Procedural Coding in Physical Therapy Practice - Week 6 Flashcards
What is the difference between ICD-10 codes and CPT codes?
- CPT are procedural codes, identify procedures or interventions that you provided to patients
- CPT what you use to bill for services you provide
- ICD-10 codes used to identify diagnosis
Big picture for CPT
- Created by the American Medical Associateion to report medical procedures and services to public and private payers
- It coding system evolves/changes as practice evolves so that it best represents services being provided and it updated every year
- Used for billing for outpatient therapy services
- Used for productivity, staffing, and tacking in inpatient settings
- A provider can bill any code as long as the provider can legally provide that service according to state licensure laws
CPT used for what in outpatient setting ?
billing
CPT used for what in inpatient setting?
productivity, staffing, and tacking
no impact on billing because inpatient reimbursed using prospective payment systems
CPT codes have different value based on:
Work expenses
Practice expenses
Geographical location
Service-based codes
- Untimed
- Can only bill one unit of each service- based code per discipline per patient per the same insurance
- Does not matter how many different body parts you treat or how long you treat using this procedure
Time-based codes
- Require direct one-on-one patient contact
- Timed in 15 minute increments = 1 unit
- Can bill multiple units of the same time-based CPT code on the same day per discipline per patient
What series are the majority of CPT codes for PT procedures found?
- Physical Medicine and Rehabilitation: 97000 series
- Other codes outside of 97000 series describe services provided by PTs
Describe what can happen if a PT bills for procedures they didn’t provide.
- Must have documented evidence that the procedure billed for was performed
- False claim on review and audit can lead to additional audit, potential fines, litigation, loss of PT license
SUPERVISED MODALITIES (97010–97028)
- The application of a modality that does not require direct one-on-one patient contact
- Un-timed and service-based
• Can only bill one unit of each service-based code per discipline per treatment
session per patient under the same insurance
• Doesn’t matter how many different body parts you place the same modality on the patient or how long the modality is on the patient
CONSTANT ATTENDANCE (97032–97039)
• The application of a modality that requires direct one-on-one patient contact
• Direct patient contact involves visual, verbal, and/or manual contact with the
patient during provision of the service
- Time-based codes billed in 15 minute increments
- Can bill multiple units of the same CPT code to the same patient on the same day if medically necessary and meets the time requirements for billing per the insurance carrier
SUPERVISED MODALITIES: UNTIMED; 1 UNIT
examples
Only can bill once no matter how long or how many different body parts
- Hot/Cold Packs: 97010
- Mechanical Traction: 97012
- Vasopneumatic Device Therapy: 97016
- Paraffin Bath: 97018
- Whirlpool Therapy: 97022
- Diathermy: 97024
- Infrared Therapy: 97026
- Ultraviolet Therapy: 97028
- Unattended Electrical Stimulation (TENS, IFC, NMES): 97014
Medicare and United Health Care:
• Unattended Electrical Stimulation Non-
Wound Care (TENS, IFC, NMES): G0283
• Unattended Electrical Stimulation Wound Care: G0281
CONSTANT ATTENDANCE MODALITIES:
DIRECT ONE-ON-ONE PATIENT CONTACT; TIMED; 1 UNIT = 15 MINUTES
- Ultrasound / Phonophoresis: 97035
- Iontophoresis: 97033
- Contrast Bath: 97034
- Hubbard Tank: 97036
- Electrical Stimulation (FES, NMES): 97032
- Unlisted modality (Laser Therapy, fluid therapy, anodyne therapy, VAX-D): 97039
Explain what Therapeutic Procedures are:
97110–97546 (most common used by PT)
- Required to have DIRECT (one-on-one) patient contact except for group therapy. Group therapy requires constant attendance.
- Therapeutic procedure, one or more areas, each 15 minutes
- Requires the PT to maintain direct patient contact (visual, verbal, and/or manual contact) during the provision of services
Therapeutic Exercise (97110) is used for any intervention that is used to:
- use exercise as intervention
- develop strength, endurance, ROM, and flexibility
- restoring strength, endurance, ROM, flexibility where loss/restriction causes functional limitation
- Active, active-assistive, or passive participation
- Must document the skilled provided during the exercises
Therapeutic Exercise includes:
- “PROM flexion and extension to L knee to prevent joint contracture, 10x10 reps in each direction, monitoring for pain with each repetition”
- “Stationary bike at level 3 for 10 minutes with seat at level 6 to increase knee flexion, assessing RPE every 2 minutes”
- “Ambulating in hallways for 10 minutes to improve activity tolerance, assessing RPE every 5 minutes”
- “Standing shoulder flexion with 5# weight, 3 sets of 12, with verbal and tactile cues to prevent upper trap activation.”
Neuromuscular Re-education (97112) is used when you are providing interventions to improve:
- Used for movement, balance, coordination, kinesthetic sense, posture, +/or proprioception for sitting +/or standing activities
- Used to improve balance, coordination, kinesthetic sense and proprioception
Impairments that might warrant these interventions:
• nerve palsy
• muscular weakness or flaccidity
• impaired static or dynamic sitting/standing balance
• postural abnormalities
• impaired gross and fine motor coordination
• hypo/hypertonicity
• Impaired proprioception
Gait Training (97116) is defined as:
Direct-one-on-one contact in the performance of progressive exercises or activities designed to improve a patient’s ability to ambulate safely and efficiently
List examples of Gait training:
- Ambulation on level and un-level surfaces
- Stair training
- Education on use of an Assistive Device
- Ambulating with a prosthesis or orthosis
- Ambulation to decrease gait deviations
- Educating a caregiver on how to help/guard a patient during ambulation
Therapeutic Activities (97530) is defined as the use of:
- Use of functional/dynamic activities to improve/restore functional performance in a progressive manner
- Movement activities can be for a specific body part or could involve the entire body
- Focus is on Functional tasks!
examples of Therapeutic Activity:
- Bed mobility training
- Transfer training
- Car Transfer training
- Lifting and Carrying
- Pushing and Pulling
- Pinching and Grasping
- Crawling, Climbing
- Throwing, Catching, Jumping
- Simulation of any functional activities
Manual Therapy Techniques (97140) is used to
Manual therapy is used to decrease pain, increase joint mobility, increase ROM, or reduce swelling or inflammation
examples of when you would use the Manual Therapy code to bill for your services:
- Joint mobilization-peripheral/spinal
- Manipulation
- Manual lymphatic drainage/complex decongestive therapy
- Manual traction
- Myofascial release/soft tissue mobilization
stretching is not manual
Self-Care/Home Management Training (97535) is used for anything that involves:
Anything that involves training a patient how to function in their home
examples of Self-Care/Home Management interventions
- Activities of Daily Living (ADLs) like bathing, grooming, and dressing
- Instrumental Activities of Daily Living (IADLs) like medication mgmt or finance mgmt
- Compensatory training for a home task
- Meal preparation, Using appliances
- Safety procedures to use in the home
- Instruction in use of adaptive equipment for home Personal hygiene
- Basic household cleaning & chores
When instructing a patient in a Home Exercise Program (HEP), should you bill the Self Care/Home Management code?
no, would used the code that best describes the activity you want them to do at home
Aquatic Therapy (97113) can be billed
• Any activity/exercise performed in water
What must be included in the documentation when billing for Aquatic Therapy?
• Reasonable and necessary for person who can not tolerate land therapy: ROM, strength, mobility, balance; persons who cannot tolerate land therapy
Community/Work Integration Training (97537) is the code used anytime you work toward:
Used when working toward re-integrating the patient into the community