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
examples of when you would bill for Community/Work Integration:
- Shopping
- Transportation
- Money management
- Vocational activities and/or work environment-modification analysis
- Use of assistive technology device/adaptive equipment
Wheelchair Management (97542) is used for:
This code is used for Assessment, Fitting, or Training for a wheelchair
Examples of when you would bill for Wheelchair Management:
• Assessing the patient for a wheelchair
• Determining the appropriate wheelchair and accessories:
–> Type of seat cushion, back support, head/neck support, armrests, leg rests, brake extensions, antitips, etc
- Measuring the patient
- Fitting of the wheelchair and making necessary adjustments
- Training the patient and/or caregiver in the use of the wheelchair:
- Managing the parts, using the w/c, driving the w/c • Positioning to avoid pressure sores or contractures
Work Hardening (97545)/Conditioning (97546) is used to address a patient’s:
- Used to address the patient’s strength, endurance, flexibility, motor control, and cardiopulmonary capacity related to performance of the patient’s specific work-related tasks
- These are generally specific programs, that last for multiple hours at a time
- The interventions focus on work-related tasks needed for the patient to safely return to work
examples of work hardening/conditioning activities”
- Lifting, pushing, pulling, carrying, moving objects
* Anything that is specific to that person’s occupational requirements
PHYSICAL PERFORMANCE TEST OR MEASUREMENT 97750
• Used when you have performed Functional Outcome Measures or Functional Testing
–> TUG, 5x STS, BERG, Dynamic Gait Index, FIST, Tinetti, etc
- MUST include written documentation of the outcome measure
- MUST include an explanation of the results
Group Therapy (97150)
involves constant attendance, but does not require one-on-one patient contact. The therapist is working with 2 or more while providing skilled therapy.
In the outpatient setting, do patients in a group need to be performing the same activities?
no
Is Group Therapy a Timed or Untimed Code?
untimed
What code??
Left Shoulder Passive ROM into flexion, abduction, internal and external rotation, 3x10 in each direction
Therapeutic Exercise
- ROM
What code??
Standing on wobble board without UE support, focus on ankle reactions and maintaining balance
Neuromuscular Re-education
- improve balance
What code??
Electrical Stimulation (TENS) to low back, x15 minutes (while therapist documented at desk)
unattended Electrical Stimulation
What code??
Transferring in < > out of a car using a walker with CGA and cues for correct sequencing
Therapeutic Activity
- focus on functional activity
What code??
Ambulating in the hallway with a quad cane x8 minutes to improve activity tolerance
Therapeutic Exercise
- focus is on increasing activity tolerance or endurance
What code??
Sidestepping to Right and Left over small hurdles with 3# ankle weights with focus on increasing hip flexion to clear the hurdle
Therapeutic Exercise
- focus on increasing hip flexion strength or ROM
What code??
Sidestepping to Right and Left over small hurdles with 3# ankle weights with focus on ankle reactions and increasing single leg stance
Neuromuscular Re-education
- focus on improving ankle reaction and single leg stance
PT Evaluation Codes
- Reflects the expertise, skill, and responsibility of physical therapists in caring for their patients/clients
- codes reflect true patient managment
- codes should’t solely be based on time
Are Physical Therapy evaluation and re-evaluation codes timed or untimed?
untimed
Physical Therapy Evaluation codes reflect 3 levels of patient presentation:
- low complexity
- moderate complexity
- high complexity
components used to determine which Eval code to use:
- Patient history (personal factors)
- Examination
- Clinical Presentation
Patient history
the impact of co-morbidities and personal factors on the plan of care
- Low: 1-2 factors
- High: 3 or more factors
Examination
number of elements (body structures and functions, activity limitations, and participation restrictions)
- Low: 1-2 factors
- Moderate: 3 or more factors
- High: 4 or more factors
Clinical Presentation
stable, evolving, and unstable
- Low: stable
- Moderate: evolving
- High: unstable
What impact does time have on determining which Evaluation code to use?
time should never be used
elements for a low complexity evaluation CPT code
- History: no personal factors +/or comorbidities that impact the plan of care
- Examination: 1-2 elements (BSF impairments, Activity Limitations, Participation Restrictions) addressed
- Clinical Presentation: stable +/or uncomplicated; presenting as expected; symptoms/signs localized
- Clinical Decision-Making: low complexity in creating plan of care
elements for a moderate complexity evaluation CPT code
- History: 1-2 personal factors +/or comorbidities that impact the plan of care
- Examination: 3 or more elements (BSF impairments, Activity Limitations, Participation Restrictions) addressed
- Clinical Presentation: evolving with changing characteristics; such as symptoms/signs peripheralizing or weight bearing changing
- Clinical Decision-Making: moderate complexity in creating plan of care
elements for a high complexity evaluation CPT code
- History: 3 or more personal factors +/or comorbidities that impact the plan of care
- Examination: 4 or more elements (BSF impairments, Activity Limitations, Participation Restrictions) addressed
- Clinical Presentation: has unstable and unpredictable characteristics; patterns of symptoms/signs are difficult to establish; red flags; medical issues impacting clinical presentation
- Clinical Decision-Making: high complexity in creating plan of care
Describe the Re-evaluation of an established plan of care CPT code
- An examination including a review of history and use of standardized tests and measures
- A revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome
When is it appropriate to bill for a reevaluation?
- Patient has a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care (POC)
- New clinical findings during the course of treatment that are somewhat related to the original treating condition (i.e., a new diagnosis to add to the POC)
- The patient fails to respond to the treatment outlined in the current POC, so a change to the POC is necessary
- If the state practice act requires re-evaluations at specific time intervals
- Check with the payer and state practice acts if treating a patient with a chronic condition, and you don’t see the patient very often.
- Medicare requires an initial evaluation if 60 days have passed
- Check with state practice act if it includes guidance on when evaluations and re-evaluations are required
What are modifiers?
• Modifiers help ensure you receive the appropriate amount of reimbursement for your physical therapy services
4 common modifiers that physical therapists can use when submitting billing to payers:
- 59 Modifier
- GP Modifier
- KX Modifier
- GA Modifier
What is a GP modifier and when is it used?
- This modifier is used to indicate that a physical therapist’s services have been provided
- This is most commonly used in the inpatient and outpatient setting where multiple therapy disciplines are being provided in the same day (PT, OT, SLP)
Explain the 59 modifier and give examples:
- The National Correct Coding Initiative (NCCI) labels commonly used CPT codes as “edit pairs”
- When these “pairs” are billed in the same day, Medicare will only pay for one of the CPT codes, not both
- This modifier signifies to Medicare that you performed both of those services separately and you should be reimbursed for both codes
- Documentation needs to support those services were provided as separate and distinct
Example:
• The PT is treating a patient with an ankle sprain, and billing 15 minutes of manual therapy and 15 minutes of therapeutic activity on the same date of service. The procedures where performed during separate 15 minute increments.
What is the KX modifier and when would you use it?
- Used when a Medicare beneficiary requires medically necessary care that exceeds the Medicare Part B threshold
- Services must be reason able and necessary
- Require the skills of a therapist
- Services need to be justified by supporting documentation in the patient’s medical record
- A patient was treated for a hip fracture early in the year and hit the Medicare threshold. But later in the year, he has a stroke and requires therapy beyond that threshold, so the therapist applies a KX modifier to justify continued care.
What is a GA modifier and when is it used?
- Indicates that a required Advance Beneficiary Notice(ABN) is on file for a service not considered medically necessary
- Allows the provider to bill a secondary insurance for non-Medicare-covered services, and it also allows the provider to bill the patient directly
The PT is treating a Medicare patient for 6 weeks for post-op services and the patient has reached a functional plateau. PT services are no longer considered medically necessary. She still wants to attend PT for wellness services and to maintain accountability.
MEDICARE PART B 8-MINUTE RULE
The 8-Minute Rule governs the process by which rehabilitation therapists determine how many units they should bill to Medicare Part B for the outpatient therapy services they provide on a particular date of service. A therapist must provide direct, one-on-one therapy for at least 8 minutes to receive reimbursement for a time-based treatment code billed for a Medicare Part B beneficiary.
The 8-minute rule is only used for time based codes.
- 1 unit of treatment time = 8-22 minutes
- 2 units of treatment time = 23-37 minutes
- 3 units of treatment time = 38-52 minutes
- 4 units of treatment time = 53-67 minutes
- 5 units of treatment time = 68-82 minutes
- 6 units of treatment time = 83- 97 minutes
Explain how you determine how many units you can bill for a treatment session:
- add up total mins of skilled 1-1 therapy and divide by 15, if 8 or more mins are left over you can bill for 1 more minute
- using the 8-minute chart, the maximum # of units for time-based codes = 4 units
- OR Divide the total time by 15 = 45 minutes + 8 remainder minutes
Explain the Substantial Portion Methodology used by Non-Medicare insurers.
- In order to charge for a unit of service you must have performed that service for a “substantial portion” of that 15 minutes (at least 8 minutes)
- This means, Substantial Portion Methodology may enable you to bill for more units than 8-Minute Rule
What qualifies for billable minutes, list examples?
All the things you have to do to deliver an intervention:
- assessing the patient prior to performing a hands-on intervention
- assessing the patient’s response to the intervention
- instructing, counseling, and advice-giving about at-home self-care
- answering patient and/or caregiver questions
What activities are non-billable minutes, list examples?
- Unskilled preparation time
- Unskilled clean-up time
- Multiple timed units due to the presence of multiple therapists
- Rest periods and other break times
- Supervising a patient who is performing a therapeutic exercise program independently • “Rounding up”
- Documentation
Upcoding
charging for more extensive and costly services than the therapist actually delivered, entering incorrect billing codes that lead to overcharges
Utilization abuse
this is the practice of scheduling extra visits or providing unnecessary services
Overcharging
the act of charging additional units of the services the therapist performed or tacking on codes for services the therapist didn’t perform at all
What is the Bottom Line when it comes to coding and billing for PT services?
Provide medically necessary services specific to the patient’s treatment plan, and only bill for the services you actually provide
