dial-in instructions · to all settings v. understand recent oig audits concerning the misuse of...

Conference Name: An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes

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An Encore Presentation - Codingand Billing for Rehab Services:avoiding the pitfalls of the 2006

codes

1:00 p.m.–2:45 p.m (Eastern)

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presents . . .

A 105-minute interactive audioconference

Wednesday, March 29, 2006

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Dear colleague,

Thank you for participating in our “An Encore Presentation - Codingand Billing for Rehab Services: avoiding the pitfalls of the 2006codes” audioconference with Rick Gawenda, PT, and Ken Mailly, PT,moderated by Kevin Moschella. We are excited about the opportunity tointeract with you directly and encourage you to take advantage of theopportunity to ask our experts your questions during the audioconference.If you would like to submit a question before the audioconference, pleasesend it to [email protected] and provide the program date in the sub-ject line. We cannot guarantee your question will be answered during theprogram, 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 wemight improve our audioconferences, or if you have any questions aboutthe audioconference itself, please do not hesitate to contact me. And if youwould like any additional information about other products and services,please contact our Customer Service Department at 800/650-6787.

Along with these audioconference materials, we have enclosed a fax eval-uation. We value your opinion. After the audioconference, please take aminute to complete the evaluation to let us know what you think.

Thanks again for working with us.

Best regards,

Shannon TierneyAudioconference coordinatorFax: 781/639-2982E-mail: [email protected]

200 Hoods LaneP.O. Box 1168

Marblehead, MA 01945Tel: 800/650-6787Fax: 800/639-8511


Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi

Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

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

Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41CCI Edits

Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44Codes Frequently cited as “Problematic” by Payers

Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47Claims Review Checklist

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Contents


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


Speaker profiles

Kevin Moschella, moderator

Kevin Moschella is an editorial assistant at HCPro, Inc. He writes about issues of safety, security, infectioncontrol, rehabilitation, and finance.

Rick Gawenda, PT

Rick Gawenda graduated in 1991 with a Bachelor of Science in physical therapy from Wayne StateUniversity in Detroit. Gawenda is currently director of physical medicine and rehabilitation at Detroit ReceivingHospital and owner of Gawenda Seminars. He has worked in all areas of therapy within the hospital settingand worked in home healthcare for five years. He has provided valuable education and consulting to bothhospitals and his peers in the area of coding, billing, documentation, reimbursement, and the appealsprocess for Medicare denied claims. Gawenda’s Web site, www.gawendaseminars.com, provides a valuablesource 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 onOutpatient Rehab Reimbursement and Regulations. He is a member of the American College ofHealthcare Executives, American Physical Therapy Association (APTA), Michigan Physical TherapyAssociation (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 UnitedGovernment 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 Reimbursementand Regulations and Eli’s Rehab Report on various topics, such as advance beneficiary notices, Medicarecertification/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 completinghis master’s in public administration at Seton Hall University. For over 10 years, he has focused on issuesrelated to healthcare policy and management.

In addition to his graduate studies, with well over 2,000 hours of continuing physical therapy education, Maillyhas amassed an extremely diverse and extensive knowledge of the clinical practice of physical therapy. Hisprimary clinical focus is on management of patients with bleeding and chronic soft-tissue disorders, and he iscertified as an ergonomic specialist.


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 ofboth plaintiffs and defendants in numerous malpractice cases. He has also been consulted on state and fed-eral 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 fre-quent contributor and consultant for Advance, Eli’s Rehab Report, Briefings on Outpatient Regulation andReimbursement, and Non-Physician Practitioner News. He has also been published in The OrthopedicClinics 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. Hehas served APTA in various capacities, including delegate, professional affairs representative, and director ofgovernment relations. He has also served on the direct-access task force for APTA and serves, along withpartner Barry Inglett, as a member consultant on coding initiatives and as a member of the APTA consultingservice.

Mailly was also recently appointed to the Empire Medicare Services Provider Communications AdvisoryGroup (PCOM) as a representative of physical therapists. He has presented during many state and nationalmeetings and was the recipient of several professional awards, including being a two-time awardee of theAPTA of NJ President’s Award. He is a member of the health policy and administration and private practicesections of APTA.

Mailly’s focus in the activities of M&I Consulting is on compliance with professional standards, state and fed-eral regulations, and management strategies.


Exhibit A

Presentation by Rick Gawenda, PT, and Ken Mailly, PT

1

EXHIBIT A

2 Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes

1

Coding & Billing for RehabServices: Avoiding the Pitfallsof the 2006 Codes

Presented by:Rick Gawenda, PT

&Ken Mailly, PT

2

Objectives

� Identify new, deleted, and revised CPTcodes for 2006

� Identify problem CPT codes

� Define group therapy in various settings

An Encore Presentation - Coding and Billing for Rehab Services: avoiding the pitfalls of the 2006 codes 2

3Coding and Billing for Rehab Services: Avoiding the pitfalls of the 2006 codes

EXHIBIT A

3

Objectives

� Define, identify, and understand CCIedits

� Define, identify, and understand when itis appropriate to use modifier-59 bytherapists

� Be able to charge correctly for theservices you provide – UnderstandingMedicare�s “8” minute rule

4

CPT

A Closer Look


EXHIBIT A


5

Who can use them?

� Anyone whose legal scope of practice(qualified) permits the performance ofthe procedure described by the code.

� There are no PT, OT or SLP codes perse.

� Modifiers are used to describe whoperformed service� GN, GO, GP

6

Physical Medicine &

Rehabilitation

97000 Level I Series CPT Codes



EXHIBIT A

7

Types of CPT Codes

� Time – Based codes

� Service – Based codes

8

Time Based Codes

� Requires direct one on one time spentwith patient

� Contact is 15-120 minutes in length

� Can bill multiple units of the same timebased CPT code on the same day perdiscipline per patient


EXHIBIT A


9

Service Based Codes

� Does not require direct one on onetime with the patient

� Are un-timed

� Can only bill one unit of each service-based code daily per discipline perpatient

10

Pre-Test #1CVA Patient

� 20 Minutes L/E strengthening exercises

� 20 Minutes NDT techniques to improve dynamic sitting and static standing balance



EXHIBIT A

11

Evaluations –Service Based

97001 Physical Therapy Evaluation

97002 Physical Therapy Re-Evaluation

97003 Occupational Therapy Evaluation

97004 Occupational Therapy Re-Evaluation

97005 Athletic Training Evaluation

97006 Athletic Training Re-Evaluation

12

Supervised Modalities

� The application of a modality that doesnot require direct (one on one) patientcontact by provider.

� Un-timed (service-based)

� Once per session (date of service) perdiscipline per patient

� Includes CPT codes 97010-97028


EXHIBIT A


13

Constant Attendance

� The application of a modality thatrequires direct (one on one) patientcontact by the provider

� Are time-based codes

� Can bill multiple units of these CPTcodes to the same patient on the sameday

� Includes CPT codes 97032-97039

14

Constant AttendanceModalities

97032 The application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes

97033 Iontophoresis, each 15 minutes

97034 Contrast bath, each 15 minutes

97035 Ultrasound, each 15 minutes

97036 Hubbard tank, each 15 minutes

97039 Unlisted modality (specify type and time if constant attendance)



EXHIBIT A

15

G0283 or 97014 versus 97032

� Documentation in the patient�s medical recordmust clearly show that manual electricalstimulation was provided

� Types of manual electrical stimulation includehand-held units and ultrasound/electricalstimulation combination treatments

� Constant attendance may also involve visualand/or verbal contact with the patient duringprovision of the services (CPT Assistant July2004)

16

Unlisted Modality - 97039

� May be supervised or constantattendance

� Must specify type and time if constantattendance

� Types of modalities billed using thiscode may include anodyne, light, laser,ice massage, and fluidotherapy if notbilled under 97022


EXHIBIT A


17

Pre-Test #2Low Back Patient

� 15 Minutes Joint mobilizations and soft tissue mobilization

� 17 Minutes Stretching and strengthening ex�s

� 6 Minutes Ultrasound to low back

18

Therapeutic Procedures

� A manner of effecting change through theapplication of clinical skills and/or servicesthat attempt to improve function.

� Therapist or therapist assistant required tohave direct (one on one) patient contact.

� Therapist or therapist assistant must need tobe one-on-one with the patient

� Includes CPT codes 97110-97140 and97530-97762



EXHIBIT A

19

Exercise v. Activity

� Exercise: patient performing somethingthat they would not normally perform ineveryday life (CPT code 97110)

� Activity: patient IS performingsomething that they may be doingeveryday, but with therapeutic intent(CPT Code 97530)

20

Critical points!

� Coding is as much about the intent ofthe activity, as it is the activity itself.

� e.g.: Electrical Stimulation

� BAPS


EXHIBIT A


21

The Biggie!!!

97150

22

97150

� Therapeutic procedure(s), group (2 ormore individuals)

� Group therapy procedures involve constantattendance of the therapist or therapistassistant, but by definition do not requireone-on-one patient contact by the provider.

� This code is un-timed. May only bill oneunit per patient per discipline regardless ofthe amount of time the patient participatedin the group



EXHIBIT A

23

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 totalminutes in a week per discipline may be in a group

� Transmittal 1872, January 24, 2003http://www.cms.hhs.gov/Transmittals/Downloads/R1872A3.pdf

� Federal Register SNF Final Rule, July 30, 1999

� http://www.cms.hhs.gov/TherapyServices/

24

Group Therapy orOne-on-One

� What are the patients doing, but moreimportantly…

� What is the therapist or therapist assistantdoing!

� Is the therapist or assistant in constantattendance with both patients or are theygoing back and forth between the patientsspending one-on-one time with each patientin small increments


EXHIBIT A


25

SNF Part A SettingConcurrent Therapy

� Treating 2 or more patients during the same timeperiod

� 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 theroom, supervising the entire treatment process

� Minutes for set up and preparing the patient fortreatment may be counted

� http://www.cms.hhs.gov/SNFPPS/Downloads/sbmanual112005-RUG53.pdf

� Page 3-72 to 3-76

26

Concurrent TherapyCase Example

� PT has Patient A beginning therapy at 9:00AMon a specific task

� PT has Patient B beginning therapy at 9:15AMon a specific task different than Patient A

� Treatment ends for each patient 30 minutesafter it began.

� PT is present the entire time with both patients

� Each patient receives 30 minutes of one-on-one time on the MDS for that date of service



EXHIBIT A

27

SNF Part A or Part BGroup Case Scenario

� SLP has 2 patients beginning therapy at9:00AM and lasts until 9:45AM

� Both patients work on activities to strengthenthe tongue to move the bolus to the back ofthe mouth for swallowing for 25 minutes then

� Work on lip strengthening exercises to keepthe food in the mouth for 20 minutes

� Both patients would receive 45 minutes billedas group treatment on the MDS for that dateof service or 1 unit 92508 if an outpatient

28

Wheelchair Management

� CPT code 97542

� Now includes assessment, fitting, and training

� Assessment includes, but is not limited to,determination of the patient�s need for a WCand type of WC required, patient�s strengthand ROM, endurance, skin integrity, sittingbalance, transfer ability, etc., measurements,and testing the patient�s ability with variouschair functions.

� Acknowledges “custom seating”.

� CPT Changes 2006-An Insiders View


EXHIBIT A


29

Orthotic Management &Prosthetic Management

� New heading added to the Medicinesection of the CPT manual in 2006

� New heading includes CPT codes97760 (formerly 97504), 97761(formerly 97520), and 97762 (formerly97703)

30


� CPT code 97760 Orthotic(s) managementand training (including assessment and fittingwhen not otherwise reported), upperextremity(s), lower extremity(s) and/or trunk,each 15 minutes

� This CPT code allows for reporting theassessment and management of a patientrequiring a pre-fabricated or customfabricated orthotic



EXHIBIT A

31


� 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

32


� If you bill an “L” code for the pre-fabricated orcustom fabricated orthotic, you may only billthe appropriate number of units of 97760 forthe orthotic training based on the number ofminutes spent providing the training

� The “L” code reimbursement includes theassessment, fabrication time, and fitting

� CPT Assistant December 2005


EXHIBIT A


33

97760 versus 97762

� 97760 used for the assessment,fabrication, fitting, and training of anorthotic

� 97762 used when adjustments need tomade to an orthotic, orthotic needs tobe modified or re-issued, etc.

34

New CPT Codes for 2006

98960 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



EXHIBIT A

35


98961 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

36


98962 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


EXHIBIT A


37

Education & Training Codes

98960 - 98962

� CMS not reimbursing for these CPT codesin 2006

� Does not necessarily affect PT, OT, or SLPservices, in fact we are really not expectedto be using these codes

� Whatever we are training the patient and/orcaregiver in, those minutes areincluded/counted under the CPT code thatbest describes our treatment/intention

38

Pre-Test #3Speech

� 30 minutes strengthening exercises toimprove voice communication

� 15 minutes oromotor exercises toimprove patients swallow

� 15 minutes teaching the patient andtheir spouse in compensatoryswallowing strategies



EXHIBIT A

39

Evaluations –Service Based

92506 Evaluation of speech, language, voice, communication, and/or auditory processing

92610 Evaluation of oral and pharyngeal swallowing function

92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording

40

Speech Therapy Services

92507 Treatment of speech, language,voice,communication, and/or auditoryprocessing disorder; individual

92508 Group, two or more individuals

92526 Treatment of swallowingdysfunction and/or oral functionfor feeding


EXHIBIT A


41

Speech TherapyCPT Codes Not To Be Used

� 97110 Therapeutic exercise

� 97112 Neuromuscular re-education

� CMS announced this during a SNFopen door forum

� ASHA issued this announcement inNovember 2004

42

Speech Central NervousSystem Assessments/Tests

96105 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



EXHIBIT A

43

Speech Therapy Services

92526 Treatment of swallowing dysfunction and/or oral function for feeding

44

New Codes for SLP Services

92626 Evaluation of auditory rehabilitation status; 1 hour

92627 Evaluation of auditory rehabilitation status; each additional 15 minutes (list separately in addition to code for primary procedure


EXHIBIT A


45

New Codes for SLP Services

92630 Auditory rehabilitation; pre-lingual hearing loss

92633 Auditory rehabilitation; post- lingual hearing loss

CMS not reimbursing for these CPT codes. IfSLP provides these services, the minutes arebilled under 92507. These services are notreimbursed if provided by an audiologist asMedicare only covers audiology services thatare diagnostic in nature, not treatment.

46

National Correct Coding Initiative

(NCCI) CCI Edits

� The Centers for Medicare and Medicaid Services(CMS) developed the National Correct CodingInitiative to promote national correct codingmethodologies and to eliminate improper coding.

� CCI edits are developed based on codingconventions defined in the American MedicalAssociation's Current Procedural Terminology (CPT)Manual, current standards of medical and surgicalcoding practice, input from specialty societies, andanalysis of current coding practice.



EXHIBIT A

47

National Correct CodingInitiatives (NCCI)

� Initiated in 1996 to the private practice setting

� Expanded to hospital outpatient departmentsin August 2000

� Expanded to SNF Part B, CORF�s, RehabAgencies, and Home Health Agencies notunder a Home Health Plan of Care onJanuary 1, 2006

� Current version is 12.0 for private practiceand physician owned therapy clinics and 11.3for all other settings

48

Modifiers

� In certain circumstances, specific CCIedits will be bypassed if requiredmodifiers are present.

� The most commonly used modifiertherapists utilize is modifier-59.


EXHIBIT A


49

Modifier - 59

� Distinct Procedural Service

� Indicates that a procedure or service was distinct orindependent from other services performed on thesame day

� Used to identify procedures/services that are notnormally reported together, but are appropriate underthe circumstances

� Documentation must support use of modifier – 59 inthat the procedures/services were provided atseparate and distinct times, were medically necessaryand required the skills of a therapist or therapistassistant under the supervision of a therapist

50

Modifier-59 DocumentationExample

� 9:00AM-9:30AM, aquatic therapy of(list what was provided), 9:45AM-10:10AM, land-based exercises of (listwhat was provided)

� Aquatic therapy of (list what wasprovided) followed by land-basedexercise of (list what was provided)



EXHIBIT A

51

CCI Edits

2 types of edits

1.) Mutually exclusive codes

2.) Column 1/Column 2 codes

52

Mutually Exclusive Codes

� Codes that cannot be billed together because theywould not normally be performed together

� Speech group (92508) and speech therapytreatment (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)


EXHIBIT A


53

Column 1/Column 2 Codes

� Codes in which one of the codes isconsidered a component of a morecomprehensive code on the bill

� Aquatic therapy (97113) and therapeuticexercise (97110)

� Therapeutic activities (97530) and gaittraining (97116)

� Therapeutic exercise (97110) and PT re-eval(97002) or OT re-eval (97004)

54

Column 1/Column 2 Codes

� Swallowing treatment (92526) and therapeuticexercise (97110)

� Swallowing treatment (92526) and cognitivetherapy (97532)

� Swallowing treatment (92526) and Neuro re-education (97112)

� Swallowing treatment (92526) and therapeuticactivities (97530)

� Swallowing treatment (92526) and unattendede-stim (G0283) or manual e-stim (97032)



EXHIBIT A

55

CCI Edits

� Are applicable to one specific disciplineof therapy billing different procedures onthe same day that require modifier-59

� Are applicable when multiple disciplinesof therapy occur to the same beneficiaryon the same day billing procedures thatrequire modifier-59

56

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 oftherapeutic activities (97530) and 30 minutesof Neuro Re-ed (97112) on 09/05/03


EXHIBIT A


57

CCI Edit Example

� By discipline, none of the procedures requiremodifier-59 to be reimbursed

� Since this patient was seen on the same dayby more than one discipline, need to checkbetween all disciplines (cross-check) as theneed for modifier-59 does apply

� CMS billing system does not recognizetherapy specific modifiers (GN, GO, GP)

58

CCI Edit Example

� Would need to append modifier-59 to 97110,97112, 97116, and 97530

� Documentation would need to support thatthe services were performed at separate anddistinct times

� Not appending modifier-59 in this examplewould cost you approximately $240 in lostreimbursement



EXHIBIT A

59

CCI Updates

� Updated quarterly

� www.gawendaseminars.com

� http://www.cms.hhs.gov/NationalCorrectCodInitEd/

� Private practice and physician owned therapyclinics, click on NCCI Edits – physicians. Allother settings, click on NCCI Edits - Hospital

60

“8 Minute Rule”

� Applies to direct contact CPT codes only

� For any single CPT code, providers bill theappropriate number of units based on the timeintervals on the next slide

� If more than one CPT code is billed on acalendar day, then the total number of units thatcan be billed is constrained by the total treatmenttime. Do not count minutes of service-based CPTcodes

� Schedule on the next slide does not imply thatany minute until the eighth should be excludedfrom the total count


EXHIBIT A


61

“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 < 113 7 units

�113 to < 128 8 units

62

“8” Minute Reference

� Medicare Claims Processing Manual,Chapter 5 – Part B Outpatient Rehabilitationand CORF Services, Section 20.2 and 20.3

http://www.cms.hhs.gov/manuals/downloads/clm104c05.pdf



EXHIBIT A

63

Pre-Test #1CVA Patient

� 20 Minutes L/E strengthening exercises

� 20 Minutes NDT techniques to improve dynamic sitting and static standing balance

64

Post-Test #1


EXHIBIT A


65

Pre-Test #2Low Back Patient

� 15 Minutes Joint mobilizations and soft tissue mobilization

� 17 Minutes Stretching and strengthening ex�s

� 6 Minutes Ultrasound to low back

66

Post-Test #2



EXHIBIT A

67

Pre-Test #3Speech

� 30 minutes strengthening exercises toimprove voice communication

� 15 minutes oromotor exercises toimprove patients swallow

� 15 minutes teaching the patient andtheir spouse in compensatoryswallowing strategies

68

Post-Test #3Speech


EXHIBIT A


69

References

��American Medical AssociationCurrent Procedural Terminology; CPT2006; Standard Edition

��Ingenix St. Anthony Publishing/MedicodeCoding and Payment Guide for the PhysicalTherapist; 2006, 11th Edition

��Ingenix St. Anthony Publishing/Medicode

ICD-9-CM Expert for Hospitals-Volumes 1,2,& 3. 2005. 6th Edition

70

Essential References

� CPT-2005/6

� https://webstore.ama-assn.org/index.jhtml

� cpt Assistant

� CCI

� http://www.cms.hhs.gov/NationalCorrectCodInitEd/

� APTA, AOTA, ASHA

� CMS Therapy Resources

� http://www.cms.hhs.gov/TherapyServices/



EXHIBIT A

71

References for BillingInternet-Only Manuals

� www.cms.hhs.gov/Manuals

� Click on Internet-Only Manuals

� Click on Pub 100-4Medicare Claims Processing Manual

� Choose the appropriate chapterdepending on your setting

72

Billing References

� Chapter 5, Part B OutpatientRehabilitation and CORF Services

� Chapter 6, SNF Inpatient Part A

� Chapter 7, SNF Part B

� Chapter 10, Home Health Agency


EXHIBIT A


73

� Ken Mailly, PT� Barry Inglett, PT, Cert MDT

68 Seneca Trail, Wayne, NJ, 07470Tel: 973 692-0033Fax: 973 633-9557www.NJPTAid.biz

74

Mailly & Inglett Consulting

The mission of M&I is to promote andassist in the fair and equitablereimbursement for legitimate physicaltherapy services. In order to fulfill thismission, we have identified two majorgoals for both providers and payersrespectively:



EXHIBIT A

75

Mailly & Inglett Consulting

1. Assist PTs and PTAs in improving theeffectiveness and efficiency of their practice,regardless of setting, in a compliant manner.

2. Assist payers in recognizing andreimbursing for appropriate and legitimatecare, while reducing improper payments andimproper denials

76

Rick Gawenda, P.T.

� [email protected]

� [email protected]

� www.gawendaseminars.com

� (313) 745-3533

� (734) 717-1101


EXHIBIT A


77

Gawenda Seminars

� CPT and ICD-9 Coding

� Rehabilitation Documentation

� Medicare Appeals Process

� Consultation in the above

78


Exhibit B

CCI Edits

Source: Rick Gawenda, PT. Reprinted with permission.

EXHIBIT B


Exhibit C

Codes Frequently cited as “Problematic” by Payers

Source: Ken Mailly, PT. Reprinted with permission.

EXHIBIT C

Codes Frequently cited as “Problematic” by Payers

95851: Range of motion measurements and report (separate procedure); each extremity (excludinghand) 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 howmotion may be changing in a joint over time. This is most often necessary in the presence ofautoimmune diseases, such as RA, Lupus, or conditions such as OA. Such testing and reportingwould be done very infrequently (such as monthly) and would include a report of each involved jointin an extremity. It would be inappropriate to do such testing in the vast majority of musculoskeletalconditions, where the focus of treatment would be on function rather than range of motion, and anyimpairment of joint ROM are secondary and temporary concerns. Furthermore, the billing of 95851in such musculoskeletal cases may be an unbundling of the re-evaluation covered by 97002.

97112: Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation ofmovement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/orstanding 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 nervesupply to peripheral musculature; strengthening alone may be ineffective is addressing a patient'sfunctional limitations and physical impairment. This code would be commonly used in patients whomay have suffered a stroke, vestibular disorders, peripheral nerve injury, and other neurological con-ditions. It could also be justified by the presence of severe joint effusion causing reflex muscle inhi-bition, or in cases of severe joint sprain or other capsular damage causing proprioceptive impair-ments. 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 coveredwithin their legal scope of practice.

97530: Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamicactivities to improve functional performance), each 15 minutes

• Clarify the difference between this & 97110.

The critical piece in this code is the focus on “dynamic activities” and “functional performance”. Thiscode would require that the patient is actually doing something that they could conceivably do ineveryday life. Examples might be stepping up or down a curb, rising or sitting, lifting or pulling; witha focus on improving performance of these activities. The main focus of such activities might be toincrease patient safety, or reducing the energy or effort required to perform them by improving the


EXHIBIT C


quality of their movement. If the activities are being simply to improve the strength of the musclesor motion of the joints involved in performing the activity, 97110 would be more appropriate.

97535: Self-care/home management training (e.g., activities of daily living (ADL) and compensatorytraining, meal preparation, safety procedures, and instructions in use of assistive technologydevices/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 appro-priately used to teach, and check proper understanding of what has been taught. The documenta-tion would obviously also have to include the activity requiring training. Such education would typi-cally occur no more than 3-4 times, per episode of care. This frequency would obviously varydepending upon the total length of the episode, and the amount of change in clinical status that apatient may experience.

97026: infrared

• When would this normally be billed?

This supervised modality, classified as a heating modality, and would not normally be combined withother heating modalities in the same session. It is probably most often associated with treatment ofintegumentary diseases and disorders. Some payers may note increased utilization of this code inrecent 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 as97026, but 97039, unlisted modality.


Exhibit D

Claims Review Checklist

Source: Ken Mailly, PT. Reprinted with permission.

EXHIBIT D


Claims Review Checklist

I General1. 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 Review1. 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 Modalities1. 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 Credentials1. 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?


Resources


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-and-

answer section that will test your therapists’ coding knowledge, and make certain that they aredocumenting 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 appealsand 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.

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RESOURCES

Speaker resourcesRick Gawenda, PTDirector, physical medicine and rehabilitationDetroit Receiving Hospital4201 St. Antoine BlvdDetroit, MI 48201Phone: 313/745-3533Fax: 313/966-7664E-mail: [email protected]

Ken Mailly, PTMailly & Inglett Consulting, LLC68 Seneca TrailWayne, NJ 07470Phone: 973/692-0033Fax: 973/633-9557E-mail: [email protected] site: www.NJPTAid.biz

HCPro sites

HCPro: www.hcpro.com

With more than 17 years of experience, HCPro, Inc., is a leading provider of integrated information, educa-tion, 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 thehealthcare industry and to learn from and respond to our customers with services that meet or exceed thequality they expect.

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‚ 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 e-mailnewsletters, check out our in-depth how-to information in our premium newsletters, and get advice from ourknowledgeable experts.

The Greeley Company: www.greeley.com

Get connected with leading healthcare consultants and educators at The Greeley Company’s Web site. Thisonline service provides the fastest, most convenient, and most up-to-date information about our quality con-sulting, national-education offerings, and multimedia training products for healthcare leaders. Visitors will finda complete listing of our services that include consulting, seminars, and conferences.

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New!• Discharge Planning Summit• Core Privileging Advanced Course• Front-End Solutions Workshop• Physician Performance Profile Course

• Public Accountability for Quality• Case Management Institute

To register, call 800/801-6661 or visit www.greeley.com

Seminar Calendar

Spring

2006

9th Annual

Credentialing Resource Center

Symposium

May 17th & 20th

Pre- and Post- Conferences

Send a Team and Save!

Sears Tower, Chicago, IL

Viva Las Vegas!

Sunny Amelia Island, FL

Phoenix,

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April 6-7, 2006, The Ritz-Carlton Hotel, Phoenix, AZ

NEW! Case Management Institute: Managing by influence to maximize the effectiveness of your case management program

Through the institute’s step-by-step strategies, leaders can find solutions to problems related to excessive utilization andclinical resource costs, the enhancement of quality (while keepingexpenditures in check), and the improvement of communication/cooperation between case management, physician, and hospital leaders.

Early-Bird Discount: Register by February 2 to save $100!

April 6-7, 2006, The Ritz-Carlton Hotel, Phoenix, AZ

Effective JCAHO Survey Preparation for the Medical Staff

The JCAHO is seeking to re-engage physicians in a new, moredynamic survey process. Train your physicians and their teamson what to do when they disagree with the surveyor’s findings,the 2006 standards and patient safety goals, documentationchallenges, and much more.


April 7, 2006, The Westin Hotel, Michigan Avenue, Chicago, IL

NEW! Discharge Planning Summit

Decrease denials, maximize length of stay, and increase efficiency. Learn how to comply with significant federal regulations and use your discharge planning process to support the business side of healthcare. You’ll walk away from this summit with strategies to boost revenue without losing sight of the needs of the patient.

Register early for team discounts!

April 20–21, 2006, The Ritz-Carlton Golf Resort, Naples, FL

UPDATED! Medical Staff Quality: Practical strategies for effective peer review, physician performance feedback, and managing physician performance

Get concrete steps to make your medical staff quality programtruly effective. Learn how to encourage positive physician performance, create effective physician performance feedbackreports, solve the challenges of peer review, improve hospitalsystems, and address clinical performance problems.



Advanced Medical Staff Leadership Retreat: Where today’sleaders come to solve their toughest medical staff problems

Get an in-depth look at the six toughest challenges faced bymedical staff leaders today: ED coverage, disruptive physicianbehavior, physician/hospital collaboration and competition,matching proven competency with clinical privileges, physi-cian/physician and physician/hospital conflict, lack of effectivephysician leaders.



Surgical Team Summit: Bringing together chiefs of surgery, chiefs of anesthesia, and surgical services leadership to tackle the toughest OR challenges

Surgical teams can bring in some of the highest revenue foryour facility. However, stress-free, efficient operating-room (OR) management is difficult to attain. Improve revenue andreduce inefficiencies while getting practical strategies for ORmanagement, regulatory compliance, turf-battle resolution,credentialing, and patient flow.


Spring 2006 Seminar Calendar

MARCHMarch 3, 2006, MGM Grand Hotel, Las Vegas, NV

Rapid Response Team Retreat

Learn how to create Rapid Response Teams—dedicated staff that respond to an emergency before it occurs. This life-saving patient safetyinnovation—featured in the Wall Street Journal and part of The Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign—hasbeen adopted by facilities of all sizes to decrease mortality rates by reducing adverse events and codes in critically ill patients.


APRIL

To register, or for continuing education credit opportunities for these seminars, call 800/801-6661 or visit www.greeley.com.

©2006 The Greeley Company, a Division of HCPro, Inc. HCPro is not affiliated in any way with the Joint Commission onAccreditation of Healthcare Organizations, which owns the JCAHO trademark.


June 1–2, 2006, The Ritz-Carlton, Amelia Island, Amelia Island, FL

Medical Executive Committee Institute: The essential trainingprogram for all medical staff leaders

Gain skills never taught in medical school. Topics include how to solve MEC challenges (turf battles, disruptive physicians, ED coverage, impaired physicians, conflict of interest, medical recordscompletion, external peer reviews, fair hearings, physician apathy)and improve performance for medical staff leaders.

Early-Bird Discount: Register by March 30 to save $100!

Coming Soon (June date and location to be announced)

Public Accountability for Quality

Hospital and physician data is being measured and reportedpublicly with consequences for marketing, reimbursement andaccreditation. This program will teach hospital teams responsiblefor improving performance on publicly reported data how togather data, interpret data, train management on how to usedata, and much more.

Ask about additional discounts!

May 17, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV

NEW! Core Privileging Advanced Course: Design and implementation

Are you charged with the job of reviewing and recommending aredesign to core privileging? Where do you start, and how can youavoid the roadblocks that can hamper smooth implementation ofcore privileges? A pre-conference to the 9th Annual CredentialingResource Center Symposium, this full-day offering will takeparticipants through the key steps needed to design, modify, andimplement core privileges.


May 18–19, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV

UPDATED! The 9th Annual Credentialing Resource CenterSymposium

Learn practical and innovative approaches to solving your toughestcredentialing and medical staff challenges. For the past nine years,experts from The Greeley Company have offered medical staff andcredentialing professionals nationwide seminars on credentialinghot topics. Past topics have included low-volume/no-volumeproviders, core privileging, physician performance profiles, newtechnology, and much more.



UPDATED! Achieving Continuous Survey Readiness ThroughPatient Tracers: A practical 5-step model to compliance

On January 1, 2006, the unannounced survey process goes intoeffect. Prepare now with the 5-step model to continuous surveyreadiness, a look at JCAHO hot spots, what’s new for 2006.



Magnet Resource Center Advanced Workshop

Confused and overwhelmed by how to achieve Magnet status—the highest seal of nursing excellence? Then attendthis seminar to work one-on-one with the elite few nursingprofessionals who have already achieved Magnet status. These experts will outline clear action plans toward successfulcompletion of your Magnet application.



NEW! Front-End Solutions Workshop

Need help in improving your front end payment collections?Worried about the challenges of collecting high deductiblesand negotiating patient drug coverage that will change underMedicare Part D? Learn how to collect copays, respond to payment refusals, reduce bad debt, track results, and interactwith customers to help increase future business.


May 20, 2006, Mandalay Bay Resort & Casino, Las Vegas, NV

NEW! Physician Performance Profile Course: Quality data andcurrent competence

Understand the collection and use of quality data to improvephysician performance and appraise the ongoing competenceof your medical staff. Topics include the domains of physicianperformance, the use and application of rule, rate and reviewindicators, and gaining physician buy-in.


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200 Hoods Lane, P.O. Box 1168, Marblehead, MA 01945 • tel 800/801-6661 • fax 800/738-1533 • e-mail [email protected] • web www.greeley.com

Spring 2006 Seminar Calendar


dial-in instructions · to all settings v. understand recent oig audits concerning the misuse of...

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