2017 Spring Convention

Transcription

1 2017 Spring Convention CPT Coding & Modifiers Paul Andrews

2 Please scan IN at the start of class Please scan OUT at the end of class You must attend the entire session to earn your credit(s) for this class

3 MODALITIES 2 Types Supervised to Constant Attendance to 97035

4 Not Time Based Health care provider on site Supervised Service Billed Once per encounter regardless of regions being treated or time

5 Time Based Pre, Intra, Post Service time Intra-service; first 8 to less than 23 minutes count as one 15 minute unit. 23 to less than 38 minutes is two units. And so on

6 Constant Attendance According to the AMA, Constant Attendance involves visual, verbal, and/or manual contact with patient during provision of the service. AMA CPT Assistant, July 2004.

7 Direct (One - on- One) Contact Direct one-on-one contact by the physician or other qualified health care professional Other Qualified Health Care Professional a licensed health care provider who performs professional services within their state scope of practice and independently reports those services. This does not include clinical staff, such as physician assistants, who perform services under the supervision of a physician or other qualified healthcare professional * *2017 ChiroCode DeskBook 25 th Edition Page 348

8 Constant Attendance Time includes all aspects of the service: pre- intra- and post Constant Attendance Timed Based Direct One-on-One contact No matter how many time based codes are administered, the total intra-service time is added to determine the units billable.

9 97014-EMS-Unattended Supervised: therefore NOT timed based and only need provider on premises (NOT One-on-One) Only billed once per day, per patient, per encounter, regardless of regions being treated or time Two disposable electrodes are included in the (RBRVS*) payment methodology *Resource Based Relative Value Scale

10 97014-EMS-Unattended Medicare, United Healthcare, Aetna, and other payers accept G0283 instead of Not appropriate for sale or rental of TENS units

11 97012 Traction, Mechanical Supervised: NOT timed based and only need provider on premises Only billed once per day, per patient, per encounter, regardless of regions being treated or time Some payers specifically exclude roller tables from reimbursement, e.g. BCBSKS Computerized Vertebral Axial Decompression - report S9090 or unless payer policy requires Flexion/Distraction CMT technique should not report 97012

12 97032-EMS-Manual-Attended Constant Attendance: therefore it IS timed based* One-on-One 52 Modifier (Reduced Service) is not appropriate Regardless of regions being treated, units are based on time Manual Component required typically a wand that delivers the E-Stim A skilled therapist is required and should be documented. *2015 ACA - Timed Codes: Constant Attendance Modalities and Therapeutic Procedures

13 Therapeutic Procedures to A manner of affecting change through the application of clinical skills and/or services that attempt to improve function Direct One-on-One contact by the provider or other qualified healthcare professional. Regardless of regions being treated, the units are based on time

14 97140-Manual Therapy Therapeutic Procedure: Time based and One-on-One Includes: mobilization, manual lymphatic drainage, manual traction, myofascial release, trigger point therapy Regardless of regions being treated, the units are time based Performing in lieu of CMT requires specific documentation for rationale Not interchangeable with or (and of course the CMT codes) Manual Therapy is not billable if CMT is performed on the same anatomical region.

15 CPT Coding Assistant - November 2016 page 9 Frequently Asked Questions: Medicine: Physical Medicine and Rehabilitation Question: Is it appropriate to report code 97140, Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes, with modifier 59, Distinct Procedural Service, appended for a separate procedure such as myofascial release, when performed by the same provider at the same session with chiropractic manipulative treatment (CMT), where both procedures are performed to the same spinal region? Answer: No, modifier 59 indicates that the procedure was provided to a separate anatomical body region. Given the similarity in the two procedures (CMT as compared to procedures described in code 97140), reporting of both procedures to the same body region is not appropriate. The rationale behind disallowing CMT and manual therapy techniques represented by code to be reported for the same anatomic site is due to overlap of preservice, intraservice, and postservice work that is inherent to both codes. The intraservice overlap occurs as the provider identifies the osseous, articular, and soft tissue restrictions. In addition, both procedures incorporate spinal and peripheral manual joint and soft tissue techniques. Under certain circumstances, it may be appropriate to additionally report CMT/OMT codes in addition to code if the procedures were performed on separate anatomical regions. In those cases, modifier 59 should be appended ( ) to indicate that a distinct procedural service was provided. Emphasis Added

16 CPT Coding Assistant September 2016 page 9 Frequently Asked Questions Question: Instrument-assisted soft tissue mobilization (IASTM) uses a hard-edged instrument made of metal, plastic, or ceramic to add shearing stress to soft tissue, in order to enhance the body's healing response. Is it appropriate to report CPT code for this service? Answer: Yes, it is appropriate to report code 97140, Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes, for this service, as the tools used to deliver these techniques are held in the hand, and the technique requires that the provider have consistent manual contact with the tool in order to get the desired effect in the targeted soft tissues. Emphasis Added

17 CPT Coding Assistant - February 1999 page 10 Medicine Therapeutic Procedures, (Q&A) Question Can my doctor report the new CPT code for manual therapy techniques, when he performs a chiropractic manipulative treatment (CMT), or has this code been developed for use by physical therapists and occupational therapists only? AMA Comment Code Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes, does not describe chiropractic manipulative treatment. Chiropractic manipulation (CMT) is described by codes From a CPT coding perspective, in certain circumstances it may be appropriate to report CMT or osteopathic manipulative treatment (OMT) procedures and CPT code For example, if separate body regions are being addressed by different techniques, then it is appropriate to report these services separately. For example, a patient has severe injuries (such as an auto accident) with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques (as described by CPT code 97140) to the neck region and CMT to the lumbar region. In this case, it would be appropriate to report CPT codes and In this example the -59 modifier would be used to indicate that a distinct procedural service was provided. Emphasis Added

18 97112-Neuromuscular Re-education Therapeutic Procedure: Time based and One-on-One neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Regardless of regions being treated, the units are based on time Clinical Rationale and metrics for progress should be documented Not interchangeable with or Examples include, Proprioceptive Neuromuscular Facilitation (PNF), Feldenkreis, Bobath, BAP s Boards and desensitization techniques.

19 97110-Therapeutic Exercises Therapeutic Procedure: Time based and One-on-One Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Regardless of regions being treated, the units are based on time Clinical Rationale and metrics for progress should be documented Not interchangeable with or Examples include, Therapy Balls, Therapy Bands, Weights, etc

20 CPT Coding Assistant - June 2016 page 9 Frequently Asked Questions: Medicine: Physical Medicine and Rehabilitation Question: A provider uses a chair that provides heat, massage, and traction all at the same time. Is it appropriate to report all of the following codes for this service: 97012, Application of a modality to 1 or more areas; traction, mechanical, for mechanical traction; code 97110, Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility, for massage as a therapeutic procedure; and code 97010, Application of a modality to 1 or more areas; hot or cold packs, for heat therapy? If not, what is the most appropriate code to use to report this service? Answer: A qualified health care professional (QHP) who provides an intervention that includes the use of a piece of equipment that has the effect of providing heat, traction, and some mechanical massage performed in an unattended manner, should report code 97039, Unlisted modality (specify type and time if constant attendance), as the QHP does not have any contact with the patient other than setting the patient up with the equipment and taking them off (or out of) the chair. To clarify, therapeutic massage code 97124, Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion), is a direct, one-on-one procedure and would not be considered direct one-on-one therapeutic exercise for strength, range of motion, flexibility, and endurance, which is represented by code When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (e.g., procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure; well as the time, effort, and equipment necessary to provide the service. Emphasis Added

21 CMT (Chiropractic Manipulative Therapy) 5 Spinal Regions: 1. Cervical Region (including atlanto-occipital) 2. Thoracic Region (including costovertebral & costotransverse) 3. Lumbar Region 4. Pelvic Region (including sacro-iliac) 5. Sacral Region Region CMT Region CMT Region CMT

22 98943 CMT Extraspinal 1+ Regions Extraspinal regions: Head (including temporomandibular joint, excluding atlanto-occipital) Lower extremities (hip, leg, knee, ankle, and foot) Upper extremities (shoulder, arm, elbow, wrist, and hand) Rib cage (excluding costotransverse and costovertebral joints) Abdomen

23 98943 CMT Extraspinal 1+ Regions When treating Extra-Spinal regions: 1. Extremity complaint as a Chief Complaint(s). 2. Extremity findings are detailed in examination. 3. Extremity Diagnosis rendered as a result of 1 and Treatment should be directed toward resolving 1, 2 and 3. Technique Concerns: There are accepted chiropractic techniques that, by protocol, commonly adjust extremities as a means of stabilizing the adjacent spinal structures and resolving spinal complaints without an actual extremity issue.

24 Common Modifiers Added to service codes Further define or describe the service rendered Delineate the service from another service being reported Report additional information relative to the service rendered You can compound modifiers when needed

25 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Added to exam codes when reporting CMT on same day

26 26 Professional Component Added to X-Ray codes to report the reading and radiology report of x-rays

27 TC Technical Component Added to X-Ray codes to report taking of x-rays TC TC TC

28 59 Distinct procedure or service Added to CPT when reported with CMT same day when services performed on separate anatomical sites

29 X Set Modifiers XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service XS

30 32 Mandatory Service Added to NEW Patient Exams under Massachusetts Workers Compensation Claims

31 AT Acute Treatment Added to CMT for Medicare and Medicare replacement plan claims that fall under the LCD definition of Active Care AT

32 GA Waiver on file Added to CMT for Medicare claims that fall under the LCD definition of maintenance when an Advanced Beneficiary Notice was signed by the patient GA

33 GY item or service is statutorily excluded or does not meet the definition of any Medicare benefit Added to all service does except the CMT for Medicare claims as all services except the Chiropractic Adjustment are not covered under the Medicare Program when rendered by a chiropractor GY AT GY

34 GP Physical Therapy under a plan of care Added to all modality & therapy services when reporting to certain insurance carriers. In Massachusetts chiropractic services cannot be advertised with the terms Physiotherapy or Physical Therapy. Other States can use the terms in a chiropractic setting. GP used for reporting purposed with carriers such as Cigna GP

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36 Please scan OUT as you leave If you are staying in this classroom for the next session you must have your badge scanned OUT for this session and scanned IN for the next session Thank you! Mark & Paul

37 Disclaimer TOP Education & the instructors acting on behalf of TOP Education are here this weekend to educate. They are not representatives nor speak on the behalf of any Insurance Company. Any discussion of a specific Insurance Company is for examples purposes only. All carrier specific policy or procedure questions should be directed to that carrier