97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training) direct (one-on-one) patient contact by the provider, each 15 minutes

* Compensatory training is provided to make up for a deficiency or loss of cognitive skills resulting from brain injury or psychiatric disorders.

* Cognitive impairments addressed by this code include attentional impairments (loss of focused, sustained, alternating and divided attention), memory impairments, and problem solving impairments (inability to initiate a behavioral response, to organize parts or concepts or thoughts into a whole, and to sequence thoughts so as to modify behavior). (CPT Assistant, Vol. 11, Issue 12, December 2001)

* This procedure is not medically reasonable and necessary when the patient's cognitive skills are not expected to improve.

* This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures to effect continued improvement.


97533 Sensory integrative techniques to enhance sensory processing and promote adaptive response to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

* These treatments are performed when a deficit in processing input from one of the sensory systems decreases the patient’s ability to make adaptive sensory, motor, and behavioral responses to environmental demands.

* These patients may demonstrate sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems. (CPT Assistant, Vol.11, Issue 12, December 2001)

* Sensory integrative interventions enhance sensory processing by persons with deficits in sensory systems (e. g., vestibular, proprioceptive, tactile) by increasing their ability to make adaptive sensory, motor, and behavioral responses to environmental demand.

* Sensory integrative treatments are almost exclusively provided to a pediatric population for responses to environmental demand and are almost exclusively provided for conditions such as autism, developmental disorders, attention deficit hyperactivity disorder, cerebral palsy, and motor apraxia. Similar techniques used in treatment for adults should be coded with 97112.

* This procedure is not medically reasonable and necessary when the patient's sensory processing and adaptive responses are not expected to improve.

* This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures to effect continued improvement.


97535 Self care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one on one contact by provider, each 15 minutes:

* This procedure is medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific outcome.
* The patient must have the capacity to learn from instructions.
* Medical treatment may generally require up to 12 visits in 4 weeks. Coverage beyond 12 visits in 4 weeks may require documentation supporting the medical necessity of continued treatment.
* Documentation must relate the training to expected functional goals that are attainable by the patient.
* The medical record should document the distinct goals and service rendered when self-care/home management training is done during the same visit as gait training (97116), orthotics fitting and training (97504) or prosthetic training (97520).

97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one on one contact by provider, each 15 minutes:

* This training may be medically necessary when performed in conjunction with a patient’s individual treatment plan aimed at improving or restoring specific functions which were impaired by an identified illness or injury and when expected outcomes that are attainable by the patient are specified in the plan.

* This training is medically necessary only when it requires the professional skills of a provider. Generally speaking, the professional skills of a provider are not required to effect improvement or restoration of function where a patient suffers a temporary loss or reduction of function which could reasonably be expected to improve as the patient gradually resumes normal activities. General activity programs and all activities which are primarily social or diversional in nature will be denied because the professional skills of a provider are not required.

* Services which are related solely to specific employment opportunities, work skills or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1) of the Social Security Act (Medicare Benefit Policy Manual, Pub. 100-2, Chapter 15, Section 220.2, formerly Ref. MCM 2217.B).

* The CPT code 97537 was modified in 2004. This code is expanded to complement the 97755 assessment code. The modification is intended to allow the post-assessment patient fitting and training for use of the advanced technology device/adaptive equipment.
* The patient must have the capacity to learn from instructions.
* Medical treatment may generally require up to 12 visits in 4 weeks.
* Documentation must relate the training to expected functional goals that are attainable by the patient.


97520 Prosthetic training, upper and/or lower extremities, each 15 minutes:

* The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training (97116), orthotics fitting and training (97504) or self care/home management training (97535).
* Periodic revisits beyond the third month may require supportive documentation of medical necessity if requested.
* In some cases, prosthetic training may require more than 30 minutes on a given date and when this occurs the medical record must document the medical necessity of the additional time.
* Note: The following items are included in the Durable Medical Equipment Regional Contractor (DMERC) reimbursement for a prosthesis within 90 days of delivery of the prosthesis and, therefore, are not separately billable to Medicare:
a. Evaluation of the residual limb and/or gait
b. Fitting of the prosthesis
c. Cost of base component parts and labor contained in HCPCS base codes
d. Repairs due to normal wear or tear
e. Adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component when the adjustments are not necessitated by changes in the residual limb or the patient’s functional abilities.