Dial-In Instructions

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1 Dial-In Instructions Conference Name: An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes Scheduled Conference Date: Wednesday, March 29th, 2006 Scheduled Conference Time: Scheduled Conference Duration: 1:00 p.m. 2:45 p.m. (Eastern), 12:00 p.m. 1:45 p.m. (Central), 11:00 a.m. 12:45 p.m. (Mountain), 10:00 a.m. 11:45 a.m (Pacific) 105 Minutes PLEASE NOTE: If the audioconference occurs April through October, the time reflects daylight savings. If your area does NOT observe daylight savings, times will be one hour earlier. Your registration entitles you to ONE telephone connection to the audioconference. Invite as many people as you wish to listen to the audioconference on your speakerphone. Permission is given to make copies of the written materials for anyone else who is listening. In order to avoid delays in connecting to the conference, we recommend that you dial into the audioconference 15 minutes prior to the start time. Dial-In Instructions: 1. Dial 800/ and follow the voice prompts. 2. You will be greeted by an operator 3. Give the operator your pass code and the last name of the person who registered for the audioconference. 4. The operator will verify the name of your facility. 5. You will then be placed into the conference. Technical Difficulties 1. If you experience any difficulties with the dial-in process, please call the conference center reservation line at 800/ If you should need technical assistance during the audio portion of the program, please press the star (*) key fol lowed by the 0 key on your touch-tone phone and an operator will assist you. If you are disconnected during the con ference, dial 800/ PLEASE NOTE: This is an encore presentation of the original broadcast including the original 45-minute question and answer session. Program Evaluation Survey In your materials on page 2, we have included a Program Evaluation Letter that has the URL link to our program survey. We would appreciate it if when you return to your office you would go to the link provided and complete the survey. Continuing Education Documentation If CE s are offered with this program, a separate link containing important information will be provided along with the program materials. Please follow the instructions in the CE documentation.

2 presents... An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes A 105-minute interactive audioconference Wednesday, March 29, :00 p.m. 2:45 p.m (Eastern) 12:00 p.m. 1:45 p.m.. (Central) 11:00 a.m. 12:45 p.m. (Mountain) 10:00 a.m. 11:45 a.m. (Pacific)

3 In our materials we strive to provide our audience with useful, timely information. The live audioconference will follow the enclosed agenda. Occasionally our speakers will refer to the materials enclosed. We have noticed that other non-hcpro audioconference materials follow the speaker s presentation bullet-by-bullet, page-by-page. Because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker s entire presentation. The materials contain helpful forms, crosswalks, policies, charts, and graphs. We hope that you find this information useful in the future. HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations, which owns the JCAHO trademark. An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes

4 The An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes audioconference materials package is published by HCPro, 200 Hoods Lane, P.O. Box 1168, Marblehead, MA Copyright 2006, HCPro, Inc. Attendance at the audioconference is restricted to employees, consultants, and members of the medical staff of the Licensee. The audioconference materials are intended solely for use in conjunction with the associated HCPro audioconference. Licensee may make copies of these materials for your internal use by attendees of the audioconference only. All such copies must bear this legend. Dissemination of any information in these materials or the audioconference to any party other than the Licensee or its employees is strictly prohibited. Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions. HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations, which owns the JCAHO trademark. For more information, contact HCPro, Inc. 200 Hoods Lane P.O. Box 1168 Marblehead, MA Phone: 800/ Fax: 781/ customerservice@hcpro.com Web site: An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes

5 200 Hoods Lane P.O. Box 1168 Marblehead, MA Tel: 800/ Fax: 800/ Dear colleague, Thank you for participating in our An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes audioconference with Rick Gawenda, PT, and Ken Mailly, PT, moderated by Kevin Moschella. We are excited about the opportunity to interact with you directly and encourage you to take advantage of the opportunity to ask our experts your questions during the audioconference. If you would like to submit a question before the audioconference, please send it to stierney@hcpro.com and provide the program date in the subject line. We cannot guarantee your question will be answered during the program, but we will do our best to take a good cross-section of questions. If at any time you have comments, suggestions, or ideas about how we might improve our audioconferences, or if you have any questions about the audioconference itself, please do not hesitate to contact me. And if you would like any additional information about other products and services, please contact our Customer Service Department at 800/ Along with these audioconference materials, we have enclosed a fax evaluation. We value your opinion. After the audioconference, please take a minute to complete the evaluation to let us know what you think. Thanks again for working with us. Best regards, Shannon Tierney Audioconference coordinator Fax: 781/ stierney@hcpro.com An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes

6 Contents Agenda vi Speaker profiles vii Exhibit A Presentation by Rick Gawenda, PT, and Ken Mailly, PT Exhibit B CCI Edits Exhibit C Codes Frequently cited as Problematic by Payers Exhibit D Claims Review Checklist Resources An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes

7 Agenda I. Identify new, deleted, and revised CPT codes for 2006 II. Identify problem CPT codes III. Define group therapy in various settings IV. Define, identify, and understand CCI edits: Their application to all settings V. Understand recent OIG audits concerning the misuse of modifier -59 and poor documentation VI. Q&A An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes

8 Speaker profiles Kevin Moschella, moderator Kevin Moschella is an editorial assistant at HCPro, Inc. He writes about issues of safety, security, infection control, rehabilitation, and finance. Rick Gawenda, PT Rick Gawenda graduated in 1991 with a Bachelor of Science in physical therapy from Wayne State University in Detroit. Gawenda is currently director of physical medicine and rehabilitation at Detroit Receiving Hospital and owner of Gawenda Seminars. He has worked in all areas of therapy within the hospital setting and worked in home healthcare for five years. He has provided valuable education and consulting to both hospitals and his peers in the area of coding, billing, documentation, reimbursement, and the appeals process for Medicare denied claims. Gawenda s Web site, provides a valuable source of information about rehabilitation rules and regulations, coding, documentation, and reimbursement. Gawenda is on the editorial advisory board for ADVANCE for Directors In Rehabilitation and Briefings on Outpatient Rehab Reimbursement and Regulations. He is a member of the American College of Healthcare Executives, American Physical Therapy Association (APTA), Michigan Physical Therapy Association (MPTA), MPTA Insurance Policy Committee, and Program Committee of the Health Policy & Administration section of the APTA. Gawenda serves as the liaison between the MPTA and United Government Services, which is the Medicare fiscal intermediary for the state of Michigan. Gawenda has provided his expertise for many articles in Briefings on Outpatient Rehab Reimbursement and Regulations and Eli s Rehab Report on various topics, such as advance beneficiary notices, Medicare certification/recertification, the utilization of L codes as they relate to therapy, and the use of aides in therapy. In addition, he has written articles for ADVANCE for Directors in Rehabilitation about CPT coding, modifier -59, and the Medicare appeals process. Ken Mailly, PT Ken Mailly is a graduate of the State University of New York at Downstate Medical Center and is completing his master s in public administration at Seton Hall University. For over 10 years, he has focused on issues related to healthcare policy and management. In addition to his graduate studies, with well over 2,000 hours of continuing physical therapy education, Mailly has amassed an extremely diverse and extensive knowledge of the clinical practice of physical therapy. His primary clinical focus is on management of patients with bleeding and chronic soft-tissue disorders, and he is certified as an ergonomic specialist. An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes

9 Along with this clinical knowledge base, Mailly has devoted the past eight years to the areas of regulation, legislation, and reimbursement of physical therapy services. He has served as an expert witness on behalf of both plaintiffs and defendants in numerous malpractice cases. He has also been consulted on state and federal inquiries regarding physical therapy and rehabilitation billing and regulatory issues. Mailly has served as a guest lecturer at Seton Hall University, University of Medicine and Dentistry of NJ, Richard Stockton College of NJ, Bergen Community College, and Mercer County College. He is also a frequent contributor and consultant for Advance, Eli s Rehab Report, Briefings on Outpatient Regulation and Reimbursement, and Non-Physician Practitioner News. He has also been published in The Orthopedic Clinics of North America and featured in PT Magazine. Mailly has been extensively involved in APTA at the local, state, and national levels for over 15 years. He has served APTA in various capacities, including delegate, professional affairs representative, and director of government relations. He has also served on the direct-access task force for APTA and serves, along with partner Barry Inglett, as a member consultant on coding initiatives and as a member of the APTA consulting service. Mailly was also recently appointed to the Empire Medicare Services Provider Communications Advisory Group (PCOM) as a representative of physical therapists. He has presented during many state and national meetings and was the recipient of several professional awards, including being a two-time awardee of the APTA of NJ President s Award. He is a member of the health policy and administration and private practice sections of APTA. Mailly s focus in the activities of M&I Consulting is on compliance with professional standards, state and federal regulations, and management strategies. An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes

10 Exhibit A Presentation by Rick Gawenda, PT, and Ken Mailly, PT 1

11 Coding & Billing for Rehab Services: Avoiding the Pitfalls of the 2006 Codes Presented by: Rick Gawenda, PT & Ken Mailly, PT 1 Objectives Identify new, deleted, and revised CPT codes for 2006 Identify problem CPT codes Define group therapy in various settings 2 2 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 2

12 Objectives Define, identify, and understand CCI edits Define, identify, and understand when it is appropriate to use modifier-59 by therapists Be able to charge correctly for the services you provide Understanding Medicares 8 minute rule 3 CPT A Closer Look 4 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 3 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 3

13 Who can use them? Anyone whose legal scope of practice (qualified) permits the performance of the procedure described by the code. There are no PT, OT or SLP codes per se. Modifiers are used to describe who performed service GN, GO, GP 5 Physical Medicine & Rehabilitation Level I Series CPT Codes 6 4 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 4

14 Types of CPT Codes Time Based codes Service Based codes 7 Time Based Codes Requires direct one on one time spent with patient Contact is minutes in length Can bill multiple units of the same time based CPT code on the same day per discipline per patient 8 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 5 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 5

15 Service Based Codes Does not require direct one on one time with the patient Are un-timed Can only bill one unit of each servicebased code daily per discipline per patient 9 Pre-Test #1 CVA Patient 20 Minutes L/E strengthening exercises 20 Minutes NDT techniques to improve dynamic sitting and static standing balance 10 6 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 6

16 Evaluations Service Based Physical Therapy Evaluation Physical Therapy Re-Evaluation Occupational Therapy Evaluation Occupational Therapy Re-Evaluation Athletic Training Evaluation Athletic Training Re-Evaluation 11 Supervised Modalities The application of a modality that does not require direct (one on one) patient contact by provider. Un-timed (service-based) Once per session (date of service) per discipline per patient Includes CPT codes Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 7 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 7

17 Constant Attendance The application of a modality that requires direct (one on one) patient contact by the provider Are time-based codes Can bill multiple units of these CPT codes to the same patient on the same day Includes CPT codes Constant Attendance Modalities The application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Iontophoresis, each 15 minutes Contrast bath, each 15 minutes Ultrasound, each 15 minutes Hubbard tank, each 15 minutes Unlisted modality (specify type and time if constant attendance) 14 8 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 8

18 G0283 or versus Documentation in the patients medical record must clearly show that manual electrical stimulation was provided Types of manual electrical stimulation include hand-held units and ultrasound/electrical stimulation combination treatments Constant attendance may also involve visual and/or verbal contact with the patient during provision of the services (CPT Assistant July 2004) 15 Unlisted Modality May be supervised or constant attendance Must specify type and time if constant attendance Types of modalities billed using this code may include anodyne, light, laser, ice massage, and fluidotherapy if not billed under Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 9 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 9

19 Pre-Test #2 Low Back Patient 15 Minutes Joint mobilizations and soft tissue mobilization 17 Minutes Stretching and strengthening exs 6 Minutes Ultrasound to low back 17 Therapeutic Procedures A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Therapist or therapist assistant required to have direct (one on one) patient contact. Therapist or therapist assistant must need to be one-on-one with the patient Includes CPT codes and Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 10

20 Exercise v. Activity Exercise: patient performing something that they would not normally perform in everyday life (CPT code 97110) Activity: patient IS performing something that they may be doing everyday, but with therapeutic intent (CPT Code 97530) 19 Critical points! Coding is as much about the intent of the activity, as it is the activity itself. e.g.: Electrical Stimulation BAPS 20 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 11 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 11

21 The Biggie!!! Therapeutic procedure(s), group (2 or more individuals) Group therapy procedures involve constant attendance of the therapist or therapist assistant, but by definition do not require one-on-one patient contact by the provider. This code is un-timed. May only bill one unit per patient per discipline regardless of the amount of time the patient participated in the group Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 12

22 Group Therapy-Medicare Patients need not be performing the same activity (Part B) Patients must be working on the same activity (Part A) Provider must be in constant attendance Direct one-on-one contact not required No limit of patients for Part B unless specified in LCD Limited to 4 patients per group for Part A SNF setting In SNF Part A setting, no more than 25% of the total minutes in a week per discipline may be in a group Transmittal 1872, January 24, Federal Register SNF Final Rule, July 30, Group Therapy or One-on-One What are the patients doing, but more importantly What is the therapist or therapist assistant doing! Is the therapist or assistant in constant attendance with both patients or are they going back and forth between the patients spending one-on-one time with each patient in small increments 24 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 13 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 13

23 SNF Part A Setting Concurrent Therapy Treating 2 or more patients during the same time period Also known as dovetailing or supervisory therapy Patients are performing different activities Therapist can go back and forth between the patients Key is the therapist or therapist is assistant is in the room, supervising the entire treatment process Minutes for set up and preparing the patient for treatment may be counted Page 3-72 to Concurrent Therapy Case Example PT has Patient A beginning therapy at 9:00AM on a specific task PT has Patient B beginning therapy at 9:15AM on a specific task different than Patient A Treatment ends for each patient 30 minutes after it began. PT is present the entire time with both patients Each patient receives 30 minutes of one-onone time on the MDS for that date of service Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 14

24 SNF Part A or Part B Group Case Scenario SLP has 2 patients beginning therapy at 9:00AM and lasts until 9:45AM Both patients work on activities to strengthen the tongue to move the bolus to the back of the mouth for swallowing for 25 minutes then Work on lip strengthening exercises to keep the food in the mouth for 20 minutes Both patients would receive 45 minutes billed as group treatment on the MDS for that date of service or 1 unit if an outpatient 27 Wheelchair Management CPT code Now includes assessment, fitting, and training Assessment includes, but is not limited to, determination of the patients need for a WC and type of WC required, patients strength and ROM, endurance, skin integrity, sitting balance, transfer ability, etc., measurements, and testing the patients ability with various chair functions. Acknowledges custom seating. CPT Changes 2006-An Insiders View 28 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 15 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 15

25 Orthotic Management & Prosthetic Management New heading added to the Medicine section of the CPT manual in 2006 New heading includes CPT codes (formerly 97504), (formerly 97520), and (formerly 97703) 29 Orthotic Management & Prosthetic Management CPT code 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 This CPT code allows for reporting the assessment and management of a patient requiring a pre-fabricated or custom fabricated orthotic Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 16

26 Orthotic Management & Prosthetic Management Orthotic management may include: Assessing the patient Determining the type of orthotic Designing, selecting, and fabricating the orthotic Orthotic training including exercises performed in the orthotic, instruction in skin care and wearing schedule 31 Orthotic Management & Prosthetic Management If you bill an L code for the pre-fabricated or custom fabricated orthotic, you may only bill the appropriate number of units of for the orthotic training based on the number of minutes spent providing the training The L code reimbursement includes the assessment, fabrication time, and fitting CPT Assistant December Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 17 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 17

27 97760 versus used for the assessment, fabrication, fitting, and training of an orthotic used when adjustments need to made to an orthotic, orthotic needs to be modified or re-issued, etc. 33 New CPT Codes for Education and training for patient self management by a qualified, non-physician healthcare professional using standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; individual patient Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 18

28 New CPT Codes for Education and training for patient self management by a qualified, non-physician healthcare professional using standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; 2-4 patients 35 New CPT Codes for Education and training for patient self management by a qualified, non-physician healthcare professional using standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; 5-8 patients 36 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 19 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 19

29 Education & Training Codes CMS not reimbursing for these CPT codes in 2006 Does not necessarily affect PT, OT, or SLP services, in fact we are really not expected to be using these codes Whatever we are training the patient and/or caregiver in, those minutes are included/counted under the CPT code that best describes our treatment/intention 37 Pre-Test #3 Speech 30 minutes strengthening exercises to improve voice communication 15 minutes oromotor exercises to improve patients swallow 15 minutes teaching the patient and their spouse in compensatory swallowing strategies Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 20

30 Evaluations Service Based Evaluation of speech, language, voice, communication, and/or auditory processing Evaluation of oral and pharyngeal swallowing function Motion fluoroscopic evaluation of swallowing function by cine or video recording 39 Speech Therapy Services Treatment of speech, language, voice,communication, and/or auditory processing disorder; individual Group, two or more individuals Treatment of swallowing dysfunction and/or oral function for feeding 40 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 21 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 21

31 Speech Therapy CPT Codes Not To Be Used Therapeutic exercise Neuromuscular re-education CMS announced this during a SNF open door forum ASHA issued this announcement in November Speech Central Nervous System Assessments/Tests Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 22

32 Speech Therapy Services Treatment of swallowing dysfunction and/or oral function for feeding 43 New Codes for SLP Services Evaluation of auditory rehabilitation status; 1 hour Evaluation of auditory rehabilitation status; each additional 15 minutes (list separately in addition to code for primary procedure 44 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 23 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 23

33 New Codes for SLP Services Auditory rehabilitation; pre-lingual hearing loss Auditory rehabilitation; postlingual hearing loss CMS not reimbursing for these CPT codes. If SLP provides these services, the minutes are billed under These services are not reimbursed if provided by an audiologist as Medicare only covers audiology services that are diagnostic in nature, not treatment. 45 National Correct Coding Initiative (NCCI) CCI Edits The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative to promote national correct coding methodologies and to eliminate improper coding. CCI edits are developed based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT) Manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practice Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 24

34 National Correct Coding Initiatives (NCCI) Initiated in 1996 to the private practice setting Expanded to hospital outpatient departments in August 2000 Expanded to SNF Part B, CORFs, Rehab Agencies, and Home Health Agencies not under a Home Health Plan of Care on January 1, 2006 Current version is 12.0 for private practice and physician owned therapy clinics and 11.3 for all other settings 47 Modifiers In certain circumstances, specific CCI edits will be bypassed if required modifiers are present. The most commonly used modifier therapists utilize is modifier Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 25 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 25

35 Modifier - 59 Distinct Procedural Service Indicates that a procedure or service was distinct or independent from other services performed on the same day Used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances Documentation must support use of modifier 59 in that the procedures/services were provided at separate and distinct times, were medically necessary and required the skills of a therapist or therapist assistant under the supervision of a therapist 49 Modifier-59 Documentation Example 9:00AM-9:30AM, aquatic therapy of (list what was provided), 9:45AM- 10:10AM, land-based exercises of (list what was provided) Aquatic therapy of (list what was provided) followed by land-based exercise of (list what was provided) Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 26

36 CCI Edits 2 types of edits 1.) Mutually exclusive codes 2.) Column 1/Column 2 codes 51 Mutually Exclusive Codes Codes that cannot be billed together because they would not normally be performed together Speech group (92508) and speech therapy treatment (92507) Group therapy (97150) and therapeutic exercise (97110), neuromuscular re-education (97112), aquatic therapy (97113), or gait training (97116) Mechanical traction (97012) and manual therapy (97140) Manual therapy (97140) and therapeutic Activities (97530) 52 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 27 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 27

37 Column 1/Column 2 Codes Codes in which one of the codes is considered a component of a more comprehensive code on the bill Aquatic therapy (97113) and therapeutic exercise (97110) Therapeutic activities (97530) and gait training (97116) Therapeutic exercise (97110) and PT re-eval (97002) or OT re-eval (97004) 53 Column 1/Column 2 Codes Swallowing treatment (92526) and therapeutic exercise (97110) Swallowing treatment (92526) and cognitive therapy (97532) Swallowing treatment (92526) and Neuro reeducation (97112) Swallowing treatment (92526) and therapeutic activities (97530) Swallowing treatment (92526) and unattended e-stim (G0283) or manual e-stim (97032) Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 28

38 CCI Edits Are applicable to one specific discipline of therapy billing different procedures on the same day that require modifier-59 Are applicable when multiple disciplines of therapy occur to the same beneficiary on the same day billing procedures that require modifier CCI Edit Example Pt receives 60 minutes of SLP treatment (92507) on 09/05/03 Pt receives 30 minutes of therapeutic exercise (97110) and 30 minutes of gait training (97116) in PT on 09/05/03 Pt receives OT consisting of 30 minutes of therapeutic activities (97530) and 30 minutes of Neuro Re-ed (97112) on 09/05/03 56 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 29 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 29

39 CCI Edit Example By discipline, none of the procedures require modifier-59 to be reimbursed Since this patient was seen on the same day by more than one discipline, need to check between all disciplines (cross-check) as the need for modifier-59 does apply CMS billing system does not recognize therapy specific modifiers (GN, GO, GP) 57 CCI Edit Example Would need to append modifier-59 to 97110, 97112, 97116, and Documentation would need to support that the services were performed at separate and distinct times Not appending modifier-59 in this example would cost you approximately $240 in lost reimbursement Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 30

40 CCI Updates Updated quarterly nited/ Private practice and physician owned therapy clinics, click on NCCI Edits physicians. All other settings, click on NCCI Edits - Hospital 59 8 Minute Rule Applies to direct contact CPT codes only For any single CPT code, providers bill the appropriate number of units based on the time intervals on the next slide If more than one CPT code is billed on a calendar day, then the total number of units that can be billed is constrained by the total treatment time. Do not count minutes of service-based CPT codes Schedule on the next slide does not imply that any minute until the eighth should be excluded from the total count 60 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 31 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 31

41 8 Minute Rule 8 to < 23 1 unit 23 to < 38 2 units 38 to < 53 3 units 53 to < 68 4 units 68 to < 83 5 units 83 to < 98 6 units 98 to < units 113 to < units 61 8 Minute Reference Medicare Claims Processing Manual, Chapter 5 Part B Outpatient Rehabilitation and CORF Services, Section 20.2 and Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 32

42 Pre-Test #1 CVA Patient 20 Minutes L/E strengthening exercises 20 Minutes NDT techniques to improve dynamic sitting and static standing balance 63 Post-Test #1 64 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 33 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 33

43 Pre-Test #2 Low Back Patient 15 Minutes Joint mobilizations and soft tissue mobilization 17 Minutes Stretching and strengthening exs 6 Minutes Ultrasound to low back 65 Post-Test # Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 34

44 Pre-Test #3 Speech 30 minutes strengthening exercises to improve voice communication 15 minutes oromotor exercises to improve patients swallow 15 minutes teaching the patient and their spouse in compensatory swallowing strategies 67 Post-Test #3 Speech 68 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 35 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 35

45 References American Medical Association Current Procedural Terminology; CPT 2006; Standard Edition Ingenix St. Anthony Publishing/Medicode Coding and Payment Guide for the Physical Therapist; 2006, 11 th Edition Ingenix St. Anthony Publishing/Medicode ICD-9-CM Expert for Hospitals-Volumes 1,2, & th Edition 69 Essential References CPT-2005/6 cpt Assistant CCI APTA, AOTA, ASHA CMS Therapy Resources Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 36

46 References for Billing Internet-Only Manuals Click on Internet-Only Manuals Click on Pub Medicare Claims Processing Manual Choose the appropriate chapter depending on your setting 71 Billing References Chapter 5, Part B Outpatient Rehabilitation and CORF Services Chapter 6, SNF Inpatient Part A Chapter 7, SNF Part B Chapter 10, Home Health Agency 72 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 37 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 37

47 Ken Mailly, PT Barry Inglett, PT, Cert MDT 68 Seneca Trail, Wayne, NJ, Tel: Fax: Mailly & Inglett Consulting The mission of M&I is to promote and assist in the fair and equitable reimbursement for legitimate physical therapy services. In order to fulfill this mission, we have identified two major goals for both providers and payers respectively: Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 38

48 Mailly & Inglett Consulting 1. Assist PTs and PTAs in improving the effectiveness and efficiency of their practice, regardless of setting, in a compliant manner. 2. Assist payers in recognizing and reimbursing for appropriate and legitimate care, while reducing improper payments and improper denials 75 Rick Gawenda, P.T. rgawenda@gawendaseminars.com rgawenda@dmc.org (313) (734) Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 39 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 39

49 Gawenda Seminars CPT and ICD-9 Coding Rehabilitation Documentation Medicare Appeals Process Consultation in the above Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 40

50 Exhibit B CCI Edits Source: Rick Gawenda, PT. Reprinted with permission.

51 EXHIBIT B An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 42

52 EXHIBIT B An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 43

53 Exhibit C Codes Frequently cited as Problematic by Payers Source: Ken Mailly, PT. Reprinted with permission.

54 EXHIBIT C Codes Frequently cited as Problematic by Payers 95851: Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) What are the Clinical Indications? ROM measurements may be appropriate in cases where the major focus of treatment is on how motion may be changing in a joint over time. This is most often necessary in the presence of autoimmune diseases, such as RA, Lupus, or conditions such as OA. Such testing and reporting would be done very infrequently (such as monthly) and would include a report of each involved joint in an extremity. It would be inappropriate to do such testing in the vast majority of musculoskeletal conditions, where the focus of treatment would be on function rather than range of motion, and any impairment of joint ROM are secondary and temporary concerns. Furthermore, the billing of in such musculoskeletal cases may be an unbundling of the re-evaluation covered by : Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. What is this, and who can do this? If a patient has a disorder of the central or peripheral nervous system, or a disturbance in nerve supply to peripheral musculature; strengthening alone may be ineffective is addressing a patient's functional limitations and physical impairment. This code would be commonly used in patients who may have suffered a stroke, vestibular disorders, peripheral nerve injury, and other neurological conditions. It could also be justified by the presence of severe joint effusion causing reflex muscle inhibition, or in cases of severe joint sprain or other capsular damage causing proprioceptive impairments. In this case, it would only be appropriate until such time as the patient has recovered full & normal control of the motion involved. As far as who may bill this code, the answer would be anyone that has the above activity covered within their legal scope of practice : Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Clarify the difference between this & The critical piece in this code is the focus on dynamic activities and functional performance. This code would require that the patient is actually doing something that they could conceivably do in everyday life. Examples might be stepping up or down a curb, rising or sitting, lifting or pulling; with a focus on improving performance of these activities. The main focus of such activities might be to increase patient safety, or reducing the energy or effort required to perform them by improving the An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 45

55 EXHIBIT C quality of their movement. If the activities are being simply to improve the strength of the muscles or motion of the joints involved in performing the activity, would be more appropriate : Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes How many times per episode of care should this be billed? Since this code is primarily focused on education and instruction (training), it would be most appropriately used to teach, and check proper understanding of what has been taught. The documentation would obviously also have to include the activity requiring training. Such education would typically occur no more than 3-4 times, per episode of care. This frequency would obviously vary depending upon the total length of the episode, and the amount of change in clinical status that a patient may experience : infrared When would this normally be billed? This supervised modality, classified as a heating modality, and would not normally be combined with other heating modalities in the same session. It is probably most often associated with treatment of integumentary diseases and disorders. Some payers may note increased utilization of this code in recent years, due to the manufacturing of Near Infrared and Monochromatic Infrared devices, which do not produce heat. Thus, these devices would likely not be most appropriately coded as 97026, but 97039, unlisted modality. 46 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 46

56 Exhibit D Claims Review Checklist Source: Ken Mailly, PT. Reprinted with permission.

57 EXHIBIT D Claims Review Checklist I General 1. Did a PT perform the examination? 2. If claim is for Worker s Comp, are findings and interventions related to compensable event? 3. Are interventions based on examination findings? 4. Do interventions comply with accepted standards of practice? 5. Is frequency and duration appropriate? 6. Were stated outcomes reached? II Referral 1. If referral was made for PT, is it present in medical record? 2. If referrals were made for services other than PT, is follow-up documented? III Record Review 1. Was intervention rendered with documented progress or goal attainment? 2. Did written report document the results of tests performed? 3. Did PT documentation follow APTA Guidelines for Physical Therapy Documentation and state law? 4. Was intervention record and documentation consistent with billing statement? IV Modalities 1. Were local modalities continued unmodified for more than two weeks without evidence of improved condition? 2. Were palliative modalities limited to 6-8 weeks post injury? 3. If so, were they provided without any other intervention? 4. If more than 3 modalities were used daily, was appropriate justification included? 5. Does the intervention fade (decrease in frequency over time)? 6. If a medical device was used during intervention, was it FDA approved and therefore reimbursable? V Provider Credentials 1. Are the credentials of provider included in the treatment record? 2. Is license number included as appropriate? 3. If PTA was involved in care, did they document such? 4. Is PTA documentation cosigned by a PT? 48 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 48

58 Resources

59 Audioconference Attendees SAVE 20%! The How-To Manual for Rehab Documentation A Complete Guide to Increasing Reimbursement and Reducing Denials With ever-changing regulations and constant time-constraints, we know getting your therapists to document appropriately can be a colossal challenge but failing to do so can cost you precious dollars. Introducing the newly revised How-To Manual for Rehab Documentation, by noted billing and documentation expert Rick Gawenda, PT. This comprehensive book and CD-ROM will help you understand the requirements for documentation no matter what your therapy setting and decrease the frequency of your denials. It details the certification and recertification process for Medicare Part A and Part B therapy services, and features 20 forms that demonstrate correct documentation. The book even includes a question-andanswer section that will test your therapists coding knowledge, and make certain that they are documenting the services that they perform correctly. If you happen to have a Medicare therapy claim denied, The How-To Manual for Rehab Documentation will take you step-by-step through the Medicare appeals process. It outlines the various levels of appeals and tells you what information and documentation you must include to support your appeal. The ultimate result? Your facility will collect more of the rehab reimbursement it deserves. Mail, fax, or phone-in your order today! Save 20% when you respond to this special offer, exclusively for audioconference attendees. HCPro, Inc 200 Hoods Lane P.O. Box 1168 Marblehead, MA Phone 800/ Fax 800/639/8511 Yes! Send me a copy of The How-To Manual for Rehab Documentation at the special discounted price of just $ that s a 20% savings reserved exclusively for audioconference attendees! Publication Price Code Quantity Total How-To Manual for Rehab Documentation $ (Regularly $249) HTMRD Order online at Enter your source code at checkout to save 20%! Your order is fully covered by HCPro s risk-free, money-back guarantee. Your source code is: MB42537A Ship to: Your Name & Title Organization Street Address City/State/Zip Shipping ($ to AK, HI, PR) $18.00 *Your state sales tax $ Grand Total $ FOUR EASY WAYS TO PAY! (Please check one). Bill me Charge VISA MasterCard AmEX Check enclosed (pay to HCPro) Bill my facility with P.O. # Account # Expires Signature Thank you for your order! * Tax Information States that tax products and shipping and handling: CA, IL, MA, MD, NJ, VA, VT, FL, CT, GA, IN, MI, NC, NY, OH, PA, SC, TN, TX, WI; States that tax products only: AZ. 50 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes

60 RESOURCES Rick Gawenda, PT Director, physical medicine and rehabilitation Detroit Receiving Hospital 4201 St. Antoine Blvd Detroit, MI Phone: 313/ Fax: 313/ Speaker resources Ken Mailly, PT Mailly & Inglett Consulting, LLC 68 Seneca Trail Wayne, NJ Phone: 973/ Fax: 973/ Web site: HCPro sites HCPro: With more than 17 years of experience, HCPro, Inc., is a leading provider of integrated information, education, training, and consulting products and services in the vital areas of healthcare regulation and compliance. The company s mission is to meet the specialized informational, advisory, and educational needs of the healthcare industry and to learn from and respond to our customers with services that meet or exceed the quality they expect. Visit HCPro s Web site and take advantage of our online resources. At hcpro.com you ll find the latest news and tips in the areas of accreditation corporate compliance credentialing health information management infection control long-term care medical staff nursing pharmacy Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes 51 An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 51

61 RESOURCES physician practice quality/patient safety safety HCPro offers the news and tips you need at the touch of a button sign up for our informative, FREE newsletters, check out our in-depth how-to information in our premium newsletters, and get advice from our knowledgeable experts. The Greeley Company: Get connected with leading healthcare consultants and educators at The Greeley Company s Web site. This online service provides the fastest, most convenient, and most up-to-date information about our quality consulting, national-education offerings, and multimedia training products for healthcare leaders. Visitors will find a complete listing of our services that include consulting, seminars, and conferences. If you re interested in attending one of our informative seminars, registration is easy. Simply go to www. greeley.com and take a couple of minutes to fill out our online form. Visitors of will also find faculty and consultant biographies. Learn about our senior-level clinicians, administrators, and faculty who are ready to assist your organization with your consulting needs, seminars, workshops, and symposiums. detailed descriptions of all The Greeley Company consulting services. a list of Greeley clients. catalogue and calendar of Greeley s national seminars, conferences, and available CMEs. user-friendly online registration/order forms for seminars. HCPro s Healthcare Marketplace: Looking for even more resources? You can shop for the healthcare management tools you need at HCPro s Healthcare Marketplace at Our online store makes it easy for you to find what you need, when you need it, in one secure and user-friendly e-commerce site. At HCPro s Healthcare Marketplace you ll discover all of the newsletters, books, videos, audioconferences, online learning, special reports, and training handbooks that HCPro has to offer. Shopping is secure and purchasing is easy with a speedy checkout process. 52 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 52

62 CERTIFICATE OF ATTENDANCE attended An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes a 105-minute audioconference on March 29, 2006 Rob Stuart Senior Vice President / Chief Operating Officer

63 A S U P P L E M E N T T O HCP R O P U B L I C A T I O N S Phoenix, Sunny Amelia Island, FL Spring 2006 Sears Tower, Chicago, IL Seminar Calendar Viva Las Vegas! 9th Annual Credentialing Resource Center Symposium May 17th & 20th Pre- and Post- Conferences Send a Team and Save! New! Discharge Planning Summit Core Privileging Advanced Course Front-End Solutions Workshop Physician Performance Profile Course Public Accountability for Quality Case Management Institute Golf To register, call 800/ or visit An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 54