Coding and Payment Guide for the Physical Therapist. An essential coding, billing, and reimbursement resource for the physical therapist

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1 Coding and Payment Guide for the Physical Therapist An essential coding, billing, and reimbursement resource for the physical therapist 2011

2 Contents Introduction...1 Coding Systems... 1 HCPCS Level II Codes... 2 Claim Forms... 2 Contents and Format of This Guide... 2 How to Use This Guide... 3 The Reimbursement Process...5 Coverage Issues... 5 Payer Types... 5 Payment Methodologies... 9 Calculating Costs Other Factors Influencing Medicare Payment Participation in Medicare Plans Workers Compensation Collection Policies Documentation An Overview...35 General Guidelines for Documentation Guidelines: Physical Therapy Documentation of Patient/Client Management Claims Processing...51 What to Include on Claims Clean Claims Medicare Billing for Physical Therapists in Private Practice The Health Insurance Portability and Accountability Act Processing the Claim The Appeals Process...56 Benefit Notices...65 The CMS-1500 Claim Form...69 The UB-04 Claim Form...81 Procedure Codes...89 Appropriate Codes for Physical Therapists...89 Definitions and Guidelines: Procedures...91 Procedure Codes...93 CPT Index ICD-9-CM Index ICD-9-CM Coding Conventions Manifestation Codes Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital Based and Physician Office) ICD-9-CM Codes Alphabetic Index to External Causes of Injury and Poisoning (E Code) Medicare Official Regulatory Information Glossary Index Ingenix CPT codes only 2010 American Medical Association. All Rights Reserved. iii

3 Introduction describing services rendered to patients. Known as HCPCS Level I, the CPT coding system is the most commonly used system to report procedures and services. Copyright of CPT codes and descriptions is held by the AMA. This system reports outpatient and provider services. CPT codes predominantly describe medical services and procedures, and are adapted to provide a common billing language that providers and payers can use for payment purposes. The codes are required for billing by both private and public insurance carriers, managed care companies, and workers compensation programs. The AMA s CPT Editorial Panel reviews the coding system and adds, revises, and deletes codes and descriptions. The panel accepts information and feedback from providers about new codes and revisions to existing codes that could better reflect the provided service or procedure. The American Physical Therapy Association (APTA) is represented on the Health Care Professional Advisory Committee (HCPAC) for both the AMA CPT Editorial Panel and the AMA Relative Value Update Committee (RUC). The CPT HCPAC representative provides input for the development and revision of CPT codes, while the RUC HCPAC representative provides input into the establishment of relative values for the codes. The majority of codes are found in category I of the CPT coding system. These five-digit codes describe procedures and services that are customarily performed including those performed by the physical therapist. CPT category II codes are supplemental tracking codes that are primarily used when participating in the Physician Quality Reporting System (PQRS) established by Medicare and are intended to aid in the collection of data about quality of care. At the present time, participation in this program is optional. Category II codes are alphanumeric, consisting of four digits followed by an F and should never be used in lieu of a category I CPT code. A complete list of the category II codes can be found at the AMA website at More information regarding the PQRS can be found on the CMS website at Category III of the CPT coding system contains temporary tracking codes for new and emerging technologies that are meant to aid in the collection of data on these new services and procedures as well as facilitate the payment process. However, it should be noted that few payers reimburse for emerging technology procedures and services. CPT category III codes consist of four numeric digits followed by a T. Like category II codes, category III codes are released twice a year (January 1 and July I) and can be found on the AMA CPT website at RVUs are not assigned for category III codes and payment is made at the discretion of the payer. A service described by a CPT code may eventually become a category I code, as the efficacy and safety of the service is documented and as the category II codes are sunsetted after five years and then must be reviewed for continued use as category III descriptors. HCPCS Level II Codes HCPCS Level II codes are commonly referred to as national codes or by the acronym HCPCS (Healthcare Common Procedure Coding System, pronounced hik piks ). HCPCS codes are used for billing Medicare and Medicaid patients and are also used by some third-party payers. Coding and Payment Guide for the Physical Therapist HCPCS Level II codes, updated and published annually by the CMS, are intended to supplement the CPT coding system by including codes for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); drugs; and biologicals. These Level II codes consist of one alphabetic character (A through V) followed by four numbers. In many instances, HCPCS Level II codes are developed as precursors to CPT codes. Claim Forms Institutional (facility) providers use the UB-04 claim form, also known as the CMS-1450, to file a Medicare Part A claim to Medicare contractors for service providers in hospital outpatient settings or in the electronic format using the 837i format. Noninstitutional providers and suppliers (private practices or other health care providers offices) utilize the CMS-1500 form or the 837p electronic format to submit claims to Medicare contractors for Medicare Part B-covered services. Medicare Part A coverage includes inpatient hospital, skilled nursing facilities (SNF), hospice, and home health. Part A providers also include rehabilitation agencies and comprehensive outpatient rehabilitation facilities (CORF). Medicare Part B coverage provides payment for medical supplies, physician services, and outpatient services delivered in a private practice setting (PTPP). Not all services rendered by a facility are inpatient services. Providers working in facilities routinely render services on an outpatient basis. Outpatient services are provided in settings that include rehabilitation centers, certified outpatient rehabilitation facilities, SNFs, and hospitals. Outpatient and partial hospitalization facility claims might be submitted on either a CMS-1500 or a UB-04 depending on the payer. For professional component billing, most claims are filed using ICD-9-CM diagnosis code to indicate the reason for the service, CPT codes to identify the service provided, HCPCS Level II codes to report supplies on the CMS-1500 paper claim or the 837p electronic format. Contents and Format of This Guide The Coding and Payment Guide for the Physical Therapist contains chapters that address reimbursement, official Medicare regulatory information, and a glossary. Reimbursement The first section of the guide provides comprehensive information about the coding and reimbursement process. It contains four chapters: an introduction, The Reimbursement Process, Documentation An Overview, and Claims Processing. These chapters are predominantly narrative in nature; however, the claims processing chapter provides step-by-step explanations to complete the CMS-1500 and UB-04 claim forms and a crosswalk for electronic submissions. Procedure Codes for Physical Therapists The next chapter, Procedure Codes for Physical Therapists, contains a numeric listing of procedure codes most commonly used by a physical therapist. Each page identifies the information associated with that procedure (or in some cases, related procedures) including an explanation of the service, coding tips, and associated diagnoses. Please note that this list of associated 2 CPT codes only 2010 American Medical Association. All Rights Reserved Ingenix

4 Coding and Payment Guide for the Physical Therapist Explanation Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes The physical therapist works one-on-one with an individual with sensory integration disorders to provide techniques for enhancing sensory processing and adapting to environmental demands. Sensory integration disorders may be the result of a learning disability, illness, or brain injury. Sensory experiences include touch, movement, body awareness, sight, sound, and the pull of gravity. The process of the brain organizing and interpreting this information is called sensory integration. Sensory integration provides a crucial foundation for later, more complex learning and behavior. Coding Tips This modality requires direct (one-to-one) patient contact by the provider and includes a time component. According to CMS guidelines, at least eight minutes of direct contact with the patient must be provided for a single unit of service to be appropriately billed. Medical record documentation should indicate the total amount of time for the direct one-to-one patient contact provided by the physical therapist, as well as total treatment time (as defined by all timed and untimed codes). AMA guidelines state that incremental intervals of treatment performed on the same session may be added together when determining total time. Check with other third-party payers for their guidelines. According to the CPT guidelines, this code is not reported with modifier 51 but has not been designated as a modifier 51 exempt or an add-on code in the CPT book. Please see the beginning of this section for more information on the use of modifiers. ICD-9-CM Diagnostic Codes Late effects of intracranial abscess or pyogenic infection (Use additional code to identify condition: 331.4, , ) Leukodystrophy (Use additional code to identify associated mental retardation) Cerebral lipidoses (Use additional code to identify associated mental retardation) Cerebral degeneration in generalized lipidoses (Use additional code to identify associated mental retardation. Code first underlying disease: 272.7) Cerebral degeneration of childhood in other diseases classified elsewhere (Use additional code to identify associated mental retardation. Code first underlying disease: 277.5) Alzheimer's disease (Use additional code, where applicable, to identify dementia: , ) V57.1 V57.22 Pick's disease (Use additional code, where applicable, to identify dementia: , ) Paralysis agitans Secondary Parkinsonism (Use additional E code to identify drug, if drug-induced) Huntington's chorea Friedreich's ataxia Primary cerebellar degeneration Amyotrophic lateral sclerosis Progressive muscular atrophy Subarachnoid hemorrhage (Use additional code to identify presence of hypertension) Intracerebral hemorrhage (Use additional code to identify presence of hypertension) Nontraumatic extradural hemorrhage (Use additional Subdural hemorrhage (Use additional code to identify presence of hypertension) Acute, but ill-defined, cerebrovascular disease (Use additional Cognitive deficits due to cerebrovascular disease (Use additional Aphasia due to cerebrovascular disease (Use additional Dysphasia due to cerebrovascular disease (Use additional Late effect of open wound of head, neck, and trunk Late effect of crushing Late effect of intracranial injury without mention of skull fracture Late effect of injury to cranial nerve Late effect of spinal cord injury Other physical therapy (Use additional code to identify the underlying condition) Encounter for vocational therapy (Use additional code to identify the underlying condition) Please note that this list of associated ICD-9-CM codes is not all inclusive. The procedure may be performed for reasons other than those listed that support the medical necessity of the service. Only those conditions supported by the medical record documentation should be reported. IOM References Procedure Codes 100-2,15,230; 100-2,15,230.1; 100-2,15,230.2; 100-2,15,230.4; 100-4,5,10; 100-4,5,20; 100-4,12,30 CCI Version T, 0216T, 0228T-0231T, , , , , 64493, , 97002, Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above. Work Value Non-Fac PE Fac PE Malpractice Non-Fac Total Fac Total Ingenix CPT only 2010 American Medical Association. All Rights Reserved. 175

5 Procedure Codes Physician review and interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report Explanation The physical therapist reviews and interprets computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography performed using codes 96000, 96001, 96002, and to report the service. Coding and Payment Guide for the Physical Therapist ICD-9-CM Diagnostic Codes The application of this code is too broad to adequately present ICD-9-CM diagnostic code links here. Refer to your ICD-9-CM book. CCI Version , , 97116, Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above. Coding Tips Hemiplegia and hemiparesis (category 342) codes are to be used when hemiplegia (complete) (incomplete) is reported without further specification, or is stated to be old or long standing but of unspecified cause. The category is used also for multiple coding to identify these types of hemiplegia resulting from any cause. Hemiplegia and hemiparesis resulting from cerebrovascular disease is classified to category 438. Assigning a code from the 438 category is inappropriate in cases of past history of cerebrovascular disease that resulted in no neurological deficits. The appropriate code assignment would be V12.54 Transient ischemic attack (TIA), and cerebral infarction without residual deficits.code is assigned for the nonspecific diagnosis of stroke or CVA, not otherwise specified. Terms To Know cerebrovascular accident. Disruption in blood flow to the brain caused by an embolism, thrombosis, or other occlusion, resulting in a lack of perfusion and infarction of brain tissue. Current CVAs are reported with codes from the 434 rubric of ICD-9-CM with a fifth digit of 1 to indicate that cerebral infarction has occurred. An impending CVA is reported as an unspecified transient ischemic attack (TIA), 435.9, in which intermittent ischemia of the brain tissue occurs. When a cerebrovascular accident occurs postoperatively, report Sequelae or late effects of CVA can include paralysis, weakness, speech problems, and aphasia, and are reported within the 438 category reserved for late effects of cerebrovascular disease. A healed or old cerebral infarction is coded to V12.59, a personal history of circulatory system disease. Synonym(s): CVA, stroke. electromyography. (EMG). Examining and recording the electrical activity of a muscle. hemiplegia. Paralysis of one side of the body. kinetics. Motion or movement. neuromyopathy. Disease or disorder affecting both the nerves and the muscles, particularly a muscular disease of nervous origin. Report this condition with a code from ICD-9-CM category 358. TIA. Transient ischemic attack. Intermittent or brief cerebral dysfunction from lack of oxygenation with no persistent neurological deficits; associated with occlusive vascular disease. Work Value Non-Fac PE Fac PE Malpractice Non-Fac Total Fac Total CPT only 2010 American Medical Association. All Rights Reserved Ingenix

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