97535 CPT code description, modifiers, and examples

CPT code 97535, is a billing code used in medical industry, refers to a group of healthcare services called “self-care/home management training.” These services aim to enhance an individual’s ability to independently perform day-to-day activities and manage their health conditions. Healthcare professionals provide this category of services to patients or their caregivers to ensure they can efficiently perform activities of daily living (ADLs) while caring for their health.

It can be used for patients of all ages, including children and adults. It can also be used for patients with a variety of conditions, including:

• Arthritis
• Stroke
• Multiple sclerosis
• Parkinson’s disease
• Cerebral palsy
• Brain injury
• Spinal cord injury
• Amputation
• Burns
• Cancer
• Chronic pain
• Diabetes

If you are still determining whether CPT code 97535 is appropriate for a particular patient, consult your supervisor or billing department.

When to use CPT code 97535?

CPT code 97535 can be used for a variety of patients, including those who have:

• After undergoing a surgical procedure or experiencing a medical event, they may face difficulties performing their daily activities and require additional assistance and support.
• They have acquired a disability due to a medical condition or injury, which has affected their ability to perform specific tasks and activities.
• They have been diagnosed with a chronic condition that impacts their ability to manage their daily routine and perform tasks that were once easy for them.
• Are transitioning from a hospital or rehabilitation facility to a home

Here are a few examples

• Teaching a patient how to use a walker after a hip replacement surgery
• Instructing a patient on how to manage their diabetes at home
• Providing training on how to use a wheelchair to a patient with spinal cord injury
• Helping a patient develop a meal plan that is appropriate for their dietary restrictions
• Showing a patient how to use a prosthetic limb

Modifiers for CPT code 97535

The following modifiers are commonly used with CPT code 97535:

• 59: Distinct procedural service
• 76: Repeated procedure by the same provider
• 80: Assistant surgeon
• 82: Subsequent visit
• LT: Left side
• RT: Right side
• 25: Same-day significant evaluation and management service by a physician or other qualified healthcare professional.

Also read: 97112 CPT Code Description

Documentation requirements for CPT code 97535

It includes:

Assessment

It should describe the patient’s impairments, functional limitations requiring skilled intervention, and prior operational level.

Examples

A 75-year-old male with a stroke history has weakness and coordination issues in his right arm. He needs assistance with dressing, bathing, cooking, and household chores.

Plan of care

It should include a description of the specific self-care/home management training to be provided, as well as the expected functional goals.

Example

Patients will receive training to improve ADL performance and enhance independence and quality of life.

Intervention

Documentation must detail self-care/home management training provided, including ADL/compensatory training, safety procedures, adaptive tech/equipment, assistance type, and client’s response.

Examples

The patient received training on dressing, bathing, meal preparation, home safety procedures, and how to use a cane. The patient was able to perform all tasks with minimal assistance.

Progress

The documentation should describe the patient’s progress toward their expected functional goals.

Examples

The patient has made significant progress in self-care. He can now dress, bathe, prepare meals, and use his cane safely.

In addition to the above, the documentation must also support the following:

• Medical necessity: It must demonstrate that the self-care/home management training is medically necessary for the patient’s condition.
• Skilled intervention: It must demonstrate that the self-care/home management training provided requires the skills of a qualified healthcare professional.
• One-on-one contact: The documentation must demonstrate that the one-on-one self-care/home management training was provided.
• Time: The documentation must include the total time spent on self-care/home management training in 15-minute increments.

Also read: 96372 CPT Code Description 2023

Can CPT 97535 be billed alongside other codes?

Yes, It can be billed alongside other codes if multiple services are provided during the same session. 

What modifiers are typically used with the 97535 code?

Modifiers for CPT code 97535 include -GP (direct patient contact), -GO (telemedicine), and -GN (services under a plan of care). Its choice depends on the service provided.

How does insurance coverage apply to 97535?

Insurance coverage varies depending on the patient’s insurance plan. It’s essential to check with the insurance provider to determine coverage and any potential out-of-pocket costs.

Can patients use this code for self-payment?

Patients may self-pay for CPT code 97535 if uninsured or want to keep healthcare expenses separate from insurance claims.

What is the session duration eligible for billing under CPT code 97535?

Don’t bill CPT code 97535 for less than 8 minutes. It’s billed in 15-minute increments.