pps cpt coding and billing final...

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CPT Coding & Billing for the Physical Therapist and Physical Therapist AssistantRick Gawenda, PTPresidentGawenda Seminars & ConsultingOctober 20, 2016

Property of Gawenda Seminars & Consulting, Inc. All Rights

Reserved!

DISCLOSURE

Rick Gawenda is the owner of Gawenda Seminars & Consulting, Inc. and has no outside relationship with any companies, vendors, etc. that could be viewed as creating a conflict of interest, or give the appearance of a conflict of interest, that might bias the content of the presentation.

Property of Gawenda Seminars & Consulting, Inc. All Rights Reserved!

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CPT Code Disclaimer

CPT codes, description, and material are copyright 2016

American Medical Association. CPT is a trademark of the

American Medical Association. All rights reserved. No fee

schedules, basic units, relative values, or related listings are

included in CPT. The AMA assumes no liability for the data

contained herein


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Physicians Current Procedural Terminology, Fourth Edition

Is a proprietary code set developed by the American Medical Association (AMA)

Provides enumeration and standardization of medical and surgical procedures

Widely required by governmental and private insurance programs for claims processing and reimbursement

Generally updated annually and becomes effective January 1 of the new calendar year

What is CPT


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Time – Based Codes

Service – Based Codes (un-timed)

Types of CPT Codes


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Many, but not all, require direct one on one contact with the patient in order to bill to an insurance carrier

Contact time ranges from 15-120 minutes in length. Most codes used by PT and OT are timed in 15-minute increments.

Can bill multiple units of the same time based CPT code on the same day per discipline per patient

Time Based CPT Codes


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Are un-timed unless told otherwise by the payer (i.e. Some state Medicaid programs). If told otherwise by a payer, follow that payers specific policy.

Can only bill one unit of each service-based code daily per discipline per patient per the same insurance. Does not matter how many different body parts you place the same modality on the patient or how long the same modality is on the patient.

Service Based CPT Codes


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Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified healthcare professional or entity.

CPT 2016

CPT Usage


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The application of a modality that does not requiredirect (one on one) patient contact

Supervised modalities are un-timed & servicebased

Can only bill one unit of each service-based codeper discipline per treatment session per patient under the same insurance. Does not matter how many different body parts you place the samemodality on the patient or how long the modality ison the patient

Supervised Modalities


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97010 Application of a modality to 1 or more areas; hot or cold packs

97012 Traction, mechanical

97014 Electrical Stimulation (unattended) (Not for Medicare – see next slide)

97016 Vasopneumatic Devices

97018 Paraffin Bath

97022 Whirlpool (May include fluidotherapy unless told otherwise by an insurance carrier)

97024 Diathermy

97026 Infrared

Supervised Modalities: Un-Timed


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G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (i.e. TENS, IFC, NMES)

Is un-timed

Valid for Medicare for all outpatient therapy settings

Most other insurance carriers still recognize 97014 for unattended electrical stimulation. Some recognize either G0283 or 97014

If still being reimbursed for 97014 for unattended electrical stimulation, my recommendation is to continue to use 97014 for unattended electrical stimulation

G-Code for Unattended E-stim


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The application of a modality that requires direct (one on one) patient contact

Direct patient contact involves visual, verbal, and/or manual contact with the patient during provision of the service

Are time-based codes in 15-minute increments

Can bill multiple units of the same CPT code to the same patient on the same day if medically necessary and meets the time requirements for billing per the insurance carrier

Is rare to bill more than one unit of the same modality CPT code to an insurance carrier on the same day on the same patient per the same discipline

Constant Attendance


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97032 The application of a modality to 1 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

97039 Unlisted modality (specify type and time ifconstant attendance) Some possible examplescould be laser, fluidotherapy, anodyne therapy, VAX-D.

Constant Attendance Modalities


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97032 The application of a modality to 1 or more areas;electrical stimulation (manual), each 15 minutes

64550 Application of surface (trancutaneous)neurostimulator

Not all insurance carriers reimburse for 64550 under a

Therapy plan of care. Insurance carrier may also dictate

which CPT Code to use.

CPT Assistant April 2002, Page 18

Home TENS Unit Instruction2 Options – May Be Payer Specific


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95992 Canalith repositioning procedure(s) (eg. Epleymaneuver, Semont maneuver), per day

CMS began reimbursing for this code January 1, 2011 under the Medicare Physician Fee Schedule

Canalith Repositioning


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95831 Muscle testing, manual (separate procedure) withreport; extremity (excluding hand) or trunk

95832 hand, with or without comparison with normal side

95833 total evaluation of body, excluding hands

95834 total evaluation of body, including hands

Manual Muscle Testing


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95851 Range of motion measurements and report(separate procedure); each extremity(excluding hand) or each trunk section (spine)

95852 hand, with or without comparison with normal side

CPT Assistants April 2003, February 2004, and May 2008

Range of Motion Testing


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A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.

Physician or other qualified health care professional (i.e. therapist) required to have direct (one on one) patient contact except for group therapy. Group therapy requires constant attendance.

Therapeutic procedure, one or more areas, each 15 minutes; … requires the therapist to maintain direct patient contact (ie, visual, verbal and/or manual contact) during provision of the service

CPT Assistant December 1999

Therapeutic Procedures


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97110 Therapeutic procedure, 1 or more areas, each 15 minutes;therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112 Neuromuscular reeducation of movement,balance, coordination, kinesthetic sense, posture,and/or proprioception for sitting and/or standingactivities (i.e. Baps Board, Trampoline, Swiss Ball,Body Blade, PNF, NDT, etc.)

97113 Aquatic therapy with therapeutic exercise

97116 Gait training (includes stair climbing)

97124 Massage, including effleurage, petrissage and/ortapoment (stroking, compression, percussion)



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97140 Manual therapy techniques (eg. Mobilization/manipulation, manuallymphatic drainage, manual traction), one ormore regions, each 15 minutes

i.e. soft tissue mobilization, myofascial release, serial

compression bandaging, joint mobilizations

CPT Assistant May 2009



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29581 - Application of multi- layer compression system; leg (below knee), including ankle and foot

29582 - Application of multi-layer compression system; thigh and leg,including ankle and foot, when performed

29583 - Application of multi-layer compression system; upper arm and forearm

29584 - Application of multi-layer compression system; upper arm,forearm, hand, and fingers

CPT Assistant 2010: An Insider’s View

CPT Assistant 2012: An Insider’s View

Compression Bandaging


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97150 Therapeutic procedure(s), group (2or more individuals) (Group therapyprocedures involve constant attendanceof the physician or other qualifiedhealth care professional (i.e. therapist),but by definition do not require one onone patient contact by the samephysician or other qualified health careprofessional) Is un-timed


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Under outpatient therapy, it is not what the patient(s) is doing that determines if it is group therapy or one-on-one treatment, it is what the therapist or assistant is doing with the patient(s). How are they treating them?

Is the therapist or assistant one-on-one with one patient while the other patient is doing an intervention independently or under supervision or are they in constant attendance of both patients providing a skilled intervention with no measurable amount of direct one-on-one time spent with either patient?



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Therapist or assistant is in constant attendance of 2 or more patients providing skilled therapy/intervention, but not providing any significant amount of measurable one-on-one time to either patient whether on land or in aquatic setting

This would be group therapy and each patient would be billed 1 unit of 97150 since group therapy is a service based CPT code

Example of Group Therapy

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Therapist or assistant provides 8 minutes of direct one-on-one therapy (therapeutic exercise) to Patient A and then moves over to Patient B to provide 9 minutes of direct one-on-one therapy (manual therapy) while Patient A works under the supervision of the therapist or assistant

Therapist or assistant then goes back to Patient A for7 more minutes of direct one-on-one exercise while Patient B works under the supervision of the therapist or assistant

Therapist or assistant then goes back to Patient B for 6 more minutes of direct one-on-one manual therapy while Patient A works under the supervision of the therapist or assistant

Patient A would be billed 1 unit of 97110 and Patient B 1 unit of 97140 for the 15 minutes of one-on-one time the therapist or assistant spent with each of them providing one-on-one therapy services.

Same logic would be true in the aquatic setting

Example of Intermittent One-on-One

97530 Therapeutic activities, direct (one on one) patientcontact (use of dynamic activities toimprove functional performance), each 15 minutes

Lifting, carrying, pushing, pulling, pinching, grasping, crawling, climbing, throwing, catching, jumping, car transfers, overhead activities, simulation of functional activities, etc.

May also include bed mobility and transfer training

Involves the use of functional activities to restore functional performance in a progressive manner



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97535 Self care/home management training (eg,activities of daily living (ADL) andcompensatory training, meal preparation,safety procedures, and instruction in use ofadaptive equipment) direct one on onecontact, each 15 minutes (bathing, grooming,dressing, personal hygiene, basic householdcleaning & chores, cooking, using appliances,medication management)



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CPT code 97542 - Wheelchair management (assessment, fitting, training), each 15 minutes

Assessment includes, but is not limited to, documentation of the event that necessitates the need for the WC, determination of the patient’s need for a WC and type of WC required (manual versus powered), patient’s strength and ROM, endurance, sensation, pain, edema, tone, skin integrity, sitting balance, standing balance, transfer ability, etc., measurements, and testing the patient’s ability with various chair functions.

Also includes determining type of seat cushion, back support, head/neck support, armrests, leg rests, brake extensions, anti-tips, etc.

Training the patient/family in the use of the wheelchair.

Acknowledges “custom seating”.CPT Changes 2006-An Insiders View

Wheelchair Management


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97750 Physical performance test or measurement (eg,musculoskeletal, functional capacity) with writtenreport, each 15 minutes

(Timed Get Up & Go, Tinetti, Berg Balance Test, Dynamic Gait Index, isokinetic/isometric muscle testing, Performance Oriented Mobility Assessment, Four Square Step Test, Fullerton Advanced Balance Scale, Purdue Pegboard Test, etc.)

Includes the time required to analyze and interpret the resulting data while the patient is present

CPT 97750 is intended to focus on patient performance of a specific activity or group of activities

Test and Measurements


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97760 Orthotic(s) management and training (includingassessment and fitting when not otherwise reported),upper extremity(s), lower extremity(s), and/or trunk,each 15 minutes

Orthotic management may include:

Determining the type of orthotic (i.e. static vs dynamic,custom vs prefabricated)

Assessing the patient (ROM, strength, skin integrity, sensation, pain, edema, etc.)

Designing, selecting, and possibly fabricating the orthotic Orthotic fitting and training

Orthotic & Prosthetic Management


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97760 is used for the assessment, possible fabrication, fitting, and training of an orthotic. Training includes instruction in wearing time, skin care, modification of the orthotic due to healing of tissues, change in edema, or interruption in skin integrity, safety precautions as well as patient instruction in exercises to be performed while the orthotic is in place

Document specific orthotic provided, skilled training provided, and patient’s response to TX

Reference is CPT Assistant December 2005 & February 2007

Orthotic Training


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97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes

97762 is used for established patients who have already received the permanent or temporary orthotic or prosthetic. Includes patient’s response to wearing the device, whether the patient is donning/doffing the device correctly, patient’s need for padding, underwrap, or socks, and of the patient’s tolerance to any dynamic forces being applied.

Document reason for assessment and findings from assessment




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97761 Prosthetic training, upper and/or lower extremities,each 15 minutes

Includes preparation of the stump, strengthening of the remaining musculature, modification of prosthetic fit using stump socks or socket liners, mobility training, use during functional activities as well as skin care and overall conditioning

Once a patient begins gait training with the prosthesis, it is appropriate to report such training with 97116

Document type of prosthesis, specific training and amount of assistance required, and any complicating factors and specific descriptions of these factors




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Applies to Medicare, Medicaid and other federally funded insurance carriers such as TriCare, Federal Blue Cross and Medicare and Medicaid Managed Care insurance carriers

Applies to CPT codes timed in 15-minute increments only

For any single timed CPT code, providers bill the appropriate number of units based on the time intervals outlined 2 slides ahead

If more than one 15-minute timed CPT code is billed on a calendar day, then the total number of time-based units that can be billed is constrained by the total treatment time of time-based interventions by that discipline. Do not count minutes of service-based CPT codes

“8-Minute Rule”


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When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of timed service determines the number of time-based units billed

If any 15 minute timed service that is performed for 7 minutes or less on the same day as another 15 minute timed service that was performed for 7 minutes or less and the total time of the 2 is 8 minutes or greater, then bill 1 unit for the service performed for the most minutes

“8-Minute Rule”


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≥ 8 through 22 minutes 1 unit

≥ 23 through 37 minutes 2 units






≥113 through 127 minutes 8 units

“8-Minute Rule”


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What defines “each 15 minutes”?

What is considered “substantial” of a time-based CPT per the American Medical Association (AMA) to bill a time-based CPT code to an insurance carrier who does not follow Medicare’s “8-minute rule”?

What does AMA say in the CPT book regarding substantial?

Check with specific insurance carriers and be able to defend what you bill for with rationale

Private Insurance Carriers


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16 Minutes Joint mobilizations and soft tissuemobilization

21 Minutes Range of motion and strengthening ex’s

20 Minutes Unattended E-stim for pain reduction

15 Minutes Cervical mechanical traction

Billing Scenario #1


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1 Unit 97012 Mechanical traction

1 Unit 97014/G0283 Unattended E‐stim

1 Unit 97110 Therapeutic exercise

1 Unit 97140 Manual therapy

Billing Scenario #1 - Answer

10 Minutes Unattended electrical stimulation

12 Minutes Strengthening and active – assist range of motion exercises

6 Minutes Manual therapy to increase ROM

7 Minutes Functional activities of grasping andpinching activities

Billing Scenario #2 - Medicare


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1 Unit G0283 Unattended electrical stimulation


1 Unit 97530 Therapeutic activities


25 Minutes Re-evaluation

18 Minutes Shoulder strengthening and ROMexercises

12 Minutes Manual therapy techniques to increaseAROM

Billing Scenario #3


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1 Unit 97002 Re-evaluation


1 Unit 97140 Manual therapy


25 Minutes Therapeutic exercises for strengthening of the shoulder

25 Minutes Manual therapy techniques to increaseshoulder range of motion

Billing Scenario #4


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If Following AMA Billing Guidelines, bill:2 units 971102 units 97140

If Following Medicare’s “8‐Minute Rule”, bill:2 units 97110 and 1 unit 97140

OR1 unit 97110 and 2 units 97140


10 minutes of therapeutic exercise

10 minutes of manual therapy

10 minutes of therapeutic activities

Billing Scenario #5


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If Following AMA Billing Guidelines, bill:1 unit 971101 unit 971401 unit 97530

If Following Medicare’s “8‐Minute Rule”, bill:1 unit 97110 and 1 unit 97140

OR1 unit 97110 and 1 unit 97530

OR1 unit 97140 and 1 unit 97530


American Medical Association Current Procedural Terminology; CPT 2017; Professional Edition

CMS Therapy Services

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

CPT Assistants

https://commerce.ama-assn.org/store/?node_id=nn1402

In search box, type in: CPT Assistant Newsletter

References


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https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html

Click on Internet-Only Manuals

Click on Pub 100-4Medicare Claims Processing Manual

Chapter 5, Part B Outpatient Rehabilitation

CMS Therapy Billing


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APTA Coding and Billing

http://www.apta.org/Payment/CodingBilling/

Private Practice Section of APTA – Payment Portal

http://ppsapta.org/c/paymentad.cfm?

APTA and PPS Resources

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