Coding Flashcards
Why is coding important?
Supports our Interventions
How we communicate with others
How we measure quality and effectiveness of our services
It’s the basis for pay!
Legal reasons
- poor coding can be fraud
What does your intermediary do?
Cannot write law or change policy
- must follow federal policy
Can interpret codes and regulations
Work for you/your company and the insurance
Staffed by OT/PT
What are the 2 primary codes we deal with?
ICD 10
CPT codes
ICD-10 codes
Diagnostic codes-International Classification of Diseases
- The basis for everything we do
- Important part of the “what is accepted practice” process
Important that you code to the highest level of specificity
- This should NOT be left to the billing person
ICD 10 is changing to…
Combine more codes
Expand mental health codes
Greater specificity
Add postprocedural disorders (cast disease)
What’s the big deal about the right diagnostic code?
Some CPT codes or equipment codes can only be used with certain ICD-10 codes
Level I code
CPT - Current procedural terminology
Majority of codes we use
Used for procedures we perform
Level II codes
HCPCS
Used for specific procedures, orthotics and prosthetics, and equipment
We generally use the “L” codes
Required to be an Approved DMEPOS Agent-(Durable Medical Equipment and Prosthetics, Orthotics, and Supplies)
Most common OT CPT codes
- therapeutic exercise (97110)
- manual therapy (97140)
- E-Stim (97032)
Types of CPT codes
Procedural
- One time per day (no matter the time!)
- Example: PT/OT eval
- Modifiers can be used in some instances
Timed codes (most are in 15 min increments)
- Can use as much as needed (some talk about limit of 6)
- What is the minimum time?
“For any single CPT code, providers bill a single 15 minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes”
8 minute rule
GO/GP/GN modifier
helps with duplication of services
OT does therapeutic exercise: GO
PT does therapeutic exercise: GP
KX modifier
Use when client has surpassed their Medicare threshold for services ($2330 for OT, and for PT/ST)
9X015
CPT code 9X015: Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face; initial 30 minutes,
9X016
CPT code 9X016: each additional 15 minutes (List separately in addition to code for primary service) (Use 9X016 in conjunction with 9X015)
9X017
CPT code 9X017: Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers.
GA modifier
Client has met functional plateau but wishes to continue therapy (maintenance)-pt will be responsible for bill
MPPR
Multiple procedure payment reduction
If you use one code over and over you are paid less for it each time (in a single session).
If a COTA does the intervention is a 15% deduction.
Who does medicare deem as unskilled?
BY definition, if someone other than an OT or COTA, PT or PTA is doing it, it is unskilled… e.g., aide, ATC, exercise physiologist
What is skilled?
A service that requires the specialized knowledge of a professional
This includes the treatment plan, the clinical reasoning, and your knowledge base
ATCs CPT codes
97169-97172
What is abuse?
accidental up coding
“our policy is that everyone gets e-stim after therapy”
To much abuse quickly turns to FRAUD
If everyone is getting it, you can’t be using clinical reasoning!
What is faud?
Intentional up-coding
Billing for services not performed
ATC, AIDES
“it looks just like the real thing”
Penalties may include…
Financial repayment
- With fines and interest
Loss of Provider Status
- Temporary or permanent
Jail time
Violation of Licensure Law
Why are abuse and fraud a big deal?
Devalues the profession
Effectiveness
Image
Anyone can do it-allows others to get our piece of the pie
OT Eval codes
97165-67
Low-High complexity
Low complexity eval code
History: OT profile, medical and therapy history
Assessment: 1-3 performance deficits that result in activity limitations and/or participation restrictions
Decision making: low analytic complexity, which includes analysis of profile, data from problem-focused assessments, and consideration of a limited number of treatment options
- Pt presents with no comorbidities
- Modification of tasks or assistance with assessments is not necessary
Moderate completxity eval
History: OT profile, medical and therapy history , including an expanded review of records and additional review of history related to current performance
Assessment: 3-5 performance deficits
Decision-making: moderate analytic complexity, which includes analysis of profile, data from detailed assessments, and consideration of several treatment options
- patient may present with comorbidities
- minimal to moderate modification of tasks or assistance
High complexity eval
History: OT profile, medical and therapy history including extensive additional review of history
Assessment: 5+ performance deficits
Decision-making: high analytic complexity, which includes analysis of profile, data from comprehensive assessments, and consideration of multiple treatment options
- Pt presents with comorbidities
- Significant modification to tasks or assistance
Functional reporting
YOU CAN ONLY PICK ONE. Can treat multiple areas, but only pick one to do functional reporting on. Pick the one you’re targeting the most.
Six sets
- mobility: walking/moving around
- changing/maintaining body position
- carrying, moving, handling objects
- self care activities
- other
> primary
>secondary
Severity/complexity modifiers
CH, CI, CJ, CK, CL, CM, CN
When to use therpaeutic procedure code
Should be used to document the parameters of strength, rom, flexibility, endurance and how we accomplished this
Examples:
- Lifting a 5# wt to increase biceps strength
- Playing tug of war with you to increase biceps strength
This would work if the goal was “to increase bicep strength by 2 muscle grades”
When to use neuromuscular reeducation code
Neruomuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and or proprioception for sitting or standing activities and how we accomplish this
Examples:
- Lifting 5 # objects, requiring wt shift and balance
- Playing tug a war with you while maintaining sitting balance
This would work if the goal was “to improve balance and wt shift while performing dynamic tasks in sitting”
When to use aquatic therapy code
Client must be submerged in water.
Swimming pool
When to use gait training code
as OT’s we often forget this one, if you are
working on FUNCTIONAL gait or going up stairs
with a walker ect USE IT! (remember, there are
NO “PT codes”
When to use therapeutic procedure - group (1X use) code
2 or more people
Requires direct contact, but not one on one
Example: You have two patients at 8:00, you are working on sitting balance so you have them face each other and toss a ball
Example: You have two hand patients, one is working on a weight wheel and one is on the UBE-this is group!
Example: You have two shoulder patients, one on mat 1 and one on mat 2, you sit between them and instruct them in their individual exercises- this is group OR Ther ex but you must divide the time!
** may be a limit on the percent (usually 25%)
When to use manual therapy code
If you are doing something TO the patient
Difficult retrograde massage
Joint manipulation, PROM, Stretching, handling, ECT
When to use therapeutic activity code
Designed to improve FUNCTIONAL performance
Go back to your goals
Example: lifting a 5# wt if the patient is a personal trainer
Example: playing tug of war with you if the patient is a PE teacher
The goal is to achieve the function!
When to use development of cognitive skills code
Development of Cognitive Skills to improve attention, memory, problem solving
Includes compensatory training
Should be appropriate (look to your goals)
Example: Lifting all the 5# wts 5 times and then putting them in the appropriate slot, if the goal was to work on memory, discrimination and attention
When to use sensory integration code
97533-Sensory Integration to enhance sensory processing and promote adaptive responses to environmental demands
Be careful with this one-talk to your carrier
Example: playing tug of war with you if the goal is to encourage adaptive reponses when affected by outside forces
When to use self care home management training code
Self Care/home management training (ADL), compensatory training (if rote), meal prep, safety procedures, instruction in use of adaptive equipment and assistive technology-PTs don’t use this enough!
Community work/reintegration training code
Carrier issues-watch your documentation
If you leave the house
IADLS-money management
Wheelchair management code
Assessment, fitting, training
Work hardening code
Medicare won’t pay
Orthotic and prosthetic training code
Requires a modifier if used with 97755, 97110, 97112, 97116, 97140
If you are using it with a “L” code, it must be for FUNCTIONAL training outside of normal instruction, ex: use of the splint when dressing, Prosthetic training to include driving
Can’t use manual therapy and massage code on same day
97597 and 97598: removal of devitalized tissue, less than and greater than 20 square centimeters
L codes - HCPCS - CPT II
These codes require DMEPOS provider status and in the near future, will require proof of “qualified”
The “PROOF” can come from one of eleven agencies approved by CMS (this is on HOLD for 2 years)
NBAOS: National Board of Accreditation for Orthotic Suppliers
- Non-profit
- Formed and Run by OT and PT practitioners
Why do we use L codes?
You can’t use “L” codes with out it (for Medicare)
MONEY!! L codes pay substantially more than CPT codes:
- CPT code for orthotic and prosthetics=27.56 per fifteen minutes. This is ONLY the time the orthotic is touching the client!
- L Code for a resting hand splint=$263.67
> Terminology change-don’t go by our names
> Resting hand splint=wrist/hand/finger orthosis-static
> We now have: SEWHFO, SEWHO, EO, EWHO
What to do if you are getting codes kicked back
Did you use an old code
Check the modifier
Is your documentation complete
Does it match your codes
Check the ICD-9 code
Check with the intermediary/carrier
Ask to see policy
- They have to follow federal policy
Call AOTA or APTA
Remember: To many kick backs send signals for an audit!!
Evaluation documentation musts
Reason for referral-functional loss
“treatment diagnosis”, OT?/PT diagnosis
Past level of function, current level, potential (watch check boxes)
Medical necessity-reason OT is neededP
POC documentation musts
Goals for FUNCTION-rom is not function
Treatment interventions
Frequency and duration
Physician involvement- signature
Note documentation musts
Support the CPT codes submitted
Shows progress, not just what they did in therapy
DC documentation musts
Reason for discharge
Progress they made
Future recommendations with patient input
Communication with other caregivers
Your Documentation MUST match up with your codes
Example: if you use a Theraputic Procedure Code and a Manual Therapy Code,
“See exercise flow sheet” won’t do it
You should look at your codes and basically explain why you used each one
