Coding and billing
Breaking down an ICD-10 code
-Characters 1-3: identify the category -Characters 4-6: identify etiology, anatomic site, severity or some clinical details -Character 7: extension (such as 'initial encounter' or 'subsequent encounter with patient for this condition')
Red flag #4
-charging for unskilled care
Red flag #5
-confusing timed and untimed codes -Some codes reimburse the same, regardless of the length of time spent in delivery; these are UNTIMED CODES *Untimed codes do not track units, no matter how much time is spent with the patient. -Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one-on-one) time spent in patient contact is 15 minutes; these are TIMED CODES. *Timed codes allow charges based on the amount of time spent with the patient *Providers report procedure codes for services delivered on any calendar day using CPT codes and the appropriate number of units of service (if timed).
ICD-10
-diagnostic codes -justify why we are seeing a patient
Red flag #3
-group vs 1:1 confusion
Time units
-1 unit: 8 minutes to < 23 minutes -2 units: 23 minutes to < 38 minutes -3 units: 38 minutes to < 53 minutes -4 units: 53 minutes to < 68 minutes - 5 units: 68 minutes to < 83 minutes -6 units: 83 minutes to < 98 minutes
New and sobering policy
-Beginning January 1, 2011 *This policy will pay 100% of the practice expense (PE) component of the CPT code/unit with the highest Relative Value Unit (RVU), *and then apply a 25% payment reduction to the PE of any second and subsequent codes or units. *The policy applies to all "always therapy" service codes billed by a single Part B provider or institution (as identified by NPI) for a patient in one day
CMS in 2016 and codes
-CMS looked at 2016 physicians fee schedule and identified 103 CPT codes that 'it believes are overvalued and (reimbursement) should be adjusted downward'. -Ten of those codes are typically used in our practices. -Our associations are fighting to have some of our codes REMOVED from this list
New codes that do not guarantee payment
-CPT 2009: New code 95992 Canalith repositioning procedure(s), per day -BUT...Medicare decided that it viewed this procedure as part of (bundled into) existing code 97112 (neuromuscular re-ed) and wouldn't pay separately for it.
New codes that offer payment for what we do
-CPT 2012: Two new EMG codes -CPT 2010: One new wound code *new wound care code pertaining to treatment of chronic venous insufficiency with multilayer compression *Lower Extremity Strapping - Any Age 29581 Application of multi-layer venous wound compression system, below knee *This code should not be reported with the following CPT codes: 29540 Strapping; ankle and/or foot 29580 Strapping; Unna boot
Problem for PT of ICD-10
-lost some diagnoses -Not every diagnosis received a specific code so you may have to rethink how to describe a diagnosis
Differences that developed in ICD-10
-more codes to address more conditions -(slightly) modified existing codes to make diagnoses more specific; -Added character length so increases number of codes provider can choose between for best fit -NOT a direct "1:1 matching update"
Impact of switching to ICD-10 code system
-need training to understand new coding options -more specific documentation to show why we picked one code over another **previously general codes now much more specific
Benefit for OT of new ICD-10
-new codes that differentiate between behavioral issues and non behavioral issues with mental health problems -harder to work with behavior issues and takes more time so it makes sense to get paid more and to document it
Are all CPTs financially equal
-no -the components of work (approximately 50.9%); *time required to perform the service *technical skill and physical effort *mental effort and judgment *psychological stress associated with provider's concern about the risk to the patient -practice expense (approximately 44.8%); *Beginning in 1998 and continuing today, some CPT codes were assigned two (2) practice expense RVUs: a lesser $$ amount for procedures performed in a facility (ie, a hospital, skilled nursing facility, or ambulatory surgical center) and a greater $$ amount for procedures/services performed at a non‐facility site (ie, physician's office or -professional liability (or malpractice). (approximately 4.3%) (Adjusted every 4-5 yrs) -The relative values for each of these components is adjusted by a GPCI (geographic practice cost indicies) and multiplied by a dollar conversion factor which is published by HCFA each year in the Federal Register
6 red flags of coding issues
-Up-coding -Unbundling -1:1 v. group charge -Charging for unskilled care -Charging time units for untimed codes -The problem of the 8 minute therapist
CPT code answers the question
-What was done by the provider to impact (NOT 'treat') the issues for which the client sought PT or OT care? -Which procedures (representing skilled OT or PT) were performed during the patient's visit?
Standards used to evaluate red flag situations
A practitioner does not have to intend to defraud the federal government to be held liable for fraud. In fact, the government only has to prove that the practitioner acted with "deliberate ignorance" or with "reckless disregard" for the truth or falsity of information specified on claims
The ICD-10 code answers the question
Why did the client specifically seek PT or OT care?
How many codes
currently over 8,000
Does medicare pay for telephone medical discussion
no
CPT
-billing codes -what we have done for the patient
Therapeutic procedure
-Community/work reintegration training (eg. Shopping, transportation, money management, pre-vocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment)
Process to add a code
-Complete 10 page justification form (see AMA website if interested) *must include case study to define what conditions might be treated by the new code -Submit form to Editorial Panel for review at one of the quarterly meetings -Usually a code must be deleted/combined before a new code is added (takes about 2 yrs) -Turf battles
What are CPT codes
-Current Procedural Terminology -Balanced Budget Act of 1997 required that all Medicare outpatient (Part B) OT and PT services be reported by CPT code and paid under the RBRVS fee schedule. -Used by government to study utilization of services (to decide whether to pay/deny) -They are procedure codes -Procedure codes describe specific services preformed by health care professionals. -One of the most widely used procedure-coding systems is the HCFA Common Procedure Coding System (HCPCS), which includes the American Medical Association's Physician's Current Procedural Terminology (CPT)
Selecting an ICD-10 code
-Documentation must describe patient's condition well enough to justify code chosen -More than one ICD-10 code can be used, but list first the code that represents the main reason for most of the services to be provided -caution:strictly medical diagnoses; new areas for OT/PT involvement
What is the ICD-10-CM
-International Classification of Diseases, Clinical Modification -ICM system originally developed in the US in 1950s -Provides international language that allows retrieval of medical info by diagnosis *replaced often vague words with more specific numbers *easier to track diagnostic trends -Describes the medical necessity of a visit -Allows epidemiological studies about which CPT (later in lecture)are charged for certain diagnosis
Newest codes
-Jan 1, 2017 -Farewell old PT and OT evaluation and reevaluation codes -The new tiered codes
Why code our diagnosis
-Licensed professional is responsible for paperwork submitted under that number -Fraud to bill for unskilled service *if biller chooses ICD-10 code that does not support the CPT intervention codes, your treatment can be denied bc it will seem to be incorrect -Practice act: *if wrong code picked, looks as if provided services outside of our scope. -careful use of ICD-10 codes can expand our practices -can show we are the best provider of choice -good results by OT and PT can sway insurer contracting practices
How many times an untimed codes can be billed for
-Medicare specifies that evaluation may be billed only once per discipline, per date of service, per patient. However, treatment codes can be billed for twice per day treatment if documentation shows the need for separate treatment sessions
How do insurers use CPT codes
-Monitor fraud and abuse -Track practice patterns -Identify those interventions that were most effective (ie: treatment strategies, especially those that coupled with shorter length of time to accomplish goals, might be reimbursed higher/more often)
Is specificity always helpful
-NO -more codes is not always better
What is the size limit for a group session
-Neither CMS or AMA have defined the size of a group. States may have limits in the practice act concerning the number of patients seen simultaneously but OK does not. -NOTE: A group must have at least two members or it is not a group.
What is 1:1 care
-Patient receives 'constant attendance' of provider in direct patient contact (can have interrupted intervals) -Therapist is treating 1 patient during those billing minutes -Time based code, so therapist can charge units to reflect entire amount of 1:1 time
Group therapy service (code 97150)
-Pay for outpatient physical therapy services (which includes speech-language pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy services. The individuals can be, but need not be performing the same activity -The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required. -CMS further clarified usage of the group code in Carriers Manual Transmittal 1753, dated May 17, 2002.
How does an ICD-10 code look in practice
-S52 Fracture of forearm -S52.5 Fracture of lower end of radius -S52.52 Torus fracture of lower end of radius -S52.521 Torus fracture of lower end of right radius -S52.521A Torus fracture* of lower end of right radius, initial encounter for closed fracture
What is group care
-Skilled intervention for 2 or more clients -Clients may or may not be performing the same activity -Therapist must be in 'constant attendance', but direct 1:1 patient contact not needed
Who edits the CPT
-The 16-member CPT Editorial Panel of the AMA meets 4 times a year and considers proposals for changes to CPT. The Editorial Panel is supported in its efforts by the CPT Advisory Committee, which is made up of representatives of more than 90 medical specialty societies (PT and OT too) and other health care professional organizations **we only have 1 representative
How long is a group session
-The duration of the group session should be sufficient to ensure that professional ("skilled") services are provided. -Because the code is not a timed code, it can be used with other interventions provided on the same day of services, although modifiers may be required. -Limit of 1 group per day charge
How ICD developed and changed
-The key players *a. American Medical Association (AMA) *b. World Health Organization's (WHO)classifications for data storage and retrieval -1956: goal of making patient diagnostic information more useable (by making it standardized) in the entire medical community -Since 1988, physicians have been required by law to use diagnosis codes when billing for Medicare and Medicaid -Realization that existing ICM-9 did not fully reflect medical service delivery as it was practiced today
PMR CPT codes
-The physical medicine and rehabilitation CPT -These codes do NOT belong to our disciplines and we are not restricted to these codes but we usually use these codes to bill -evaluation codes; 2017 changes!!!! -supervised modalities -constant attendance modalities -therapeutic procedures (most frequently use code) -tests and measures
What is reimbursable with a CPT code
-postive changes on patients level of desired function -We (like every other service interaction) are not paid for the act of service delivery...but for results **And we need to define 'results' before the payers do it for us because they are beginning to ask this question
Red flag #6
-the 8 minute therapist -Therapists don't have to document the minutes spent on each CPT code. They can sum up the total minutes spent providing modalities, therapeutic procedures, and evaluations/assessments (where applicable) that are timed codes and assign units as appropriate. -Then, therapists must document the total treatment time (this is where untimed codes are included). The maximum # of CPT units (to represent timed or untimed codes) CANNOT exceed the total number of minutes in the session. -For example: If a session lasts 54 minutes, then the most that can be charged is 4 units, regardless of how many timed or untimed CPT codes were generated. BUT---don't forget to document everything -Included with the release of the 8-minute guideline is the "total time guideline" that states that the total treatment time should be reflected in the billing. If a patient received 10 minutes of therapeutic exercise (97710), 10 minutes of gait training (97116) and 10 minutes of neuromuscular reeducation (97112), the provider should only bill for a total of 30 minutes of timed service (2 units). -In this situation, the provider should select two procedure codes for billing THAT REPRESENT THE MAIN PURPOSE OF THE SESSION but the documentation should reflect all the services that were provided.
Red flag #2
-unbundling -Separately billing for services that should fall under a larger code-result in overpayment -EX: daily visit for wound care can't file separate charges for: *WP *Dressing removal *Dressing application *Re-evaluation -never appropriate to unbundle
Red flag #1
-up-coding -Rounding up one charge for higher reimbursement -EX: billing 2 units instead of one; billing evaluation code for mini-screen -coding reflects ONLY time spent in treatment, not time spent in documentation, patient question, and set-up
APTA on group therapy
The policy states that outpatient therapy services provided simultaneously to two or more individuals by a practitioner constitutes group therapy services and should be billed as such. The individuals can be, but need not be performing the same activity. The therapist involved in group therapy services must be in constant attendance and must provide skilled services to the group.
