Coding and Reimbursement Highlights PDF 2024

Coding and Reimbursement Highlights October 29, 2024 Washington University Program in Physical Therapy Reimbursement Reimbursement Restitution for something owed Identify services as Physical Therapy CPT codes Modifiers Document elements of...

Coding and Reimbursement Highlights October 29, 2024 Washington University Program in Physical Therapy Reimbursement Reimbursement Restitution for something owed Identify services as Physical Therapy CPT codes Modifiers Document elements of the examination, evaluation, diagnosis, and prognosis Physical Therapist Adhere to guidelines per payer Claim processing Thorough documentation and chart retention http://www.apta.org/Payment/CodingBilling/ https://www.choosept.com/Default.aspx Physical Therapy Billing Guide | WebPT Program in Physical Therapy 2  Measures patient outcomes Need for services Complete Justifies plan of care Documentation Produces negative impact Communication Incomplete Reimbursement Documentation Risk Management Patient care Program in Physical Therapy 3 Successful Reimbursement Thorough documentation Timely claim submission Proper coding Pre-determined charge Out of pocket cost amount collection Current contracts Know and follow insurance guidelines Program in Physical Therapy  Balance Billing Eligibility Case Rate Denial CMS Billing Terminology Co- Deductible Insurance Co- CPT payment Program in Physical Therapy 5 ICD-10 Coding Official Guidelines https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding- guidelines.pdf Mostly alphanumeric with 3 to 7 characters 7th Character Initial-Subsequent-Sequela ICD-10 utilized in all settings ICD-10-CM-outpatient ICD-10-PCS-inpatient Program in Physical Therapy 6 CPT Codes Current Procedural Terminology (CPT) Set of medical codes used by physicians, allied health professionals, non physician practitioners, hospitals, outpatient facilities, and laboratories Each code has a written description of a procedure or service Describes procedures being performed Determine reimbursements Streamlines medical billing practices CPT - CPT Codes - Current Procedural Terminology - AAPC Program in Physical Therapy 7  Evaluation Modalities Orthotic/Prosthetic (Supervised and Management Constant Attendance) Wound Care Re-evaluation Management Therapeutic Tests and Procedures Measurements Program in Physical Therapy 8 Fraud/Abuse/Waste Fraud Deliberate act or deception to obtain improper reimbursement Deliberate actions to disregard guidelines Results in criminal and civil penalties Examples of fraud: Billing for services not provided Obtaining kickbacks Offering incentives to certain patients not offered to all Utilizing inaccurate diagnosis codes or falsifying information https://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf Program in Physical Therapy 9 Fraud/Abuse/Waste Abuse Deception or misrepresentation resulting in inappropriate payment Unintentional Can be considered fraud if pattern observed If warned about an abusive practice, but it continues, could be considered intentional. Examples of Abuse Providing medically unnecessary services without medical necessity documentation. Billing services in access not needed by patient Over collecting deductible or co-insurance amounts from a patient Program in Physical Therapy 10 Fraud/Abuse/Waste Waste Overutilization of services or other practices Outcome is unnecessary expenses to healthcare systems As a result of deficient management, practices, systems, or controls Generally considered misuse of resources Program in Physical Therapy 11 Evaluation Evaluate examination findings Determine prognosis Develop a plan of care including: Anticipated goals Expected outcomes Interventions Information to be utilized at discharge summary Establish treatment Program in Physical Therapy 12 Evaluation Physical Therapy Evaluations 97161-Low Complexity 97162-Moderate Complexity 97163-High Complexity Program in Physical Therapy 13 Identify Components of Evaluation Review components when selecting the correct evaluation level History Examination Clinical Presentation Clinical Decision Making Guiding Factors Coordination Consultation Collaboration of care consistent with the nature of the problem and needs of patient. Program in Physical Therapy 14 Low Complexity-97161 Complexity Level Low Complexity 97161 History History of present issue with no personal factors and/or comorbidities that impact Plan of Care. Examination Exam completed with standardized tests/measures for 1-2 elements from: body structures and functions, activity limits, and/or participating restrictions. Clinical Presentation Stable and/or uncomplicated. Decision Making Low complexity identified by utilizing standardized patient assessment and/or measurable assessment of functional outcome. Program in Physical Therapy 15 Moderate Complexity-97162 Complexity Level Moderate Complexity 97162 History History of present issue with 1-2 personal factors and/or comorbidities that impact Plan of Care. Examination Exam completed with standardized tests/measures for 3 or more elements from: body structures and functions, activity limits, and/or participating restrictions. Clinical Presentation Evolving with changing characteristics. Decision Making Moderate complexity identified by utilizing standardized patient assessment and/or measurable assessment of functional outcome. Program in Physical Therapy 16 High Complexity-97163 Complexity Level High Complexity 97163 History History of present issue with 3 or more factors and/or comorbidities that impact Plan of Care. Examination Exam completed with standardized tests/measures for 4 or more elements from: body structures and functions, activity limits, and/or participating restrictions. Clinical Presentation Unstable with unpredictable characteristics. Decision Making High complexity identified by utilizing standardized patient assessment and/or measurable assessment of functional outcome. Program in Physical Therapy 17 Physical Therapy Re-Evaluation-97164 CPT 97164 Patient examined to evaluate progress Modify or redirect intervention Revise anticipated goals and excepted outcomes Re-examination may be indicated more than once during a plan of care based on medical necessity. Include tests and measures Modify the plan of care Support medical necessity of skilled intervention Program in Physical Therapy 18 Billing Re-Evaluation-Medicare Separately payable Significant improvement/decline in patient’s condition or functional status Planned discharge Focuses on evaluation of progress toward current goal Professional judgment Continuation of care Modify plan of care Goals and/or treatment Terminating services Same professional skills as evaluation May not be as extensive New clinical findings Program in Physical Therapy 19 Physical Medicine and Rehabilitation Codes Timed or Un-timed Un-Timed Bill units in quantity of one Evaluation Timed 15 minute increments Equals quantity of units billed Therapy treatment Program in Physical Therapy 20 Treatment Time Reporting Medicare Guidelines Individual services billed in timed minute intervals 15 minute interval If treatment performed in excess of 15 minutes, the remaining time can be added to another treatment code If service represented by 15 minute timed code is performed for at least 15 minutes, service must be billed for at least 1 unit Program in Physical Therapy 21 Medicare 8 Minute Rule Timed services One timed service provided per day and less than 8 minutes; do not bill Document total number of timed minutes Refer to 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 220.3B Documentation Requirements for Therapy Services Medicare Manual Referencing Timed Services Chapter 5 http://www.cms.gov/manuals/downloads/clm104c05.pdf Program in Physical Therapy 22 Time Intervals 1 unit: ≥ 8 minutes through 22 minutes 2 units: ≥ 23 minutes through 37 minutes 3 units: ≥ 38 minutes through 52 minutes 4 units: ≥ 53 minutes through 67 minutes 5 units: ≥ 68 minutes through 82 minutes 6 units: ≥ 83 minutes through 97 minutes 7 units: ≥ 98 minutes through 112 minutes 8 units: ≥ 113 minutes through 127 minutes Program in Physical Therapy 23 Medicare Timed Code Examples Program in Physical Therapy 24 25 minutes of gait training (CPT code 97116) 15 minutes of therapeutic activity (CPT code 97530) Total of 40 minutes of treatment time Bill 3 units as total treatment time is 38-52 minutes. o Bill 2 units of gait training o Bill 1 unit of therapeutic activity Each service was provide for at least 15 minutes and should be billed for at least one unit. More units are assigned to the service that took the most time (gait training). Do not bill any one code for all 3 units. Program in Physical Therapy 25 10 minutes of therapeutic exercise (code 97110) 10 minutes of gait training (code 97116) 10 minutes of therapeutic activity (code 97530) Total of 30 minutes of treatment time Bill 2 units as total treatment time is 30 minutes. Time spent on each service is equal, so provider will choose which codes to bill based on clinical judgement. Program in Physical Therapy 26 20 minutes of gait training (CPT code 97116) 20 minutes of therapeutic activity (CPT code 97530) Total of 40 minutes of treatment time Bill 3 units as total treatment time is 38-52 minutes Each service was provided for at least 15 minutes and should be billed for at least one unit each. When time spent on each service is the same (each 20 minutes), the provider should use their clinical judgment to determine which code to bill for 2 units. Bill the remaining code for 1 unit Do not bill any one code for all 3 units Program in Physical Therapy 27 Sources/Resources AAPC-American Academy of Professional Coders http://www.aapc.com/ICD-10/ APTA http://www.apta.org https://www.apta.org/your-practice/compliance APTA Therapist 2024 Coding and Payment Guide for the Physical Therapist https://www.optumcoding.com/product/60828/ CDC Website on Classification of Diseases https://www.cdc.gov/nchs/icd/index.html CMS http://www.cms.gov HCPCS Level II Expert https://www.optumcoding.com/product/49246/ Program in Physical Therapy 28 Sources/Resources HealthInsurance.org https://www.healthinsurance.org/ Healthcare.gov https://www.healthcare.gov/ Humana https://www.humana.com/about/legal/disclaimer-and-licensure/fraud-waste- and-abuse World Health Organization http://www.who.int/classifications/icd/en/ WEB PT https://www.webpt.com/blog/farewell-97001-how-to-use-the-new-pt-and- ot-evaluation-codes/ https://www.webpt.com/guides/medicare/ Program in Physical Therapy 29 Rosalie Schreckenberg Manager, Patient Accounts (314) 286-1579 [email protected] ©2016 Program in Physical Therapy