Unit 2 Procedural Coding Flashcards
What is the difference between ICD-10 codes and CPT codes?
-ICD-10 codes are used for identifying diagnoses
-CPT codes are for identifying the treatments of preventions that you provide during your sessions
The Big Picture for CPT codes
*Created by the ________________________ to report medical procedures and services to public and private payers
*It __________________________ so that it best represents services being provided and it updated every _________________
*Used for ___________________ for outpatient therapy services
*Used for _______________________in inpatient settings
*A provider can bill any code as long as the provider can legally provide that service according to state licensure laws
*American Medical Association
*evolves/changes; every year
*billing
*productivity, staffing, and tracking
CPT codes have different value based on:
*________________ expenses
*________________ expenses
*____________________ location
*work
*practice
*geographical
While most payers have their own fee schedule—and their own guidelines for CPT code reporting—many use the _____ as a baseline
Physician Fee Schedule from the Centers for Medicare and Medicaid Services (CMS)
What should be used in determining which code to bill for?
which will be the best intervention for the patient
Compare and Contrast Service-based and Time-based CPT codes
-Service-Based Codes
-Time-Based Codes
-Service-Based Codes: untimed, can only be billed one unit of each service based code per discipline per pt 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 pt contact; timed in 15 minute increments = 1 unit; can bill multiple units on the same time-based CPT codes 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
Describe what can happen if a PT bills for procedures they didn’t provide.
if documentation does not support the codes that you are billing for you will not reimbursed and you could be audited.
Providing a false claim on a review and audit can lead to additional audit, potential fines, litigation, and loss of PT license
List the groups of codes that are found in the 97000 series:
o97010–97028:
o97032–97039:
o97110–97546:
o97161-97164:
o97597–97606:
o97750–97755:
o97760–97762:
o97010–97028: supervised (untimed) modalities
o97032–97039: constant attendance (one-on-one) modalities (billable in 15-min increments)
o97110–97546: therapeutic (one-on-one) procedures
o97161-97164: PT evaluation and re-evaluation
o97597–97606: active wound care management
o97750–97755: tests and measurements
o97760–97762: orthotic and prosthetic management
Compare and contrast Supervised Modalities versus Constant Attendance Modalities
-supervised modalities: the application of a modality that does not require direct one-on-one pt contact; untimed and service-based; can only bill one unit of each per discipline per treatment session per pt under the same insurance
-constant attendance modalities: the application of a modality that requires direct one-on-one pt contact; time-based billed in 15 min increments; can bill multiple units of the same CPT code to the same pt on the same day if medically necessary and meets time requirements for billing per the insurance carrier
List the specific modalities that fall under each category:
-Supervised Modalities (Untimed)
-Constant Attendance Modalities (Timed)
-Supervised Modalities (Untimed): hot/cold packs, mechanical traction, vasopneumatic device, paraffin bath, whirlpool, diathermy, infrared, ultraviolet, unattended electrical stimulation
-Constant Attendance Modalities (Timed): ultrasound/phonophoresis, iontophoresis, contrast bath, Hubbard tank, functional electrical stimulation, unlisted modality (laser therapy, fluidotherapy, anodyne, VAX-D)
Explain what Therapeutic Procedures are:
-required to have direct patient contact except for group therapy, group therapy requires contact attendance
-one or more areas, each 15 minutes
-requires the PT to maintain direct pt contact during the provision of services
Therapeutic Exercise (97110) is used for any intervention that is used to:
-develop strength, endurance, ROM, and flexibility
-used for restoring where loss/restriction causes functional limitation
-active, active-assistive, or passive participation
-must document the skill provided during the exercises
Therapeutic Exercise includes:
anything used for restoring strength, endurance, ROM, and flexibility where loss/restriction causes functional limitation
List examples of documenting “skill” for Therapeutic Exercise:
-PROM
-stationary bike while assessing RPE every 2 min
-ambulating while assessing RPE every 5 min
-standing shoulder flexion with verbal and tactile cues to prevent upper trap activation
Neuromuscular Re-education (97112) is used when you are providing interventions to improve:
balance, coordination, kinesthetic sense and proprioception
Gait Training (97116) is defined as:
direct one-on-one contact in the performance of progressive exercises or activities designed to improve a pt’s ability to ambulate safely and efficiently
List examples of Gait training:
-ambulation on level and un-level surfaces
-stair traning
-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 pt during ambulation
Therapeutic Activities (97530) is defined as the use of:
functional/dynamic activities to improve/restore functional performance in a progressive manner
List 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:
decrease pain, increase joint mobility, increase ROM, or reduce swelling or inflammation
List 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
Self-Care/Home Management Training (97535) is used for anything that involves:
training a pt how to function in their home
List examples of Self-Care/Home Management interventions:
-activities of daily living like bathing, grooming, and dressing
-instrumental activities of daily living 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 and chores
When instructing a patient in a Home Exercise Program (HEP), should you bill the Self Care/Home Management code?
no, use the code that best describes the focus of the activity
Aquatic Therapy (97113) can be billed:
for any activity or exercise performed in water
What must be included in the documentation when billing for Aquatic Therapy?
it is reasonable and necessary for: ROM, strength, mobility, or balance; persons who cannot tolerate land therapy
Community/Work Integration Training (97537) is the code used anytime you work toward:
re-integrating the pt into the community
List 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:
assessment, fitting, or training for a wheelchair
