CMS Pub. 100-04, ch. 4, § 200.9

Non-Therapy Services for Hospital Outpatients

(Rev. 3156, Issued: 12-22-14, Effective: 01-01-15, Implementation: 01-05-15)

Section 1834(k) of the Act, as added by Section 4541 of the BBA, allows payment at 80

percent of the lesser of the actual charge for the services or the applicable fee schedule

amount for all outpatient therapy services; that is, physical therapy services, speech-language pathology services, and occupational therapy services. As provided under

Section 1834(k)(5) of the Act, a therapy code list was created based on a uniform coding

system (that is, the HCPCS) to identify and track these outpatient therapy services paid

under the Medicare Physician Fee Schedule (MPFS).

The list of therapy codes, along with their respective designation, can be found on the

CMS Website, specifically at

http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage.

Two of the designations that are used for therapy services are: “always therapy” and

“sometimes therapy.” An “always therapy” service must be performed by a qualified

therapist under a certified therapy plan of care, and a “sometimes therapy” service may

be performed by physician or a non-physician practitioner outside of a certified therapy

plan of care.

Under the OPPS, separate payment is provided for certain services designated as

“sometimes therapy” services if these services are furnished to hospital outpatients as a

non-therapy service, that is, without a certified therapy plan of care. Specifically, to be

paid under the OPPS for a non-therapy service, hospitals SHOULD NOT append the

therapy modifier GP (physical therapy), GO (occupational therapy), or GN (speech

language pathology), or report a therapy revenue code 042x, 043x, or 044x in association

with the “sometimes therapy” codes listed in the table below.

To receive payment under the MPFS, when “sometimes therapy” services are performed

by a qualified therapist under a certified therapy plan of care, providers should append

the appropriate therapy modifier GP, GO, or GN, and report the charges under an

appropriate therapy revenue code, specifically 042x, 043x, or 044x. This instruction does

not apply to claims for “sometimes therapy” codes furnished as non-therapy services in

the hospital outpatient department and paid under the OPPS.

Effective January 1, 2015, two HCPCS codes designated as “Sometimes Therapy”

services, G0456 (Negative pressure wound therapy, (e.g. vacuum assisted drainage

collection) using a mechanically-powered device, not durable medical equipment,

including provision of cartridge and dressing(s), topical application(s), wound

assessment, and instructions for ongoing care, per session; total wounds(s) surface area

less than or equal to 50 square centimeters) and G0457 (Negative pressure wound

therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device,

not durable medical equipment, including provision of cartridge and dressing(s), topical

application(s), wound assessment, and instructions for ongoing care, per session; total

wounds(s) surface area greater than 50 square centimeters) would be terminated and

replaced with two new CPT codes 97607 (Negative pressure wound therapy, (eg, vacuum

assisted drainage collection), utilizing disposable, non-durable medical equipment

including provision of exudate management collection system, topical application(s),

wound assessment, and instructions for ongoing care, per session; total wounds(s) surface

area less than or equal to 50 square centimeters) and 97608 (Negative pressure wound

therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable

medical equipment including provision of exudate management collection system, topical

application(s), wound assessment, and instructions for ongoing care, per session; total

wounds(s) surface area greater than 50 square centimeters).

The list of HCPCS codes designated as “sometimes therapy” services that may be paid as

non-therapy services when furnished to hospital outpatients is displayed in the table

below.

Services Designated as “Sometimes Therapy” that May be Paid as Non-Therapy

Services for Hospital Outpatients

HCPCS

Code

Long Descriptor

92520 Laryngeal function studies (i.e., aerodynamic testing and acoustic

testing)

HCPCS

Code

Long Descriptor

97597 Removal of devitalized tissue from wound(s), selective debridement,

without anesthesia (eg., high pressure waterjet with/without suction,

sharp selective debridement with scissors, scalpel and forceps), with or

without topical application(s), wound assessment, and instruction(s) for

ongoing care, may include use of a whirlpool, per session; total

wound(s) surface area less than or equal to 20 square centimeters

97598 Removal of devitalized tissue from wound(s), selective debridement,

without anesthesia (e.g., high pressure waterjet with/without suction,

sharp selective debridement with scissors, scalpel and forceps), with or

without topical application(s), wound assessment, and instruction(s) for

ongoing care, may include use of a whirlpool, per session; total

wound(s) surface area greater than 20 square centimeters

97602 Removal of devitalized tissue from wound(s), non-selective

debridement, without anesthesia (e.g., wet-to-moist dressings,

enzymatic, abrasion), including topical application(s), wound

assessment, and instruction(s) for ongoing care, per session

97605 Negative pressure wound therapy (e.g., vacuum assisted drainage

collection), including topical application(s), wound assessment, and

instruction(s) for ongoing care, per session; total wound(s) surface area

less than or equal to 50 square centimeters

97606 Negative pressure wound therapy (e.g., vacuum assisted drainage

collection), including topical application(s), wound assessment, and

instruction(s) for ongoing care, per session; total wound(s) surface area

greater than 50 square centimeters

97607 Negative pressure wound therapy, (eg, vacuum assisted drainage

collection), utilizing disposable, non-durable medical equipment

including provision of exudate management collection system, topical

application(s), wound assessment, and instructions for ongoing care, per

session; total wounds(s) surface area less than or equal to 50 square

centimeters

97608 Negative pressure wound therapy, (eg, vacuum assisted drainage

collection), utilizing disposable, non-durable medical equipment

including provision of exudate management collection system, topical

application(s), wound assessment, and instructions for ongoing care, per

session; total wounds(s) surface area greater than 50 square centimeters

97610 Low frequency, non-contact, non-thermal ultrasound, including topical

application(s), when performed, wound assessment, and instruction(s)

for ongoing care, per day