy without cues. (2) Money management: making change for $20, patient independent."
Can 97537 be billed for community outings?
Yes — community outings with a therapist providing skilled instruction qualify. Document the specific community skills trained, assist level, safety performance, and therapeutic rationale.
97542
OTPT
Full code
97542
Billing unit
15-minute timed units
Includes
Propulsion · Transfers · Pressure relief · Obstacle navigation
Related
97755 (AT assessment) for evaluation
Medicare
Separately billable
When to use: Apply 97542 for wheelchair management training — skilled instruction in safe and effective wheelchair use. Includes manual WC propulsion, power WC operation, pressure relief techniques, WC transfers, obstacle navigation, ramp/curb management, and home mobility. Used in SCI, stroke, MS, and neurodegenerative conditions.
"Wheelchair management ×2 units (30 min): (1) Manual WC propulsion 100 feet — bilateral UE technique, shoulder protection positioning. (2) Wheelie training for curb management — 4-inch curb ascent/descent with spotter. Pressure relief: 15-second weight shift every 30 min trained."
AT assessment vs training: 97755 = evaluation for device prescription (generates LMN). 97542 = training on an already-prescribed device. For power WC: 97755 → LMN → device approval → 97542 training.
Is 97542 appropriate for power wheelchair training?
Yes — 97542 covers both manual and power WC training. Document joystick control, directional accuracy, safety awareness, obstacle avoidance, and navigation. Power WC trials may require a prior AT assessment (97755).
97755
OTPTSLP
Full code
97755
Billing unit
15-minute timed units
Common uses
Power WC · AAC · Complex seating · ECU
Written report
Required — Letter of Medical Necessity (LMN)
Medicare
Separately billable
When to use: Apply 97755 for assistive technology assessment — formal evaluation for prescription of power wheelchairs, complex seating systems, AAC devices, and other DME requiring clinical justification. Generates a Letter of Medical Necessity (LMN) required for DME authorization and insurance coverage.
AT assessment vs training: 97755 = evaluation and prescription (generates LMN). 97542 = wheelchair training. 92597 = AAC evaluation (SLP-specific). Do not bill 97755 for ongoing training sessions — use 97542.
LMN must include: Patient's mobility/communication profile, devices trialed and performance, access assessment, recommended device with rationale, and functional goals with the recommended device.
Does 97755 cover AAC evaluations by SLP?
97755 can be used by PT, OT, and SLP for AT assessments. SLPs may prefer 92597 (AAC-specific). Both require an LMN. Verify payer preference for SLP-performed AAC evaluations.
92521
SLP
Full code
92521
Type
Untimed · Diagnostic
Common ICD-10 pairs
F98.5 · F80.81
Medicare
GN modifier required
When to use: Bill 92521 for a comprehensive evaluation of speech fluency disorders, including stuttering, cluttering, and neurogenic fluency disorders.
Do not use when: Do not bill 92521 when the evaluation includes both fluency and language components. Use 92523 instead.
Comprehensive fluency evaluation completed using SSI-4 and speech sample analysis. Dysfluency rate, secondary behaviors, severity, and functional impact documented.
This is an untimed evaluation code. Bill once per evaluation session regardless of time spent. Use GN modifier for Medicare.
Can I bill 92521 and 92523 together?
No. Choose the code that best matches the evaluation scope.
92522
SLP
Full code
92522
Type
Untimed · Diagnostic
Common ICD-10 pairs
F80.0 · F80.1 · R47.89
Medicare
GN modifier required
When to use: Bill 92522 when evaluating speech sound production without a language comprehension component. This includes articulation testing, phonology analysis, stimulability, and motor speech screening.
Do not use when: Do not use 92522 if receptive language was evaluated. Use 92523 when language comprehension is part of the evaluation.
Speech sound production evaluation completed using standardized and non-standardized measures. Error patterns, intelligibility, stimulability, and functional impact documented.
Use once per evaluation. Document the specific tools used and confirm language comprehension was not part of the evaluation.
When should I use 92522 vs 92523?
Use 92522 for speech sound production only; use 92523 when speech and language comprehension are both evaluated.
92523
SLP
Full code
92523
Type
Untimed · Comprehensive evaluation
Common ICD-10 pairs
F80.1 · F80.2 · F80.89
Medicare
GN modifier required
When to use: Bill 92523 when the evaluation includes both speech sound production and language comprehension. This is common in pediatric speech-language evaluations.
Do not use when: Do not use 92523 for fluency-only evaluations or speech-sound-only evaluations.
Comprehensive speech and language evaluation completed. Speech sound findings, receptive language results, standardized scores, clinical interpretation, and plan of care documented.
Document both evaluated domains clearly. If the report only supports one domain, payer review may question use of 92523.
Is 92523 only for children?
No. It can apply to adult patients when both speech sound production and language comprehension are evaluated.
92524
SLP
Full code
92524
Type
Untimed · Behavioral analysis
Common ICD-10 pairs
R49.0 · R49.1 · J38.3
Medicare
GN modifier required
When to use: Bill 92524 for behavioral and qualitative analysis of voice and resonance, including perceptual voice quality, pitch, loudness, resonance, and functional voice impact.
Do not use when: Do not use 92524 for instrumental laryngeal function studies. Use 92520 if instrumental testing is performed and supported by payer policy.
Voice evaluation completed with perceptual ratings, pitch/loudness assessment, resonance findings, functional impact, and treatment recommendations.
Document ENT referral or clearance when clinically appropriate, especially for persistent hoarseness or suspected vocal fold pathology.
Can 92524 be used for gender-affirming voice evaluation?
Yes, when the service is medically necessary and documentation supports voice/resonance assessment.
92540
SLP
Full code
92540
Type
Untimed · Diagnostic bundle
Common ICD-10 pairs
H81.13 · R42 · H81.09
Medicare
Verify payer policy
When to use: Bill 92540 for a basic vestibular evaluation when all required vestibular components are performed and documented.
Do not use when: Do not use 92540 if only one vestibular component is completed. This code is a bundled evaluation service.
Vestibular evaluation completed with spontaneous, gaze, positional, and optokinetic nystagmus findings documented.
Verify state scope and payer credentialing before billing vestibular evaluation codes under SLP.
Can SLPs bill 92540?
Scope and payer policy vary, so verify credentialing before use.
92626
SLP
Full code
92626
Type
Timed · First hour
Common ICD-10 pairs
H90.3 · Z96.21 · H91.90
Medicare
GN modifier required
When to use: Bill 92626 for evaluation of auditory rehabilitation status, commonly used in cochlear implant and hearing habilitation programs.
Do not use when: Do not use 92626 for AAC evaluation or general speech-language evaluation without a specific auditory rehabilitation focus.
Auditory rehabilitation evaluation completed with speech perception testing, functional listening measures, device status, and treatment recommendations.
Document total evaluation time and the specific auditory perception tools used.
Is 92626 only for cochlear implant patients?
No, but the defining requirement is auditory rehabilitation evaluation.
92597
SLP
Full code
92597
Type
Untimed · AAC evaluation
Common ICD-10 pairs
R47.01 · F84.0 · G12.21 · G35
Medicare
GN modifier required
When to use: Bill 92597 when evaluating a patient for AAC device prescription, candidacy, access method, symbol system, and device matching.
Do not use when: Do not use 92597 for routine speech-language treatment or AAC training after device selection.
AAC evaluation completed. Communication needs, motor access, cognition, language level, trialed systems, caregiver input, and device recommendation documented.
Device trials and medical necessity should be clearly connected to functional communication needs.
Is 92597 for low-tech AAC too?
It can be, when the evaluation supports AAC device prescription and functional communication planning.
92607
SLP
Full code
92607
Type
Timed · First hour
Common ICD-10 pairs
R47.01 · F84.0 · G12.21
Medicare
GN modifier required
When to use: Bill 92607 for the first hour of evaluation for a speech-generating device.
Do not use when: Do not use 92607 when the service is AAC treatment or training rather than evaluation.
SGD evaluation completed with device trials, access method testing, vocabulary system comparison, patient performance, and recommendation.
Document start/end time and why the selected device is medically necessary.
What if evaluation takes more than one hour?
Use the appropriate add-on code when payer policy supports additional time.
92608
SLP
Full code
92608
Type
Timed · Add-on
Common ICD-10 pairs
R47.01 · F84.0 · G12.21
Medicare
GN modifier required
When to use: Bill 92608 for each additional 30 minutes of SGD evaluation beyond the first hour when used with 92607.
Do not use when: Do not bill 92608 as a standalone code.
Additional SGD evaluation time documented with trials performed, patient response, caregiver training needs, and recommendation details.
Must be paired with 92607 and supported by total time documentation.
Can 92608 be billed alone?
No. It is an add-on code to 92607.
92609
SLP
Full code
92609
Type
Timed · Treatment
Common ICD-10 pairs
R47.01 · F84.0 · G12.21
Medicare
GN modifier required
When to use: Bill 92609 for therapeutic services focused on use of a speech-generating device after evaluation and device selection.
Do not use when: Do not use 92609 for the initial device evaluation. Use 92607/92608 or 92597 as appropriate.
SGD therapy completed targeting message selection, operational use, functional communication, caregiver cueing, and carryover.
Document skilled training, functional communication targets, device settings addressed, and patient/caregiver response.
Is 92609 the same as 92507?
No. 92609 is specific to therapeutic services for use of a speech-generating device.
92507
SLP
Full code
92507
Type
Untimed · Per session
Common ICD-10 pairs
F80.1 · F80.2 · R47.01 · R49.0
Medicare
GN modifier required
When to use: Bill 92507 for individual speech-language therapy sessions addressing speech, language, voice, fluency, or communication treatment.
Do not use when: Do not use 92507 for swallowing treatment. Use 92526 when the primary treatment is feeding or swallowing.
Individual SLP treatment completed. Targets, cueing level, accuracy, skilled interventions, patient response, and home carryover documented.
This is untimed for many payers. Bill once per session unless payer policy says otherwise.
Can 92507 be used for voice therapy?
Yes, when voice treatment is the skilled service provided.
92508
SLP
Full code
92508
Type
Untimed · Group
Common ICD-10 pairs
F80.1 · F80.2 · R47.01
Medicare
GN modifier required
When to use: Bill 92508 for group speech-language treatment when two or more patients are treated in the same session.
Do not use when: Do not use 92508 when the patient receives individual one-on-one treatment only.
Group SLP treatment documented with group size, individual goals, skilled cues provided, patient participation, and response.
Do not overlap group treatment time with individual treatment billing unless clearly separated.
Can group therapy and individual therapy happen the same day?
Yes, when clearly separate and documented.
92526
SLP
Full code
92526
Type
Untimed · Per session
Common ICD-10 pairs
R13.10 · R13.12 · F98.2
Medicare
GN modifier required
When to use: Bill 92526 for treatment of swallowing dysfunction or oral function for feeding.
Do not use when: Do not use 92526 for a swallowing evaluation. Use 92610, 92611, or 92612 depending on the evaluation type.
Swallowing treatment completed with diet level, compensatory strategies, exercises, bolus trials, safety response, and caregiver education documented.
Medical necessity should connect treatment to aspiration risk, nutrition, hydration, safety, or functional feeding goals.
Is 92526 only for dysphagia?
It also covers oral function for feeding when clinically supported.
92610
SLP
Full code
92610
Type
Untimed · Clinical evaluation
Common ICD-10 pairs
R13.10 · R13.12 · R63.30
Medicare
GN modifier required
When to use: Bill 92610 for clinical evaluation of oral and pharyngeal swallowing function.
Do not use when: Do not use 92610 for instrumental swallow studies. Use 92611 for MBSS/VFSS or 92612 for FEES.
Clinical swallow evaluation completed with oral motor exam, cranial nerve findings, PO trials, signs of aspiration, diet recommendation, and treatment plan.
Document medical necessity, observed impairment, safety recommendations, and whether instrumental assessment is indicated.
Is 92610 the same as bedside swallow evaluation?
Yes, when it is a skilled clinical swallowing evaluation.
92611
SLP
Full code
92611
Type
Untimed · Instrumental study
Common ICD-10 pairs
R13.10 · R13.12 · R13.13
Medicare
GN modifier required
When to use: Bill 92611 for motion fluoroscopic evaluation of swallowing function, commonly called MBSS or VFSS.
Do not use when: Do not use 92611 for a clinical bedside swallow evaluation.
MBSS completed with consistencies tested, penetration/aspiration findings, residue, compensatory strategies, and diet recommendations documented.
Coordinate documentation with radiology/facility billing requirements and payer authorization rules.
Can 92611 and 92610 be billed on the same day?
Only when both services are medically necessary and separately documented.
92612
SLP
Full code
92612
Type
Untimed · Instrumental endoscopy
Common ICD-10 pairs
R13.10 · R13.12 · R13.13
Medicare
GN modifier required
When to use: Bill 92612 for FEES when flexible endoscopic evaluation of swallowing is performed and recorded.
Do not use when: Do not use 92612 for clinical swallow evaluation without endoscopic visualization.
FEES completed with laryngeal anatomy, vocal fold function, secretion management, residue, penetration/aspiration, and strategy response documented.
Verify FEES credentialing, facility policy, state scope rules, and prior authorization requirements.
Do I need special credentialing for FEES?
Yes. FEES requires specific training and often facility credentialing.
98940
DC
Full Code
98940
Type
Untimed · Per Visit
Common ICD-10 Pairs
M54.50, M54.2, M99.01
Medicare
AT modifier required
When to use: Bill 98940 when performing spinal manipulation to one or two spinal regions. The five spinal regions are: cervical (including the occiput), thoracic, lumbar, sacral, and pelvic. Use 98940 when only the cervical region is treated, or when only the lumbar and sacral regions are treated — as long as the total does not exceed two regions.
DC application: The most commonly billed CMT code for focused cervical or lumbar care. Appropriate for acute cervical strain, single-level disc involvement, or patients requiring targeted adjustment of one spinal region per visit. Document the specific region(s) manipulated, the technique used (e.g., diversified, drop table, flexion-distraction), and the clinical rationale connecting the manipulation to the patient's diagnosis.
Do not bill 98940 when: three or more spinal regions are treated — use 98941 or 98942. Do not bill 98940 for extraspinal manipulation (extremities, ribs, skull) — use 98943. Do not bill 98940 without documenting the specific region(s) treated — undocumented region count is the most common CMT audit failure. Do not bill 98940 on the same claim as 98941 or 98942 for the same patient on the same date.
Sample note: "Spinal manipulation performed to lumbar region (1 region — 98940). Technique: diversified high-velocity low-amplitude thrust, L3–L4 and L4–L5 segments, bilateral. Cavitation noted bilaterally. Patient reported immediate reduction in lumbar stiffness. Active ROM reassessment post-treatment: lumbar flexion improved from 40° to 55°. Diagnosis: M54.50 (low back pain, unspecified). Patient tolerated procedure well. No adverse reactions. Plan: continue CMT 2x/week x 3 weeks, reassess."
AT modifier — Medicare: The AT modifier (acute treatment) is required on all CMT codes billed to Medicare (98940–98943). Medicare covers CMT only for acute or subacute subluxation — it does not cover maintenance care. The AT modifier signals to Medicare that the treatment is active/corrective. Never bill CMT to Medicare without AT; the claim will deny.
Most commercial payers do not require AT but verify plan-by-plan. Document subluxation findings using the PART components (Pain/tenderness, Asymmetry/misalignment, Range of motion abnormality, Tissue tone/texture changes) — Medicare LCD for CMT requires subluxation documentation. Bill 98940 once per visit regardless of how many segments within the 1–2 regions were treated.
How do I count spinal regions for CMT billing?
The five spinal regions are: (1) cervical including occiput, (2) thoracic, (3) lumbar, (4) sacral, (5) pelvic. Count the number of distinct regions where manipulation was performed, not the number of vertebral segments. Treating L3, L4, and L5 all within the lumbar region = 1 region = 98940.
Can I bill 98940 and an E/M code on the same day?
Yes, if a significant and separately identifiable evaluation and management service was performed beyond the routine pre-manipulation assessment. Modifier 25 must be appended to the E/M code to indicate it was a separate service. Document the E/M service distinctly from the CMT encounter note.
98941
DC
Full Code
98941
Type
Untimed · Per Visit
Common ICD-10 Pairs
M54.50, M54.2, M99.02, M99.03
Medicare
AT modifier required
When to use: Bill 98941 when performing spinal manipulation to three or four of the five spinal regions in a single visit. This is the most commonly billed CMT code in general chiropractic practice, covering full-spine or near-full-spine manipulation protocols.
DC application: Appropriate for patients with multi-region spinal complaints — cervical, thoracic, and lumbar involvement is a classic 3-region presentation (98941). Full-spine protocols treating cervical, thoracic, lumbar, and sacral regions qualify as 4-region (98941). Document each distinct region treated and the clinical findings justifying treatment of each region. Treating additional regions without documented clinical rationale is a common audit vulnerability.
Do not bill 98941 when: only 1–2 regions are treated — use 98940. Do not bill 98941 when all 5 regions are treated — use 98942. Do not document "full spine manipulation" without specifying which of the five regions were treated — this creates audit exposure. Do not upcode by routinely billing 98941 when clinical documentation only supports 1–2 region treatment.
Sample note: "Spinal manipulation performed to cervical, thoracic, and lumbar regions (3 regions — 98941). Cervical: diversified HVLA C3–C7 bilateral, restricted motion noted on segmental assessment. Thoracic: drop-table technique T4–T8, reduced posterior joint play pre-treatment. Lumbar: side-posture diversified L2–L5, pain provocation positive pre-treatment. Post-treatment ROM: cervical rotation improved bilaterally; lumbar flexion +15°. Diagnoses: M54.2 (cervicalgia), M54.50 (LBP). Patient tolerated all techniques without adverse response. AT modifier applied — Medicare active/corrective care."
AT modifier — Medicare: Required on all CMT codes billed to Medicare. Confirms active corrective treatment, not maintenance care. Without AT, Medicare CMT claims deny automatically. Medicare only covers spinal CMT (98940–98942) — extraspinal (98943) is not a covered Medicare benefit.
98941 is one of the most frequently audited CMT codes because it is the most commonly billed. Payers look for routine 98941 billing without documentation variability — if you bill 98941 for every patient every visit, expect scrutiny. Let the clinical findings drive the region count and document those findings specifically for each region treated every visit.
Why is 98941 the most audited CMT code?
98941 is the highest-volume CMT code nationally. Payers flag practices where 98941 represents an unusually high percentage of CMT billing — it suggests potential upcoding from 98940. Ensure your billing distribution across 98940, 98941, and 98942 reflects your actual clinical findings and treatment patterns.
98942
DC
Full Code
98942
Type
Untimed · Per Visit · All 5 Regions
Common ICD-10 Pairs
M54.50, M54.2, M99.01–M99.05
Medicare
AT modifier required
When to use: Bill 98942 when spinal manipulation is performed to all five spinal regions in a single visit: cervical (including occiput), thoracic, lumbar, sacral, and pelvic. This is true full-spine CMT — all five regions must be treated and documented to justify this code.
DC application: Appropriate for patients with global spinal dysfunction, scoliosis-related multi-region presentations, or complex spinal conditions requiring treatment across the entire spine. Each of the five regions must have documented clinical findings justifying manipulation — it is not sufficient to document treatment without individual region-specific subluxation findings. This code carries the highest audit risk in the CMT family and demands the most thorough documentation.
Do not bill 98942 when: fewer than all 5 spinal regions are treated — use 98940 or 98941. Do not bill 98942 as a default full-spine code without region-by-region clinical documentation. Do not bill 98942 routinely without variability in clinical findings to support it — payers flag practices where 98942 appears with high frequency. Do not bill 98942 to Medicare expecting coverage if the documentation does not clearly support medical necessity for all five regions.
Sample note: "Spinal manipulation performed to all 5 spinal regions (98942). Cervical: restricted rotation C1–C2, tenderness suboccipital bilaterally, diversified HVLA technique. Thoracic: posterior joint restriction T3–T6, hypertonic paraspinals, drop table. Lumbar: flexion restriction L3–L5, positive Kemp's test right, side-posture technique. Sacral: SI joint restriction right, positive PSIS tenderness, sacral drop technique. Pelvic: innominate rotation right (ASIS inferior right vs left), blocking technique. All five regions with documented subluxation findings. AT modifier applied — Medicare active/corrective care. Patient tolerated all techniques."
AT modifier — Medicare: Required. Additionally, Medicare auditors apply heightened scrutiny to 98942 claims. The documentation must show individualized clinical justification for all five spinal regions — a single generic note will not survive audit. Each region needs its own positive findings using the PART criteria (Pain/tenderness, Asymmetry, Range of motion, Tissue changes).
Keep your 98942 billing rate in proportion to your patient population. A practice billing 98942 for 60%+ of visits will draw payer attention. Statistically, most chiropractic patients present with 2–4 region involvement; routine full-5-region billing is a red flag. Let your documentation drive the code, not the other way around.
Is the pelvic region different from the sacral region?
Yes. For CMT billing purposes, the sacral and pelvic regions are counted separately. The sacral region refers to the sacrum itself, while the pelvic region refers to the innominate bones (ilium, ischium, pubis) and the sacroiliac joint complex. Both can be treated and counted as individual regions toward the 98942 five-region total.
98943
DC
Full Code
98943
Type
Untimed · Per Visit
Common ICD-10 Pairs
M25.511, M77.11, M23.200
Medicare
NOT covered — bill patient
When to use: Bill 98943 for chiropractic manipulation of extraspinal regions — extremities (shoulder, elbow, wrist, hand, hip, knee, ankle, foot), ribs (costovertebral and costochondral joints), cranium/temporomandibular joints, and other non-spinal articulations. Bill once per visit regardless of how many extraspinal regions are treated.
DC application: Use when manipulation of peripheral joints or ribs is the primary or secondary focus of treatment. Can be billed alongside spinal CMT codes (98940–98942) on the same day when both spinal and extraspinal manipulation are performed. Common presentations: ankle sprain with cuboid manipulation, shoulder dysfunction with glenohumeral HVLA, rib dysfunction causing anterior chest pain, TMJ dysfunction.
Do not bill 98943 to Medicare — extraspinal CMT is explicitly excluded from Medicare Part B coverage. Attempting to bill 98943 to Medicare will result in denial. A Medicare ABN (Advance Beneficiary Notice) should be obtained and the patient billed directly. Do not confuse 98943 with manual therapy (97140) — 98943 is chiropractic manipulation of a joint; 97140 is manual therapy techniques including mobilization, which are different procedures.
Sample note: "Extraspinal manipulation performed — right ankle and right rib (ribs 5–6 right costochondral) — 98943. Ankle: restricted talocrural dorsiflexion, anterior talar drawer mild positive, HVLA distraction technique applied, immediate improvement in dorsiflexion ROM +12°. Ribs: right rib 5–6 posterior restriction, painful inspiration, spring test positive at costochondral junction, anterior rib release technique. Post-treatment: pain with deep inspiration reduced from 6/10 to 2/10. Diagnoses: M99.07 (subluxation — ankle), M99.08 (subluxation — rib cage). Note: 98943 not covered by Medicare; ABN obtained, patient billed directly."
Medicare exclusion: 98943 is not a covered Medicare benefit. Never submit 98943 to Medicare. For Medicare patients requiring extraspinal manipulation, obtain a signed ABN and bill the patient directly at your standard fee. Failure to obtain the ABN means you cannot collect from the patient if Medicare denies.
Most commercial payers do cover 98943 but verify plan-by-plan. 98943 can be billed on the same date as 98940, 98941, or 98942 when both spinal and extraspinal services are provided. Document each area treated with its own clinical rationale — do not combine spinal and extraspinal findings in a single generic note paragraph.
Can I bill 98943 and 98941 on the same day?
Yes. If spinal manipulation (98941) and extraspinal manipulation (98943) are both performed and documented in the same visit, both codes may be billed on the same date. Ensure the documentation clearly distinguishes the spinal findings and technique from the extraspinal findings and technique. For Medicare patients, bill only 98941 (spinal) — 98943 is non-covered and requires ABN and patient billing.
99202
DC
Full Code
99202
Type
Timed or MDM · New Patient
Time
15–29 minutes total
Medicare
Modifier 25 if same day as CMT
When to use: Bill 99202 for new patient office visits involving straightforward medical decision making or 15–29 minutes of total time on the date of service. As of 2021 E/M guidelines, code selection is based on either MDM complexity or total time — not history and exam component levels.
DC application: Appropriate for new chiropractic patients presenting with uncomplicated, acute musculoskeletal complaints — a simple acute low back pain episode without neurological involvement, single-region cervicalgia with no red flags. Straightforward MDM = minimal number/complexity of problems, minimal data reviewed, minimal risk. A typical "first visit intake" for an uncomplicated strain/sprain may qualify here if total time is 15–29 minutes.
Do not bill 99202 when: the complexity of findings or time exceeds straightforward MDM — use 99203 or 99204. Do not bill 99202 for an established patient — new patient E/M codes require the patient has not received professional services from any physician of the same specialty in the same group within the past 3 years. Do not bill 99202 and a CMT code without Modifier 25 on the E/M when both services are provided on the same date.
Sample note: "New patient evaluation — total time 22 minutes. CC: acute low back pain x 3 days after lifting. HPI: sudden onset lifting incident, localized lumbar pain 5/10, no radiation, no bowel/bladder changes. ROS: MSK positive LBP, all other systems negative. Exam: lumbar tenderness L4–L5 midline, flexion 35° limited by pain, SLR negative bilaterally, neurological screen intact. Assessment: M54.50 acute lumbar strain. MDM: straightforward — single uncomplicated problem, minimal data, minimal risk. Plan: CMT 98941 initiated today, home exercise program, reassess in 1 week."
Modifier 25 — same-day CMT: When an E/M service (99202–99214) is billed on the same date as a CMT code (98940–98943), Modifier 25 must be appended to the E/M code. This modifier signals that the E/M was a significant, separately identifiable service beyond the routine pre-manipulation assessment. Without Modifier 25, the E/M claim will bundle with the CMT and deny.
Since 2021, E/M documentation must support either the MDM level or the total time spent. Time billing requires documenting total time on the date of service — not just face-to-face time. For MDM billing, document the number and complexity of problems addressed, data reviewed, and risk of complications.
Can chiropractors bill E/M codes?
Yes. Doctors of chiropractic (DC) are licensed to perform and bill for evaluation and management services within their scope of practice. E/M codes 99202–99215 are billable by DCs when a qualified E/M service is performed. Medicare covers chiropractic E/M services as well as CMT — verify that your payer includes E/M under chiropractic benefits, as some commercial plans restrict DC billing to CMT only.
99203
DC
Full Code
99203
Type
Timed or MDM · New Patient
Time
30–44 minutes total
Medicare
Modifier 25 if same day as CMT
When to use: Bill 99203 for new patient visits with low complexity medical decision making or 30–44 minutes of total time. Low MDM = a low number/complexity of problems (typically one stable chronic condition or one acute uncomplicated illness/injury with minor treatment options considered), limited data reviewed, and low risk.
DC application: Most standard new chiropractic intake exams fall in the 99203 range — a new patient with multi-region spinal complaints, prior imaging reviewed, orthopedic and neurological screening performed, and a plan of care developed. 30–44 minutes total for a typical comprehensive first-visit evaluation, including intake paperwork review, case history, physical examination, and treatment plan discussion.
Do not bill 99203 when: total time is under 30 minutes and MDM is straightforward — use 99202. Do not bill 99203 when moderate or high complexity findings are present — use 99204 or 99205. Do not bill 99203 for established patients — use 99213. Modifier 25 required when billing same day as CMT code.
Sample note: "New patient evaluation — total time 38 minutes. CC: neck pain and headaches x 6 weeks, gradual onset. HPI: bilateral cervical stiffness, occipital headaches daily, prior cervical injury 2019 (MVA), no imaging since then. ROS: MSK positive, neuro negative. PMH: hypertension (controlled). Exam: cervical ROM restricted all planes, upper cervical tenderness bilaterally, Spurling's negative, neurological screen upper extremities intact, posture assessment — forward head carriage. Data: reviewed prior notes from PCP. Assessment: M54.2 (cervicalgia), G44.309 (cervicogenic headache). MDM: low — one acute problem with prior injury history, reviewed prior records, prescription drug management not indicated. Plan: CMT series, postural exercises, reassess in 2 weeks."
Modifier 25 required when billing 99203 on the same date as any CMT code. Document clearly that the E/M service was separate from and beyond the pre-manipulation assessment. The exam that justifies CMT (subluxation assessment) does not count as the E/M — the E/M is the comprehensive new patient history, physical exam, and MDM that would occur even if CMT were not provided that day.
Time billing: document start and stop time or total time on date of service. Include all time spent on the visit — history taking, examination, documentation, care coordination. Face-to-face time only was the old rule; post-2021 E/M guidelines count all clinician time on the date of service.
Is 99203 the right code for most new chiropractic patients?
For most general chiropractic new patient exams, 99203 or 99204 is appropriate. 99203 fits uncomplicated musculoskeletal presentations with standard chiropractic workup. 99204 fits more complex presentations — multiple comorbidities, neurological involvement, imaging ordered, or specialist referral consideration. Track your average time and MDM level to ensure you are selecting the correct code for each patient.
99204
DC
Full Code
99204
Type
Timed or MDM · New Patient
Time
45–59 minutes total
Medicare
Modifier 25 if same day as CMT
When to use: Bill 99204 for new patient visits requiring moderate complexity medical decision making or 45–59 minutes of total time. Moderate MDM = one or more chronic conditions with exacerbation/progression, multiple diagnoses, independent review of test results, prescription drug management risk, or referral decisions.
DC application: Use for new patients with complex presentations — radiculopathy with neurological signs, post-surgical spine patients, MVA patients with multiple injury regions requiring imaging review, or patients with complicating comorbidities. If you review MRI or X-ray results, consider specialist referral, or manage a patient with multiple spinal diagnoses, 99204 may be appropriate. Always bill based on actual MDM or time — do not default to 99204 for all new patients.
Do not bill 99204 when: the presentation is straightforward or low complexity — use 99202 or 99203. Do not bill 99204 routinely for all new patients without documenting the moderate MDM elements. Do not use 99204 for established patients — use 99214. Modifier 25 is required when 99204 is billed same day as CMT.
Sample note: "New patient evaluation — total time 52 minutes. CC: right arm pain, numbness index and middle fingers x 8 weeks following workplace lifting injury. HPI: cervical radiculopathy symptoms, C6–C7 distribution. PMH: DM type 2, hypertension, prior cervical disc herniation 2021. Data: reviewed MRI cervical spine (outside 3/2026) — C6–C7 right paracentral disc herniation contacting C7 nerve root. Exam: reduced right grip strength 4/5, reduced right biceps reflex, positive Spurling's right, positive cervical distraction test. Assessment: M54.12 (radiculopathy, cervical), M50.12 (C6–C7 disc degeneration). MDM: moderate — new problem with uncertain prognosis, independent review of MRI, prescription drug management risk considered (gabapentin discussion declined). Neurosurgery referral discussed; patient prefers conservative trial. Plan: CMT 98940 cervical initiated (flexion-distraction technique), re-evaluate in 3 weeks."
Modifier 25 required when billing 99204 same day as CMT. Moderate MDM documentation must explicitly show: (1) the complexity of the problems addressed, (2) the data reviewed and its source, and (3) the risk involved in treatment decisions. Simply documenting a complex patient history is insufficient — document your clinical decision-making process.
Post-2021 E/M guidelines allow either MDM or time as the basis for code selection. For 99204 by time, total time must be 45–59 minutes. This is the total clinician time on that date — including time reviewing records before the visit, the face-to-face encounter, and documentation time. It does not require all time to be face-to-face.
What data counts toward moderate MDM for 99204?
For 2024–2026 E/M guidelines, data review for moderate MDM includes: reviewing results of each test (labs, imaging), independently interpreting a test performed by another clinician, or discussing management with an external provider. Reviewing a patient's own MRI counts as reviewing test results. Document the specific studies reviewed, who ordered them, your interpretation, and how the results influenced your management decisions.
99205
DC
Full Code
99205
Type
Timed or MDM · New Patient
Time
60–74 minutes total
Medicare
Modifier 25 if same day as CMT
When to use: Bill 99205 for new patient visits requiring high complexity medical decision making or 60–74 minutes of total time. High MDM = one or more chronic conditions with severe exacerbation or progression, new problem with uncertain prognosis threatening life or bodily function, or drug therapy requiring intensive monitoring.
DC application: Reserved for the most complex new chiropractic patients — severe myelopathy presentations requiring urgent referral decision-making, complex polytrauma (MVA with multiple system involvement), or post-surgical spine patients with persistent deficits requiring detailed diagnostic workup and care coordination. 99205 should be relatively rare in chiropractic practice. If you are billing 99205 for a significant percentage of new patients, expect payer scrutiny.
Do not bill 99205 when: the presentation does not support high complexity MDM — use 99203 or 99204. Do not routinely bill 99205 without documentation that clearly reflects high MDM elements. High frequency 99205 billing by a chiropractic practice is a red flag for payer audit. Do not use 99205 for standard new patient musculoskeletal complaints without complicating factors.
Sample note: "New patient evaluation — total time 68 minutes. CC: bilateral lower extremity weakness and gait disturbance x 4 months, worsening. HPI: progressive bilateral leg weakness, balance loss, urinary urgency onset 3 weeks ago (new). PMH: DM2, hypertension, cervical stenosis diagnosed 2022. Data: reviewed MRI C-spine (2/2026) — severe multilevel stenosis C3–C6, cord signal change at C4–C5 consistent with myelopathy; MRI L-spine (3/2026) reviewed — L3–L4 moderate stenosis. Exam: hyperreflexia bilateral patella and Achilles, Babinski positive bilateral, Lhermitte's sign positive, gait ataxic. Assessment: G99.2 (myelopathy in disease classified elsewhere), M47.12 (cervical spondylosis with myelopathy). MDM: high — new problem threatening bodily function, urgent referral indicated. Plan: CMT deferred — emergent neurosurgery referral placed today. Patient counseled."
Modifier 25: If CMT is also provided on the same day as 99205, Modifier 25 is required on the E/M. However, in the scenario above (myelopathy with urgent referral), CMT would typically be deferred — a 99205 without same-day CMT is appropriate and does not require Modifier 25.
High MDM must be explicitly documented: the nature of the problem threatening life or bodily function, the specific data reviewed and your independent interpretation, and the high-risk treatment decision (urgent referral, drug initiation, or decision not to treat due to risk). Vague documentation of a complex patient does not constitute high MDM.
When should a chiropractor defer CMT and bill only the E/M?
When evaluation findings reveal a contraindication to manipulation — myelopathy, cord compression with neurological progression, fracture, severe osteoporosis with fracture risk, vertebrobasilar insufficiency — CMT should be deferred and the appropriate referral made. In these cases, the E/M visit (99205 or appropriate level) stands alone without a CMT code. Document the contraindication and the clinical decision clearly.
99211
DC
Full Code
99211
Type
Timed · Established Patient
Time
Up to 10 minutes
Medicare
Modifier 25 if same day as CMT
When to use: Bill 99211 for minimal established patient visits — brief encounters not requiring the presence of a physician, typically involving review of test results, prescription refills, or a simple question addressed by ancillary staff under physician supervision. Total time up to 10 minutes.
DC application: Rarely used in chiropractic practice as a primary code. 99211 may apply when a patient calls with a question that requires a brief chart review and clinical response, or when an established patient comes in briefly for a quick status check without a full treatment session. More commonly, established chiropractic patients presenting for their regular treatment visits will have a 99213 or 99214 E/M if separately identifiable from the CMT.
Do not bill 99211 when: a more substantive E/M service is provided — use 99213 or 99214. Do not bill 99211 as a routine add-on to every CMT visit — this is a common audit pattern. 99211 is appropriate only when the criteria are genuinely met. Do not bill 99211 and CMT on the same date without Modifier 25 on the 99211.
Sample note: "Established patient brief visit — total time 7 minutes. Patient returned to office to discuss MRI results received from radiology (ordered last visit). DC reviewed report with patient: L4–L5 mild disc bulge without nerve root compression, findings consistent with current symptom pattern. Patient questions answered regarding findings. No clinical change to plan of care indicated. Patient to continue scheduled CMT series. No manipulation performed today."
99211 does not require the presence of a physician or chiropractor by CPT definition — it may be provided by clinical staff. However, the supervising DC must be available and the service must be documented. Modifier 25 required if billed same day as CMT. Because 99211 represents minimal service, payers scrutinize high-frequency billing of this code by chiropractic practices.
Can I bill 99211 every time I do CMT?
No. Routine pre-manipulation assessment (checking in, reviewing subjective complaints, performing a brief scan) is considered part of the CMT service and is not separately billable as an E/M. 99211 is appropriate only when a genuinely separate and distinct minimal E/M service occurs that would be provided even without the CMT. Billing 99211 at every CMT visit is a red flag for audit.
99213
DC
Full Code
99213
Type
Timed or MDM · Established Patient
Time
20–29 minutes total
Medicare
Modifier 25 if same day as CMT
When to use: Bill 99213 for established patient visits with low complexity MDM or 20–29 minutes of total time. Low MDM typically involves a single stable chronic condition or minor acute problem. Appropriate when a re-examination is warranted but findings are improving on schedule.
DC application: Use for periodic progress re-examinations — end of a treatment series reassessment, mid-care re-eval at a planned milestone, or when a patient reports a new complaint during their treatment course that warrants a separate clinical assessment. Document that the E/M was a separately identifiable service beyond the routine pre-manipulation check. This is the most common established patient E/M code in chiropractic when a re-eval is warranted.
Do not bill 99213 at every CMT visit — only when a separate and distinct E/M service beyond routine pre-manipulation assessment is performed. Do not bill 99213 when findings support moderate complexity — use 99214. Modifier 25 required when billed same day as CMT.
Sample note: "Established patient re-examination — total time 24 minutes (E/M only). Patient 4 weeks into CMT series for M54.50. Subjective: pain reduced from 7/10 to 3/10, functional improvement in prolonged sitting tolerance (now 45 minutes vs 15 minutes at intake). Exam: reassessment of lumbar ROM, SLR, and neurological screen — flexion improved to 65° (from 35°), SLR negative bilaterally, neuro intact. Assessment: M54.50 improving as expected. Low MDM: stable problem, improving, data limited to today's exam, low risk. Plan: continue CMT x 2 weeks, add therapeutic exercise (97110). Note: E/M performed as separate progress re-exam today in addition to scheduled CMT visit. Modifier 25 applied to E/M."
Modifier 25 required when 99213 is billed same day as CMT. The E/M note must be clearly distinct from the CMT treatment note — document the re-examination findings, updated assessment, and clinical decision-making separately. A combined note that blurs the E/M and CMT into a single SOAP note risks denial of the E/M code.
Payers often perform audits on chiropractic E/M billing looking for E/M codes that are routinely billed with CMT without clinical justification. Establish a clear policy in your practice for when re-examinations are indicated — typically at set visit intervals (e.g., every 12 visits) or when a new complaint arises — and document consistently.
How often can I bill 99213 for established chiropractic patients?
There is no CPT-defined frequency limit, but payers expect E/M codes to reflect clinical necessity. Common practice is to perform a formal re-examination every 10–14 visits or at the end of each plan of care period, billing the appropriate E/M level at that time. Billing a full E/M at every visit alongside CMT will draw audit scrutiny — the routine pre-manipulation assessment is part of the CMT service and is not separately billable.
99214
DC
Full Code
99214
Type
Timed or MDM · Established Patient
Time
30–39 minutes total
Medicare
Modifier 25 if same day as CMT
When to use: Bill 99214 for established patient visits requiring moderate complexity MDM or 30–39 minutes of total time. Moderate MDM includes: one or more chronic conditions with exacerbation or progression, independent review of test results (imaging, labs), prescription drug management risk, or referral consideration.
DC application: Use for established patients undergoing a significant clinical change — renewed radiculopathy symptoms in a patient previously responding to CMT, new imaging results requiring interpretation and management change, or a patient whose condition has worsened or plateaued unexpectedly. Also appropriate for re-exams that include independent MRI review, referral discussions, or complex multidisciplinary coordination.
Do not bill 99214 when: the re-examination is straightforward or low complexity — use 99213. Do not bill 99214 for routine interval re-exams without moderate complexity findings. Modifier 25 required when billed same day as CMT. Do not use 99214 without documenting the specific moderate MDM elements that support it.
Sample note: "Established patient re-examination — total time 34 minutes. Patient 6 weeks into CMT for cervicalgia — new complaint: right hand paresthesias onset 1 week ago, not present at intake. Exam: new positive Spurling's right, reduced right triceps reflex, grip strength 4/5 right. Data: reviewed new MRI C-spine ordered by PCP (4/20/26) — C6–C7 right foraminal stenosis. Assessment: M54.12 (cervical radiculopathy, new finding), M54.2 (cervicalgia, ongoing). MDM: moderate — new problem with uncertain prognosis, independent interpretation of new MRI, prescription drug consideration (NSAIDs vs referral). Plan: modified CMT technique, neurology referral placed, continue monitoring. Modifier 25 applied — separately identifiable E/M from today's CMT visit."
Modifier 25: Required when 99214 is billed same day as CMT. The E/M documentation must be distinct — describe the separate clinical evaluation, the moderate MDM elements, and the clinical decision-making beyond what is required to perform CMT. Separate your CMT note and your E/M note clearly, whether in the same encounter record or as distinct documentation sections.
99214 is frequently overbilled nationally. Payers benchmark established patient E/M levels by specialty — if your 99214 rate is significantly above the DC peer benchmark, expect a review. Audit your own billing periodically: review a random sample of 99214 encounters and confirm each one has documentation that genuinely supports moderate MDM.
Does reviewing a new X-ray justify 99214 for an established chiropractic patient?
Independent interpretation of a test result (imaging, lab) is one element that can contribute toward moderate MDM data review — but it is one of three data elements required, and it must be combined with appropriate problem complexity and risk. Reviewing an X-ray alone does not automatically qualify for 99214. Document the X-ray findings, your independent interpretation, and how the results changed your clinical management plan.