Reporting PT Services (CPT codes and Medicare coding) – Flashcards

A universal alpha numeric language to describe our work Basis for the fee-for-service reimbursement model Developed and copyrighted by the American Medical Association (AMA) Codes are selected to describe the interventions that were provided

The provider is paid a pre-determined fee regardless of the time of treatment application or the number of body areas being treated. Each of these codes can only be billed once per treatment session. Medicare documentation standards require recording the time the patient was receiving that service even though it is not a timed code.

97001 Physical Therapy Evaluation 97002 Physical Therapy Re-evaluation 97003 Occupational Therapy Evaluation 97004 Occupational Therapy Evaluation 97012 Mechanical traction 95992 Canalith Repositioning

Based on the PROVIDER'S time spent one-on-one with the patient Time must be spent providing skilled services *Time includes pre-treatment, intra-treatment, and post-treatment minutes*

97032 Electrical stim (manual) 97035 Ultrasound 97110 Therapeutic exercise 97112 Neuromuscular re-education 97116 Gait training 97140 Manual therapy 97530 Therapeutic activities 97535 Self care/home management 97750 Physical performance test and measure

Time such as assessment and management, assessing patient progress, inspection of the tissue or body part, analyzing the results of previous treatment, asking the patient questions, and clinical judgment to establish the days treatment. This time begins with the *first professional interaction with the patient.*

Time spent providing the intervention

Time analyzing patient response to the intervention, education, counsel, advice, and professional communication with other providers and documentation so long as the *patient is present*.

A dynamic process in which the therapist makes clinical judgments based on data gathered during examination. Examination includes taking a comprehensive history, performing a systems review and conducting tests and measures. The PT will evaluate the examination findings, establish a physical therapy diagnosis, determine the prognosis, and develop a plan of care that includes anticipated goals and expected outcomes, interventions to be used, and anticipated discharge plans. These are UNTIMED codes

Anticipate implementation of 3 levels of evaluation codes Still will not be time based (completely) Based on patient complexity and intensity of clinical decision-making

The PT re-examinations the patient/client to evaluate progress and to modify or redirect interventions and/or revise anticipated goals and expected outcomes. Re-examination may be indicated more than once during an episode of care. The PT/OT will *significantly modify the established plan of care* as is indicated and support medical necessity of skilled intervention. These codes are UNTIMED codes

Significant change in patient presentation (adding a diagnosis, adjacent body part) An established POC is significantly modified in response to treatment or to something else Changes in long term goals Not justified at each visit (when re-examination and assessment occurs) Not justified at arbitrary intervals (ie. POC certifications) Not justified if on track

For modalities, pick the code that describes the service provided For procedures, pick the code that best describes the INTENT of your intervention Specific payment policy may dictate which code is used to report a given service

The clinician and/or patient performs therapeutic exercise to one or more body areas to develop *strength, range of motion, endurance, and flexibility*. This code requires direct contact and may be billed in 15-minute units (a timed code)

The clinician and/or patient perform activities to one or more body areas that facilitate *reeducation of movement, balance, coordination, kinesthetic sense, posture and proprioception*. This code requires direct contact and may be billed in 15-minute units (a timed code)

Balance training Stabilization exercise Posture training in sitting or standing using cues and/or supports Facilitation or inhibition techniques Taping (kinesio, McConnell) Desensitization Dexterity and manipulation skills Proprioceptive training (NDT, Feldenkrais, PNF) Plyometrics

The clinician trains the patient in specific activities that will facilitate ambulation and stair climbing with or without an assistive device. *Proper sequencing and safety instructions* are included when appropriate. This code requires direct contact and may be billed in 15-minute units (a timed code).

The clinician performs manual therapy techniques including *soft tissue and joint mobilization, manipulation, manual traction and/or manual lymphatic drainage to one or more areas*. This code requires direct contact with the patient and may be billed in 15-minute units (a timed code).

The clinician uses *dynamic therapeutic activities designed to achieve improved functional performance* This code requires direct contact and may be billed in 15-minute units (a timed code). The focus of this code is on *function* (not on strength, for example) This code is not about movement per se, but rather about functional movement, or movement with a purpose This code describes the therapist's activity that is one-on-one with the patient (must be present and interacting with the patient when the patient practices the movement) The service must be a "skilled" service

Swinging a golf club Getting in and out of a car Other transfers Shoveling snow Raking the leaves Lifting the baby out of the car seat Pushing the wheelbarrow Bending to lift from the floor Reaching overhead Throwing a ball

Includes *instruction and training in activities such as ADLs, compensatory training, meal preparation, safety procedures, and instructions in the use of adaptive equipment in the kitchen, bath, and/or car. (not an all inclusive list)* *Falls preventive* strategies around the house Edema control through positioning Signs of wound infection *Transfer training*: could also be Ther Activities Home PC set up and posture Medicare requires the modality code to be reported when instructing the patient in home use of the modality

The therapist performs a test of physical performance determining function of one or more body areas or measuring an aspect of physical performance (e.g., musculoskeletal, functional capacity). A written report is part of this service. This code requires direct contact and may be billed in 15-minute increments (a timed code).

Canalith Repositioning procedure(s) [eg, Epley maneuver, Semont maneuver], per day

Based on the PROVIDER'S time spent on skilled services Billed in timed increments (15, 30, 2 hrs) or units Medicare calculates time by summing up all of the minutes of timed codes and then determining the number of units that are billed MN calculates time on a per intervention basis

If more than one unit is reported on a calendar day, then the total number of units that can be billed is constrained by the total treatment time (i.e. 4 timed units in 1 hour) The sum of minutes provided for all timed services determines how many units can be billed. 1 Unit: >8min to 23min to 38 min to 53 min to <68 min

1. Total timed code minutes: the sum of all of the minutes relating to timed interventions 2. Total treatment time: in minutes (includes timed code minutes + minutes for untimed treatments)

Result of state healthcare reform bill in 2007 Statute 62J.536 Intent-uniformity in the claims submission process The guidance applies to all providers and all payers in MN with the following exception: "The requirements do NOT apply to the exchange of covered transactions with Medicare and other payers for Medicare products;"

"*Do not follow Medicare's rounding rules for speech, occupational, and physical therapy services. Each modality and unit(s) is reported separately by code definition. Do not combine codes to determine total time units*." Use the same grid as what you use in Medicare

Accurately code to describe your work. Coding is separate and different from clinical decision making and practice. Only apply necessary interventions to achieve best outcome (medical necessity). Documentation must support chosen code. Do not increase time you bill for therapy services or change your practice to increase your billing. Correctly apply Medicare Rules (federal plans) and MUCG Rules (non-federal plans) to timed-code treatment minutes.

Medicare Medicare Advantage Plans (MAPS) TriCare

Medical Assistance (MA) Worker's Comp Auto Commercial Health Plans (BCBS,HP, PreferredOne, Medica, Ucare)