CPT Coding & Billing for the Physical Therapist and Physical Therapist Assistant

Transcription

1 CPT Coding & Billing for the Physical Therapist and Physical Therapist Assistant Rick Gawenda, PT President Gawenda Seminars & Consulting October 20, 2016 Property of Gawenda Seminars & Consulting, Inc. All Rights Reserved! 1

2 DISCLOSURE 3! Rick Gawenda is the owner of Gawenda Seminars & Consul=ng, Inc. and has no outside rela=onship with any companies, vendors, etc. that could be viewed as crea=ng a conflict of interest, or give the appearance of a conflict of interest, that might bias the content of the presenta=on. CPT Code Disclaimer 4 CPT codes, description, and material are copyright 2016 American Medical Association. CPT is a trademark of the American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein 2

3 What is CPT 5! Physicians Current Procedural Terminology, Fourth Edition! Is a proprietary code set developed by the American Medical Association (AMA)! Provides enumeration and standardization of medical and surgical procedures! Widely required by governmental and private insurance programs for claims processing and reimbursement! Generally updated annually and becomes effective January 1 of the new calendar year Types of CPT Codes 6! Time Based Codes! Service Based Codes (un-timed) 3

4 Time Based CPT Codes 7! Many, but not all, require direct one on one contact with the patient in order to bill to an insurance carrier! Contact time ranges from minutes in length. Most codes used by PT and OT are timed in 15-minute increments.! Can bill multiple units of the same time based CPT code on the same day per discipline per patient Service Based CPT Codes 8! Are un-timed unless told otherwise by the payer (i.e. Some state Medicaid programs). If told otherwise by a payer, follow that payers specific policy.! Can only bill one unit of each service-based code daily per discipline per patient per the same insurance. Does not matter how many different body parts you place the same modality on the patient or how long the same modality is on the patient. 4

5 CPT Usage 9 Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified healthcare professional or entity. CPT 2016 Supervised Modalities 10 " The application of a modality that does not require direct (one on one) patient contact " Supervised modalities are un-timed & service based " Can only bill one unit of each service-based code per discipline per treatment session per patient under the same insurance. Does not matter how many different body parts you place the same modality on the patient or how long the modality is on the patient 5

6 Supervised Modalities: Un-Timed Application of a modality to 1 or more areas; hot or cold packs Traction, mechanical Electrical Stimulation (unattended) (Not for Medicare see next slide) Vasopneumatic Devices Paraffin Bath Whirlpool (May include fluidotherapy unless told otherwise by an insurance carrier) Diathermy Infrared G-Code for Unattended E-stim 12! G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (i.e. TENS, IFC, NMES)! Is un-timed! Valid for Medicare for all outpatient therapy settings! Most other insurance carriers still recognize for unattended electrical stimulation. Some recognize either G0283 or 97014! If still being reimbursed for for unattended electrical stimulation, my recommendation is to continue to use for unattended electrical stimulation 6

7 Constant Attendance 13! 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! Are time-based codes 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! Is rare to bill more than one unit of the same modality CPT code to an insurance carrier on the same day on the same patient per the same discipline Constant Attendance Modalities 14! The application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes! Iontophoresis, each 15 minutes! Contrast bath, each 15 minutes! Ultrasound, each 15 minutes! Unlisted modality (specify type and time if constant attendance) Some possible examples could be laser, fluidotherapy, anodyne therapy, VAX-D. 7

8 Home TENS Unit Instruction 2 Options May Be Payer Specific The application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Application of surface (trancutaneous) neurostimulator Not all insurance carriers reimburse for under a Therapy plan of care. Insurance carrier may also dictate which CPT Code to use. CPT Assistant April 2002, Page 18 Canalith Repositioning 16! Canalith repositioning procedure(s) (eg. Epley maneuver, Semont maneuver), per day! CMS began reimbursing for this code January 1, 2011 under the Medicare Physician Fee Schedule 8

9 Manual Muscle Testing Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk hand, with or without comparison with normal side total evaluation of body, excluding hands total evaluation of body, including hands Range of Motion Testing Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) hand, with or without comparison with normal side CPT Assistants April 2003, February 2004, and May

10 Therapeutic Procedures 19! A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.! Physician or other qualified health care professional (i.e. therapist) 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 therapist to maintain direct patient contact (ie, visual, verbal and/or manual contact) during provision of the service! CPT Assistant December 1999 Therapeutic Procedures Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (i.e. Baps Board, Trampoline, Swiss Ball, Body Blade, PNF, NDT, etc.) Aquatic therapy with therapeutic exercise Gait training (includes stair climbing) Massage, including effleurage, petrissage and/or tapoment (stroking, compression, percussion) 10

11 Therapeutic Procedures Manual therapy techniques (eg. Mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes i.e. soft tissue mobilization, myofascial release, serial compression bandaging, joint mobilizations CPT Assistant May 2009 Compression Bandaging 22! Application of multi- layer compression system; leg (below knee), including ankle and foot! Application of multi-layer compression system; thigh and leg, including ankle and foot, when performed! Application of multi-layer compression system; upper arm and forearm! Application of multi-layer compression system; upper arm, forearm, hand, and fingers! CPT Assistant 2010: An Insider s View! CPT Assistant 2012: An Insider s View 11

12 Therapeutic Procedures 23! Therapeutic procedure(s), group (2 or more individuals) (Group therapy procedures involve constant attendance of the physician or other qualified health care professional (i.e. therapist), but by definition do not require one on one patient contact by the same physician or other qualified health care professional) Is un-timed Therapeutic Procedures 24! Under outpatient therapy, it is not what the patient(s) is doing that determines if it is group therapy or one-on-one treatment, it is what the therapist or assistant is doing with the patient(s). How are they treating them?! Is the therapist or assistant one-on-one with one patient while the other patient is doing an intervention independently or under supervision or are they in constant attendance of both patients providing a skilled intervention with no measurable amount of direct one-on-one time spent with either patient? 12

13 Example of Group Therapy 25! Therapist or assistant is in constant attendance of 2 or more patients providing skilled therapy/ intervention, but not providing any significant amount of measurable one-on-one time to either patient whether on land or in aquatic setting! This would be group therapy and each patient would be billed 1 unit of since group therapy is a service based CPT code Example of Intermittent One-on-One 26! Therapist or assistant provides 8 minutes of direct one-on-one therapy (therapeutic exercise) to Patient A and then moves over to Patient B to provide 9 minutes of direct one-on-one therapy (manual therapy) while Patient A works under the supervision of the therapist or assistant! Therapist or assistant then goes back to Patient A for7 more minutes of direct one-on-one exercise while Patient B works under the supervision of the therapist or assistant! Therapist or assistant then goes back to Patient B for 6 more minutes of direct one-on-one manual therapy while Patient A works under the supervision of the therapist or assistant! Patient A would be billed 1 unit of and Patient B 1 unit of for the 15 minutes of one-on-one time the therapist or assistant spent with each of them providing one-on-one therapy services.! Same logic would be true in the aquatic setting 13

14 Therapeutic Procedures Therapeutic activities, direct (one on one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes! Lifting, carrying, pushing, pulling, pinching, grasping, crawling, climbing, throwing, catching, jumping, car transfers, overhead activities, simulation of functional activities, etc.! May also include bed mobility and transfer training! Involves the use of functional activities to restore functional performance in a progressive manner Therapeutic Procedures 28! Self care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct one on one contact, each 15 minutes (bathing, grooming, dressing, personal hygiene, basic household cleaning & chores, cooking, using appliances, medication management) 14

15 Wheelchair Management 29! CPT code Wheelchair management (assessment, fitting, training), each 15 minutes! Assessment includes, but is not limited to, documentation of the event that necessitates the need for the WC, determination of the patient s need for a WC and type of WC required (manual versus powered), patient s strength and ROM, endurance, sensation, pain, edema, tone, skin integrity, sitting balance, standing balance, transfer ability, etc., measurements, and testing the patient s ability with various chair functions.! Also includes determining type of seat cushion, back support, head/ neck support, armrests, leg rests, brake extensions, anti-tips, etc.! Training the patient/family in the use of the wheelchair.! Acknowledges custom seating. CPT Changes 2006-An Insiders View Test and Measurements Physical performance test or measurement (eg, musculoskeletal, functional capacity) with written report, each 15 minutes (Timed Get Up & Go, Tinetti, Berg Balance Test, Dynamic Gait Index, isokinetic/isometric muscle testing, Performance Oriented Mobility Assessment, Four Square Step Test, Fullerton Advanced Balance Scale, Purdue Pegboard Test, etc.)! Includes the time required to analyze and interpret the resulting data while the patient is present! CPT is intended to focus on patient performance of a specific activity or group of activities 15

16 Orthotic & Prosthetic Management 31! Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s), and/or trunk, each 15 minutes! Orthotic management may include: # Determining the type of orthotic (i.e. static vs dynamic, custom vs prefabricated) # Assessing the patient (ROM, strength, skin integrity, sensation, pain, edema, etc.) # Designing, selecting, and possibly fabricating the orthotic # Orthotic fitting and training Orthotic Training 32! is used for the assessment, possible fabrication, fitting, and training of an orthotic. Training includes instruction in wearing time, skin care, modification of the orthotic due to healing of tissues, change in edema, or interruption in skin integrity, safety precautions as well as patient instruction in exercises to be performed while the orthotic is in place! Document specific orthotic provided, skilled training provided, and patient s response to TX! Reference is CPT Assistant December 2005 & February

17 33 Orthotic & Prosthetic Management! Checkout for orthotic/prosthetic use, established patient, each 15 minutes! is used for established patients who have already received the permanent or temporary orthotic or prosthetic. Includes patient s response to wearing the device, whether the patient is donning/ doffing the device correctly, patient s need for padding, underwrap, or socks, and of the patient s tolerance to any dynamic forces being applied.! Document reason for assessment and findings from assessment! Reference is CPT Assistant December 2005 & February 2007 Orthotic & Prosthetic Management 34! Prosthetic training, upper and/or lower extremities, each 15 minutes! Includes preparation of the stump, strengthening of the remaining musculature, modification of prosthetic fit using stump socks or socket liners, mobility training, use during functional activities as well as skin care and overall conditioning! Once a patient begins gait training with the prosthesis, it is appropriate to report such training with 97116! Document type of prosthesis, specific training and amount of assistance required, and any complicating factors and specific descriptions of these factors! Reference is CPT Assistant December 2005 & February

18 8-Minute Rule 35! Applies to Medicare, Medicaid and other federally funded insurance carriers such as TriCare, Federal Blue Cross and Medicare and Medicaid Managed Care insurance carriers! Applies to CPT codes timed in 15-minute increments only! For any single timed CPT code, providers bill the appropriate number of units based on the time intervals outlined 2 slides ahead! If more than one 15-minute timed CPT code is billed on a calendar day, then the total number of time-based units that can be billed is constrained by the total treatment time of time-based interventions by that discipline. Do not count minutes of service-based CPT codes 8-Minute Rule 36! When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of timed service determines the number of time-based units billed! If any 15 minute timed service that is performed for 7 minutes or less on the same day as another 15 minute timed service that was performed for 7 minutes or less and the total time of the 2 is 8 minutes or greater, then bill 1 unit for the service performed for the most minutes 18

19 8-Minute Rule 37! 8 through 22 minutes 1 unit! 23 through 37 minutes 2 units! 38 through 52 minutes 3 units! 53 through 67 minutes 4 units! 68 through 82 minutes 5 units! 83 through 97 minutes 6 units! 98 through 112 minutes 7 units! 113 through 127 minutes 8 units Private Insurance Carriers 38! What defines each 15 minutes?! What is considered substantial of a time-based CPT per the American Medical Association (AMA) to bill a time-based CPT code to an insurance carrier who does not follow Medicare s 8-minute rule?! What does AMA say in the CPT book regarding substantial?! Check with specific insurance carriers and be able to defend what you bill for with rationale 19

20 Billing Scenario #1 39! 16 Minutes Joint mobilizations and soft tissue mobilization! 21 Minutes Range of motion and strengthening ex s! 20 Minutes Unattended E-stim for pain reduction! 15 Minutes Cervical mechanical traction Billing Scenario #2 - Medicare 40! 10 Minutes Unattended electrical stimulation! 12 Minutes Strengthening and active assist range of motion exercises! 6 Minutes Manual therapy to increase ROM! 7 Minutes Functional activities of grasping and pinching activities 20

21 Billing Scenario #3 41! 25 Minutes Re-evaluation! 18 Minutes Shoulder strengthening and ROM exercises! 12 Minutes Manual therapy techniques to increase AROM Billing Scenario #4 42! 25 Minutes Therapeutic exercises for strengthening of the shoulder! 25 Minutes Manual therapy techniques to increase shoulder range of motion 21

22 Billing Scenario #5 43! 10 minutes of therapeutic exercise! 10 minutes of manual therapy! 10 minutes of therapeutic activities References 44! American Medical Association Current Procedural Terminology; CPT 2017; Professional Edition! CMS Therapy Services CPT Assistants In search box, type in: CPT Assistant Newsletter 22

23 CMS Therapy Billing 45! Guidance/Manuals/index.html! Click on Internet-Only Manuals! Click on Pub Medicare Claims Processing Manual! Chapter 5, Part B Outpatient Rehabilitation APTA and PPS Resources 46! APTA Coding and Billing Private Practice Section of APTA Payment Portal 23

24 Contact Information 47 Phone: (661) Like Gawenda Seminars & Consulting at: Consulting-Inc/ Follow me on Twitter at: 24