Patient Benefit and Clinical Revenue

in Seating and Positioning

Theresa F. Berner, MOT, OTR/L

Rehabilitation Team Leader

Smart Wheel User Group Conference

November 2, 2006

Overview

• Identify the CPT Codes utilized for seating and mobility therapy services.

• Understand the Medicare LCD documentation requirements for reimbursement.

• Identify weighting productivity to understand the therapists use of time.

• Identifying advanced training programs for Seating Clinics.

Therapy CPT Codes

• PT Evaluation: 97001

• PT Re-evaluation: 97002

• OT Evaluation: 97003

• OT Re-evaluation: 97004

• Assistive Technology Assessment:

97755• ALL EVALUATION CODES

2007 CPT code book. Professional Addition

American Medical Association

Therapy CPT Codes

• Wheelchair Management and training

– 97542

• Self-care/home mgmt. training

– 97535

• Therapeutic Activities

– 97530

• Community work re-entry

– 97537

Be aware

of use of

modifiers

Therapy CPT Codes

• Physical Performance Test or Measurement; 97750

• One-on-one patient contact

• Objective findings of a patient’s condition or status that requires him/her to receive therapy services.

• Include functional capacity wheeled mobility evaluation.

PT/OT Evaluation: 97001/3

• Components of the evaluation include

the patient history, relevant review of

systems, pertinent physical

assessments and tests/measurements.

• The evaluation must state the reason

for the initial referral to

physical/occupational therapy.

PT/OT Re-evaluation: 97002/4

• Continuous evaluation of the patient’s progress is a component of ongoing PT/OT services. A formal re-evaluation is covered only of the documentation supports the need for further tests and measurements after the initial evaluation.

• Indications for a re-evaluation include new clinical findings, a significant change in patient's condition, or failure to respond to the therapeutic interventions outline in the plan of care.

Wheelchair Management

and Training: 97542

• 15 minutes

• This service trains the patient in functional

activities that promote optimal safety, mobility

and transfers.

• Patients who are wheelchair bound may need

skilled instruction on positioning, positioning

supplies, and wheelchair modifications to

avoid pressure points, contractures, and

other medical complications.

Wheelchair Management

and training: 97542

• Typically 3-4 sessions are sufficient to teach the patient and/or caregiver these functional skills unless the patient is severely impaired or presents with another condition requiring additional treatment sessions.

• Subsequent visits may be occasionally necessary for the re-evaluation and modification of the wheelchair management and propulsion training in patients with neurological disorders such as ALS, MS or Parkinson's disease.

Wheelchair Management

and training: 97542

• Documentation must relate the training

to expected functional goals that are

reasonably attainable by the patient

and/or caregiver.

• Be aware to document medical

necessity when going beyond the 3-4

visits.

Assistive Technology

Assessment: 97755

• To restore, augment or compensate for

existing function, optimize functional tasks

and/or maximize environmental accessibility

• Direct one-on-one contact by provider with

written report

• Each 15 minutes

(To report augmentative or alternative

communication devices, use 92605, 92607)

Billing Combinations

• Can not bill 2 evaluation codes together

– Higher charge will be bumped out.

• Should not have variations of evaluation

charge: i.e.: eval; brief eval

– Higher charge will be bumped out

• Can bill Assistive Tech + w/c mgmt

together - or- Eval + w/c mgmt.

Medicare LCD requirements

• Medical Code

• Therapy Code; Clinicians must pick from LCD

• Functional level at the start of care

• Objective tests and measures

• Functional loss; why skilled therapy is needed

(self-care, mobility, safety)*

• Pain Assessment

• History of illness

www.adminastar.com

Functional Loss*

• Self-care dependence: i.e., loss of ability to

feed self, to dress, or maintain personal

hygiene.

• Mobility dependence: i.e., transfer ability, gait

training, stair climbing, wheelchair mobility,

level of strength, muscle spasticity, pain level,

joint contracture, coordination level,

perceptual motor loss, need for orthotics or

mobility device.

Functional Loss*

• Safety issues: i.e., high probability

of falling, swallowing difficulties,

severe loss of sensation,

progressive joint contracture, and

infection.

Internal Productivity

• RVU: The calculated amount of time it takes to produce 1 unit of service. Represents a weighted amount used in productivity formulas to adequately represent time required for productivity.

– Includes documentation time, materials, travel, patient preparation, supplies, etc.

• Ensure your CPT codes have accurate RVU weights. These are facility specific.

Think Differently

• Seating Clinics can be a referral base into your outpatient clinic.

• Try not to do everything all in one visit.

• Develop Clinical Guidelines and Pathways using seating. Integrate with other departments.

• Think about volume and program growth.

• Use data to return demonstration for minor equipment and FTE’s. The volume generated from referrals can pay back dollars spent on equipment.

Think differently

• Build case for increased FTE by increasing

growth from a new referral base (clinics).

• Look at where referrals are coming from and

take time to educate them on outcome of your

referral and state of the industry.

• Links with Driving Rehab Programs; working

with BVR and BWC.

Program Development

• Wheelchair Seating Clinic

– Power Wheelchair Training

– Propulsion Training

– Pressure Mapping Assessments

– Neuro Rehab Referrals

– Custom Molding

Wheelchair

Seating and

Positioning Clinic

Power Wheelchair

Trails/Training

Pressure Mapping

Evaluation

Propulsion

Training

Neuro-rehab

referral

Follow-up

and final fitting

Power Wheelchair Training

Power

Wheelchair Trial

(97542 per 15 minutes)

Power wheelchair training

(97542 per 15 minutes)

Continue as long as medically necessary

Final Fitting

(97002/4)

Pressure Mapping

Evaluation

Mapping Evaluation

(97755 per 15 minutes)

Pressure mapping

follow up @ 3 month

(97755 per 15 minutes)

Pressure mapping

follow up @ 6 month, 1 year

(97755 per 15 minutes)

Propulsion

Training

Propulsion Training

Baseline + Instruction

(97755 per 15 minutes and 97542)

Propulsion training post 2 weeks

(97755 per 15 minutes and 97542)

Propulsion training final fitting

(97755 per 15 minutes and 97542)

Propulsion training 1 month

(97755 per 15 minutes and 97542)

Propulsion training

• Identification of fitting and adjustments

• Investigating where they are wheeling

and what they are doing/not doing

• Training on propulsion efficiency

• Advanced wheelchair training

• Final fitting and necessary follow up

Wheelchair Seating

and

Positioning Clinic

Propulsion Training

Baseline + Instruction

Propulsion training

post 2 weeks

Pressure Mapping

Evaluation

Pressure mapping

follow up x3m

Pressure mapping

follow up x6m, 1 yearPropulsion training

1 month

Propulsion training

final fitting

Example of

referrals for

growth

Wheelchair Seating

and

Positioning Clinic

Propulsion Training

Baseline + Instruction

Propulsion training

post 2 weeks

Pressure Mapping

Evaluation

Pressure mapping

follow up x3m

Pressure mapping

follow up x6m, 1 yearPropulsion training

1 month

Propulsion training

final fitting

1 AT

3 w/c

4 AT

4 AT

2 AT

1 eval

1 AT

3 w/c

1 AT

3 w/c

1 AT

3 w/c

Instead of 1 visit for w/c eval,

below is gained

Visits= 8

UOS = 27

Program Development

• Looking into lifestyle needs and

opportunities for increased

independence. Use of good interviewing

skills.

• The billing is driven on what your goals

and perspective. Documentation needs

to reflect the CPT codes used.

Opportunities for Collaboration

• Physician Clinics

– PM&R

– MS Centers

– MDA/ALS Centers

– Local family practices

– Movement Disorder Clinics

• Wound Care Centers; Plastic Surgery

• Your own clinics!!