CPT 97545 Work Hardening Reimbursement Benchmarks | OpenPayer

Summary & Overview

CPT 97545: Work Hardening/Conditioning, Initial 2 Hours

CPT code 97545 represents the initial two hours of work hardening or conditioning, a specialized therapeutic procedure within physical medicine and rehabilitation. This code is nationally recognized for its role in supporting patients who require intensive, structured rehabilitation to regain physical function and return to work following injury or illness. The procedure is typically performed in an office setting and is delivered by qualified rehabilitation professionals, including physical therapists, occupational therapists, and physicians specializing in physical medicine and rehabilitation.

Major commercial payers such as Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare provide coverage for services billed under CPT code 97545. This publication offers a comprehensive overview of the code's clinical context, payer coverage, and associated billing practices. Readers will gain insights into relevant benchmarks, policy updates, and the procedural landscape for work hardening and conditioning. The summary also highlights common modifiers and related codes, providing a clear understanding of how 97545 fits within broader therapeutic and rehabilitation services. This information is essential for stakeholders seeking to stay informed about national trends and requirements in medical billing for physical medicine and rehabilitation procedures.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareCPT 97545work hardeningconditioningphysical medicinerehabilitationtherapeutic proceduresoffice settingmedical billingclinical benchmarks

CPT Code Overview

CPT code 97545 is used to report work hardening or conditioning services for the initial two hours. This procedure is part of Physical Medicine and Rehabilitation Therapeutic Procedures, focusing on helping patients restore physical function and return to work after injury or illness. The typical site of service for this code is the office setting (POS 11). These services are designed to address physical limitations and improve functional capacity through structured, goal-oriented activities.

Clinical & Coding Specifications

Clinical Context

A patient recovering from a musculoskeletal injury, such as low back pain or knee pain, is referred to a physical medicine and rehabilitation clinic. The patient has difficulty walking and generalized muscle weakness, impacting their ability to return to work. The provider, typically a physical therapist, occupational therapist, or physical medicine & rehabilitation physician, initiates a work hardening/conditioning program. The initial session, billed under CPT code 97545, involves a structured, two-hour therapeutic intervention focused on improving physical function, endurance, and work-related tasks. The service is delivered in an office setting (Place of Service 11), and documentation includes the patient's functional deficits, goals, and progress toward returning to work.

Coding Specifications

Modifiers:
- Modifier 59: Distinct Procedural Service. Used when work hardening/conditioning is performed separately from other services, indicating it is not part of a bundled procedure.
- Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional. Used when the same provider repeats the work hardening/conditioning service on the same day.
Provider Taxonomies:

National Reimbursement Benchmarks

For CPT code 97545, national mean rates among commercial payers are notably higher than typical Medicare rates, with BUCA (average commercial) at $156.99. UnitedHealth Group and Cigna report the highest mean rates at $195.21 and $187.63, respectively, while Aetna is the lowest among the major commercial payers at $114.48.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Aetna has the tightest range at $44.00, indicating less variability in rates, while Cigna shows the widest spread at $109.90, reflecting greater rate variability. Blue Cross Blue Shield and BUCA also exhibit substantial dispersion, with ranges of $89.06 and $62.33, respectively.

The table and chart below present a detailed breakdown of national benchmarks for CPT code 97545 by payer, including mean rates and percentile values.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska's reimbursement rates for CPT code 97545 show a wide spread across payers, with UnitedHealth Group offering the highest mean rate at $378.55 and Cigna the lowest at $254.30. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for Cigna ($220.46), indicating significant variability in payments. Other payers, such as Aetna and UnitedHealth Group, display much narrower spreads, suggesting more consistent reimbursement levels.

Compared to national averages, all Alaska payers provide substantially higher mean rates for CPT code 97545. This regional premium is evident across the board, with Alaska's lowest mean rate still exceeding the highest national mean rate among the listed payers. The table and chart below present the full breakdown of payer-specific rates in Alaska.

Key Insights for Alaska

UnitedHealth Group is the highest paying payer for CPT 97545 in Alaska, with a mean rate of $378.55.
Cigna is the lowest paying payer, with a mean rate of $254.30.
All Alaska payer rates are significantly higher than their respective national averages, indicating a substantial regional premium.

CPT 97542: Wheelchair Management Assessment, Fitting, and Training

97113-AQUATIC-THERAPY-WITH-THERAPEUTIC-EXERCISES-ONE-OR-MORE

CPT 97113: Aquatic Therapy with Therapeutic Exercises

97157-ADAPTIVE-BEHAVIOR-TREATMENT-BY-PROTOCOL-ADMINISTERED-BY

CPT 97157: Adaptive Behavior Treatment by Protocol, Multiple-Family Group

97124-MASSAGE-INCLUDING-EFFLEURAGE-PETRISSAGE-ANDOR-TAPOTEMENT

CPT 97124: Massage Therapy, Therapeutic Procedures

97550-CAREGIVER-TRAINING-IN-STRATEGIES-AND-TECHNIQUES-TO

CPT 97550: Caregiver Training for Functional Performance, Initial 30 Minutes

97129-THERAPEUTIC-INTERVENTIONS-THAT-FOCUS-ON-COGNITIVE-FUNCTION

CPT 97129: Cognitive Therapeutic Interventions, Initial 15 Minutes

97139-UNLISTED-THERAPEUTIC-PROCEDURE

CPT 97139: Unlisted Therapeutic Procedure in Physical Medicine and Rehabilitation

97537-COMMUNITYWORK-REINTEGRATION-TRAINING-FACETOFACE-ONEONONE

CPT 97537: Community and Work Reintegration Training, Face-to-Face

97116-THERAPEUTIC-PROCEDURE-1-OR-MORE-AREAS-EACH-15-MINUTES-GAIT

CPT 97116: Gait Training Therapeutic Procedure

CPT-97130-COGNITIVE-THERAPY-ADD-ON-15-MINUTE

CPT 97130: Cognitive Rehabilitation, Per 15 Minutes

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`225100000X`	Physical Therapist
`225200000X`	Occupational Therapist
`208100000X`	Physical Medicine & Rehabilitation Physician

OpenPayer

Summary & Overview

CPT 97545: Work Hardening/Conditioning, Initial 2 Hours

CPT Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes