Billing – Flashcard
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What are CPT codes for?
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Medicare Part B or per contracted rates with private insurers
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What do CPT codes identify?
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Procedures performed by healthcare professionals in order to bill for service - may be timed or service-based (untimed)
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How are CPT codes reimbursed?
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Using Medicare physician fee schedule (MPFS) or per contracted rates with private insurers
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What is the Healthcare Common Procedure Classification system (HCPCS)?
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Resource based relative value scale (RBRVS) to determine fees for each CPT code
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Describe a Level I CPT code.
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- 5 numbers corresponding to 6 sections based on type of service provided - Physical medicine: 97001-97799 - May use codes in other sections if rational and documentation support
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Describe a Level II CPT code.
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- Describes supplies, some procedures and DME - 1 letter A-V followed by 4 numbers (ex. L0510 = custom-fabricated flexible lumbosacral support)
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Who reviews the CPT codes?
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AMA reviews annually, published in Nov., and effective Jan. 1
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How is the nation value determined by the CMS?
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- based on relative cost of the resources required to provide those services - provides a relative value, which is adjusted by a Geographic Practice Cost Index to establish the allowed charge
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What is the code of patient education?
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There is no specific code, you would put it under that code that is corresponds to
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What code is therapeutic exercise and what does it include?
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97110 Therapeutic exercises to develop strength and endurance, range of motion, and flexibility (15 minutes)
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What code is manual therapy techniques and what does it include?
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- connective tissue massage - joint mobilization and manipulation - manual traction - pt education - measurements (15 minutes)
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What code is electrical stimulation (unattended)?
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97014
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What code is neuromuscular re-education and what does it include?
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97112 Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (15 minutes)
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What code is physical therapy evaluation?
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97001
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What code is physical therapy reevaluation?
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97002 **NOT A CHECK UP!!
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What code is therapeutic activity and what does it include?
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97530 - Dynamic activities to improve functional performance, direct (one-on-one) with the patient (15 minutes) - "-ing" (i.e. teaching gardening, proper landing) **get most reimbursement for this
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What code is ultrasound?
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97035
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What code is gait training?
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97116 (15 minutes) - Includes stair climbing
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What code is self-care/home management training and what does it include?
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97535 - activities of daily living [ADL] and compensatory training - meal preparation - safety procedures - instructions in use of assistive technology devices/adaptive equipment - direct one-on-one contact (15 minutes)
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What code is iontophoresis?
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97033 (15 minutes)
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What code is group therapeutic procedure (s)? (two or more individuals)
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97150
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Check to make sure I'm not missing any codes that needed to be learned!
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Stopped on pg.4
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What are the service based codes?
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97001 (PT eval) 97002 (PT re-eval) 97150 (2 or more individuals and constant attendance) 97597 (selective debridement) 97598 (selective debridement with a wound surface greater than or = to 20 sq. cm 97602 (non-select debridement) 95992 (Canalith repositioning/vestibular rehab)
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When is a PT re-eval reasonable and necessary?
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- Only if professional assessment indicates a significant improvement or decline that was not anticipated in POC, new clinical findings noted, or patient failed to respond to the treatment in POC - Is not a routine or recurring service - Need for progress report, physician note, or updated POC does not justify reevaluation
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Describe the parameters for group therapy for all payers.
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Not what the patient(s) is doing, it is what the therapist or assistant is doing with the patient
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Is supervised therapy group therapy?
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No (i.e. exercising on machines independently is not a skilled service and cannot be billed)
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Describe the parameters for group therapy for Medicare B patients.
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- Patients do not have to be performing the same activity - Provider must be in constant attendance - Direct 1-on-1 contact not required - No limit in number of patients unless specified in local coverage determination (usually 4, not just Medicare)
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Describe selective debridement.
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• Pulse lavage, sharp debridement, may include WP • Total wound surface area less than or = to 20 sq. cm (different code for larger areas) • Includes wound assessment and pt ed.
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Is non-select debridement paid by Medicare?
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No
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Describe nonselective debridement.
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• Not paid by Medicare • Blunt debridement, enzymatic debridement, wet-to-moist dressing, chemical or autolytic debridement
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How many minutes per unit are time-based codes?
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;8-22 minutes per unit
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What occurs during treatment time?
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- Time spent providing actual service - Not documentation time or extended rest periods, unless assessing pt's physiological status or response to procedure
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T/F. Medicare requires total number of timed minutes to be documented.
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True. Not specified, but suggested beginning and end time or time spent on each activity
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What modalities are considered time-based?
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97012 (mechanical traction) 97014- not valid with Medicare 97016 (vasopneumatic device) 97026 (infrared) 97018 (paraffin bath) 97022 (WP-includes fluidotherapy) 97024 (diathermy)
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Describe the supervised modalities.
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Modality is set-up and started by practitioner and patient supervised from a distance
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What does it mean that supervised modalities are a procedural code?
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You can only bill 1 unit per day, regardless of time on modality??????????
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What modalities are timed codes that require constant attendance?
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97032 (manual e-stim) 97033 (iontophoresis) 97035 (US) 97036 (Hubbard tank) 97039 (unlisted modality) 90911 (biofeedback) 97026/S8948 (low level laser)
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Describe the manual e-stim code.
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- E-stim/US comb - Costs of supplies bundled into charge
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What portion of iontophoresis is considered skilled?
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- Run time of modality is not skilled - Skilled part is assessment, setting up of parameters, and adjusting (i.e. 2-3 min) - Patch included in cost - Patient may pay for medication - In SD, Medicare not paying for so need advanced beneficiary notice because patient will have to pay for service
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What portion of US is considered skilled?
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- Pre and post assessment included - Phono under - Set up is not included
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What is covered for low level laser?
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Medicare doesn't recognize, but can get reimbursed if pt signs an advanced beneficiary notice - Costs of supplies bundled into charge
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Define therapeutic procedures.
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Application of clinical skills to effect change in a patient or service that attempts to increase function in a patient
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What should you document in regards to your intent of therapeutic procedures?
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- Show limitations (had loss of ROM, so perform ther ex- give measurements before and after treatment) - Any cueing? - Document response to treatment - Be careful with stating "pt performing HEP w/o difficulties" and then doing same ex in PT - Pain
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What should you document in regards to a patient's pain?
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- Describe the presence or absence of pain and its effect on the beneficiary's functional abilities - Submit a description of the intensity, type, changing pattern, and location at specific joint ROM - Describe the limitations of the patient's self-care, mobility, safety
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What codes are considered direct patient contact (one-on-one) and time based?
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97110 Ther ex (Strength or ROM) 97530 Transfer skills or lifting posture 97112 Neuro re-ed (Proprioceptive awareness) 97113 Aquatic therapy with there ex 97116 Gait training 97124 Massage 97140 Manual therapy 97530 Ther act 97535 Self-care and home management training 97542 WC management 97750 Physical performance test or measurement with written report 97760 Orthotic management and prosthetic management 97762 Checkout for orthotic/prosthetic use 97761 Prosthetic training
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Describe ther ex.
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Exercises for strength endurance (use term "activity tolerance limitations" instead), ROM, flexibility
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Describe neuro re-ed.
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- Reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities - Some payers limit what ICD-9 can use 112 - Some insurers, including Medicare, determine medical necessity by matching or linking ICD-9 diagnosis codes to CPT codes - Tests for balance not billed under
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What is an exception when billing for aquatic therapy with ther ex?
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If an insurance doesn't pay for 113 (aquatic therapy with ther ex), you can't bill under 110 (ther ex)
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What must occur in order to be able to bill for gait training?
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- Repetitive walking not billable unless document trying to change gait characteristics, used verbal cues, etc. - Includes stair climbing
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Describe massage.
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- Effleurage, petrissage, tapotement - "Feel good massage"
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Describe manual therapy.
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- Hands on PT - Mobilization, manual lymphatic drainage, manual traction, STM, MFR, serial compression bandaging, contract-relax
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What happens if the contract says you can't bill 140 (manual therapy)?
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Fraudulent to do manual therapy and bill under something else
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Describe ther activity.
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- Use of dynamic activities to improve functional performance - "ings" - lifting, rolling, ... - Also transfers, bed mobility, overhead activities, simulation of functional activities
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Describe self-care and home management training.
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- ADLs, meal preparation, safety procedures, instruction of use of adaptive equipment, household cleaning - Not same as home assessment - Not for HEP
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Describe WC management.
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- Fitting, assessment (including need for WC, type of WC, patient strength and ROM, endurance, skin integrity, balance, ability to perform chair functions, and need for custom equipment), training
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Will Medicare pay for a PT eval if just fitting for a WC?
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No
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Describe a physical performance test or measurement with written report.
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- Biodex, Tinetti, Berg, etc. - Includes time to analyze and interpret the results while the patient is present - Not time to write up report
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Can you do a physical performance test or measurement on the same day as an eval or re-eval?
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No
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Describe orthotic management and prosthetic management.
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- Includes assessing the patient (ROM, etc.), determining type of orthotic, designing/selecting/fabricating orthotic, orthotic fitting and training (wearing time, skin care, safety precautions, exercises with orthotic in place) - Doesn't include supplies - DME is not included???
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What is the max amount of treatment sessions that can be billed under orthotic management and prosthetic management?
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Usually 4 treatment sessions max
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What happens if you bill "L" code (pays better) for ?????
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Then cannot charge 97760 for the assessment, fabrication and fitting
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Describe the checkout for orthotic/prosthetic use.
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- For established patient who have already received the orthotic or prosthetic - Response to wearing device, whether DON/DOFF properly, need for padding, etc.
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Describe prosthetic training.
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- Preparation of stump, strengthening of musculature, modification of prosthetic fit using stump socks, mobility training, skin care, conditioning
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What is the appropriate billing code once a patient begins gait training with prosthesis?
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97116
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What does CCI stand for?
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Correct coding intitative
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What codes should you not bill in combination with 97002 (pt re-eval)? [n]
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97001n
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What codes must you use a modifier with if you bill for 97033 (Electrical current)? [y]
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97002y
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What codes must you use a modifier with if you bill for 97035 (US)? [y]
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97002y
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What codes must you use a modifier with if you bill for 97110 (ther ex)? [y]
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97002y
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What codes must you use a modifier with if you bill for 97112 (neuromuscular re-education)? [y]
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97002y
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What codes must you use a modifier with if you bill for 97116 (gait training)? [y]
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97002y
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What codes must you use a modifier with if you bill for 97140 (manual therapy)? [y]
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97002y reeval 97530y ther activity
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What codes must you use a modifier with if you bill for 97150 (group therapy)? [y]
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97002y 97110y ther ex 97112y neuro reed 97116y gait training 97140y manual therapy 97530y ther activity
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What codes must you use a modifier with if you bill for 97530 (therapeutic activities)? [y]
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97002y 97116y gait training
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What is the purpose for component code?
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Used to support that both procedures were performed at separate and distinct periods of time
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Define modifiers.
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Indicate procedure or service has been modified in some way away from standard description
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What is the purpose of modifiers?
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Sends message that clinician understands these codes are not ordinarily billed together, but services represented are appropriate with documentation to support separate and distinct services
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Are you guaranteed pay if you use a modifier?
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No
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Define the modifier -59.
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Distinct procedural service
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Define the modifier -52.
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Reduced services (97033 shortened due to anxiety)
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Define the modifier -76.
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Repeat procedure by same provider
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Define the modifier -KX.
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when billing for services deemed medically necessary beyond the annual therapy cap (to be discussed later), justified via documentation and approved as exception to the cap
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Define the modifier - GX.
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indicates that you have provided the patient with the voluntary ABN and have it on file, CMS should automatically reject the claim and you will receive a denial for your files so can bill secondary insurer, if appropriate??
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Define the modifier -GY
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indicates that you did not provide the patient with the ABN because it is not required, but the services will still be denied and you will have the record of the denial in your files so that you can bill the secondary insurer??
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Define MPPR.
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Multiple procedure payment reduction
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What is the purpose of a MPPR?
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• Implements a 50% payment reduction to the practice expense value of certain CPT codes deemed "always therapy services" (not a true 50% reduction) • For 2nd and each subsequent code, the practice expense value will be reduced o Example 97110 x 2: In Iowa, may be paid $60.18 for 1st 97110 and $53.24 for 2nd
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What type of insurance are G-codes important for?
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Medicare Part B **will not be reimbursed if not using G-codes and using them correctly
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What is the purpose of G codes?
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TO help develop an improved payment system
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What letters are used to designate Physical Therapy POC?
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"GP"
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T/F. G-Codes are function based.
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True, tied to some functional assessment (i.e. neck disability index)
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How many G-Codes can you report at one time?
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1
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What are the applicable sets of G-Codes?
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Mobility: Walking & Moving Around Changing & Maintaining Body Position Carrying, Moving, and Handling Objects Self-Care Other PT/OT Primary Other PT/OT Subsequent
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When do you use the "other" G-code?
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When functional assessment tools don't adequately represent a deficit that fits into categories listed above
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Which code set should you choose?
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The code set which represents the patient's biggest functional limitation/deficit/concern
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What are the G-codes for Mobility: walking and moving around?
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G8978 current status G8979 goal status G8980 mobility d/c status
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What are the G-codes for Changing and maintaining body position?
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G8981current status G8982 goal status G8983 mobility d/c status
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What are the G-codes for carrying, moving and handling objects?
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G8984 current status G8985 goal status G8986 mobility d/c status
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What are the G-codes for self care?
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G8987 current status G8988 goal status G8989 mobility d/c status
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What are the G-codes for other PT/OT primary?
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G8990 current status G8991 goal status G8992 mobility d/c status
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What are the G-codes for other PT/OT subsequent?
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G8993 current status G8994 goal status G8995 mobility d/c status
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What does the modifier CH mean?
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0 percent impaired, limited or restricted
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What does the modifier CI mean?
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At least 1 percent but less than 20 percent impaired, limited or restricted
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What does the modifier CJ mean?
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At least 20 percent but less than 40 percent impaired, limited or restricted
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What does the modifier CK mean?
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At least 40 percent but less than 60 percent impaired, limited or restricted
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What does the modifier CL mean?
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At least 60 percent but less than 80 percent impaired, limited or restricted
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What does the modifier CM mean?
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At least 80 percent but less than 100 percent impaired, limited or restricted
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What does the modifier CN mean?
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100 percent impaired, limited or restricted
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What information should be used for the selection of the severity modifier?
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- Interpretation of scores from standardized functional assessment tools - Additional objective data including pain, motion, strength, etc. - Other considerations that impact the severity of the pt including comorbidities, age, condition, prognosis, time since onset, etc. **if the pt doesn't expect the patient to make improvements, the current status and goal can use the same modifier
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When are you required to use G-Codes?
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- Initial evaluation - Every 10th visit or 30 days, whatever comes first - Therapy discharge - Therapy re-evaluation (to begin a new set of G-codes on a different functional limitation)
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Can you report G-codes in all daily notes?
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Yes, in the assessment portion
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What does ICD-10 stand for?
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International statistics classification of diseases and related health problems
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What does ICF stand for?
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International classification of functioning, disability and health
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ICF disability and functioning are viewed as outcomes of interactions between what two things?
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1. Health conditions (diseases, disorders and injuries) 2. Contextual factors
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What are examples of contextual factors?
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1. Environmental factors (social attitudes, architectural characteristics, legal and social structures, as well as climate, terrain) 2. Personal factors (gender, age, coping styles, social background, education, profession, past and current experience, overall behavior pattern, character)
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What are the three levels of human functioning classified by ICF?
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1. Functioning at the level of body or body part 2. The whole person 3. Whole person in a social context
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Disability involves dysfunctioning at what levels?
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Impairments, activity limitations and participation restrictions
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What is the minute requirement for one timed charge/unit?
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8-22 minutes
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What is the minute requirement for two timed charge/units?
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23-37
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What is the minute requirement for three timed charge/units?
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38-52
