Revinue - Week 3 Flashcards
Modality CPT - Service Codes (not timed)
~ doesn’t matter how long or how many body parts
Example of Constant Attendance: requires direct visual, verbal, or manual contact
E-stim
When modalities there is what types of CPT codes
unattended and attended.
97022 Whirlpool (includes
fluidotherapy)
Modality that Medicare stopped paying based on ONE EBP article)
97033 Iontophoresis (Medicare stopped paying based on ONE EBP article)
95992 Vestibular Canalith –
1 charge per day, began paying in 2009
97150 Group Therapy:
2 or more individuals
(1 unit to each patient) if charged one patient, must have charged a second patient
Two patients present in outpatient ortho clinic at same time. You go back & forth working with each, at times giving direction for exercise then working with the other. They chat and encourage each other in a therapeutic way. Both are there 30 min.
Can you charge for Group?
Can you charge each for individual 30 min of exercise?
Yes. Each pt gets charges 1 unit of a group. or they each gets charged for 15 minutes of treatment.
Fee for services
the insurance says what their charges are worth.
Untimed CPT codes doesn’t matter how long.
CPT timed how long
8-22 = 1 unit
23-37 = 2 units
38-52 = 3 units
you have to add 15 minutes in order to move up to next time code.
What is the 8 minute rule?
CPT timed codes the min amount of time is 8 minutes
Splints: for purposes of documentation and billing ALWAYS use the word
Orthoses
Why can’t you use the word splint?
The word “Splint” is associated with fractures and casting: mainly used in MD office
Orthotic Mgmt is $6 more per unit than __________ which many charge to teach exercises in the splint
L-Codes: (100+) charge for a specific type of splint
therapeutic exercise
Service Orthosis CodesL Codes: Specific to Orthosis
From the Level 2 Code Section of HCPCS Manual
Service Code (un-timed)
Includes orthosis fabrication & supplies
Does NOT include wear schedule, skin care, or exercise instructions
Evaluations require what using CPT
the amount of time was spent with pt.
L Codes: Specific to Orthosis require the clinic to have a special
DME license.
General orthotic code is
timed
specialized orthotic code or L code is
not timed
Timed CPT Orthosis Codes
97760 Orthotic Management and Training (15 min per unit)
Includes assessment, fitting, and training
Does NOT include supplies
Includes teaching wear, care, skin care, modification of splint, and patient instruction in exercises to be completed while wearing splint
initial orthosis fabrication is _______
Any changes on same splint is _______
97760 Orthotic Management and Training (15 min per unit)
97763 Check out Orthotic for established patient
If the patient got a prefab orthosis you would use what code
97763 - check out orthotic for established pt.
What to do if the patient receives 8 minutes or 24 minutes of treatment?
Look at 8 minute chart.
8 minutes = 1 unit
24 minutes = 2 units
15-minute increments
Can charge 2 or more of same code depending on the time spent
8 Minute CPT Code Rule
- Count service-based codes first
- Count timed codes second
- Don’t add service codes into your total minutes
Although we usually think of a unit of service as 15 minutes…
1 unit can be charged if you have provided a minimum of 8 minutes of service
8 minutes CPT code rule - Applied to time-based CPT Codes only
8-22 minutes= 1 unit
23-37 minutes= 2 units
38-52 minutes= 3 units
Always reach the multiple of 15 min, then add 8 min to identify where you will reach and be able to charge at next unit level
15 min + 8 min = 23 min or > = 2 units
30 min + 8 min = 38 min or > = 3 units
You saw a patient for 44 minutes of therapeutic exercise. How many units can you charge?
A. 2 units
B. 3 units
B. 3
You saw a patient for
total of 44 minutes to
teach them to don their socks for 22 minutes
upper body strengthening for 22 minutes
What will you charge?
A 1 unit of ADL, 1 unit of Exercise
B 2 units of ADL, 1 unit of Exercise
C 1 unit of ADL, 2 units of Exercise
C 1 unit of ADL, 2 units of Exercise
97110 Therapeutic Exercise
to develop
strength, endurance, ROM, flexibility
97112 Neuromuscular Treatment
Can include things like
PNF, NDT, swiss ball, body blade, baps board
Discussion about being sure you are charging for the right thing
Neuromuscular actually pays about
$1.25 more
BC/BS of Tennessee does not pay for Neuromuscular: considers it experimental
Patient who lives with girlfriend and is receiving treatment in rehab facility
Had recent paraplegia and she is in a wheelchair
Practicing home-making of making meal in kitchen for 54 minutes
Which code would you choose
97535: Self Care/Home Mgmnt $28
97150 Group Therapy $28
97530 Therapeutic Activities $38
97542 Wheelchair Management $34
97535: Self Care/Home Mgmnt $28
Therapuetic timed codes
97535 Self Care/Home Management
ADL and IADL training
Therapuetic timed codes
97542 Wheelchair Management
Assessment, fitting, training
97530 Therapeutic Activities, direct patient contact, 15 min.
Lifting, carrying, pushing, pulling, grasping, overhead activities, may include bed mobility, transfer training, functional activities
Consider many of the occupation based activities may fit more closely with therapeutic activities than straight therapeutic exercise which most therapists tend to use. Therapeutic Activities tends to pay
$3. more per visit than therapeutic exercise
97124 Massage
Percussion, stroking compression, effleurage
97140 Manual Therapy
Soft tissue mob, joint mob, myofascial release, contract-relax, neural glides, lymphedema
Patient with flexor tendon repair receives 12 minutes of scar tissue release followed by teaching extension exercises to limits of splint for 8 minutes.
97110 Therapeutic Exercise: $35
97124: Massage $32
97140: Manual Therapy $34
97530 Therapeutic Activities $38
97760 Ortho Mgmnt and Training $41
97140 - manual therapy and
97110 - therapeutic exercise
Two patients in an orthopedic clinic at same time for rehab from wrist fracture. The therapist goes back and forth between the two patients. At times giving instructions for independent exercises so the therapist can work with the other patient. Patients are present for 60 minutes all together. Each patient received a total of 12 minutes of joint mobilization, soft tissue release, and contract-relax to promote increased ROM and 16 minutes of direct work on prescribed eccentric and concentric exercises using either theraband or therapist hand over hand assist. Could I build an L code? Which codes would you use?
97110 Therapeutic Exercise: $3597124: Massage $3297140: Manual Therapy $34
97150 Group Therapy $28
97530 Therapeutic Activities $38
97760 Ortho Mgmnt and Training $41
L3916 Wrist Orthotic $250
No.
Therapeutic activity
group therapy
manual therapy
therapeutic exercise
MUE: Modified Unlikely Edits (2007) …it’s a Medicare thing
- Sets maximum units of a specific CPT you can charge in one day
- Prevent fraud or accidental error in automated system
You can still make the Charges: - Just add MUE to your bill:
Examples: of MUE
might be charging for two splints (Left and Right)
Charging for electrical stim in OT for thumb and Electric stim in PT on same day for knee
Medical Hospital Inpatient Coverage
Payment based on Medicare’s Diagnostic Related Group “DRG” system (i.e., hip replacement) is a form of episode-based payment
Hospital receives a “per episode” rate based on admission diagnosis
Adjusted for complicating factors
Medicare’s Diagnostic Related Group “DRG” system
form of episode-based payment
Hospital receives a “per episode” rate based on admission diagnosis
Adjusted for complicating factors
Per Episode DRG rate:
based on the level of service an individual hospital typically provides
OT still submits CPT code “charges” to help demonstrate level of service provided (tracking productivity)
In reality,
OT is an included service in the daily rate, just like nursing and meals
Utilization Reviewer or Case Manager:
Hospital employed nurse or
Insurance employee (often nurse)
Often BOTH working together
Purpose of Utilization reviewer or case manager -
identify cost containment
assure services are provided in a timely manner
Hospital’s nurse case manager focused on:
Making sure processes run efficiently
Reducing delay in care (advocate for patient)
Utilization Review (Hospital)
Insurance Case Manager/Reviewer focused on:
Evaluating necessity of service
Pre-admission certification
2nd opinion before surgery
Clinical Pathways (Hospital
Clinical Pathways
Team developed standard process to manage care for similar DRG case admissions
Assure services needed are ordered at the right time and that processes work efficiently for a timely placement at discharge
resulted in increased OT referrals
Clinical Pathways Example (Hospital)
Admission for Hip Replacement
Clinical Pathway will trigger automatic orders: certain lab work, nursing care, prn pain medication
Rehab ordered in a standard way:
Day 0 (day of surgery) or Day 1: PT bedside for transfers & ambulation
Day 1: OT begin LE dressing & transfer training
Episodic Payment Models (EPM)
Began in 2017 (67+ Hospitals NOW)
DRG system (i.e., hip replacement) is a form of episode-based payment
One lump sum payment covers ALL Services through to 90 days post-discharge for specific diagnoses
Inpatient hospital coordinates payment/care
Currently Includes:
Surgical Hip/Femur Fracture Treatment
Acute MI (Myocardial Infarction)
CABG (Coronary Artery Bypass Graft)
Psychiatric Inpatient Hospitalization
DRG Exempt: paid on a per diem rate rather than based on the diagnostic related group (DRG)
This covers all needed services (including OT) based on statistics of each hospital’s costs
Hospice Care Services
Physician must certify the client is terminally ill
OT may only provide services to control symptoms or maintain ADL and basic functional skills
Medicare Part A: Home Health Agency (HHA)
Eligibility based on need for skilled nursing, PT, or SLP
OT covered only after qualifying for above skilled service (OT used to be NOT first in home)
COVID-19 Pandemic Emergency Rule
Once receiving OT can continue to do so even if other skilled services no longer needed
Home Health Agency is very _________ based
function. Need to document patient response
PDGM: Home Health Patient Driven Groupings Model (Miller, 2019)
Uses 30-day periods as a basis for payment that considers diagnosis, functional impairment level, and co-morbidities
Payment for PDGM is a
lump sum provided based on single rate for 30-days (recent change from 60), based on prediction of care needs upon completion of screening tool (OASIS)
PDPM: Oct 1, 2019
Patient Driven Payment Model:
Applies to all Medicare A settings
Value based payment: based on patient performance – improvement in function
More holistic approach to billing. Looks at all services provided and the severity of the patient case.
New case-mix classification for reimbursement in SNF, Rehab, and HH (PDGM)
Medicare Part AHome Health Agency
OASIS: “Outcome and Assessment Information Set”
Name of Assessment Documentation form
Completed initially by PT or Nursing only
OT will provide input and may complete OASIS once active on case
COVID-19 Pandemic Emergency Rule
OT can now initiate homecare services
To be called Rehab facility- need to have a specific mix of
conditions admitted.
Generally, payment is for 100 days or less (unless extenuating circumstances)
Generally to qualify for rehab, payment is for
100 days or less (unless extenuating circumstances)
Acute Rehab: meets
3-hour therapy/day rule
Subacute Rehab: can have
less hour of therapy/day
Medicare A: Eligible first 100 days only if
patient needs skilled Nursing (i.e., decubitus care) PT, OT, or SLP
SKilled nursing facility
Must receive therapy services at least 5 days/week
to qualify for SNF - Must have been hospitalized for a minimum of ______ prior to admission to qualify
3 days
75% of therapy must be individual therapy (only 25% of treatment can be provided in a group or concurrent format)
PDPM: Patient Driven Payment Model
CARE Plan “Continuity Assessment Record and Evaluation”
Multidisciplinary document used to demonstrate assessment and care (PDPM)
Scored based on first three days of admit and last three days before discharge => improvements drive reimbursement rate
Generally completed by a Nursing Administrator
Expected to have input from other disciplines despite nursing admin completing
Self-Care and Mobility (Section GG) should be completed by OT
AOTA Advocates that OTs use the 6-point scale to provide information to the main care plan document
Self-Care Items Scored
Eating
Oral Hygiene
Toilet Hygiene
Wash Upper Body
Shower/bathe self
Upper Body dressing
Lower body dressing
Putting on/taking off footwear
Section GG 6-Point Rating Scale
Section GG 6-Point Rating Scale
Code 06 Independent
Code 05 Setup or Clean-Up Assistance
Code 04 Supervision or touching Assistance
Verbal cues, steadying assistance constant or intermittent
Code 03 Partial Moderate Assistance
Helper does LESS THAN HALF the effort; lifts, holds, supports limbs.
Code 02 Substantial/Maximal Assistance
Helper does MORE THAN HALF the effort; lifts, holds, supports limbs.
Code 01 Dependent
Helper does ALL of the effort. Or assistance of 2 or more to complete
GG code if treatment not attempted
Code 07 Resident Refused
Code 09 Not applicable
If resident did not perform this activity prior to current illness, exacerbation, or injury
Code 88 Not attempted due to medical condition or safety concerns
Outpatient OT Services: cost is based on
Current Procedural Terminology (CPT Code) directly
Documentation must reflect service is part of code chosen
Requires a skill performed by an OT
Multiple procedure payment reduction (MPPR)
They give you less the more codes you charge
Outpatient OT and Medicare
Requires current MD prescription & Plan of Care approved by physician (i.e., 700 form)
Focus on improved safety or function
Medicare B pays 80%, patient pays 20% or goes to a supplemental insurance policy (i.e., AARP)
Retrospective Review of Services to determine if Medicare will pay
Only pays 85% of charge if COTA treated (CO Modifier)
Multiple procedure payment reduction (MPPR)
Medicare Cap~
Medicare Cap~
Voted successfully to eliminate and has been repealed
Must use the KX Modifier for a threshold amount of $2150. for OT services (claims over this amount without the KX modifier are denied) at $3000. automatically do a review
Requires therapist to submit documentation that proves:
- Prove: needs are complex & medically necessary
- Prove: Further therapy WILL achieve higher level of function in a reasonable period of time.
Outpatient & Medicare Part B:
Instead of automatic Medicare Cap…
Center for Medicare & Medicaid Services (CMS) will:
Monitor High Usage of Services and audit
Retrospective review: red flags = review
Outpatient and Other Insurances What questions should you ask?
Is there a limit to number of visits?
Does your patient have a copay or high deductible?
Is there a yearly cap on number of visits?
Did the patient have therapy somewhere else?
Are you in network?
Is there a case manager?
Avg. reimbursement for OT
$50-100/visit
high copays lead to
Decreased Therapy Visits
Medicare Changes & AOTA
Law requires -> opportunity for public comment prior to implementation
AOTA monitors -> provides assistance in interpreting potential changes
AOTA lobbies for your benefit
=> Be an AOTA member
