Documentation Unit 2
Procedural Coding:
"Common Procedural Terminology" or "CPT" codes = 7 digits
G8990, G8991, G8992, G8993, G8994, G8995
"Other" PT/OT - used when first four does not cover functional limitation
Many codes are "timed" to
(15-minute "units")
Modifiers - 2-character codes (alphanumeric) Examples:
-GP added to 97001 = 97001-GP: means PT eval was performed by a PT -59 added to indicate distinct procedures. Therapeutic exercise 97110 could overlap with aquatic therapy 97113. If land-based exercise performed in addition to aquatic 97110-59 and 97113-59
Describe some common screening tools used in physical therapy
00
Describe the similarities and the main differences that may occur between Discharge Summary Notes and Interim Progress Notes
00
Describe what outcome measures are and why they are used
00
Who can determine G-Codes?
00
tx Unit lengths
1 unit = 8-22 minutes 2 units = 23-37 minutes 3 units = 38-52 minutes 4 units = 53-67, and so on . . .
Codes Used in other countries since
1990s
Treatment Note example
3x/week, or daily treatment - one note per week may be more like a "progress note," while the other notes during the week are shorter and less detailed
how many functional G-codes
42 (14 sets of 3 codes each)
First three digits code ex:
715 = osteoarthritis
Full Code ex:
715.15 = osteoarthritis of knee, primary site of involvement
The main difference between interim and discharge notes
ALL LONG-TERM GOALS SHOULD BE ADDRESSED in the discharge summary
when therapy is not intended to treat a functional limitation, instead of a severity modifier, use a
CH modifier
Requirements from third party payers
CHANGE on a regular basis, Particularly in outpatient settings
Who oversees Medicare?
CMS (Centers for Medicare/Medicaid Services)
Purposes of Treatment Note
Document what occurred during the session, Document skill required for the session, Support billing codes used for that date, Detail to accurately reflect the session and allow replication of interventions
The Discharge Summary Note
Documentation of the final visit for an episode of care, very similar to the Interim Progress Note
Documentation is required for
EVERY patient visit or encounter
3-7 alphanumeric codes:
First 3 digits: alpha (not U), numeric, numeric - Category Next 3 digits: any alphanumeric combo - Etiology, Anatomical Site, Severity Last digit: alpha or numeric - Extension (not always used) to provide data about the characteristic of the encounter Ex: A = initial encounter (seeing MD first time for c/c) S = Sequela (for PT ongoing visits)
Codes 3-5 digits
First 3 digits: health condition, followed by decimal After decimal, 2 more digits can be added for further clarification (e.g. body part)
Reassessment/Reevaluation Notes
Formal reevaluation would entail essentially a new examination/evaluation - note will be similar to the initial examination/evaluation note Much more detailed than Treatment or Progress Notes
Starting July 1, 2013 all claims MUST have
G-Codes (in addition to other coding)
Do I write a "Treatment Note" or a "Progress Note"?
GENERAL RULE: At a minimum, Progress Notes should occur monthly If billing insurance for physical therapy services, you should always be aware of and follow directives from third party payers about documentation requirements
These codes are ALWAYS therapy codes
GP: in PT POC GO: in OT POC GN: in SLP POC
Retired as of October 2015
ICD-9 codes (developed by WHO over 30 years ago)
Severity Modifiers Chart
Modifier Impairment / Limitation / Restriction CH 0% impaired, limited, or restricted CI 1% to <20% impaired, limited, or restricted CJ 20% to <40% impaired, limited, or restricted CK 40% to <60% impaired, limited, or restricted CL 60% to <80% impaired, limited, or restricted CM 80% to <100% impaired, limited, or restricted CN 100% impaired, limited, or restricted
Part C Medicare
Now called "Medicare Advantage" - replaces A and B for those who choose to enroll premiums paid with benefits beyond typical A and B coverage (such as prescription drugs, dental, vision, health club memberships)
ICD-10 finally started in US in
October 2015
G-Codes are reported at these times
Onset of therapy episode of care (evaluation) At least once every 10 treatment days Re-evaluation Discharge End of reporting on one set of G-Codes and initiating a new set to continue therapy
Medicare "Parts"
Part A: Inpatient hospital stays (acute care, rehabilitation), skilled nursing facilities (SNFs), home health. Typically no premium paid. Part B: Physician visits, outpatient services including PT. Premium paid to receive. Can only have B if have Part A. Part C: Now called "Medicare Advantage" - replaces A and B for those who choose to enroll, premiums paid with benefits beyond typical A and B coverage (such as prescription drugs, dental, vision, health club memberships) Part D: Private prescription drug enrollment plan
Medicare Part B Considerations related to reimbursement
Pays on fee-for-service model, Cost control measures, Review of claims (compare dx c visits, etc.), Therapy cap (annual), Audits for documentation compliance, Plan of care (POC) based on PT exam Include standard functional measures (e.g. FOTO) Initial POC signed by physician, and recertified every 90 days or per POC indications Reassess and write progress report every 10 visits (or every 30 days) PT must document initial exam, progress notes, and discharge PTA may only document daily/treatment notes
Part B Medicare
Physician visits, outpatient services including PT. Premium paid to receive. Can only have B if have Part A
Documentation and billing should be
accurate and consistent, complete, support tx, do not add information later (appears fraudulent)
If more than one G-Code set applies
choose the ONE functional limitation that: Is most clinically relevant to successful outcome for patient Would yield the greatest functional progress Example: mobility vs. self-care - choose the one that will take the longest but still achievable and Is the greatest priority for the patient
What should you always document when using severity modifiers?
clinical judgment in choosing a severity modifier
Discharge Subjective
direct comparison between initial/interim documentation and final documentation Comparisons relate to patient complaints, concerns, goals Comments on overall improvement, specific functional improvements, changes brought by interventions Typically will not need subheadings in the Subjective portion of the Discharge Summary Note
If a claim is denied based on Technical errors (missing claim info, minor coding issues)
fix problems and resubmit
Discharge Summary Note
for last encounter in the episode of care
Length of a Treatment note can depend on
frequency of treatment
Preventing DENIALS and need for appeals can be accomplished by
good documentation and billing, know CP codes, know exclusions/limitations, show skill with CPT (ex: code for gait training instead of ambulation)
Show skill with CPT terminology
how your PT skills are necessary using CPT language. Example: Use "gait training" instead of "ambulation" - indicates skill, language from CPT coding
Websites where codes can be looked up
https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx http://www.icd10data.com/ICD10CM/Codes
Typically Objective portion will be the longest portion to describe
interventions
treatment provided is not covered)
may file an appeal- APPEALS: file if you believe care met coverage requirements - these may take months to get paid, if you get paid at all
For most patient situations, reassess/reeval
not needed or performed
Many codes require 1:1 treatment performed meaning
one PT per pt
Other encounters you may document
phone calls, electronic communication, communication with other health care providers about the patient's care
A Treatment Note CAN be as long as (and include) as much information as a
progress note, but is not required to do so
US health care costs are increasing mostly because
providers and insured persons being insulated from costs
Discharge Objective
reassess tests and measures that address LTGs, Other pertinent tests, measures, observations can be performed as well
MACs purpose
receive, review, and pay Medicare claims for health care services in their region
Severity modifiers for G codes are used to
reflect score from a functional assessment tool or performance measurement by the use of multiple tools (clinical judgment used to combine results into functional limitation percentage)
CMS contracts with
regional Medicare administrative contractors (MACs)
Medicare/CMS
sets the standard protocol
Reassessment/Re-eval notes can be dictated by
state law or facility policy
Interim Notes
subsequent visits (includes: Treatment notes, Progress notes, Reassessment notes, or Reevaluations)
Discharge Assessment
summary statement similar to that in the initial exam/eval, but the discharge note would include: Summary of pt hx and progress, Reasons for d/c from therapy (due to all goals met), Discontinuation due to lack of progress/request to discontinue/insurance coverage/financial resource problems/physician directive, Transfer of care Patient's overall satisfaction with therapy In the assessment section, all LTGs are addressed as having been met or not met
Medicare/Medicaid
tax-funded pool
Initial Examination/Evaluation Note
the initial visit
Can only bill for a reevaluation as determined by
third party payers
Documentation required for every
visit/encounter
Treatment Notes (might also be called "Daily Notes") are written _______
written EVERY visit unless a progress note or re-eval is written instead
G8978, G8979, G8980
Mobility: walking and moving around
procedural coding Example
97001 = PT evaluation
Rising costs of healthcare initiated the creation of
Affordable Care Act introduced in 2010
Know your CPT codes because
CPT code descriptions can be very similar but mean different things Example: 97110 and 97112 - both are therapeutic exercises 97110 = "therapeutic exercises to improve strength, endurance, ROM, flexibility" 97112 = "exercises for balance, coordination, proprioception"
G8984, G8985, G8986
Carrying, moving, and handling objects
G8981, G8982, G8983
Changing and maintaining body positions
Good documentation habits
Complete documentation immediately or same day Avoid ambiguous phrases like "tolerated treatment well", Make decision-making process clear, Avoid vague phrases such as "Continue as above" in POC - use POC to show progress and what you will be doing next visit, Give clear descriptions to completely reproduce the same intervention at a later visit
Billing:
Completion of standardized claim form (usually) either manually or electronically for reimbursement
Each G-Code set contains
Current status Projected goal status Discharge status
Within the 3 code sets of G codes are
Current, Goal, Discharge related to the functional limitation 6 sets used for PT and OT functional limitations
G-Codes Applies to
Medicare Plan B (outpatient - including some Part A (e.g., hospital observation)) PT, OT, SLP
Claims denials and appeals:
If insurer denies payment on a claim, then a denial and Explanation of Benefits (EOB) is sent to patient and provider
Know exclusions and limitations because
Informed consent on treatments that are excluded in coverage- then patient may be billed directly if insurance denies claim
Part A Medicare
Inpatient hospital stays (acute care, rehabilitation), skilled nursing facilities (SNFs), home health. Typically no premium paid
3-7 alphanumeric code Examples:
M00-M99 = Diseases of the musculoskeletal system and connective tissue M15-M19 = Osteoarthritis
Code ex:
M17 = Osteoarthritis of the knee M17.11 = Unilateral primary osteoarthritis, right knee M17.11XS = Unilateral primary osteoarthritis, right hip, (X = place holder), sequela
Most private insurance companies model which set of policies and claims submission processes?
Medicare's
Choose ONE G-Code set which most closely relates to
Primary functional limitation related to treatment, OR Primary reason for treatment
Part D Medicare
Private prescription drug enrollment plan
Discharge Plan
Provide list of anything that will take place following final session with the patient ex: Follow-up plans? Referral to other providers/settings HEP, Transition to participation (work, school, etc.) Plans for pt to progress toward goals not yet met Communication with other providers re: status
Progress Notes are written at regular intervals depending on
Rate of patient progress Policies and procedures of the facility Frequency of patient visits
When to write Treatment or Progress Note?
Reassessment/Reevaluation Notes
Reimbursement Claims Steps
Register new patient: verify insurance and coverage, submit required documentation (such as referrals) Diagnosis Coding: conversion of patient info into a format ("codes") to be submitted to insurance company
managed care may include any of these items (not an exhaustive list)
Restriction of choice of health care providers, Use of gatekeepers, Co-pays, deductibles, HMOs, IPAs, PPOs, Pre-authorization for services, Diagnosis exclusions, Caps on allowed amounts, Bundling of services into "combos" (e.g., prospective payment systems, capitation)
8 sets of G codes used for
SLP functional limitations
There are other coding systems used in which specialized settings?
SNFs, home health
G8987, G8988, G8989
Self-care
Progress Notes
Similar to Treatment Note, but longer and more detailed, Reassess more of the initial tests and measures that are pertinent to the impairments, activity limitations, and participation restrictions the patient is experiencing, Will have longer assessment and plan portions of note
Medicare
Social insurance program established in 1965 for Americans in three categories: aged >65 or With disabilities or end-stage renal disease
Reassessment/Re-eval note required when
There is any significant change in pt status/ change in plan of care
Types of Interim Notes
Treatment (Daily) Notes Progress Notes
TYPES OF INTERIM NOTES
Treatment Notes, Progress Notes, Reassessment/Re-eval notes
Describe the different types of Interim Documentation
Treatment Notes, Progress Notes, Reassessment/Reevaluation Notes
Describe what is included in the SOAP in each of the different types of interim documentation
Tx = what occurs during visit; Progress = longer and more detailed than tx note, includes retest measures; Reassess/re-eval =similar to initial exam/eval, will have more detail than tx or progress notes
