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ICD-10

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1. developed by and maintained World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) 2. used by HIPAA- covered entities 3. tells the payer "here is the diagnosis" 4. greater specificity than ICD-9

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ICD-10 Code Structure

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1. in an outpatient setting, include multiple ICD-10 codes 2. PT diagnosis, MD diagnosis, MOI, Co-morbidities

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examples of ICD-10 codes

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S86.011D, Strain of right achilles tendon, subsequent encounter

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what do the first 3 characters of any ICD-10 code mean?

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the category of the diagnosis (example on slide)

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what do the next 3 characters indicate?

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the related etiology (the cause, set of causes, or manner of causation of a disease or condition), anatomic site, severity, or other vital clinical details

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what does the 7th character indicate?

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it documents the episode of care; A - initial encounter (primary care provider or PT direct access) D - subsequent encounter; MD referral to PT for rehabilitation S - sequela; indicates a complication or condition that arises as a direct result of an injury (ex. a scar resulting from a burn; or imbalance from MS)

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Bizarre ICD-10 codes

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slide 5 - these are real

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CPT codes

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stands for Current Procedural Terminology 1. developed and maintained by American Medical Association (AMA) 2. tells the payer "here's the treatment - and what you need to pay for" 3. roles of clinician: select most appropriate CPT code and use supportive documentation

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CPT codes (cont)

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1. greater opportunity for evidence-based practice - differentiates what we do as PTs 2. better insight for optimizing grouping and reimbursement processes 3. seamless exchange of data across all healthcare platforms (interoperability)

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how we get paid as PTs?

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1. percent of charges 2. paid per diem 3. paid per CPT code

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percent of charges

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insurance carrier reimburse a percentage of usual and customary charges (least common)

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paid per diem

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e.g. $75/day; as long as you charge more than $75, you will get full rate

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paid per CPT code

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most common; typically called Fee-For-Service; the more you bill, the more you are paid

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how are CPT codes valued? (Fee-For-Service)

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1. work RVU (Relative Value Unit) - relative level of time, skill, training, and intensity to provide service 2. practice expense RVU - cost of maintaining practice (rent, equipment, supplies, non-clinical staff costs) 3. malpractice - payment for professional liability expenses

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layman terms of CPT codes

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value = parts + labor + liability

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slide 9

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more on CPT code values and how to calculate

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time based CPT codes

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1. requires 1:1 direct contact (10ft away - verbal, visual) 2. typically 15 min increments for rehab codes 3. multiple units of the same code on the same day

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service based CPT codes

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1. time or number of body parts treated are not factors 2. can only charge one unit of each service per date of service, per discipline, per patient; ex. if you apply EStim to two areas on the same date of service, you can only charge once for the service; ex. 15 mins of heat on neck and 4 mins on back - still 1 unit

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common time based CPT codes

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1. THERAPEUTIC EXERCISE - 97110 2. MANUAL THERAPY - 97140 3. THERAPEUTIC ACTIVITIES - 97530 4. NEUROMUSCULAR RE-EDUCATION - 97112 5. AQUATIC THERAPY WITH THERAPEUTIC ACTIVITIES - 97113 6. Gait training - 97116 7. Physical performance testing - 97750 8. Constant attendance modalities *those that are in all-caps are evidence based procedures

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therapeutic exercise

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strength, ROM, flexibility *NOT for aerobic conditioning, maintenance, weight loss, overall fitness or endurance; biking warm up "for weight loss" - may not be reimbursed

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manual therapy

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remember the document rationale, body part, technique used, subjective/objective data as compared to the other side, functional limitations/effects of the intervention (test/treat/re-test), patient response; the only thing that differentiates us from our competitors (PROM - did you use distraction? MT instead of TE?)

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therapeutic activities

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for functional training (lifting, carrying, walking, sitting, climbing ladder, sit to stands, etc); documented deficits in these areas should be present and tied to the activities

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neuromuscular re-education

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posture, balance, proprioception, kinesthetic sense - documented deficits in these areas should be documented and tied to activities; in TN only: Blues do not reimburse due to being "experimental"

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aquatic therapy

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in the pool; typically good for 8 visits unless documented large progress

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in the outpatient setting, which code is the most expensive (also associated with large payment)?

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aquatic therapy

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gait training

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most appropriate for geriatric; SCI and amputee populations

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PPT (physical performance testing)

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most appropriate for FCEs or isokinetic testing

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constant attendance modalities

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examples are ultrasound, phonophoresis, iontophoresis, direct e-stim

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overall with CPT codes

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make a clinical decision on the best code to use

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constant attendance modalities (cont)

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1. requires direct 1:1 patient contact (visual, verbal, manual contact; each 15 mins) 2. 97032 - electrical stimulation (manual) 3. 97033 - iontophoresis 4. 97035 - ultrasound

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if using a combination of ultrasound and e-stim for 10 mins - you cannot bill for both. which one do you bill for?

answer

ultrasound, because the heat helps with healing

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common service based CPT codes

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1. 97010 - hot or cold packs 2. 97012 - traction, mechanical (cervical, lumbar) 3. 97014 - electrical stimulation (unattended) 4. G0283 - electrical stimulation (unattended) to one or more indications other than wound care

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how many units can you bill for 10 mins of e-stim on right shoulder and 4 mins on lower back?

answer

one unit

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what does billable time include?

answer

1. chart review for treatment 2. set up of activities and the equipment area 3. performance of the service/therapeutic procedure 4. patient/family education (pain neuroscience education) 5. communication with other healthcare professionals 6. calls to referring physician for additional information or clarification *all components must be performed on the date of service *it does not include non-therapeutic rests, bathroom breaks, or waiting for equipment

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how can you change a non-therapeutic rest break into a therapeutic rest break?

answer

take vitals, education

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importance of documentation

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component of quality care; documentation of services are essential for claim review and payment; documentation enhances communication between MD/Therapist/Patient

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lumbar stabilization crunches

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I would chose therapeutic exercise because the exercise is helping strengthen the abdominal muscles in stabilizing the lower back

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cupping/STM

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manual therapy

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squats, to stimulate playing on the floor with children

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therapeutic activities

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pain neuroscience education for improved sleep

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therapeutic activities; helping them sleep

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treadmill for warm up

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cannot bill; if it was for ROM you could call it

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document your CPT codes wisely

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these codes can apply to different techniques or exercises; if your written documentation supports the intent of the exercise or activity chosen; for example, heel raises can be documented as a TA, TE, NMR, or gait training code if your documentation supports its use in that manner

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when does billable time begin?

answer

when the PT asks about HEP

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evaluation codes

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all untimed 1. 97001 PT eval 2. 97002 PT re-eval -every 90 days for medicare (PN every 10 visits) OR -patient doesn't respond as expected under the current POC (includes improvement or decline); OR there are new clinical findings; OR significant change in the patient's new condition; OR new diagnosis, requiring new goals and interventions

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untimed codes

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CMS will collect data for the full year before deciding where price difference is between levels

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step towards payment reform

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recognizes how comorbidities and other personal factors contribute to complexity of POC

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new CPT evaluation codes (started jan 1 2017) for outpatient, MC Part B

answer

evaluation 1. 97161 - low complexity 2. 97162 - moderate complexity 3. 97163 - high complexity re-evaluation 1. 97164 - same as before, does not take into account different complexity levels, established POC, exam + review of history, tests and measures, describes significantly revised POC

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Parts of PT eval

answer

1. history 2. exam 3. clinical presentation 4. clinical decision-making

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history

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comorbidities, PLOF, prior treatment, other providers, work status, social history/personal history (education, profession, behavioral patterns)

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exam

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body structure + function; activity limitations, participation restrictions

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clinical presentation

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1. stable and complicated - symptoms are not fluctuating 2. changing in regular way - starts in the back, now down leg, not getting better 3. evolving and unstable - orthostatic hypotension, unpredictable/unsafe

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clinical decision-making

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1. low, moderate, or high complexity 2. functional outcome measures

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97161 low complexity evaluation

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1. history - no personal factors or comorbidities 2. examination - standardized tests + measures addressing 1-2 elements from body structures and functions, activity limitations and/or participation restrictions 3. presentation - stable and/or uncomplicated characteristics 4. clinical decision - standard outcome measure; low complexity

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97162 moderate complexity evaluation

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1. history - 1-2 personal factors or comorbidities 2. examination - standardized tests + measures addressing 3 or more elements from body structure and functions, activity limitations, and/or participation restrictions 3. presentation - evolving clinical presentation with changing characteristics 4. standard outcome measure; moderate complexity

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97163 high complexity evaluation

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1. history - 3 or more personal factors or comorbidities 2. examination - standardized tests + measures addressing 4 or more elements from body structures and functions, activity limitations, and/or participation restrictions 3. presentation - unstable and unpredictable clinical presentation with changing characteristics 4. standard outcome measure; high complexity

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case example (slide 24)

answer

oswestry 35/50 - a lot of disability (goal is 6) history - hypertension; frequency/chronicity examination - work, sitting, sleeping presentation - evolving, mod-severe pain clinical decision - oswestry 35 - moderate complexity

question

group therapy services 97150

answer

1. therapeutic procedure (group) - 2 or more individuals 2. constant attendance required (not direct contact) 3. performing the same or similar activities in a group setting 4. reported for each member of the group in the note 5. may be land based or aquatic 6. recognized by Medicare programs

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example of group therapy

answer

the patients might all have knee surgery; or they may all benefit from specific types of pool exercises; or they might all be part of a class for people waiting to be fitted for lower limb prostheses

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medicare patients: group

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1. used when patients are receiving the same treatment in a group setting 2. must be two or more patients 3. group must be documented 4. it is usually purposely scheduled this way

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medicare patients: one on one

answer

1. used when patients are receiving individualized treatment programs 2. may be one or more patients 3. you cannot accumulate one on one treatment time with two Medicare patients at the same time 4. appropriate scheduling is key

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what is the best practice with scheduling patients in a MC program

answer

to space these patients at least 30 mins apart

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medicare patients: 8 min rule

answer

1. applies to CPT time based codes in 15-min increments 2. use TOTAL TIME as a guideline when choosing codes to describe service provided

question

how many units to bill here? 15 mins Ther-ex, 12 mins NMre-ed, 10 mins manual therapy

answer

1. 1 of each code? NO 2. add up the minutes: 15+12+10 = 37 mins - can only bill 2 units; you can count assessment of ROM/MMT and add that to the time of manual therapy

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slide 29

answer

refer to powerpoint for detailed explanation

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1 unit

answer

greater than 8 mins to less than/equal to 22 mins

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2 units

answer

greater than 23 mins to less than/equal to 37 mins

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3 units

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greater than 38 mins to less than/equal to 52 mins

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4 units

answer

greater than 53 mins to less than/equal to 67 mins

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5 units

answer

greater than 68 mins to less than/equal to 82 mins

question

slides 30-33

answer

examples of patient scenarios

billing and coding for physical therapists – Flashcards

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