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Conference Name: An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes
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Continuing Education Documentation If CE’s are offered with this program, a separate link containing important information will be provided along with the pro- gram materials. Please follow the instructions in the CE documentation. presents . . . An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes
A 105-minute interactive audioconference
Wednesday, March 29, 2006
1:00 p.m.–2:45 p.m (Eastern) 12:00 p.m.–1:45 p.m. . (Central) 11:00 a.m.–12:45 p.m. (Mountain) 10:00 a.m.–11:45 a.m. (Pacific) In our materials we strive to provide our audience with useful, timely information. The live audioconference will follow the enclosed agenda. Occasionally our speakers will refer to the materials enclosed. We have noticed that other non-HCPro audioconference materials follow the speaker’s presentation bullet-by-bullet, page-by-page. Because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker’s entire presentation. The materials contain helpful forms, crosswalks, policies, charts, and graphs. We hope that you find this information useful in the future.
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes The “An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes” audioconference materials package is published by HCPro, 200 Hoods Lane, P.O. Box 1168, Marblehead, MA 01945.
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 200 Hoods Lane P.O. Box 1168 Marblehead, MA 01945 Dear colleague, Tel: 800/650-6787 Fax: 800/639-8511 Thank you for participating in our “An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes” audioconference with Rick Gawenda, PT, and Ken Mailly, PT, moderated by Kevin Moschella. We are excited about the opportunity to interact with you directly and encourage you to take advantage of the opportunity to ask our experts your questions during the audioconference. If you would like to submit a question before the audioconference, please send it to [email protected] and provide the program date in the sub- ject line. We cannot guarantee your question will be answered during the program, but we will do our best to take a good cross-section of questions.
If at any time you have comments, suggestions, or ideas about how we might improve our audioconferences, or if you have any questions about the audioconference itself, please do not hesitate to contact me. And if you would like any additional information about other products and services, please contact our Customer Service Department at 800/650-6787.
Along with these audioconference materials, we have enclosed a fax eval- uation. We value your opinion. After the audioconference, please take a minute to complete the evaluation to let us know what you think.
Thanks again for working with us.
Best regards,
Shannon Tierney Audioconference coordinator Fax: 781/639-2982 E-mail: [email protected]
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes Contents
Agenda ...... vi
Speaker profiles ...... vii
Exhibit A ...... 1 Presentation by Rick Gawenda, PT, and Ken Mailly, PT
Exhibit B ...... 41 CCI Edits
Exhibit C ...... 44 Codes Frequently cited as “Problematic” by Payers
Exhibit D ...... 47 Claims Review Checklist
Resources ...... 49
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes Agenda
I. Identify new, deleted, and revised CPT codes for 2006
II. Identify problem CPT codes
III. Define group therapy in various settings
IV. Define, identify, and understand CCI edits: Their application to all settings
V. Understand recent OIG audits concerning the misuse of modifier -59 and poor documentation
VI. Q&A
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes Speaker profiles
Kevin Moschella, moderator
Kevin Moschella is an editorial assistant at HCPro, Inc. He writes about issues of safety, security, infection control, rehabilitation, and finance.
Rick Gawenda, PT
Rick Gawenda graduated in 1991 with a Bachelor of Science in physical therapy from Wayne State University in Detroit. Gawenda is currently director of physical medicine and rehabilitation at Detroit Receiving Hospital and owner of Gawenda Seminars. He has worked in all areas of therapy within the hospital setting and worked in home healthcare for five years. He has provided valuable education and consulting to both hospitals and his peers in the area of coding, billing, documentation, reimbursement, and the appeals process for Medicare denied claims. Gawenda’s Web site, www.gawendaseminars.com, provides a valuable source of information about rehabilitation rules and regulations, coding, documentation, and reimbursement.
Gawenda is on the editorial advisory board for ADVANCE for Directors In Rehabilitation and Briefings on Outpatient Rehab Reimbursement and Regulations. He is a member of the American College of Healthcare Executives, American Physical Therapy Association (APTA), Michigan Physical Therapy Association (MPTA), MPTA Insurance Policy Committee, and Program Committee of the Health Policy & Administration section of the APTA. Gawenda serves as the liaison between the MPTA and United Government Services, which is the Medicare fiscal intermediary for the state of Michigan.
Gawenda has provided his expertise for many articles in Briefings on Outpatient Rehab Reimbursement and Regulations and Eli’s Rehab Report on various topics, such as advance beneficiary notices, Medicare certification/recertification, the utilization of L codes as they relate to therapy, and the use of aides in therapy. In addition, he has written articles for ADVANCE for Directors in Rehabilitation about CPT coding, modifier -59, and the Medicare appeals process.
Ken Mailly, PT
Ken Mailly is a graduate of the State University of New York at Downstate Medical Center and is completing his master’s in public administration at Seton Hall University. For over 10 years, he has focused on issues related to healthcare policy and management.
In addition to his graduate studies, with well over 2,000 hours of continuing physical therapy education, Mailly has amassed an extremely diverse and extensive knowledge of the clinical practice of physical therapy. His primary clinical focus is on management of patients with bleeding and chronic soft-tissue disorders, and he is certified as an ergonomic specialist.
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes Along with this clinical knowledge base, Mailly has devoted the past eight years to the areas of regulation, legislation, and reimbursement of physical therapy services. He has served as an expert witness on behalf of both plaintiffs and defendants in numerous malpractice cases. He has also been consulted on state and fed- eral inquiries regarding physical therapy and rehabilitation billing and regulatory issues.
Mailly has served as a guest lecturer at Seton Hall University, University of Medicine and Dentistry of NJ, Richard Stockton College of NJ, Bergen Community College, and Mercer County College. He is also a fre- quent contributor and consultant for Advance, Eli’s Rehab Report, Briefings on Outpatient Regulation and Reimbursement, and Non-Physician Practitioner News. He has also been published in The Orthopedic Clinics of North America and featured in PT Magazine.
Mailly has been extensively involved in APTA at the local, state, and national levels for over 15 years. He has served APTA in various capacities, including delegate, professional affairs representative, and director of government relations. He has also served on the direct-access task force for APTA and serves, along with partner Barry Inglett, as a member consultant on coding initiatives and as a member of the APTA consulting service.
Mailly was also recently appointed to the Empire Medicare Services Provider Communications Advisory Group (PCOM) as a representative of physical therapists. He has presented during many state and national meetings and was the recipient of several professional awards, including being a two-time awardee of the APTA of NJ President’s Award. He is a member of the health policy and administration and private practice sections of APTA.
Mailly’s focus in the activities of M&I Consulting is on compliance with professional standards, state and fed- eral regulations, and management strategies.
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes Exhibit A
Presentation by Rick Gawenda, PT, and Ken Mailly, PT
1 EXHIBIT A
Coding & Billing for Rehab Services: Avoiding the Pitfalls of the 2006 Codes
Presented by: Rick Gawenda, PT & Ken Mailly, PT
1
Objectives
Identify new, deleted, and revised CPT codes for 2006
Identify problem CPT codes
Define group therapy in various settings
2
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 2 EXHIBIT A
Objectives
Define, identify, and understand CCI edits
Define, identify, and understand when it is appropriate to use modifier-59 by therapists
Be able to charge correctly for the services you provide – Understanding
Medicares “8” minute rule 3
CPT
A Closer Look
4
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 3 EXHIBIT A
Who can use them?
Anyone whose legal scope of practice (qualified) permits the performance of the procedure described by the code.
There are no PT, OT or SLP codes per se.
Modifiers are used to describe who performed service GN, GO, GP 5
Physical Medicine & Rehabilitation
97000 Level I Series CPT Codes
6
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Types of CPT Codes
Time – Based codes
Service – Based codes
7
Time Based Codes
Requires direct one on one time spent with patient
Contact is 15-120 minutes in length
Can bill multiple units of the same time based CPT code on the same day per discipline per patient
8
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Service Based Codes
Does not require direct one on one time with the patient
Are un-timed
Can only bill one unit of each service- based code daily per discipline per patient
9
Pre-Test #1 CVA Patient
20 Minutes L/E strengthening exercises
20 Minutes NDT techniques to improve dynamic sitting and static standing balance
10
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Evaluations –Service Based
97001 Physical Therapy Evaluation
97002 Physical Therapy Re-Evaluation
97003 Occupational Therapy Evaluation
97004 Occupational Therapy Re-Evaluation
97005 Athletic Training Evaluation
97006 Athletic Training Re-Evaluation 11
Supervised Modalities
The application of a modality that does not require direct (one on one) patient contact by provider.
Un-timed (service-based)
Once per session (date of service) per discipline per patient
Includes CPT codes 97010-97028 12
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Constant Attendance
The application of a modality that requires direct (one on one) patient contact by the provider
Are time-based codes
Can bill multiple units of these CPT codes to the same patient on the same day
Includes CPT codes 97032-97039 13
Constant Attendance Modalities
97032 The application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes 97033 Iontophoresis, each 15 minutes 97034 Contrast bath, each 15 minutes 97035 Ultrasound, each 15 minutes 97036 Hubbard tank, each 15 minutes 97039 Unlisted modality (specify type and time if constant attendance) 14
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G0283 or 97014 versus 97032
Documentation in the patients medical record must clearly show that manual electrical stimulation was provided
Types of manual electrical stimulation include hand-held units and ultrasound/electrical stimulation combination treatments
Constant attendance may also involve visual and/or verbal contact with the patient during provision of the services (CPT Assistant July
2004) 15
Unlisted Modality - 97039
May be supervised or constant attendance Must specify type and time if constant attendance Types of modalities billed using this code may include anodyne, light, laser, ice massage, and fluidotherapy if not billed under 97022
16
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 9 EXHIBIT A
Pre-Test #2 Low Back Patient
15 Minutes Joint mobilizations and soft tissue mobilization
17 Minutes Stretching and strengthening exs
6 Minutes Ultrasound to low back
17
Therapeutic Procedures
A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.
Therapist or therapist assistant required to have direct (one on one) patient contact.
Therapist or therapist assistant must need to be one-on-one with the patient
Includes CPT codes 97110-97140 and 97530-97762 18
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Exercise v. Activity
Exercise: patient performing something that they would not normally perform in everyday life (CPT code 97110)
Activity: patient IS performing something that they may be doing everyday, but with therapeutic intent (CPT Code 97530)
19
Critical points!
Coding is as much about the intent of the activity, as it is the activity itself.
e.g.: Electrical Stimulation
BAPS
20
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The Biggie!!! 97150
21
97150
Therapeutic procedure(s), group (2 or more individuals)
Group therapy procedures involve constant attendance of the therapist or therapist assistant, but by definition do not require one-on-one patient contact by the provider.
This code is un-timed. May only bill one unit per patient per discipline regardless of the amount of time the patient participated in the group 22
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Group Therapy-Medicare
Patients need not be performing the same activity (Part B) Patients must be working on the same activity (Part A) Provider must be in constant attendance Direct one-on-one contact not required No limit of patients for Part B unless specified in LCD Limited to 4 patients per group for Part A SNF setting In SNF Part A setting, no more than 25% of the total minutes in a week per discipline may be in a group Transmittal 1872, January 24, 2003 http://www.cms.hhs.gov/Transmittals/Downloads/R1872A3.pdf Federal Register SNF Final Rule, July 30, 1999
http://www.cms.hhs.gov/TherapyServices/ 23
Group Therapy or One-on-One
What are the patients doing, but more importantly…
What is the therapist or therapist assistant doing!
Is the therapist or assistant in constant attendance with both patients or are they going back and forth between the patients spending one-on-one time with each patient in small increments 24
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 13 EXHIBIT A
SNF Part A Setting Concurrent Therapy
Treating 2 or more patients during the same time period Also known as dovetailing or supervisory therapy Patients are performing different activities Therapist can go back and forth between the patients Key is the therapist or therapist is assistant is in the room, supervising the entire treatment process Minutes for set up and preparing the patient for treatment may be counted http://www.cms.hhs.gov/SNFPPS/Downloads/sbmanual112005-RUG53.pdf
Page 3-72 to 3-76 25
Concurrent Therapy Case Example
PT has Patient A beginning therapy at 9:00AM on a specific task PT has Patient B beginning therapy at 9:15AM on a specific task different than Patient A Treatment ends for each patient 30 minutes after it began. PT is present the entire time with both patients Each patient receives 30 minutes of one-on- one time on the MDS for that date of service 26
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SNF Part A or Part B Group Case Scenario
SLP has 2 patients beginning therapy at 9:00AM and lasts until 9:45AM Both patients work on activities to strengthen the tongue to move the bolus to the back of the mouth for swallowing for 25 minutes then Work on lip strengthening exercises to keep the food in the mouth for 20 minutes Both patients would receive 45 minutes billed as group treatment on the MDS for that date
of service or 1 unit 92508 if an outpatient 27
Wheelchair Management
CPT code 97542 Now includes assessment, fitting, and training Assessment includes, but is not limited to, determination of the patients need for a WC and type of WC required, patients strength and ROM, endurance, skin integrity, sitting balance, transfer ability, etc., measurements, and testing the patients ability with various chair functions. Acknowledges “custom seating”.
CPT Changes 2006-An Insiders View 28
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Orthotic Management & Prosthetic Management
New heading added to the Medicine section of the CPT manual in 2006
New heading includes CPT codes 97760 (formerly 97504), 97761 (formerly 97520), and 97762 (formerly 97703)
29
Orthotic Management & Prosthetic Management
CPT code 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes
This CPT code allows for reporting the assessment and management of a patient requiring a pre-fabricated or custom fabricated orthotic
30
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Orthotic Management & Prosthetic Management
Orthotic management may include: Assessing the patient Determining the type of orthotic Designing, selecting, and fabricating the orthotic Orthotic training including exercises performed in the orthotic, instruction in skin care and wearing schedule 31
Orthotic Management & Prosthetic Management
If you bill an “L” code for the pre-fabricated or custom fabricated orthotic, you may only bill the appropriate number of units of 97760 for the orthotic training based on the number of minutes spent providing the training
The “L” code reimbursement includes the assessment, fabrication time, and fitting
CPT Assistant December 2005
32
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 17 EXHIBIT A
97760 versus 97762
97760 used for the assessment, fabrication, fitting, and training of an orthotic
97762 used when adjustments need to made to an orthotic, orthotic needs to be modified or re-issued, etc.
33
New CPT Codes for 2006
98960 Education and training for patient self management by a qualified, non-physician healthcare professional using standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; individual patient
34
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New CPT Codes for 2006
98961 Education and training for patient self management by a qualified, non-physician healthcare professional using standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; 2-4 patients
35
New CPT Codes for 2006
98962 Education and training for patient self management by a qualified, non-physician healthcare professional using standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; 5-8 patients
36
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 19 EXHIBIT A
Education & Training Codes 98960 - 98962
CMS not reimbursing for these CPT codes in 2006
Does not necessarily affect PT, OT, or SLP services, in fact we are really not expected to be using these codes
Whatever we are training the patient and/or caregiver in, those minutes are included/counted under the CPT code that best describes our treatment/intention 37
Pre-Test #3 Speech
30 minutes strengthening exercises to improve voice communication
15 minutes oromotor exercises to improve patients swallow
15 minutes teaching the patient and their spouse in compensatory swallowing strategies
38
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Evaluations –Service Based
92506 Evaluation of speech, language, voice, communication, and/or auditory processing 92610 Evaluation of oral and pharyngeal swallowing function 92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording 39
Speech Therapy Services
92507 Treatment of speech, language, voice,communication, and/or auditory processing disorder; individual
92508 Group, two or more individuals
92526 Treatment of swallowing dysfunction and/or oral function for feeding
40
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 21 EXHIBIT A
Speech Therapy CPT Codes Not To Be Used
97110 Therapeutic exercise
97112 Neuromuscular re-education
CMS announced this during a SNF open door forum
ASHA issued this announcement in November 2004 41
Speech Central Nervous System Assessments/Tests
96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour
42
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Speech Therapy Services
92526 Treatment of swallowing dysfunction and/or oral function for feeding
43
New Codes for SLP Services
92626 Evaluation of auditory rehabilitation status; 1 hour
92627 Evaluation of auditory rehabilitation status; each additional 15 minutes (list separately in addition to code for primary procedure
44
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 23 EXHIBIT A
New Codes for SLP Services
92630 Auditory rehabilitation; pre-lingual hearing loss 92633 Auditory rehabilitation; post- lingual hearing loss CMS not reimbursing for these CPT codes. If SLP provides these services, the minutes are billed under 92507. These services are not reimbursed if provided by an audiologist as Medicare only covers audiology services that
are diagnostic in nature, not treatment. 45
National Correct Coding Initiative (NCCI) CCI Edits
The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative to promote national correct coding methodologies and to eliminate improper coding.
CCI edits are developed based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT) Manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practice. 46
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National Correct Coding Initiatives (NCCI)
Initiated in 1996 to the private practice setting Expanded to hospital outpatient departments in August 2000 Expanded to SNF Part B, CORFs, Rehab Agencies, and Home Health Agencies not under a Home Health Plan of Care on January 1, 2006 Current version is 12.0 for private practice and physician owned therapy clinics and 11.3
for all other settings 47
Modifiers
In certain circumstances, specific CCI edits will be bypassed if required modifiers are present.
The most commonly used modifier therapists utilize is modifier-59.
48
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 25 EXHIBIT A
Modifier - 59
Distinct Procedural Service Indicates that a procedure or service was distinct or independent from other services performed on the same day Used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances Documentation must support use of modifier – 59 in that the procedures/services were provided at separate and distinct times, were medically necessary and required the skills of a therapist or therapist assistant under the supervision of a therapist 49
Modifier-59 Documentation Example
9:00AM-9:30AM, aquatic therapy of (list what was provided), 9:45AM- 10:10AM, land-based exercises of (list what was provided)
Aquatic therapy of (list what was provided) followed by land-based exercise of (list what was provided)
50
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CCI Edits
2 types of edits
1.) Mutually exclusive codes
2.) Column 1/Column 2 codes
51
Mutually Exclusive Codes
Codes that cannot be billed together because they would not normally be performed together Speech group (92508) and speech therapy treatment (92507) Group therapy (97150) and therapeutic exercise (97110), neuromuscular re-education (97112), aquatic therapy (97113), or gait training (97116) Mechanical traction (97012) and manual therapy (97140) Manual therapy (97140) and therapeutic Activities (97530) 52
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 27 EXHIBIT A
Column 1/Column 2 Codes
Codes in which one of the codes is considered a component of a more comprehensive code on the bill
Aquatic therapy (97113) and therapeutic exercise (97110)
Therapeutic activities (97530) and gait training (97116)
Therapeutic exercise (97110) and PT re-eval (97002) or OT re-eval (97004) 53
Column 1/Column 2 Codes
Swallowing treatment (92526) and therapeutic exercise (97110) Swallowing treatment (92526) and cognitive therapy (97532) Swallowing treatment (92526) and Neuro re- education (97112) Swallowing treatment (92526) and therapeutic activities (97530) Swallowing treatment (92526) and unattended
e-stim (G0283) or manual e-stim (97032) 54
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CCI Edits
Are applicable to one specific discipline of therapy billing different procedures on the same day that require modifier-59
Are applicable when multiple disciplines of therapy occur to the same beneficiary on the same day billing procedures that require modifier-59
55
CCI Edit Example
Pt receives 60 minutes of SLP treatment (92507) on 09/05/03
Pt receives 30 minutes of therapeutic exercise (97110) and 30 minutes of gait training (97116) in PT on 09/05/03
Pt receives OT consisting of 30 minutes of therapeutic activities (97530) and 30 minutes of Neuro Re-ed (97112) on 09/05/03 56
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An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 29 EXHIBIT A
CCI Edit Example
By discipline, none of the procedures require modifier-59 to be reimbursed
Since this patient was seen on the same day by more than one discipline, need to check between all disciplines (cross-check) as the need for modifier-59 does apply
CMS billing system does not recognize therapy specific modifiers (GN, GO, GP) 57
CCI Edit Example
Would need to append modifier-59 to 97110, 97112, 97116, and 97530
Documentation would need to support that the services were performed at separate and distinct times
Not appending modifier-59 in this example would cost you approximately $240 in lost reimbursement
58
30 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 30 EXHIBIT A
CCI Updates
Updated quarterly
www.gawendaseminars.com
http://www.cms.hhs.gov/NationalCorrectCodI nitEd/
Private practice and physician owned therapy clinics, click on NCCI Edits – physicians. All other settings, click on NCCI Edits - Hospital
59
“8 Minute Rule”
Applies to direct contact CPT codes only For any single CPT code, providers bill the appropriate number of units based on the time intervals on the next slide If more than one CPT code is billed on a calendar day, then the total number of units that can be billed is constrained by the total treatment time. Do not count minutes of service-based CPT codes Schedule on the next slide does not imply that any minute until the eighth should be excluded from the total count 60
Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 31
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 31 EXHIBIT A
“8 Minute Rule”
8 to < 23 1 unit 23 to < 38 2 units 38 to < 53 3 units 53 to < 68 4 units 68 to < 83 5 units 83 to < 98 6 units 98 to < 113 7 units
113 to < 128 8 units 61
“8” Minute Reference
Medicare Claims Processing Manual, Chapter 5 – Part B Outpatient Rehabilitation and CORF Services, Section 20.2 and 20.3
http://www.cms.hhs.gov/manuals/downloads/clm104c05.pdf
62
32 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 32 EXHIBIT A
Pre-Test #1 CVA Patient
20 Minutes L/E strengthening exercises
20 Minutes NDT techniques to improve dynamic sitting and static standing balance
63
Post-Test #1
64
Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 33
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 33 EXHIBIT A
Pre-Test #2 Low Back Patient
15 Minutes Joint mobilizations and soft tissue mobilization
17 Minutes Stretching and strengthening exs
6 Minutes Ultrasound to low back
65
Post-Test #2
66
34 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 34 EXHIBIT A
Pre-Test #3 Speech
30 minutes strengthening exercises to improve voice communication
15 minutes oromotor exercises to improve patients swallow
15 minutes teaching the patient and their spouse in compensatory swallowing strategies
67
Post-Test #3 Speech
68
Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 35
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 35 EXHIBIT A
References
American Medical Association Current Procedural Terminology; CPT 2006; Standard Edition
Ingenix St. Anthony Publishing/Medicode Coding and Payment Guide for the Physical Therapist; 2006, 11th Edition
Ingenix St. Anthony Publishing/Medicode ICD-9-CM Expert for Hospitals-Volumes 1,2, & 3. 2005. 6th Edition
69
Essential References
CPT-2005/6 https://webstore.ama-assn.org/index.jhtml cpt Assistant
CCI http://www.cms.hhs.gov/NationalCorrectCodInitEd/
APTA, AOTA, ASHA
CMS Therapy Resources
http://www.cms.hhs.gov/TherapyServices70/
36 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 36 EXHIBIT A
References for Billing Internet-Only Manuals
www.cms.hhs.gov/Manuals
Click on Internet-Only Manuals
Click on Pub 100-4 Medicare Claims Processing Manual
Choose the appropriate chapter depending on your setting
71
Billing References
Chapter 5, Part B Outpatient Rehabilitation and CORF Services
Chapter 6, SNF Inpatient Part A
Chapter 7, SNF Part B
Chapter 10, Home Health Agency
72
Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 37
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 37 EXHIBIT A
Ken Mailly, PT Barry Inglett, PT, Cert MDT
68 Seneca Trail, Wayne, NJ, 07470 Tel: 973 692-0033 Fax: 973 633-9557 www.NJPTAid.biz 73
Mailly & Inglett Consulting
The mission of M&I is to promote and assist in the fair and equitable reimbursement for legitimate physical therapy services. In order to fulfill this mission, we have identified two major goals for both providers and payers respectively:
74
38 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 38 EXHIBIT A
Mailly & Inglett Consulting
1. Assist PTs and PTAs in improving the effectiveness and efficiency of their practice, regardless of setting, in a compliant manner. 2. Assist payers in recognizing and reimbursing for appropriate and legitimate care, while reducing improper payments and improper denials
75
Rick Gawenda, P.T.
www.gawendaseminars.com
(313) 745-3533
(734) 717-1101
76
Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 39
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 39 EXHIBIT A
Gawenda Seminars
CPT and ICD-9 Coding
Rehabilitation Documentation
Medicare Appeals Process
Consultation in the above
77
78
40 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 40 Exhibit B
CCI Edits
Source: Rick Gawenda, PT. Reprinted with permission. EXHIBIT B
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 42 EXHIBIT B
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 43 Exhibit C
Codes Frequently cited as “Problematic” by Payers
Source: Ken Mailly, PT. Reprinted with permission. EXHIBIT C
Codes Frequently cited as “Problematic” by Payers
95851: Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)
• What are the Clinical Indications?
ROM measurements may be appropriate in cases where the major focus of treatment is on how motion may be changing in a joint over time. This is most often necessary in the presence of autoimmune diseases, such as RA, Lupus, or conditions such as OA. Such testing and reporting would be done very infrequently (such as monthly) and would include a report of each involved joint in an extremity. It would be inappropriate to do such testing in the vast majority of musculoskeletal conditions, where the focus of treatment would be on function rather than range of motion, and any impairment of joint ROM are secondary and temporary concerns. Furthermore, the billing of 95851 in such musculoskeletal cases may be an unbundling of the re-evaluation covered by 97002.
97112: Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
• What is this, and who can do this?
If a patient has a disorder of the central or peripheral nervous system, or a disturbance in nerve supply to peripheral musculature; strengthening alone may be ineffective is addressing a patient's functional limitations and physical impairment. This code would be commonly used in patients who may have suffered a stroke, vestibular disorders, peripheral nerve injury, and other neurological con- ditions. It could also be justified by the presence of severe joint effusion causing reflex muscle inhi- bition, or in cases of severe joint sprain or other capsular damage causing proprioceptive impair- ments. In this case, it would only be appropriate until such time as the patient has recovered full & normal control of the motion involved.
As far as who may bill this code, the answer would be anyone that has the above activity covered within their legal scope of practice.
97530: Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
• Clarify the difference between this & 97110.
The critical piece in this code is the focus on “dynamic activities” and “functional performance”. This code would require that the patient is actually doing something that they could conceivably do in everyday life. Examples might be stepping up or down a curb, rising or sitting, lifting or pulling; with a focus on improving performance of these activities. The main focus of such activities might be to increase patient safety, or reducing the energy or effort required to perform them by improving the
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 45 EXHIBIT C quality of their movement. If the activities are being simply to improve the strength of the muscles or motion of the joints involved in performing the activity, 97110 would be more appropriate.
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
• How many times per episode of care should this be billed?
Since this code is primarily focused on education and instruction (training), it would be most appro- priately used to teach, and check proper understanding of what has been taught. The documenta- tion would obviously also have to include the activity requiring training. Such education would typi- cally occur no more than 3-4 times, per episode of care. This frequency would obviously vary depending upon the total length of the episode, and the amount of change in clinical status that a patient may experience.
97026: infrared
• When would this normally be billed?
This supervised modality, classified as a heating modality, and would not normally be combined with other heating modalities in the same session. It is probably most often associated with treatment of integumentary diseases and disorders. Some payers may note increased utilization of this code in recent years, due to the manufacturing of “Near Infrared” and “Monochromatic Infrared” devices, which do not produce heat. Thus, these devices would likely not be most appropriately coded as 97026, but 97039, unlisted modality.
46 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 46 Exhibit D
Claims Review Checklist
Source: Ken Mailly, PT. Reprinted with permission. EXHIBIT D
Claims Review Checklist I General 1. Did a PT perform the examination? 2. If claim is for Worker’s Comp, are findings and interventions related to compensable event? 3. Are interventions based on examination findings? 4. Do interventions comply with accepted standards of practice? 5. Is frequency and duration appropriate? 6. Were stated outcomes reached?
II Referral 1. If referral was made for PT, is it present in medical record? 2. If referrals were made for services other than PT, is follow-up documented?
III Record Review 1. Was intervention rendered with documented progress or goal attainment? 2. Did written report document the results of tests performed? 3. Did PT documentation follow APTA Guidelines for Physical Therapy Documentation and state law? 4. Was intervention record and documentation consistent with billing statement?
IV Modalities 1. Were local modalities continued unmodified for more than two weeks without evidence of improved condition? 2. Were palliative modalities limited to 6-8 weeks post injury? 3. If so, were they provided without any other intervention? 4. If more than 3 modalities were used daily, was appropriate justification included? 5. Does the intervention “fade” (decrease in frequency over time)? 6. If a medical device was used during intervention, was it FDA approved and therefore reimbursable?
V Provider Credentials 1. Are the credentials of provider included in the treatment record? 2. Is license number included as appropriate? 3. If PTA was involved in care, did they document such? 4. Is PTA documentation cosigned by a PT?
48 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes
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50 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes RESOURCES
Speaker resources
Rick Gawenda, PT Director, physical medicine and rehabilitation Detroit Receiving Hospital 4201 St. Antoine Blvd Detroit, MI 48201 Phone: 313/745-3533 Fax: 313/966-7664 E-mail: [email protected]
Ken Mailly, PT Mailly & Inglett Consulting, LLC 68 Seneca Trail Wayne, NJ 07470 Phone: 973/692-0033 Fax: 973/633-9557 E-mail: [email protected] Web site: www.NJPTAid.biz HCPro sites
HCPro: www.hcpro.com
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Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 51
An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 51 RESOURCES
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