Committee on Revenue (COR) Reimbursement Binder

Transcription

1 Committee on Revenue (COR) Reimbursement Binder Click Here and Jump Straight to Step by Step Reimbursement Process Click Here and Jump Straight to Various Reimbursement Models COR Mission Statement: The mission of the Connecticut Athletic Trainers Association Committee on Revenue is to provide and ensure continued opportunity for Certified Athletic Trainers (ATC)[LAT] to receive third party reimbursement in the State of Connecticut. The Committee is charged with educating those involved with reimbursement issues and to foster an environment in the State which values the role of the ATC in the health care of the athletic and physically active population. COR Strategic Initiatives: 1. Educate Members and Those Impacted by Athletic Training Reimbursement 2. Enhance Communication and Involvement of Members and CATA 3. Strengthen the Position of the AT in the Connecticut Health Care Marketplace 4. Ensure Financial Stability of the Committee 1

2 Table of Contents (**Scroll over the section you would like to be directed to. Ctrl & click!**) Introduction 3 Contact List 4 Connecticut Scope of Practice Act.6 Reimbursement Checklist The Value of Reimbursement...12 Reimbursement Models.14 Cash Model University Model High School Model Industrial and Occupational Athletic Trainers The Physician Extender Reimbursement Cliff Notes...21 Step by Step Reimbursement Process...26 Credentialing.28 LAT Sample Letter to Insurers.29 Sample Patient Letter to Insurers..30 Sample Athlete Letter to Insurers..31 Sample MD Letter to Insurers...32 APPENDICIES...33 CPT Codes (Appendix A) Documentation and Coding Guidelines (Appendix B) Helpful Links 43 Resources..44 2

3 Introduction The Connecticut Athletic Trainers Association (CATA) through leadership, education, and cooperative efforts with other organizations and allied health professions, strives to improve the quality of health care for the athletic and physically active, enhance the profession of Athletic Training, and serve as a resource for education in the field of Athletic Training. Since the formation of the CATA, the organization has fought for the recognition of the Athletic Trainer (AT) as a qualified health care provider. Connecticut Athletic Trainers can finally apply for licensure. The Licensure bill (PA : which is included in this binder) will allow ATs to practice as licensed health care providers and prevent no other persons to act as Athletic Trainers without being licensed. The enactment of licensure allows for the recognition of Licensed Athletic Trainers (LAT) in the eyes of the public, government, employers, other health care professionals and third party payers. ATs are now permitted to seek reimbursement for their services. The benefits of revenue for LATs may sometimes seem unclear, especially to those of us who have not yet begun the reimbursement process. The specific steps in order to actually receive reimbursement can be equally confusing if not explained properly. The reimbursement binder was put together by both certified and Student members of the CATA-COR, with help from other reimbursement committees, throughout the nation such as Wisconsin and Ohio, and individuals throughout the State of Connecticut, including the Board of Directors, executive council of the CATA, as well as, John Gilmour, Gary Morin, Vicky Graham and Tim Speicher. Please read through the binder and print any useful information. For further questions please contact one of the members of the COR and we will gladly assist you in any way we can. Thank you, Eleni Psathas, MBA, ATC, LAT Chair CATA COR 3

4 Contact List * Left to Right* Active Members Chair Eleni Psathas, MBA, ATC HEALTHSOUTH-Berlin Head Athletic Trainer Berlin High School Cell Phone: Work Phone: [email protected] Anita Eisenhauer, MAT, ATC CATA Public Relations Chair Sports Medicine Coordinator Orthopedic and Sports Medicine Center Work Phone: (203) Ext Cell Phone: (203) Fax: (203) [email protected] Sean Kennedy, ATC HEALTHSOUTH- Old Saybrook Head Athletic Trainer Old Saybrook High School Work Phone: Cell Phone: [email protected] Daphne Benas, PT, ATC Yale University Phone: [email protected] Gordon Hurlbert, ATC, CSCS Director of Clinical Athletic Training Quinnipiac University Phone: (203) Fax: (203) [email protected] Julie Murphy, ATC Valley Orthopedic Specialists Head Athletic Trainer Ansonia High School Cell Phone: [email protected] Advisory Members Past Chair Tim Speicher, ATC, MS, CSCS Sacred Heart University Clinical Assistant Professor Phone: Fax: Fax [email protected] Issac Cohen, MD Orthopedic and Sports Medicine Center Phone: Ext Fax: [email protected] 4

5 Student Sub Committee Anna Sloan University of Connecticut Kathleen Rovito Southern Connecticut State University Matt Burns University of Connecticut Janet Simon Southern Connecticut State University Seniors Juniors Erin Guertin Sacred Heart University Open Seat Central Connecticut State University Quinnipiac University Mark Maleri Sacred Heart University Open Seat Central Connecticut State University Quinnipiac University Inactive Members Mark Martire, ATC Sacred Heart University DPT Student Cell Phone: Caitlin O Connor, ATC NC State University Graduate Assistant Athletic Trainer Phone: [email protected] 5

6 Connecticut Scope of Practice Act CHAPTER 375a : ATHLETIC TRAINING Sec f. Definitions. As used in this chapter: (1) "Athletic training" means the application or provision, with the consent and under the direction of a health care provider, of (A) principles, methods and procedures of evaluation, prevention, treatment and rehabilitation of athletic injuries sustained by athletes, (B) appropriate preventative and supportive devices, temporary splinting and bracing, physical modalities of heat, cold, light massage, water, electric stimulation, sound, exercise and exercise equipment, (C) the organization and administration of athletic training programs, and (D) education and counseling to athletes, coaches, medical personnel and athletic communities in the area of the prevention and care of athletic injuries. For purposes of this subdivision, "health care provider" means a person licensed to practice medicine or surgery under chapter 370, chiropractic under chapter 372, podiatry under chapter 375 or natureopathy under chapter 373; (2) "Athletic injury" means any injury sustained by an athlete as a result of such athlete's participation in exercises, sports, games or recreation requiring strength, agility, flexibility, range of motion, speed or stamina, or any comparable injury that prevents such athlete from participating in any such activities; (3) "Athlete" means any person who is a member of any professional, amateur, school or other sports team, or is a regular participant in sports or recreational activities, including, but not limited to, training and practice activities, that require strength, agility, flexibility, range of motion, speed or stamina. For purposes of this subdivision, "regular" means not less than three times per week; (4) "Standing orders" means written protocols, recommendations and guidelines for treatment and care, furnished and signed by a health care provider specified under subdivision (1) of this section, to be followed in the practice of athletic training that may include, but not be limited to, (A) appropriate treatments for specific athletic injuries, (B) athletic injuries or other conditions requiring immediate referral to a licensed health care 6

7 provider, and (C) appropriate conditions for the immediate referral to a licensed health care provider of injured athletes of a specified age or age group; (5) "Commissioner" means the Commissioner of Public Health. Sec g. License required for practice and use of title. (a) Except as provided in section 20-65i, no person may practice athletic training unless such person is licensed pursuant to section 20-65k. (b) No person may use the title "licensed athletic trainer" or make use of any title, words, letters or abbreviations indicating or implying that such person is licensed to practice athletic training unless such person is licensed pursuant to section 20-65k. Sec h. Referral to licensed health care provider. (a) Each person who practices athletic training under standing orders shall make a written or oral referral to a licensed health care provider of any athlete who has an athletic injury whose symptoms have not improved for a period of four days from the day of onset, or who has any physical or medical condition that would constitute a medical contraindication for athletic training or that may require evaluation or treatment beyond the scope of athletic training. The injuries or conditions requiring a referral under this subsection shall include, but not be limited to, suspected medical emergencies or illnesses, physical or mental illness and significant tissue or neurological pathologies. (b) Each person who practices athletic training, but not under standing orders, may perform initial evaluation and temporary splinting and bracing of any athlete with an athletic injury and shall, without delay, make a written or oral referral of such athlete to a licensed health care provider. The limitations on the practice of athletic training set forth in this subsection shall not apply in the case of any athlete that is referred to such person by a licensed health care provider, provided such practice shall be limited to the scope of such referral Sec i. Exceptions to licensing requirement. 7

8 A license to practice athletic training shall not be required of: (1) A practitioner who is licensed or certified by a state agency and is performing services within the scope of practice for which such person is licensed or certified; (2) a student intern or trainee pursuing a course of study in athletic training, provided the activities of such student intern or trainee are performed under the supervision of a person licensed to practice athletic training and the student intern or trainee is given the title of "athletic trainer intern", or similar designation; (3) a person employed or volunteering as a coach of amateur sports who provides first aid for athletic injuries to athletes being coached by such person; (4) a person who furnishes assistance in an emergency; or (5) a person who acts as an athletic trainer in this state for less than thirty days per calendar year and who is licensed as an athletic trainer by another state or is certified by the National Athletic Trainers'Association Board of Certification, Inc., or its successor organization. Sec j. Qualifications for licensure. Licensure by endorsement. (a) Except as provided in subsections (b) and (c) of this section, an applicant for a license to practice athletic training shall have: (1) A baccalaureate degree from a regionally accredited institution of higher education, or from an institution of higher learning located outside of the United States that is legally chartered to grant postsecondary degrees in the country in which such institution is located; and (2) current certification as an athletic trainer by the Board of Certification, Inc., or its successor organization. (b) An applicant for licensure to practice athletic training by endorsement shall present evidence satisfactory to the commissioner (1) of licensure or certification as an athletic trainer, or as a person entitled to perform similar services under a different designation, in another state having requirements for practicing in such capacity that are substantially similar to or higher than the requirements in force in this state, and (2) that there is no disciplinary action or unresolved complaint pending against such applicant. (c) For the period from the effective date of this section to one year from said date, the commissioner shall grant a license as an athletic trainer to any applicant who presents evidence satisfactory to the commissioner of (1) the continuous providing of services as 8

9 an athletic trainer since October 1, 1979, or (2) certification as an athletic trainer by the National Athletic Trainers'Association Board of Certification, Inc. History: P.A effective the later of October 1, 2000, or the date notice is published by the Commissioner of Public Health in the Connecticut Law Journal indicating that the licensing of athletic trainers and physical therapist assistants is being implemented by the commissioner; P.A amended Subsec. (a) by deleting former Subdiv. (3) re passage of national examination and changing Subdiv. (2) from a description of the required course of study to a requirement of certification, and amended Subsec. (c) by changing the beginning date for licensure from January 1, 2001, to "the effective date of this section" and by making a conforming change, effective the later of October 1, 2000, or the date notice is published by the Commissioner of Public Health in the Connecticut Law Journal indicating that the licensing of athletic trainers and physical therapist assistants is being implemented by the commissioner. Sec k. License to practice athletic training. Fees. (a) The commissioner shall grant a license to practice athletic training to an applicant who presents evidence satisfactory to the commissioner of having met the requirements of section 20-65j. An application for such license shall be made on a form required by the commissioner. The fee for an initial license under this section shall be one hundred fifty dollars. (b) A license to practice athletic training may be renewed in accordance with the provisions of section 19a-88, provided any licensee applying for license renewal shall maintain certification as an athletic trainer by the Board of Certification, Inc., or its successor organization. The fee for such renewal shall be one hundred dollars. History: P.A effective the later of October 1, 2000, or the date notice is published by the Commissioner of Public Health in the Connecticut Law Journal indicating that the licensing of athletic trainers and physical therapist assistants is being implemented by the commissioner; P.A amended Subsec. (b) by adding requirement that licensee maintain national certification, effective the later of October 1, 9

10 2000, or the date notice is published by the Commissioner of Public Health in the Connecticut Law Journal indicating that the licensing of athletic trainers and physical therapist assistants is being implemented by the commissioner (Revisor's note: In 2005, a reference to "providing" in Subsec. (b) was changed editorially by the Revisors to "provided" for proper form). Sec l. Regulations. Administration within available appropriations. The commissioner may adopt regulations, in accordance with chapter 54, to carry out the provisions of this chapter. The commissioner shall administer the provisions of this chapter within available appropriations. (P.A , S. 7, 20.) Effective the later of October 1, 2000, or the date notice is published by the Commissioner of Public Health in the Connecticut Law Journal indicating that the licensing of athletic trainers and physical therapist assistants is being implemented by the commissioner. 10

11 Reimbursement Checklist The CATA COR recommends the following be considered as the reimbursement process is initiated in your setting. 1. Understand the Connecticut Athletic Trainer License and Scope of Practice. 2. Discuss reimbursement possibilities with supervisors and colleagues. 3. Discuss reimbursement possibilities with management teams. 4. Meet with medical directors and local physicians and educate them on the scope of the AT and the opportunities for reimbursement. 5. Contact insurance companies via template letters and collect data on success and challenges. (Report all data to CATA Committee on Revenue Committee). 6. Involve front desk personnel and discuss athletic training reimbursement. 7. Ensure computers are in coordination with business office, accounting, and billing. 8. Develop a charge master. 9. Educate billing and accounting personnel regarding athletic training reimbursement. 10. Make sure facility name includes the practice of athletic training. 11. Make appropriate changes to include LAT on MD prescription pads. 12. Have Standing orders signed be a physician in your setting. 13. Meet with dictation personnel and inform them about athletic training. 14. Report all reimbursement success and failure stories to CATA Committee on Revenue. 15. Avoid "turf battles" with other allied health professions at all costs! 16. Work together and learn from one another. 17. Be patient!! It is common for insurance providers to deny services initially to a new health care provider they are unfamiliar with it takes time to build recognition and relationships with insurance carriers. *Adapted from the Wisconsin Athletic Trainers Association 11

12 The Value of Reimbursement By: Tim Speicher, ATC, MS, CSCS With the health care marketplace becoming more competitive, the ability for athletic trainers to bill for their services is paramount. As a reimbursable entity, the Licensed Athletic Trainer (LAT) will be able to maintain and establish a respected position in the health care marketplace. Administrators and employers are finding it more difficult to justify hiring Athletic Trainers in light of economic pressures and constrained resources in an environment where other allied health care providers can offset these fiscal challenges. Emerging professions such as massage therapy, acupuncture and kinesiotherapy among others are also seeking to become reimbursable providers as well. However, for many Athletic Trainers who work in a traditional setting as those outlined below the need to support and work for reimbursement for ALL Athletic Trainers regardless of employment setting is not always evident or pertinent. Practice settings are expanding for athletic trainers and there are many models by which to address the expansion of the practice of athletic training into these new health care markets. The CATA-COR in conjunction with the NATA have developed several models for these emerging settings. See the CATA web-site for these models, or click on the hyperlink provided. ( As competition for the limited health care dollar increases, it is critical Athletic Trainers be treated and viewed as equals among providers who deliver sports medicine related medical services to the active population. The rationale for support of reimbursement by the traditional athletic trainer are outlined here. The High School Athletic Trainer Administrators and Athletic Trainers in the secondary school system are looking for ways to supplement their constrained budgets. Many have examined a reimbursement model of billing for soft goods such as, braces, tape, and supports as well as post-surgical rehabilitation. However, these options will only be possible if the medical services the Athletic Trainer provides are reimbursable. 12

13 The University/College Athletic Trainer Many colleges and Universities large and small have successfully implemented a reimbursement model to offset their institution s provision of athletic training. Most Athletic Trainers at these institutions comment their purpose of pursuing a model of reimbursement is to increase their staff and improve the quality of their lives and care provided to their athletes. However, many will point out that the model be designed not be profit driven, but to supplement an existing budget. Other professions have recognized the potential of billing the athlete. Several colleges and university administrators in Connecticut and across the country have advocated to replace athletic training staff with reimbursable providers or to relegate the AT to sideline coverage only. The Clinical Athletic Trainer Outpatient sports medicine facilities are finding it harder to justify the use of an Athletic Trainer when other reimbursable providers exist. In addition, physicians are no longer in control of who they refer to as evident with the recent Medicare incident-to ruling restricting the use of ATs as physician extenders for the Medicare population. Through support of State and National reimbursement efforts, the position of the Athletic Trainer in the health care marketplace will be established and the physical medicine and rehabilitation services they provide, sought after by patients, medical professionals and payors. 13

14 Reimbursement Models By: Eleni Psathas, MBA, ATC The cash model will best suit LATs who would like to directly bill patients for their services, avoiding third party payors. The objective in this type of model is to receive reimbursement directly from patients (Johnston, n.d.). Although, the LAT is not concerned with third party payors, they must still function within their scope of practice. University Model The University Model applies to athletic training programs managed by LATs who are employed by a university or college and paid by the institution. The objective is to receive reimbursement from third party payers for services rendered in the athletic training facility (Milton, n.d.). With this model, a set amount of services an AT can provide are billed, for instance: Strength and conditioning programs, rehabilitation services, counseling, evaluations, emergency medical aid, referrals to physicians and other allied healthcare professionals (Milton, n.d.). The LATs customer base with this model increases. One would normally think that services are limited to student athletes when in reality they are applicable to the student athlete, faculty, staff, administrators and even the athletes parents or responsible parties (Milton, n.d.). The third party payers consist of the patient s primary and secondary managed care company or insurance carrier. The LAT and the institution will have to take certain steps in providing the proper procedures for reimbursement in the University. The Athletic Training staff will need written authorization from the institution s legal counsel, board of governors, president/chancellor and director of athletics before the initial billing of third party payors begins (Milton, n.d.). In order to receive approval for reimbursement, the athletic training staff needs to develop a business plan or model. In addition, LATs need to remember to identify any state specific licensing and regulatory agencies and check for any specific licenses or documents needed prior to billing. Also, the LAT must review their practice act/license to understand their scope of practice and patient population. The institution s legal counsel should review whether 14

15 there is anything in the institutions mission, charter or mandate that would prevent reimbursement and billing. Another consideration is that initial start up costs are variable and are impacted by what billing system will be used, who will conduct the billing, and how much information regarding students and third party payors is already possessed. Samples of start up costs are listed in Table 1. Table 1 Computer/setup and accounting software $4000-$7000 Billing service, some services charge a flat fee per claim and some charge a monthly fee the fees range from $175 per month to over $400 per month. Many billing services charge a percentage of collections or claims paid, which is typically between 7-11 percent of the claim. ATs need to schedule additional time to work with the reimbursement program, for each 100 athletes on campus there is an estimated average of 4 hours of additional time required per month by the ATC staff. Added staff-you will probably need at least one additional clerical person on staff. You will need this person at least on a part time basis. Estimated cost for a part time clerical person is $8 per hour. If you use this person 20 hours per week your cost would be $160 per week or $8320 per year. Additional phone/internet and fax lines Fax machine and on site printer for working with insurance companies and for transmitting/receiving medical records One time charge for mass mailing an information piece regarding the new program to parents and athletes Estimated cost per piece. High School Model The high school and university models are very similar. The patient base is the same, but third party payors may differ slightly. One instance where they may differ is when the primary insurance policy of the patient is held by the parent(s) or guardian of the athlete. The patient also may have a secondary insurance carrier. The secondary policy may be a student or student athlete policy held by the school or it could be a secondary insurance plan held by a parent or other interested party (Milton, n.d.). Additionally, the initial steps to reimbursement vary from the University Model as well. The LAT must obtain written authorization from the school principal, possibly the school board, the school s legal counsel and director of athletics prior to establishing a 15

16 third party payer model. At the high school setting the athletic training staff may also wish to have the support and approval of the school nurse, counselors, coaches and other members of the athletic staff. The recommended and required tools for the reimbursement process are listed in Table 2 (Johnston, n.d.). Table 2 1) Computer hardware and software used to track patients and maintain clinical records, and for use by a billing person, billing service or billing software. 2) Staff or a service to complete forms and maintain records. 3) A policy and procedure book that you would build and maintain. This book of policies and procedures (P&Ps) should cover all probable contingencies that could occur within the program or to the student patient. The P&Ps would include procedures for being HIPAA/FERPA compliant and a procedure for contesting denied claims, billing policies and procedures. The P&Ps should be followed by all staff involved with the program, which will provide consistent and equal treatment within the program. 4) The NATA manuals on reimbursement, both manual I and II. The code manuals (Healthcare Common Procedure Coding System-HCPCS, Current Procedural Terminology-CPT, International Classification of Diseases-ICD) are also items to have on hand and available for reference 5) You will need space/work area for the computer system, manuals, documentation files and any extra staff you may need. Industrial and Occupational Athletic Trainers The Industrial and Occupational reimbursement model is targeted towards LATs in industrial/occupational settings who are full or part-time LATs and want to bill industrial companies for their services. The objective for these individuals is to receive reimbursement from industrial companies for services rendered to employees and other individuals (spouses, retirees, contractors, etc) associated with the company (Milton, n.d.). The process for this model is very different from the High School and University model because LATs in this setting are not looking to third party payors but to the actual company they employed. The typical services provided by LATs in this setting vary from others, often including: Injury rehabilitation, injury prevention, ergonomics, job site evaluations, initial injury evaluations, emergency/first aid medical care, work conditioning, work 16

17 hardening, functional capacity evaluations, functional job descriptions, return to work programs, prevention education programs, health promotion, general wellness and fitness, case management, and counseling (Milton, n.d.). LATs may find themselves treating employees, employee spouses, retirees, retiree spouses, contractors and dependents (Milton, n.d.). Companies usually fund reimbursement from their safety, occupational health or human resources budget (Milton, n.d.). In the industrial setting the LAT would first secure a contract for their services, which can be a lengthy and detailed process. As with all models, the staff needs to research licensing requirements and define the scope of practice for an LAT in the given state. After defining the scope of practice efforts to gain reimbursement in this setting can be initiated. Throughout the process it needs to be determined what services are going to be provided some companies prefer an all-inclusive package while others prefer to go a step at a time and may start with on-site rehab, then ergonomics, then work conditioning, etc. (Milton, n.d.) Thus, the LAT needs to discuss services to be included in their contract and their role in management and progression of patients after initial contact. In the Industrial Model there are only three recommended or required tools: computer software and hardware systems used to track patients and maintain clinical records a billing system, billing staff or a billing service policy and procedure, HIPAA/FERPA compliance manuals The Physician Extender Licensed Athletic Trainers have been involved very closely with physicians for many years. The relationships that develop on the playing field can lead to endless opportunities in the physician s clinic. The athletic trainer provides many useful skills to the patients treated by the physician. With these skills, there are also great possibilities for reimbursement. 17

18 The most important key to develop a physician extender program is to develop a strong working relationship with the physician in regards to the role that the athletic trainer will have in their practice. The job duties will vary based on the needs of the physician and qualifications the athletic trainer possess. Tasks that may be performed by the LAT 1. Conduct initial patient medical history, brief injury evaluation, and prepare patient for physician evaluation. 2. Assist physician during evaluation with tasks such as: documentation, diagnostic test preparation, administering of injections. 3. Removal of sutures or wound care following surgery. 4. Casting or the assisting in casting of patients. 5. Providing specific rehabilitation suggestions while the patient is evaluated by the physician. This improves knowledge and support to the physician. 6. Provide rehabilitation services to the patient both at the time of evaluation as well as extended services after the evaluation. 7. Preparation of prescriptions and patient materials after the evaluation. 8. Fitting of braces or medical supplies ordered by the physician. 9. Provide rehabilitation and athletic training services in an outreach setting. Benefits to the Physician s Practice 1. Improves the efficiency of the physician. 2. Improves the services offered to the physician s patients. 3. Allows for access to rehabilitation knowledge during the evaluation process. 4. Offers enhanced communication between the physician and the rehabilitation provider, thus enhancing the entire injury outcome. 5. Opportunity for community outreach activities which will provide marketing possibilities. 6. Provides multiple avenues for additional revenue to a physician s clinic. Basic Development of a Physician Extender Program in the Outpatient Therapy???Clinic 1. Develop role of LAT in the clinic. 2. Discus billing options with physician s business office. 3. Have a strong orientation and training plan on the practice of the physician. 4. A policy and procedure book with HIPPA/FERPA compliance manuals included. 5. The CATA/NATA Reimbursement Binders. NATA book I and II. 6. Code manuals 7. Connecticut Athletic Trainer Licensure Packet. 8. If continued rehabilitation services are required, Please remember to always contact the insurance company on each patient to verify coverage. 18

19 The Process 1. Physician Referral for athletic training with a specific diagnosis pertaining to Connecticut Athletic Trainers Licensure Law 2. Business office / insurance specialist verifies type of insurance or self-pay. 3. Business office / insurance specialist calls the insurance company for authorization or pre-authorization if formal rehabilitation is needed. 4. Insurance company response, yes or no. 5. Ask for insurance supervisor if a no response. Also make use of CATA Template. 6. Insurance companies will advise as to coverage and amount of visits or UCR, usual customary and reasonable rate of payment. This rate is based upon geographical region. 7. If ok is gained from insurance company, licensed athletic trainer will verify diagnosis with a specific evaluation. (CPT AT evaluation code 97005) Third Party Payers for LATs According to the National Athletic Trainers Association Committee on Revenue, the following insurance companies reimburse LATs in various states. Some of the more popular third party payers are Aetna, Blue Cross/Blue Shield (BC/BS), United Healthcare, CIGNA, Amerisure, Anthem BC/BS, AllState, and Travelers among many others (State Reimbursements, n.d.). Health Maintenance Organizations (HMO s), Preferred Provider Programs (PPO s) and Point of Service (POS) are among the most popular plans and provide greatest ease for athletic training reimbursement. HMOs are defined as, A type of health insurance plan that requires policyholders to use only those medical vendors approved by the company. All medical services are coordinated by a primary care physician, who acts as a gatekeeper to specialty services (Ray, 2000, p. 305). PPO s are defined by Ray (2000) as, A type of health insurance plan that provides financial incentives to encourage policyholders to use those medical vendors approved by the company (p. 307). POS is different because it combines components from HMO s and PPO s to create its own insurance type. POS is defined by Country Wide Insurance Services (2005) as: A type of managed-care plan that combines features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Most POS plans enable the insured to decide whether to go to a doctor contracted with the 19

20 plan and pay a flat dollar co-payment, or go to a doctor not contracted with the plan and pay an annual deductible and coinsurance. The cash model is a self-pay plan. The patient pays for the services provided thus there is no need to go through a third party payor. On the other hand, for the High School and University Models, the HMO s and PPO s will work best. At the high school level most high school students are insured under their parents plan and already have a Primary Care Physician (PCP). Thus, both HMO and PPO plans match well to the high school setting. HMO s will work at the high school level because the PCP of the athlete will be in the area. This will allow for easy contact and communication between the PCP and AT, allowing for referrals and prescriptions for rehabilitation. PPO s allow the patient to pick what doctors they would like to see, but they also allow for referral with in the network of the insurance provider. At the University level, PPO s are an optimal option because the insurance plan can still cover physicians outside of the network, i.e. team physicians. The patient will have to pick up the additional cost owed that the PPO does not cover, however, most universities write off these additional costs, including co-pays. In addition, the University secondary insurance plan often covers any additional costs. For industrial and occupational settings, a POS plan is also works well. Employees of the setting can make their own decisions and still receive coverage. LATs in this setting can contract with the insurance provider of the company since they are the ones paying for the services. Adapted from the Wisconsin Athletic Trainers Association ** This information is outlined again for easier viewing on page 21 in the Cliffs Notes Version. 20

21 Third Party Reimbursement Cliff Notes Version By: Ivan Milton & David Johnston NATA Committee on Revenue Objective For certified athletic trainers [LAT] to be readily viewed and accepted as reimbursable allied health care professionals by third party payers and to receive reimbursement from those organizations. Typical Services Provided by Athletic Trainers Rehabilitation therapies, mobility training, gait training, work hardening, counseling and evaluations. Note most third party payers only reimburse for covered (by benefit design) and medically necessary services. Audience and Patient Population Any third party insured or covered individual, including those covered by PPOs, Indemnity plans, HMOs*, and self insured programs. To bill an HMO you normally must be a member of the network. You must have a contract with the HMO and your contract would spell out how much and under what conditions you would be compensated. To bill services to a PPO or indemnity program you do not have to be a member of their network. Who Pays Third party payers to include but not limited to, HMOs, PPOs, traditional insurance programs and third party administrators. First Steps Pursuing reimbursement from third party payers should not be taken lightly. If you did not attend Reimbursement Seminar I or Reimbursement Seminar II, you should attend either or both of these seminars. The seminars are designed to provide you with the technical and tactical information you need to obtain third party reimbursement. NATA 21

22 has both Seminar I and Seminar II manuals available to members for a minimal cost. The critical question that needs to be asked is who is my patient and what will I bill for? This makes the reimbursement process become reality. This cliff notes version provides information to assist your decision of whether to pursue reimbursement. ATCs [LATs] currently receive reimbursement working in a variety of settings, including hospitals, physicians offices, sports rehabilitation clinics and college and university settings. Some ATCs [LATs] have received reimbursement on 60 percent to 85 percent of billings. Some have faired less favorably. Licensure is key to successful reimbursement from third party payers. Most insurance/managed care contracts are filed with the state declaring whom the company will reimburse for services. A large number of these organizations list licensed health care professionals as the only reimbursable entities, which typically encompasses certified athletic trainers [LATs]. Recommended or Required Tools (*also on pg. 15 in table format) 1) Computer software and hardware systems used to track patients and maintain clinical records, a billing system and billing staff or a billing service. 2) A policy and procedure book, HIPAA/FERPA compliance manuals (should be included in your P&Ps) 3) The NATA produced reimbursement manuals both I & II 4) Code manuals- HCPCS=healthcare common procedure coding system, CPT-current procedural terminology, ICD-international classification of diseases should be available. 5) Training materials and guides for ATCs [LATs] and other staff on documenting files, submitting claims and working with reimbursement and the insurance industry. Licenses and Regulations It is essential to review and know your practice act and licensure law [click here for CT law]. As the services you provide must be within the legal limitations. However, the legal limitations of each state s practice act are, many times, open to interpretation. 22

23 There are states where a legal review can be helpful in defining scope of practice, setting and audience. Prior to billing third party payers, check your state insurance commission codes. Check for anti-discriminatory or any willing provider laws or regulations, as these would prevent a health care company from arbitrarily not including Athletic Trainers in their provider panels. You also need to verify that any other city, county or state licenses would not be required for you to legally bill for services. Determine Costs/Set A Budget (*also on pg. 16 in Table Format) Practice settings for ATCs [LATs] are varied so projecting accurate costs is difficult. The following are some items or costs that will probably be universal. - Computer & set up, accounting and billing software, $4000-$ Billing service-flat fee rates can vary between $175-$400 per month and percentage of collections fees range between 7-11%. - Added staff for working with insurance companies and others and for maintaining accounting data and files, expect to pay at least $8-$12 per hour plus benefits if they work full time. - Extra phone/internet and fax lines, privacy and security of the patient s privacy are essential. - A secure fax machine and computer printer due to privacy regulations. Education and Training In addition to maintaining and renewing your BOC certification, you may want to take other adjunct classes [and workshops] to enhance your knowledge. The ATC [LAT] and staff will need to know the third party reimbursement process, how to complete and maintain clinical records, how to document and how to bill and work with third party payors. Documentation For medical and legal reasons the medical documentation criteria listed should already be a part of your daily work habits. When you are billing and receiving reimbursement, these guidelines definitely need to be followed. Initial evaluation, including plan of treatment and goals (SOAP notes) Appropriate patient medical history Patient examination results 23

24 Functional assessment Type of treatment and body part(s) to be treated Expected frequency and number of treatments Prognosis Goals-should be functional, measurable and time based Precautions and contraindications should be noted A statement that the treatment plan and goals were discussed and understood by the patient and possibly by the guardian Maintain daily treatment records Record any changes in physical status, physician orders or treatment plan or goals Weekly progress notes especially on goals should be kept (SOAP or function based) Copies of notes to or from the referring physician s office whether by fax, , and U.S. mail or by phone. A prescription or other state mandated documentation from a physician. Pricing When you determine your fee schedule for services, understand they probably will not match the third party payer s fee schedule. Most third party payers will reimburse UCR- Usual, Customary and Reasonable rates. This is a fee schedule based on the average or UCR costs for procedures in a geographical region. Some payers are now using RBRVS- Resource Based Relative Value Scale. This fee schedule is written and maintained by CMS (Centers for Medicare and Medicaid Services). There are published UCR fee schedules but some companies write their own so variances are always possible. If the payer has reimbursed you up to the contracted amount, additional amounts owed would have to be collected from the patient. You may also wish to use your cost(s) for services, cost=time+materials+overhead/expenses+profit. Revenue Potential The revenue you receive from third party payers is limited by your setting, your time available to treat patients and what third party payers are reimbursing. Working in an ATC [LAT] friendly state with broadened insurance regulations and laws helps tremendously. The size and abilities of your staff is a factor in increasing revenue. Resources There are resources available to assist you the NATA staff and volunteer members working with the CATA-COR can be assets. Go to the NATA web page ( 24

25 members only section, then click on directory, click on Committee on Revenue). The site has a pleathora of resources for you use. You should also visit the CATA-COR web site as well. The reimbursement manuals developed by NATA are available to members for a minimal fee. The Web is another great source of billing and third party payer information. The billing department at your institution is an additional resource to investigate use of web-based billing methods. The billing department should know the payers and can help you learn the billing process. Adapted from the National Athletic Trainers Association Committee on Revenue * Thanks and gratitude to Ivan Milton and David Johnston ATCs and members of the Committee on Reimbursement for their contributions. 25

26 Step By Step Reimbursement Process 1 Order the NATA binder titled Reimbursement Strategies to have on hand as a resource. Communicate with your facility rehabilitation/medical Director to explain the benefits of having Licensed Athletic Trainers treat patients and bill for their services. It should be emphasized that Athletic Trainers bill for Physical Medicine and Rehabilitation Services NOT Physical Therapy. The COR will be help you through this process, please contact us with questions. 2 Meet with the business office staff responsible for negotiating with insurance companies. Explain how LATs function in your specific setting and how the CT Practice Act guides LATs. At this point, you have two options: Give the office staff the template letter to be sent to insurance companies detailing how and why they should pay for Licensed Athletic Training services provided within the scope of practice per the Connecticut Athletic Trainers Practice Act. Explain that you will be contacting the main insurance companies your system works with and how you will use the template letter as an educational tool in your contact with them. 2b With your staff, design how the LATs will function side by side with the other therapy providers: Preparation of charts; Re-do prescription pads & other forms your department uses; Dictation services;. Some facilities may need to add Athletic Training as a new department if it has not already been established and; Work with your billing department to set up Athletic Trainer s with separate codes for evaluation and revaluation. *Continue to step 3b on the next page* 26

27 3a When the business office staff receives word of yes or no for reimbursement of services, they should contact you immediately with the details; Or When you receive word of yes or no for reimbursement of services, summarize the details. And then: Contact the Committee on Revenue with your Yes and No insurance companies. The committee will be compiling a database of all the details. Companies who deny AT reimbursement ( a no ) should be requested to provide an explanation of denial of services. After this explanation is received, they should be contacted as to why Athletic Training is a valued provider for their customer s health care needs and how ATs can reduce their costs. 3b Learn from your business office staff what it takes within your Preferred Provider Organization or other HMO, to be listed as a credentialed healthcare provider within your system. Once you have applied to be a panel provider, you will be listed in the manual of approved providers for that insurance provider. 4 Meet with physician groups who refer to your facility and explain the process of referring patients to an athletic trainer at your facility Enlist physicians to help you who are already advocates of AT to assist in this process. Be prepared to answer questions relating to appropriateness of referrals, etc. 5 Now that you have approval from insurance companies that they will pay for services rendered by a LAT when prescribed by an MD or other qualified physician, you may begin billing for prescribed services you provide under your license as an Athletic Trainer in the State of Connecticut. 27

28 Credentialing Another important component in the reimbursement process is credentialing of the individual who is billing for their services. Credentialing will allow the payer to recognize the health care provider. Once an LAT is established as a provider through the credentialing process the payers will recognize the LAT when they get bills. Please refer to Step 3b in the Step by Step Reimbursement Process. If you have not yet applied for your National Provider Identification number (NPI), do so now by clicking here. 28

29 Date * The following letters have been modeled from others including from the Wisconsin Athletic Trainers Association. Each letter has been modified to suit the state of Connecticut. These letters are templates* Individual Name Insurance Company Address Dear ; LAT Sample Letter to Insurers I am a policyholder with (Insurance Company) and I am also a Licensed Athletic Trainer (LAT). I write to you requesting that Athletic Trainers be added to your company s list of approved providers. Licensed Athletic Trainers are recognized by the American Medical Association as allied health care professionals and have been granted Correct Procedural Terminology (CPT) codes that are specific to this field. These codes are Athletic Training Evaluation and Athletic Training Re-evaluation. In addition, we are authorized to use physical medicine (97000 series) and rehabilitation codes among others. The services we provide to people include, but are not limited to, emergency care, rehabilitation, injury prevention, and case management. We are licensed in this state to provide this type of care. Individuals are referred to us from other health care professionals that are currently on your provider list. It is only right that Licensed Athletic Trainers be offered similar compensatory privileges as those who refer clients to us. I strongly request that LAT services be reimbursed. Reimbursing LATs will make a very costeffective allied health care provider available to my patients. Of major significance, LATs can provide your customers with outstanding return to normal function in a short period of time utilizing a specific and cost -effective plan of care. Many insurance companies are already taking advantage of LAT services and are extremely satisfied with the patient outcomes and cost containment. As a health care professional and a policyholder, I feel it is appropriate that I have the opportunity to receive reimbursement for the care I provide in the same manner as would happen if I sought care from another provider. I welcome your questions and am grateful for your attention to my request. Additional information can be obtained from the National Athletic Trainers Association at TRY-NATA or Thank you and I look forward to your response. Sincerely, Name Address 29

30 Sample Patient Letter to Insurers Date Individual s Name & Title Insurance Company Address Dear ; I am a policyholder with (Insurance Company) and I am writing to you requesting your company include Licensed Athletic Trainers (LAT) as approved providers under your health care plans. Family members of mine regularly seek medical care from Athletic Trainers and are referred to them for much of their care. It is proper therefore that these health care professionals be reimbursed for their services. Licensed Athletic Trainers deliver expert medical attention from emergency care to rehabilitation to injury prevention. They are recognized as allied health care professionals by the American Medical Association and have been granted Correct Procedural Terminology (CPT) codes specific to their field. They are authorized to use physical medicine (97000 series) and rehabilitation codes among others. I have family members who are student athletes that are regularly referred to Athletic Trainers for much of their health care needs. As such, I feel it is right that these professionals be granted the same consideration as any other provider under your plans and be allowed to bill for their services and receive suitable reimbursement for the services they deliver. As a policyholder this is important to me and I strongly urge you to add LATs to your list of approved providers. With the type of medical supervision my family receives from Athletic Trainers, I realize this is appropriate use of my health care dollars. I strongly request that LAT services be reimbursed. Reimbursing LATs will make a very costeffective allied health care provider available to my patients. Of major significance, LATs can provide your customers with outstanding return to normal function in a short period of time utilizing a specific and cost -effective plan of care. Many insurance companies are already taking advantage of LAT services and are extremely satisfied with the patient outcomes and cost containment. If you have questions, please contact me. Another source for information is the National Athletic Trainers Association at TRY-NATA or Thank you. Sincerely, Name Address Policy Number Phone 30

31 Name of Athlete Address Phone (optional) Sample Athlete Letter to Insurers Date: To whom it may concern: My name is. I am an athlete at (location or school/university). I am writing this letter in support of licensed athletic trainers (LAT) and their efforts to secure third-party reimbursement for the health care services they provide. I believe as well as many other athletes, community members, and allied health care professionals that the LAT provides a unique function in provision of health care to the active individual through the prevention, treatment and rehabilitation of musculoskeletal injuries and athletic related illnesses. Licensed athletic trainers are allied health care professionals recognized by the American Medical Association. Licensed athletic trainers must meet stringent educational and clinical qualifications in order to pass a national board examination. I have been very pleased with the medical services I have received from my certified athletic trainer and if it was not for their unique abilities to treat and rehabilitate the active individual, I would not be in the excellent physical condition am in today. I am secure in the knowledge that a health care provider such as the LAT is looking out for my health. I feel the LAT is the most qualified health care professional to care for my athletic related injuries and illnesses and they should be compensated for the provision of this care. As an individual who relies on sound medical care to perform at the highest level, I feel it is critical that I receive my primary athletic health care from an LAT. They have been there for me and without their expertise; I would undoubtedly incur additional health care costs and injuries or illnesses, limiting my abilities as an athlete and as an active member of my community. I also understand that my insurance premium or my parent s could go down if LAT where recognized and utilized by my insurance company. I strongly request that LAT services be reimbursed. Reimbursing LATs will make a very cost-effective allied health care provider available to patients. Of major significance, LATs can provide your customers with outstanding return to normal function in a short period of time utilizing a specific and cost -effective plan of care. Many insurance companies are already taking advantage of LAT services and are extremely satisfied with the patient outcomes and cost containment. Therefore, I support the need for the LAT to be incorporated into my health care plan and receive due compensation for the excellent health care they provide to my family members and myself. Sincerely, Mary or John Doe Athlete 31

32 Sample Physician Letter DATE Re: Licensed Athletic Trainer Insurance Reimbursement Dear : I am a practicing physician in the state of Connecticut. Depending on the diagnosis, many of my patients are in need of structured rehabilitation with a licensed allied health care provider. With a specific diagnosis, the physician depends upon a licensed allied health care providers to provide the patient with pre- and post-operative therapy and a return to normal function. As a practicing physician in Connecticut, I would like to mention the importance of utilizing licensed athletic trainers (LAT). Recent changes to the Connecticut Medical Practice Act have included the LAT as a recognized provider of rehabilitation services that includes the athletic and/or recreational population and the industrial patient. The LAT has extensive knowledge in anatomy and physiology, rehabilitation, nutrition, ergonomics, and counseling techniques, which makes this allied health professional invaluable to my practice. Recognized by the American Medical Association, the LAT is an important part of the allied health care arena providing the physician with unique skills in assessment and management of athletic, recreational, and occupational injuries. Licensed athletic trainers can provide my patients with a number of prescribed rehabilitation techniques. With nearly 20 physical medicine codes available for LATs, a few of the commonly used treatment codes utilized by physicians on the LAT referral form include modalities, therapeutic exercises, functional training, gait training, and orthotics/bracing. With respect to the use of Physical Medicine Codes (CPT), the Physical Medicine Codes are not therapy specific and consequently LATs are able to utilize these CPT codes. As a matter of fact, LATs have their own evaluation and re-evaluation codes (97005 and respectively). Not only do LATs have a great breadth of knowledge and experience in assessment, managing, and rehabilitating athletic, recreational, and occupational injuries, they are readily available to my patients in a variety of settings. One setting by which the physician can utilize the LAT is that of the physician extender role. Hospital, clinics, college/universities, corporations, and professional sports teams also employ licensed athletic trainers. The combination of LATs education, training, experiences, and availability to patients make them extremely valuable and a very costeffective means to treat patients. Due to the LATs vast experience and education in dealing with rehabilitation techniques to assist a safe and rapid return to normal function, I am encouraging my patients to take advantage of LAT services in all the settings. I strongly request that LAT services be reimbursed. Reimbursing LATs will make a very costeffective allied health care provider available to my patients. Of major significance, LATs can provide your customers with outstanding return to normal function in a short period of time utilizing a specific and cost -effective plan of care. Many insurance companies are already taking advantage of LAT services and are extremely satisfied with the patient outcomes and cost containment. Sincerely,, MD 32

33 APPENDICIES APPENDIX A CPT Codes Description of Physical Medicine Charges Used by Athletic Trainers *As established by the American Medical Association: The following is a guide to Current Procedural Codes that may be used by athletic trainers when billing for athletic training services. It is important to have the proper ICD- 9 diagnosis code prior to using the CPT codes. The current information is in reference to CPT codes EVALUATION CHARGES: 97005/97006 ATHLETIC TRAINER EVALUATION and RE-EVALUATION (PER VISIT) Used for evaluation of athletic injuries to determine the appropriate plan of care by regulated Athletic Trainer. Re-evaluation to re-assess the patient s progress, with goals range of motion, and functional progress. This is not time based PHYSICAL PERFORMANCE TEST (EACH 15 MIN.) Used when performing specific musculoskeletal examinations, such as specific muscle strength, closed chain testing, vestibular/balance testing, isokinetic testing, other physical performance testing. Must have a written report/documentation to support this (Example: Physician progress report for patient visit). Also used for Functional Capacity Evaluations (each 15 min.). TREATMENT CHARGES: GAIT TRAINING (EACH 15 MIN.) Used when you are performing Gait Training Activities, including stair climbing, with patients THERAPEUTIC EXERCISE (EACH 15 MIN.) Used when performing therapeutic exercises to develop strength and endurance, range of motion and flexibility to one or more areas each 15 minutes. One-on-one interaction with patient. (Example: Use this charge when performing initial ACL quad vmo and ROM exercises, or performing Lumbar Stabilization and the goal is strengthening muscles.) NEUROMUSCULAR RE-EDUCATION (EACH 15 MIN.) Used when performing neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and proprioception THERAPEUTIC ACTIVITIES (EACH 15 MIN.) Direct patient one on one contact using dynamic activities to improve functional mobility like physical and sports activities. 33

34 97113 AQUATIC THERAPEUTIC EXERCISE (EACH 15 MIN.) This charge is used for aquatic therapy when performing therapeutic exercise in water. Maybe charged if extremity is in pool and exercise is done in the pool MASSAGE (EACH 15 MIN.) Used when performing massage, including but not limited to effleurage, petrissage and or tapotement (stroking, compression, percussion) BODY MECHANICS TRAINING (EACH 15 MIN.) Used when performing therapeutic activities to train a person on proper body mechanics in order to improve functional performance MANUAL THERAPY (EACH 15 MIN.) Used for joint mobilization, manual lymphatic drainage, manual traction, myofacial release, soft tissue mobilization or desensitization techniques are utilized. Time based ORTHOTICS FITTING AND TRAINING (EACH 15 MIN.) Used for orthotic training (dynamic bracing, splinting) for upper and lower extremities. (This charge should not be used in addition to a gait training charge) THERAPEUTIC PROCEDURES GROUP (EACH VISIT) Used when working with two or more inviduals at one time on therapeutic activities/exercises. May be used with other charges. Group Lumbar Stabilization or Group Aquatic Therapy or Group Exercise Programs should use this charge SUPERVISED EXERCISE (EACH VISIT) Used when the patient requires minimal supervision with his/her exercise program or used in services needed but not directly provided by licensed personnel. (<1 hour and > 1 hour two separate possible charges) DEBRIDEMENT (EACH VISIT) Used when performing debridement procedures in conjunction with wound care (check scope of practice for state) WOUND CARE (EACH 15 MIN.) Used when performing dressing changes and wound care activities other than debridement. OR MORE SPECIFICALLY (when debridement included): Burn debridement &/or dressing, 9% or less Burn debridement &/or dressing, 10 18% Burn debridement &/or dressing, 19% or more TAPING (EACH VISIT) Charge for taping of patient during treatment session, taping shoulder, knee, ankle, etc. OR MORE SPECIFICALLY: Shoulder strapping/taping Elbow/wrist strapping/taping Hand/finger strapping/taping 34

35 29520 Hip strapping/taping Knee strapping/taping Ankle strapping/taping Toes strapping/taping Unna Boot Manual Muscle Testing Extremity/Trunk M.M.T. Hand with or without comparison with normal side M.M.T. Total evaluation of body, excluding hands M.M.T. Total evaluation of body, including hands Range of Motion of measurements & report (separate procedure); each extremity (excluding hand) or each trunk section (spine) ROM measurements of hand, with or without comparison with normal side Work Hardening/conditioning; initial 2 hours Work Hardening/conditioning; each additional hour (list separately in addition to code for primary procedure) MODALITIES: ULTRASOUND (EACH 15 MIN.) Deep heat modality used to decrease pain and muscle spasm PHONOPHORESIS (EACH 15 MIN.) This charge is not being reimbursed. Must bill for ultrasound if billing for this service. Make sure you document the use of drug, but bill for and document it as ultrasound ELECTRICAL STIMULATION (EACH 15 MIN.) Used for treatment of trigger points and muscle spasms to treat specific areas of pain using a combination of both ultrasound and electrical stimulation at the same time IONTOPHORESIS (EACH 15 MIN.) Electrical stimulation that is used to drive a medication into the tissue. Used to decrease pain and inflammation. Includes the cost for medication, the electrodes and the direct therapy time CONSTANT ELECTRICAL STIMULATION (EACH 15 MIN.) Used for treatment of trigger points for pain reduction, motor points for muscle re-education or any other electrical stimulation that requires direct (one-on-one) patient contract by the provider CONTRAST BATHS (EACH 15 MIN.) Modality used to help with edema/pain reduction ELECTRIC STIMULATION (APPLICATION TO ONE OR MORE AREAS) Used for pain modification, muscle spasm reduction and edema reduction. It is 35

36 used when there does not have to be constant attendance by the provider through the whole treatment procedure. Charged by the visit WHIRLPOOL (APPLICATION TO ONE OR MORE AREAS) Used for treatment of wounds/debridement, pain reduction, muscle relaxation, edema reduction, and improving range of motion. Charge by the visit HOT PACKS (APPLICATION TO ONE OR MORE AREAS) Application of moist heat pack used for pain modulation muscle relaxation. Can only bill for this if used in conjunction with another therapy treatment or modality. Charged by the visit COLD PACKS/ICE MASSAGE (APPLICATION TO ONE OR MORE AREAS) Application of cold pack or performance of ice massage to one or more areas used for pain reduction, edema reduction or muscle spasm reduction. Can only bill for this if used in conjunction with another therapy treatment or modality. Charged by the visit TRACTION, MECHANICAL (NOT TIME BASED) Cervical or lumbar traction used to help decrease pain and improve mobility. Charged by the visit COMPRESSION PUMP (APPLICATION TO ONE OR MORE AREAS) Vasopneumatic modality used for edema reduction. 36

37 APPENDIX B Documentation and Coding Guidelines Adapted from the NATA COR: 12/24/04 What is documentation and why is it important Medical record documentation is required and needed to record pertinent facts, findings and observations about a patient. This could include past and present examinations, tests, treatments, therapies and outcomes. The medical record chronologically documents the care and treatment of patients and is an important element for quality care, for legal purposes and for billing and receiving appropriate reimbursement for services. Proper documentation also ensures the various providers of service a complete and accurate picture of the patient and their illnesses/injuries. Proper documentation enables the physicians and other health care providers to plan and evaluate treatments and to monitor the patient s progress, or lack of, over time. Documentation can facilitate communication and continuity of care between providers. Complete and accurate documentation can produce timely claim payment and clear audits. Documentation can be used for research and education, especially in the utilization and quality of care areas. Documentation Documentation is necessary and required for each episode of physical medicine and rehabilitative care and treatment. Documentation should be Subjective, Objective, include an Assessment and a Plan. Subjective-What happened to the patient, what occurred to cause this diagnosis or condition? Objective-What is the patient s degree of motion? What is their lack or range of motion? Assessment-What have you determined to be the patient s condition, illness/injury? 37

38 Plan-How will you treat or correct the condition? Additional elements to include in the documentation: General health status (self reported) Social habits (past and current) Family illness history as well as personal illness/injury history Medical/surgical history Chief complaint at this time Functional status-patient perceived Current activity level if any and current conditions preventing desired activity level Any vitamins/minerals/supplements being used, any over the counter (OTC) treatments being taken should be noted as well as prescriptive medications. Patient s name and file number should be noted on each page of documentation. Dates and type of therapy contact should be listed. Using abbreviations when documenting is acceptable, as long as the abbreviations used are used consistently and their usage is commonplace. There are a number of reasons for documenting services and patient s records: Documentation provides the rationale for the therapy services you are providing and should show the link between services provided and desired patient outcome. Provide the reader of the documentation with the rationale and reasoning behind your decisions. Documentation will communicate to other providers medical and other information regarding the patient from your perspective as the patient s rehabilitation provider. The file and the documentation should create a clean chronological record of the patient and their interactions with the provider. The AT should document all services provided within the format and method established by the practice setting, the agency, and any external accreditation agencies and/or by payers. All ATs should maintain a permanent patient record for each case. This permanent file should be kept in a professional and legal manner. It needs to be organized, clear and concise, accurate, complete and most importantly legible. Whenever you document or work with patient s files confidentiality laws and HIPAA standards must be maintained. 38

39 What Do Payers Want and Why? Payers may require documentation that services are consistent and in line with the benefits provided by the insurance contract. The documented medical record may serve as a legal tool to verify that care billed for was provided. Payers may request information on the site of service, the medical necessity and appropriateness of the diagnostic or therapeutic care provided. They may also demand documentation that services provided were accurately reported and provided. ATs must be truthful and as accurate as possible in their documentation and medical record keeping. This is especially true when it comes to billing for and receiving reimbursement from any federal or state agencies. Proper and complete documentation will increase reimbursement and quicken the claims process. Guidelines For Medical Record Documentation Guidelines for medical record documentation are listed below; these guidelines are appropriate for most therapeutic and medical settings. The specific documentation for services may vary depending on type of service or rehabilitation performed the site of service and the overall condition of the patient. These general guidelines may be modified depending on circumstances. 1. The medical record should be legible and complete. (Numerous third party payers report that illegible documentation is one major issue in slowing claims processing) 2. Each patient s documented record should include: 39

40 a. The reason for this encounter and any relevant history, any physical examinations and findings, any prior test results. b. The diagnosis, assessment and clinical impressions c. The plan of care and treatment d. Date of service and clear identity of the provider 3. The rationale for ordering any testing or diagnostic procedures should be documented. 4. Current as well as past diagnoses should be accessible to the treating or consulting provider. 5. Health risk factors should be identified and noted 6. The patient s response to treatment, notes on any changes in treatment, the patient s progress or lack of and any revisions in diagnosis should also be documented 7. The CPT, ICD 9-CM and HCPCS codes listed and billed to third party payers on the claim form should be supported by the documentation contained in the medical record Coding Documentation and the patients file should be accurate and maintained in a timely and concise manor. The documentation and patient s file is what professional coders and billing personal will use to correctly bill for the services you ve provided. ICD-9-CM was designated in 1979 as the official system for assigning codes to diagnoses for inpatient, and outpatient care. The National Center for Health Services (NCHS) and CMS are the U.S. Department of Health and Human Services agencies that are responsible for 40

41 overseeing the ICD-9-CM system. This system was adopted and is now used by private insurance carriers. The appropriate codes from through V82.9 must be used to identify diagnoses, symptoms, problems, complaints or any other reason for the patient s therapy visit. Accurate and complete documentation is necessary for the correct ICD-9-CM code to be assigned. Codes through are used to describe reasons for the therapy visit. These codes are from the classification of injuries and diseases in the ICD-9-CM. Codes describe signs and symptoms and ill-defined conditions these would be utilized when a physician has confirmed no definitive diagnosis. Though extensive they do not contain all codes for symptoms. V codes are used when patient encounters are for reasons other than because of an injury or illness. V01.0-V82.9 For patients receiving rehabilitative services only, during a treatment, sequence the diagnoses listed in the medical record. First you would list the ICD-9-CM code for the primary diagnosis responsible for the outpatient services provided during that visit. Then you would list any additional diagnoses that describe comorbidities or conditions that were treated or medically managed or that may have influenced the patient s treatment or services provided. E-codes describe the external causes of injury, poisoning or other adverse reactions. Ecodes are descriptors and while not affecting reimbursement amounts 41

42 can expedite claims processing. Using E-codes gives the claim processors a more complete picture of what happened and where the injury occurred. You can use more than one code when filing a claim, sometimes more is better as the claims department then understands more about the case. CPT codes are the procedure codes, what treatment or physical medicine activity did you perform. These are the codes used for payment; the CPT codes are the codes that third party payers reimburse by. You should always consult your professional coder/biller for further clarification of coding and billing issues. You will also wish to consult with your compliance officer for any clarification you might need regarding documentation and record keeping. 42

43 Helpful Links Connecticut Athletic Trainers Association Legislative Toolkit National Athletic Trainers Association National Plan and Provider Enumeration System (NPI Number) Wisconsin Athletic Trainers Association tm Reimbursement Models Cash Model College and University Model High School Model Industrial and Occupational Models Physician Extender Model 43

44 References American Medical Association. CPT Codes 2000 and Fearon, Helene M. Reimbursement for Rehabilitation Services PT 11/4/00 Milton, Johnston. Third Party Reimbursement, Cliff Notes Version. ursement.pdf Recommendations for Reimbursement Strategies. WATA Reimbursement Committee. Reimbursement Checklist. Borrowed from WATA Reimbursement Committee. The Resource. Newsletter of the SOA/APTA 44