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CommonErrors– AuditingthePhysMed Record
CommonErrorsandFraudRiskinPhysicalMedicine(Chiro/PT)Coding
AuditingthePhysMed Record
Lecturer:MichaelD.MiscoeJD,CPC,CASCC,CUC,CCPC,CPCO,CPMA
CommonErrors– AuditingthePhysMed Record
DISCLAIMERThispresentationisforgeneraleducationpurposesonly.Theinformationcontainedinthesematerials,lecture,ideasandconceptspresentedisnotintendedtobe,andisnot,legaladviceorevenparticularbusinessadvicerelevanttoyourpersonalcircumstances.Thelaws,regulationsandcontractualtermsregardingbillingofanyservicetoathirdpartypayeraspresentedinthisseminarareaspublishedbytheauthoringfederalorstategovernmentorinrelevantcarrierpolicies/contracts.Suchlaws,regulations,contractsandpoliciesareopentointerpretation.Itisyourresponsibilitytoidentifyandevaluateanyrelevantlaw,regulation,contractorpolicyaswellastoseekprivatecounselwithyourattorneytodeterminehowtheselaws,regulations,policiesandcontractualtermsandanyconceptdiscussedhereapplytoyourspecificcasebeforeapplyingtheconceptsaddressedinthisseminar.
Attendanceatthispresentationshouldnotbeconstruedascreatinganattorney– clientrelationshipwiththespeakernorshouldtheinformationpresentedbeconstruedaslegaladvice.Remainingforthispresentationindicatesyouracknowledgementandagreementwiththeabove.
NOTICESCurrentProceduralTerminology(CPT®)iscopyright©2016AmericanMedicalAssociation.AllRightsReserved.CPT®isaregisteredtrademarkoftheAmericanMedicalAssociation(AMA).
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CommonErrors– AuditingthePhysMed Record
• Howtoproperlydeterminetheappropriatecodeforanyphysicalmedicinetherapyservice.
• Commonerrorsinthereportingofphysicalmedicinetherapyservices.
• RecenttrendsinpostpaymentandfalseclaimsanalysistargetingchiropracticandPTproviders.
Whatyouwilllearn
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CommonErrors– AuditingthePhysMed Record
• Analysis– Identifywhatthetherapyis
• Identifyingcreativenamingissues
– Identifytheamountofcontactprovidedandnecessary
– Identifythedurationoftheservice
TherapeuticServiceIdentification
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CommonErrors– AuditingthePhysMed Record
• ModalityDefinition:“Anyphysicalagent appliedtoproducetherapeuticchangestobiologictissue;includesbutnotlimitedtothermal,acoustic,light,mechanical,orelectricenergy.”– WherePhysicalAgentCausesChange– ThePhysical
Agent AppliedDefinestheCode.– IdentifytheLevelofContactREQUIRED
• Supervised(97010‐97028)– Notunitable• ConstantAttendance(97032‐97036)– Unitable basedontime
– Unlisted(97039)Contact/TimeRelevant?
Modalitiesvs.Procedures
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CommonErrors– AuditingthePhysMed Record
• FundamentalsofModalityCoding– Supervision:“Theapplicationofamodalitythatdoesnotrequire direct(one‐on‐one)patientcontactbytheprovider.”i.e.– stayinthebuilding.Appliestocodes97010‐97028.
– ConstantAttendance:“Theapplicationofamodalitythatrequires direct(one‐on‐one)patientcontactbytheprovider.”Note:AMAhasclarifiedthatyoucanprovideconstantattendancetomorethanonepatientincertaincircumstances.Forconstantattendancemodalities,theremustbeaneed tostaywiththepatientinordertodeliverthetherapyservice.Appliestocodes97032– 97036.
Modalitiesvs.Procedures
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CommonErrors– AuditingthePhysMed Record
• FundamentalsofProcedureCoding• ProcedureDefinition:“Amannerofeffectingchangethroughtheapplicationofclinicalskills and/orservicesthatattempttoimprovefunction.Physicianortherapistrequiredtohavedirect(one‐on‐one)patientcontact.”Appliestocodes97110‐97546.
• Clinicalskillisnecessarytoachievethespecifictherapeuticchangeandmustbeappliedduringtheentiretyoftheservice;hence,thedirectone‐on‐onecontactrequirement.
• ThePrimaryTherapeuticOutcomeIntendedDefinestheCode• Howdowedeterminetheintendedtherapeuticoutcome?
Modalitiesvs.Procedures
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CommonErrors– AuditingthePhysMed Record
Istheserviceamodalityorprocedure?• Lookatwhatiscausingthetherapeuticchange.
– APhysicalagent?• Light,Sound,Thermal,Electrical,MechanicalForce,etc.
– TheClinicalSkillofthePhysicianorTherapist?• Evidencethatclinicaldirectionisnecessarytoachievea
particulartherapeuticresult.
• Whatlevelofcontactprovided?
Modalitiesvs.Procedures
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CommonErrors– AuditingthePhysMed Record
• Ifamodality,whatisthephysicalagentandwhatlevelofcontactisrequired?– MatchthephysicalagentandlevelcontactwithintheappropriatemodalitysectionofCPT®.Ifthereisnomatch,report97039.
• Ifaprocedure,whatistheprimarytherapeuticoutcomeandwhatlevelofcontactwasprovided?– If1‐on‐1,matchtheprimaryoutcomewithacodewithintherangeof97110‐97546.Ifthereisnomatch,code97139.
– Ifnot1‐on‐1butskilledandconstantattendancewasprovided,bill97150.
– Whatifonlysupervisionisprovided?
Modalitiesvs.Procedures
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CommonErrors– AuditingthePhysMed Record
• Definitionof“Contact”– “FromaCPT® codingperspective,… Therapeuticprocedure,oneormoreareas,each15minutes;… requiresthetherapisttomaintaindirectpatientcontact(ie,visual,verbaland/ormanualcontact)duringprovisionoftheservice.”AMA,CPT® Assistant,p.11(December,1999)• Contactmustbesufficientlyskilledtoassurethattheprocedurewillcausetheintendedspecifictherapeuticchange.e.g.havinganunskilledtherapistsimplywatchapatientdoanexerciseisinsufficient.
• ConnectionbetweenCPT“contact”requirementsandCMS(andotherpayer)requirementsfor“skilled”intervention.
UnderstandingContact
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CommonErrors– AuditingthePhysMed Record
• ElectricalStimulation– TMR
• TherapeuticMagneticResonanceTreatment
– PENS• PercutaneousElectricNerveStimulation
TherapyCodingExercise
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CommonErrors– AuditingthePhysMed Record
• LightTherapy– ClassI‐II(LED)
– ClassIII(ColdLaser)
– ClassIV(HotLaser)
TherapyCodingExercise
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CommonErrors– AuditingthePhysMed Record
• HandsFreeUltrasound– PulsedUltrasound
• Phonopheresis– Ultrasound+Medication(Hydrocortisone,Dexamethasone,SalicylatesorLidocaine).
TherapyCodingExercise
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CommonErrors– AuditingthePhysMed Record
• Kinesiotaping– CPTAssistant
• 3/2012
TherapyCodingExercise
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CommonErrors– AuditingthePhysMed Record
• DecompressionTractionTherapyCodingExercise
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CommonErrors– AuditingthePhysMed Record
• PneumaticTraction(PosturePump)
• VibratoryMassage/MassageChairs
TherapyCodingExercise
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CommonErrors– AuditingthePhysMed Record
• NeuromuscularMassage• RehabilitativeExercise
– BalanceBoards– ExerciseMachines(Isotonic/Isometric/Isokinetic)– SwissBalls
TherapyCodingExercise
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CommonErrors– AuditingthePhysMed Record
• 97110‐ Therapeuticprocedure,1ormoreareas,each15minutes;therapeuticexercisestodevelopstrengthandendurance,rangeofmotionandflexibility– CPT® Assistant(Summer1995,Vol7):Therapeuticexerciseincorporatesoneparameter(strength,endurance,rangeofmotionorflexibility)tooneormoreareasofthebody.Examplesinclude,treadmill(forendurance),isokineticexercise(forrangeofmotion),lumbarstabilizationexercises(forflexibility),andgymnasticball(forstretchingorstrengthening).
• 97530‐ Therapeuticactivities,direct(one‐on‐one)patientcontact(useofdynamicactivitiestoimprovefunctionalperformance),each15minutes– CPT® Assistant(Summer,1995,p.9)Dynamicactivitiesincludetheuseofmultipleparameters,suchasbalance,strength,andrangeofmotion,forafunctionalactivity.Examplesincludeliftingstations,closedkineticchainactivity,handassemblyactivity,transfers(chairtobed,lyingtositting,etc),andthrowing,catching,orswinging:Functionalactivitiesspecificallyrelatedtowork(hardening/conditioning)shouldbecodedusing97545
97110/97530
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CommonErrors– AuditingthePhysMed Record
• CPTKnowledgeBase(2013):Code97530isatherapeuticprocedurethatrequiresdirectone‐on‐onepatientcontactbyaphysicianortherapist.Dynamicactivitiesincludetheuseofmultipleparameters,suchasbalance,strength,andrangeofmotion,forafunctionalactivity.Examples ofwhentousethiscodewouldbewhenthefollowingactivities/functionsaretakingplace:liftingstations,closedkineticchainactivity,handassemblyactivity,transfers(chairtobed,lyingtositting,etc),andthrowing,catching,orswinging.Additionalexamplesincludedexteritytasks,writing,functionalmobilityorpurposefulactivitiessuchasplacingobjectsoutofreach,manipulationtasksusingsmalltools,crossingmidline,orweight‐shiftingtaskswiththeupperbodytoimprovesafetywithunsupportedsittingorstanding.Code97530differsfrom97110inthat97110,Therapeuticprocedure,oneormoreareas,each15minutes;therapeuticexercisestodevelopstrengthandendurance,rangeofmotionandflexibility,describesservicesaimedatimprovingaparameter,suchasstrength,rangeofmotion,etc.Therapeuticactivities,asincode97530,pullalltheseparameterstogethertofocusonachievingafunctionalactivity.Thefocusincode97530isonactivityvsexercise.
97110/97530
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CommonErrors– AuditingthePhysMed Record
• 97112:Therapeuticprocedure,1ormoreareas,each15minutes;neuromuscularreeducationofmovement,balance,coordination,kinestheticsense,posture,and/orproprioceptionforsittingand/orstandingactivities.
– CPT® Assistant(Summer1995,Vol7):Examplesinclude,ProprioceptiveNeuromuscularFacilitation(PNF),Feldenkreis,Bobath,BAP'SBoards,anddesensitizationtechniques).
97112
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CommonErrors– AuditingthePhysMed Record
• AetnaPolicy(asanexample):NeuromuscularRe‐education‐ Thistherapeuticprocedureisprovidedtoimprovebalance,coordination,kinestheticsense,posture,andproprioceptiontoapersonwhohashadmuscleparalysisandisundergoingrecoveryorregeneration.Goalistodevelopconsciouscontrolofindividualmusclesandawarenessofpositionofextremities.Theproceduremaybeconsideredmedicallynecessaryforimpairmentswhichaffectthebody'sneuromuscularsystem(e.g.,poorstaticordynamicsitting/standingbalance,lossofgrossandfinemotorcoordination,hypo/hypertonicity)thatmayresultfromdiseaseorinjurysuchasseveretraumatonervoussystem,cerebralvascularaccidentandsystemicneurologicaldisease.[EmphasisAdded]
97112
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CommonErrors– AuditingthePhysMed Record
• CPT®97150‐ Therapeuticprocedure(s),group(2ormoreindividuals)– CPT®Assistant(Summer1995)GrouptherapeuticproceduresincludeCPT® codes97110‐97139.Ifanyoftheseproceduresareperformedwithtwoormoreindividuals,thenonly97150isreported.Donotcodethespecifictypeoftherapyinadditiontothegrouptherapycode.
– Mixedcontact?
NotOne‐on‐One?
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CommonErrors– AuditingthePhysMed Record
GroupandOne‐on‐One‐ CCI
• UnderCCI,alldirectone‐on‐onecontactproceduresareconsideredexcludedbythegroupcode(97150)butcanbereportedseparatelywhenaone‐on‐onecontactprocedureisperformedseparateintimefromtheexercisesperformedinagroup.
• Whereappropriatetobillbothaone‐on‐oneprocedure(e.g.97110)andagroupcode(97150)theone‐on‐oneproceduregetsthemodifier59.
CommonErrors– AuditingthePhysMed Record
• CPTEDITORIALPANELAPPROACH– 1ST UNIT– 50%(SeeCPT®Instructions)– MORETHANONEUNIT– Lessthan8minutes‐MODIFIER52?– ConcurrentPerformanceofTimeBasedTherapies
• CMSAPPROACH– Part1– Individualtimeanalysisunderthe8minuterule.– Part2– Totaltimeanalysis(wheremorethanonetimebasedserviceisperformed).
ReportingTimeBasedServices
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CommonErrors– AuditingthePhysMed Record
Whattimecounts?
• CPT:Allnecessarypre,intraandpostserviceworkassociatedwiththeservice.
• CMS:Onlytheactualtimeinvolvedinperformanceoftheservice(intraservicetime).Pre,andpostserviceworkdoesnotcount.
CommonErrors– AuditingthePhysMed Record
UnderstandingTimeRules• CPTEditorialPanelGuidance
– SingleServiceAnalysis– 1st UnitBillableif50%ofServicePerformed
• Iflessthanwhole15minutes,but7.5minutesormore,reportsingleunit.
• Whattodowhenserviceisperformedforlessthan8minutes?
• Whentoreportthe2nd Unit?
– FollowCarrierPolicy!
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CommonErrors– AuditingthePhysMed Record
UnderstandingTimeRules• CMS
– TwoPartAnalysis• EachService:8MinuteRule
– 8‐22=1Unit– 23‐37=2Units– 38‐52=3Units– 53‐67=4Units
• WhereMultipleTimeBasedServicesarePerformed,EvaluateTotalTimevs.TotalUnits
CommonErrors– AuditingthePhysMed Record
UnderstandingTimeRules• CMS– SpecialRules
– Lessthan8Minutes• Can’tBillbutSavetheTime…
– BundlingServicesofSameTime• LowerValueBundlestoHigherValue
– BundlingServicesofDifferentTime• LowerTimeBundlestoHigherTime
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CommonErrors– AuditingthePhysMed Record
PracticalExercise‐ AMA
• 97012– 15minutes• 97032– 5minutes• 97140– 10minutes• 97110– 12minutes
• 97012x1unit• Notreported• 97140x1unit• 97110x1unit
CommonErrors– AuditingthePhysMed Record
PracticalExercise– CMS– Step1
• 97012– 15minutes• 97032– 5minutes• 97140– 10minutes• 97110– 12minutes
• 97012x1unit• Notreported(savetime)• 97140x1unit• 97110x1unit
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CommonErrors– AuditingthePhysMed Record
PracticalExercise– CMS– Step2• 97012– 15minutes• 97032– 5minutes• 97140– 10minutes• 97110– 12minutes
• TotalTime=?a. 22Minb. 27Minc. 42Min
• TotalUnits=?a. 2Unitsb. 3Unitsc. 4Units
CommonErrors– AuditingthePhysMed Record
PracticalExercise– CMS– Result
• 97012– 1Unit• 97140– 1Unit• 97110– 1Unit
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CommonErrors– AuditingthePhysMed Record
PracticalExercise– CMS– Step1
• 97012– 15minutes• 97140– 10minutes• 97110– 12minutes
• 97012x1unit• 97140x1unit• 97110x1unit
CommonErrors– AuditingthePhysMed Record
PracticalExercise– CMS– Step2
• 97012– 15minutes• 97140– 10minutes• 97110– 12minutes
• TotalTime=?– 22Min
• TotalUnits=?– 2Units
IsitEnough?– No!
NowWhat?
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CommonErrors– AuditingthePhysMed Record
PracticalExercise– CMS– Result
• 97012– 1Unit• 97110– 1Unit
– Sincetherewasnotenoughtotaltime(intime‐basedservices)tojustify2totaltime‐basedunits,thelowertimeservicebundlesintothehighertimeservice.As97110wastheservicewithhighertime,97140bundlesinto97110.
CommonErrors– AuditingthePhysMed Record
PostPaymentIssues
• Miscodingoftherapyservices:– TMR:
• 76498(Unlistedmagneticresonanceprocedure(eg,diagnostic,interventional)
– PENS:• 64555‐ Percutaneousimplantationofneurostimulatorelectrodearray;neuromuscular
• 64999– Unlistedprocedure,nervoussystem
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CommonErrors– AuditingthePhysMed Record
PostPaymentIssues• CorrectCodingofTMR/PENS:
– TMR:• 97032‐ Applicationofamodalityto1ormoreareas;electricalstimulation(manual),each15minutes
– PENS:• 97014‐ Applicationofamodalityto1ormoreareas;electricalstimulation(unattended);or
• G0283‐ Electricalstimulation(unattended),tooneormoreareasforindication(s)otherthanwoundcare,aspartofatherapyplanofcare
CommonErrors– AuditingthePhysMed Record
PostPaymentIssues• Reportingone‐on‐oneserviceswhenonlyconstantattendanceorsupervisionprovided– IfConstantAttendance– Entireencounter=1unit97150– IfSupervision– Nocode.
• Why?• AuditConsiderations
– Documentationoftherapyservicedetails– Documentationoftime.– Documentationofcontact– Identityofpersonprovidingcontact
• Unfortunately,mostcommercialcarriermedicalpoliciesrequirenoneoftheabove.
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CommonErrors– AuditingthePhysMed Record
PostPaymentIssues• ContactRequiredforWorkHardening
– CPT– DirectOne‐on‐One– CPTAssistant– reprintedAPTAguidancesuggestingthatonlysupervisionisrequired.
• Whereonlysupervisionisprovided,howdoyoujustifythattheservicewasa“skilled”service?
CommonErrors– AuditingthePhysMed Record
PostPaymentIssues• ReportingServiceperformedforlessthan8minutes
– CriminalfelonyfraudconvictioninOhioforreportingmanualtherapy(97140)withmodifier52
– Serviceperformedfor40‐60secondsinmostcases.– $13Kofrelevantbilling.– Ambiguouspolicy
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CommonErrors– AuditingthePhysMed Record
PostPaymentIssues• MedicalNecessityRedFlags
– Morethan4totalunitsofservice– Morethan1hourofservice– Morethan4differentcodesperencounterassociatedwiththesamediagnosis/injury.
• ProcedureMis‐Coding– 4unitsof97112?– 4unitsof97140?
CommonErrors– AuditingthePhysMed Record
Questions?
CEUCode: