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Coding & Billing for Physical Therapy Services: Part 2

CCI Edits & Billing

Rick Gawenda, PT President

Gawenda Seminars & ConsulHng, Inc CSM 2017

February 16, 2017

Learning ObjecHves •  IdenHfy when modifier 59 is required on a CPT code and which CPT code to append the modifier 59 to on the claim form

•  Recite how one discipline’s billing may cause another discipline’s billing to require modifier 59

•  Compare the difference between Medicare's '8-‐minute rule" and definiHon of substanHal of Hme-‐based CPT codes for private insurance carriers

•  Be able to bill correctly to an insurance carrier based on services provided, amount of Hme spent on each intervenHon, and complexity of evaluaHon

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NaHonal Correct Coding IniHaHves (NCCI) •  Implemented to combat abusive and fraudulent billing pracHces

•  IniHated in 1996 in private pracHce •  Expanded to hospital outpaHent departments in August 2000

•  Expanded to Rehab Agencies (ORF), SNF Part B, CORF’s, and Home Health Agencies under Part B on January 1, 2006

•  Current version is 23.0 for private pracHce and physician owned therapy clinics and 23.0 for all other sedngs

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NCCI Edits -‐ Medicare •  In certain circumstances, specific CCI edits will be bypassed if required modifier is present & documentaHon supports the use of modifier-‐59 and the medical necessity of Tx

•  Applies to Medicare outpaHent therapy services reimbursed under the MPFS (Part B)

•  CCI edits also apply to criHcal access hospitals who are paid on a cost-‐raHo basis

•  Use of the CCI Edits for non-‐Medicare payers varies by the payer and the State


NCCI Edits – Non-‐ Medicare How Do You Know

•  Read remikance advice’s/explanaHon of benefits and work with paHent accounHng

•  Look for the following rejecHon reasons: ● This code is considered a component of a more comprehensive code on the claim and is not separately reimbursed


Modifier -‐ 59 •  DisHnct Procedural Service •  Indicates that a procedure or service was disHnct or independent from other services performed on the same day

•  Used to idenHfy procedures/services that are not normally reported together, but are appropriate under the circumstances

•  DocumentaHon must support use of modifier – 59 in that the procedures/services were provided at separate and disHnct Hmes, were medically necessary and required the skills of a therapist or therapist assistant under the supervision of a therapist


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Modifier-‐59 DocumentaHon Example

•  9:03AM-‐9:23AM, cervical mechanical tracHon (document parameters), 9:27AM-‐9:41AM, manual therapy of (document what was provided)

•  Cervical mechanical tracHon followed by manual therapy of (document what was provided, including parameters for each intervenHon)


Modifier-‐59 DocumentaHon Example

•  9:03AM-‐9:23AM, therapeuHc acHviHes working on supine to sit bed mobility and sit to stand transfers, 9:27AM-‐9:41AM, gait training with focus on weight shiming, stride length and heel-‐to-‐toe gait pakern

•  TherapeuHc acHviHes of bed mobility and transfer training followed by gait training with focus on weight shiming, stride length and heel-‐to-‐toe gait pakern (document what was provided)


Column 1/Column 2 Codes •  Codes in which one of the codes is considered a component of a more comprehensive code on the bill

•  Group Therapy (97150) and TherapeuHc Exercise (97110) or Neuromuscular Re-‐educaHon (97112)

•  Manual Therapy (97140) and TherapeuHc AcHviHes (97530) or Paraffin Bath (97018)

•  Mechanical TracHon (97012) and Manual Therapy (97140)

•  TherapeuHc AcHviHes (97530) and Gait Training (97116) •  Canalith ReposiHoning (95992) and TherapeuHc Exercise (97110), Neuromuscular Re-‐educaHon (97112), Manual Therapy (97140), and/or TherapeuHc AcHviHes (97530)


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Column 1/Column 2 Codes (cont) •  AquaHc Therapy (97113) and TherapeuHc Exercise (97110)

•  OrthoHc Management and Training (97760) and TherapeuHc Exercise (97110), Neuromuscular Re-‐educaHon (97112), Gait Training (97116) and Manual Therapy (97140)

•  ProstheHc Training (97661) and TherapeuHc Exercise (97110), Neuromuscular Re-‐educaHon (97112), Gait Training (97116), Manual Therapy (97140), OrthoHc Management and Training (97760) and Checkout for OrthoHc/ProstheHc Use (97762)

•  Any intervenHon and PT Re-‐evaluaHon (97164) or OT Re-‐evaluaHon (97168)


CCI Edit Examples Column 1 Column 2

97012 – Mechanical TracHon 97018y; 97140y; 97164y; 97168y

97140 – Manual Therapy 97018y; 97164y; 97168y; 97530y; 97750y

97150 – Group Therapy 97110y; 97112y; 97113y; 97116y; 97124y; 97140y; 97164y; 97168y; 97530y; 97532y; 97533y; 97535y; 97537y; 97542y; 97760y; 97761y

97530 – TherapeuHc AcHviHes 97113y; 97116y 97164y; 97168y; 97532y; 97533y; 97535y; 97537y; 97542y; 97750y

97750 – Physical Performance Test 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 97150n


CCI Edits •  Are applicable to one specific discipline of therapy billing different procedures on the same day that require modifier-‐59 and

•  Are applicable when mul,ple disciplines of therapy under the same provider number occur to the same beneficiary on the same day (i.e. PaHent receiving any combinaHon of PT, OT, and SLP on the same day within the same organizaHon and all services are billed on the same claim form. This occurs in SNF’s, hospitals, CORF’s, rehab agencies, home health agencies providing Part B therapy, and physician owned clinics billing incident-‐to-‐physician).


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CCI Edit Example •  Pt receives 27 minutes of SLP treatment (92507) and 32 minutes treatment of swallowing dysfuncHon (92526) on 02/08/17

•  Pt receives 28 minutes of therapeuHc exercise (97110) and 16 minutes of gait training (97116) in PT on 02/08/17

•  Pt receives OT consisHng of 32 minutes of therapeuHc acHviHes (97530) and 11 minutes of neuromuscular re-‐educaHon (97112) on 02/08/17


Modifiers

•  GN – Services delivered under an outpaHent speech-‐language pathology POC

•  GO – Services delivered under an outpaHent occupaHonal therapy POC

•  GP – Services delivered under an outpaHent physical therapy POC

•  Required since July 1, 2004 and must be on each CPT code on the claim form billed to your Medicare contractor

•  StarHng to see some non-‐Medicare payors uHlize the above modifiers such as UnitedHealthcare and some state Medicaid programs


CCI Edit Example •  By discipline, none of the procedures require modifier-‐59 to be reimbursed

•  Since this paHent was seen on the same day by more than one discipline within the same organizaHon, need to check between all disciplines (cross-‐check) for need of modifier 59

•  CMS billing system does not recognize therapy specific modifiers (GN, GO, GP) for the purpose of CCI edits


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CCI Edit Example •  In previous example, would need to append modifier-‐59 to

97110, 97112, 97116, and 97530

•  DocumentaHon would need to support that the services were performed at separate and disHnct Hmes

•  Not appending modifier-‐59 in this example would cost you approximately $140-‐$165 in lost reimbursement

•  i.e. 97110GP59 or 9753059GO or 92507GN59

•  No specific order required when applying mulHple modifier’s


CCI Edit Examples Column 1 Column 2

92507 – Speech Therapy Treatment 97110y; 97112y; 97150y; 97530y; 97532y; 97533y

92526 – Treatment of Swallowing DysfuncHon 97110y; 97112y; 97150y; 97530y; 97532y

97530 – TherapeuHc AcHviHes 97113y; 97116y 97164y; 97168y; 97532y; 97533y; 97535y; 97537y; 97542y; 97750y


CCI Updates •  Updated quarterly on the first of the month (Jan, April, July, Oct)

•  www.gawendaseminars.com •  hkp://www.cms.gov/NaHonalCorrectCodInitEd/ •  Private pracHce and physician owned therapy clinics, click on NCCI Edits – Physicians. All other sedngs, click on NCCI Edits – Hospital

•  Superscript 0 means code is not separately payable. Superscript 1 means code is separately payable. Superscript 9 means edit is no longer applicable


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End of CCI Edits

QuesHons &

Answers

“8 Minute Rule” Medicare OutpaHent

•  Applies to CPT codes Hmed in 15-‐minute increments only

•  Applies to any insurance carrier that is federally funded (TriCare, Federal BC, Medicare, Medicaid, Managed Medicare and Medicaid plans)

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

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



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

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


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≥ 8 through 22 minutes 1 unit ≥ 23 through 37 minutes 2 units ≥ 38 through 52 minutes 3 units ≥ 53 through 67 minutes 4 units ≥ 68 through 82 minutes 5 units ≥ 83 through 97 minutes 6 units ≥ 98 through 112 minutes 7 units ≥113 through 127 minutes 8 units


“8” Minute Reference •  Medicare Claims Processing Manual, Chapter 5 – Part B OutpaHent RehabilitaHon and CORF Services, SecHon 20.2

hkp://www.cms.gov/manuals/downloads/clm104c05.pdf

•  Excellent reference for Medicare’s “8 minute rule” and provides 5 case scenario’s with what was provided and the correct billing answer with the raHonale for the answer

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Non-‐Medicare Insurances “Each 15-‐Minutes” or “Per Hour ”

•  What defines “each 15 minutes” or “per hour”? •  What is considered “substanHal” of a Hme-‐based CPT per the American Medical AssociaHon (AMA) to bill a Hme-‐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 substanHal?

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


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End of Coding & Billing

QuesHons &

Answers

Almost Done

QuesHons &

Answers

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Post Test #1 Cervical Strain

•  16 Minutes Joint mobilizaHons and som Hssue mobilizaHon

•  21 Minutes Range of moHon and strengthening ex’s

•  20 Minutes Unakended E-‐sHm for pain reducHon

•  15 Minutes Cervical mechanical tracHon

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Post Test #1 Answer Cervical Strain

1 Unit 97012 Mechanical tracHon 1 Unit 97014/G0283 Unakended E-‐sHm 1 Unit 97110 TherapeuHc exercise 1 Unit 97140 Manual therapy


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Post Test #2 Wrist Fracture -‐ Medicare

•  10 Minutes Unakended electrical sHmulaHon

•  12 Minutes Strengthening and acHve – assist range of moHon exercises

•  6 Minutes Manual therapy to increase ROM

•  7 Minutes FuncHonal acHviHes of grasping and pinching acHviHes


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Post Test #2 Answer Wrist Fracture

1 Unit G0283 Unakended electrical sHmulaHon 1 Unit 97110 TherapeuHc exercise 1 Unit 97530 TherapeuHc acHviHes


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Post Test #3 Shoulder Joint Impingement

•  27 Minutes Re-‐evaluaHon

•  12 Minutes UBE for shoulder warm-‐up

•  18 Minutes Shoulder strengthening and ROM exercises

•  12 Minutes Manual therapy techniques to increase AROM


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Post Test #3 Answer Shoulder Joint Impingement

1 Unit 97002/97004 Re-‐evaluaHon 1 Unit 97110 TherapeuHc exercise 1 Unit 97140 Manual therapy


Post Test #4 Shoulder Rotator Cuff Repair

•  25 Minutes TherapeuHc exercises for strengthening of the shoulder

•  25 Minutes Manual therapy techniques to increase shoulder range of moHon


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Post Test #4 Answer Shoulder Rotator Cuff Repair

•  If Following AMA Billing Guidelines, bill: 2 units 97110 2 units 97140

•  If Following “8-‐Minute Rule”, bill: 2 units 97110 and 1 unit 97140 OR 1 unit 97110 and 2 units 97140


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Post Test #5 L/E Amputee

•  15 Minutes Strengthening exercises of the residual limb

•  25 Minutes Gait training with the prosthesis in place with focus on stride length, weight shiming, and symmetry of gait

•  10 Minutes ModificaHon of prostheHc using stump socks


Post Test #5 Answer L/E Amputee

•  If Following AMA Billing Guidelines, bill: 2 units 97116 2 units 97761

•  If Following “8-‐Minute Rule”, bill: 2 units 97116 and 1 unit 97761 OR 1 unit 97116 and 2 units 97761


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Post Test #6 •  PaHent is a 36 year-‐old male with complaint of low back pain that began 2 weeks ago; however, 2 days ago, began to experience radiaHng pain and numbness on the top and sole of his right foot. Rates his back pain as 6/10. PaHent states he wakes up 3-‐4 Hmes per night due to pain

•  PMH/PSH: Insignificant •  MMT: ankle DF 4/5, great toe DF 3+/5, ankle PF 4-‐/5


Post Test #6 •  L4 and L5 right transverse processes more posterior than lem

•  Decreased sensaHon to light touch and pinprick top and bokom of right foot

•  PaHent exhibits an antalgic gait pakern with weight bearing on right L/E. Exhibits a decreased stance Hme right L/E compared to lem L/E.

•  Oswestry score is 44%. PaHent can sit or stand no more than 30 minutes. He can’t lim heavy weights, but can lim and carry medium weight items.


History - PT Low Patient Pertinent History

A history with no personal factors (includes environmental factors) and/or comorbidities that impact the plan of care

Personal Factors: •  None Co-morbidities (Impacting P of C) •  None

Moderate A history of present problem with 1-2 personal factors (includes environmental factors) and/or comorbidities that impact the plan of care

High A history of present problem with 3 or more personal factors(includes environmental factors) and/or comorbidities that impact the plan of care


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Examination - PT Low Examination

An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions

Body Functions 1.  Sensation and Pain 2.  Muscle Power

Body Structures 1.  Structure of trunk

Activities of Daily Living Limitations 1.  Mobility – walking 2.  Maintaining Body Position –

sleeping 3.  Carrying limitations

Oswestry Score – 44%

Moderate An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions

High An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions


Clinical Presentation - PT Low Clinical Presentation

A clinical presentaHon with stable and/or uncomplicated characterisHcs

What do you think?

Moderate An evolving clinical presentaHon with changing characterisHcs

High A clinical presentaHon with unstable and unpredictable characterisHcs


Decision Making - PT Low Decision Making

Clinical decision making of low complexity using standardized paHent assessment instrument and/or measurable assessment of funcHonal outcome

What do you think?

Moderate Clinical decision making of moderate complexity using standardized paHent assessment instrument and/or measurable assessment of funcHonal outcome

High Clinical decision making of high complexity using standardized paHent assessment instrument and/or measurable assessment of funcHonal outcome Property of Gawenda Seminars &

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Post Test #7 •  PaHent is a 51 year-‐old right hand dominant female with a diagnosis of right carpal tunnel syndrome

•  PaHent works as an administraHve secretary and is currently off of work due to her condiHon

•  PaHent rates her wrist pain as 6/10 •  Dynamometer tesHng reveals lem grip strength 59 lbs and right grip strength 38 lbs

•  PMH/PSH: Colles fracture right wrist 6 months ago




Personal Factors: •  None Co-morbidities (Impacting P of C) •  Colles Fracture






Body Structures 1. Wrist joint and hand Body Functions 1.  Sensory Functions and Pain 2.  Muscle Power

Activities of Daily Living 1.  Self Care – Dressing 2.  Domestic Life – Meal Preparation




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What do you think?






What do you think?




Post Test #8 •  PaHent is a 78 year-‐old female who had a non-‐traumaHc brain stem infarcHon 9 weeks ago.

•  PaHent spent 12 days in an IRF and then 5 weeks in a skilled nursing facility and now presents to outpaHent therapy

•  Therapist did a review of hospital IRF therapy records as well as SNF physician and therapy records and documentaHon


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Post Test #8 •  Personal Factors: 5’3” and 183 pounds. Husband passed away 5 months ago. PaHent lived alone prior to the CVA and is now staying with her 53 year-‐old daughter who provides assistance to her mom. PaHent having a difficult Hme coping with death of her husband. She was going to a support group, but now is unable to akend. PaHent became very emoHonal during evaluaHon (crying)

•  PMH/PSH: Type 1 insulin dependent diabetes, legally blind, lem knee replacement 8 months ago


Post Test #8 •  PaHent presents with short-‐term memory deficits as well as sustaining akenHon to tasks

•  PaHent presents with muscle weakness right U/E and right L/E, a hemiplegic gait pakern, and propriocepHve deficits on right side

•  PaHent requires minimal PA with bed mobility and transfers and ambulates with a roller walker 35-‐50 feet with minimal PA and verbal guidance for sequencing


Post Test #8 •  PaHent requires minimal PA for U/E dressing, moderate PA for L/E dressing and minimal PA for bathing and toileHng

•  Due to physical and cogniHve deficits, paHent unable to perform domesHc acHviHes of household chores including vacuuming, dusHng and laundry

•  Due to cogniHve deficits and limitaHons with staying focused, physical therapist had to provide moderate verbal guidance and assistance to the in order for the paHent to complete some tasks


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Personal Factors: 1.  Husband passed away 5 months

ago 2.  Lives alone Co-morbidities (Impacting P of C) 1. Legally blind 2. Insulin dependent diabetes 3. Left TKA 8 months ago






Body Functions 1.  Mental functions 2.  Muscle Power 3.  Movement functions

Body Structures 1.  Structure of brain 2.  Structure of upper extremity 3.  Structure of lower extremity

Activities of Daily Living 1.  Dressing due to weakness, balance, and

proprioceptive deficits 2.  Bathing due to weakness, balance, and

proprioceptive deficits 3.  Toileting due to weakness, balance, and

proprioceptive deficits 4.  Functional mobility due to weakness, balance,

and proprioceptive deficits 5.  Bed mobility due to weakness, balance, and

proprioceptive deficits 6.  Transfers due to weakness, balance, and

proprioceptive deficits 7.  Domestic life activities due to weakness,

balance, cognitive and proprioceptive deficits






What do you think?




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What do you think?




Post Test #9 •  PaHent is a 7 year old female referred to therapy due to generalized muscle weakness, difficulty walking and recent episodes of falls. PaHent was diagnosed with cerebral palsy at 2.5 years of age

•  PMH: AkenHon Deficit HyperacHvity Disorder (ADHD)

•  Social Factors: Moodiness


Post Test #9 •  Muscle Tone: PaHent presents with dystonia bilateral L/E’s and L/E weakness.

•  Gait: PaHent presents with an in-‐toeing and waddling gait pakern while using a roller walker. PaHent requires moderate assistance during gait to prevent her from falling.

•  Coordina,on: During evaluaHon, paHent presented with dyskineHc movements that impacted her balance when assessing her gait


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Post Test #9 •  Si<ng Balance: PaHent unable to sit independently without bilateral hand support

•  Self Care: PaHent requires assistance with bathing, toileHng, and dressing due to muscle weakness and balance deficits




Personal Factors: •  Moodiness Co-morbidities (Impacting P of C) •  ADHD




Examination - PT Low Patient Pertinent History


Body Structures 1.  Structure of Lower Extremity Body Functions 1.  Muscle weakness 2.  Control of voluntary movement

functions

Activity Limitations 1.  Self Care – Dressing 2.  Self Care – Washing L/E’s 3.  Self Care - Toileting 4.  Mobility – Walking 5.  Changing and Maintaining Body

Position - Sitting




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Clinical Presentation - PT Low Patient Pertinent History


What do you think?




Decision Making - PT Low Patient Pertinent History


What do you think?




Post Test #10 •  PaHent is a 78 year-‐old male who had a right TKA 1 week ago. PaHent is 5’10” and weighs 245 lbs. PaHent resides at home alone; however, his son is staying with him for a few weeks. Son works during the day. PaHent has 3 steps into the house with one handrail. PaHent is WBAT L L/E

•  PMH: HTN, Insulin dependent diabeHc, O/A right hip, Lem TKA 3 months ago


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Post Test #10 •  ROM: Knee flexion: 86°, Knee extension: -‐6° •  MMT: Hip flexion 4/5, knee extension 3+/5, knee flexion 3+/5

•  Pain: PaHent rates pain as 4/10 •  Gait: Independent using standard walker on level surfaces. Exhibits decreased stance Hme on right L/E compared to lem and exhibits increased hip flexion on lem during swing phase to compensate for decreased ROM and strength.


Post Test #10 •  Stairs: Ascends/descends 3 steps into the house using bilateral handrails and CGA of wife.

•  Self Care: Son assists him with L/E bathing and L/E dressing. PaHent is using a tub bench for showering and an elevated toilet seat for toileHng as he is unable to stand up from the regular toilet

•  Incision: Has minimal drainage coming from distal incision site and incision is slightly open at distal end




Personal Factors: •  None Co-morbidities (Impacting P of C) •  BMI •  O/A Right Hip •  Insulin dependent diabetes •  Left TKA 3 months ago




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Examination - PT Low Patient Pertinent History


Body Structures 1. Structure of Lower Leg – Knee joint Body Functions 1.  Pain 2.  Muscle weakness 3.  Joint stiffness 4.  Protective functions of skin

Activity Limitations 1.  Self Care – Dressing 2.  Self care – Washing L/E’s 3.  Mobility – Walking and stairs 4.  Transfers from toilet




Clinical Presentation - PT Low Patient Pertinent History


What do you think?




Decision Making - PT Low Patient Pertinent History


What do you think?




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CMS NCCI Edits •  Centers for Medicare and Medicaid Services, NaHonal Correct Coding IniHaHve Edits hkp://www.cms.gov/Medicare/Coding/NaHonalCorrectCodInitEd/index.html


References 1. American Medical AssociaHon Current Procedural Terminology; CPT 2017; Professional Edi;on

2. American Medical AssociaHon CPT Changes 2017: An Insider’s View


References 1. American Physical Therapy AssociaHon: Payment Reform hkp://www.apta.org/PaymentReform/

2. CMS 2017 Final Rule for Services Paid Under the Medicare Physician Fee Schedule hkps://www.federalregister.gov/documents/2016/11/15/2016-‐26668/medicare-‐program-‐revisions-‐to-‐payment-‐policies-‐under-‐the-‐physician-‐fee-‐schedule-‐and-‐other-‐revisions


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ICF References 1. InternaHonal ClassificaHon of FuncHoning, Disability and Health hkp://apps.who.int/classificaHons/ic~rowser/

2. World Health OrganizaHon, InternaHonal ClassificaHon of FuncHoning, Disability and Health hkp://www.who.int/classificaHons/icf/en/

3. World Health OrganizaHon, A PracHcal Manual for Using the ICF hkp://www.wcpt.org/node/102810


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