1 Coding and Payment Guide for the Physical Therapist An essential coding, billing, and payment resource for the physical therapist 2014
2 Contents Introduction...1 Coding Systems... 1 Claim Forms... 3 Contents and Format of This Guide... 3 The Payment Process...5 Coverage Issues... 5 Payer Types... 5 Payment Methodologies Calculating Costs Other Factors Influencing Medicare Payment Participation in Medicare Plans Workers Compensation Collection Policies Documentation An Overview...37 General Guidelines for Documentation Principles of Documentation Guidelines: Physical Therapy Documentation of Patient/Client Management Compliance Claims Processing...53 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 Medicare Benefit Notices The CMS-1500 Claim Form The UB-04 Claim Form Procedure Codes...89 Appropriate Codes for Physical Therapists...89 Definitions and Guidelines: Procedures...91 CPT Index HCPCS Level II Definitions and Guidelines Introduction HCPCS Level II National Codes Structure and Use of HCPCS Level II Codes HCPCS Level II Codes and the Physical Therapist 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 OptumInsight, Inc. CPT codes only 2012 American Medical Association. All Rights Reserved. iii
3 Coding and Payment Guide for the Physical Therapist HCPCS Level II codes, published annually by 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. A complete list of the HCPCS Level II codes and the quarterly updates to this code set may be found at HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp. 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) use 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, and 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 payment, official Medicare regulatory information, and a glossary. Payment The first section of the guide provides comprehensive information about the coding and payment process. It contains four chapters: an introduction, The Payment 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, 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 Introduction some cases, related procedures) including an explanation of the service, coding tips, and associated diagnoses. 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. The procedure code page contains related terms and the CMS Manual System references that designate the official references to the service, which is identified by the procedure code and found in the online manual system. The full excerpt from the online CMS Manual System pertaining to the reference is provided in the Medicare official regulatory information appendix. The full text of all of the Internet-Only Manuals (IOM) may be found at Manuals/Internet-Only-Manuals-IOMs.html. The procedure code pages also have a list of codes from the official Centers for Medicare and Medicaid Services National Correct Coding Policy Manual for Part B Medicare Contractors that are considered to be an integral part of the comprehensive or mutually exclusive coding system and should not be reported separately. Please note that the CCI edits will be updated quarterly and posted on Optum s website at Finally, all relative value information pertaining to the code is listed at the bottom of the page. Indexes and Appendix The chapter containing applicable procedure codes is followed by a procedure code index, an index of diagnosis codes commonly reported by physical therapists, and HCPCS Level II definitions and guidelines. An appendix, Medicare Official Regulatory Information, and a glossary follow. How to Use This Guide The chapters: The Payment Process, Documentation An Overview, and Claims Processing may be read in their entirety and/or used as references. When using this Coding and Payment Guide for code assignment, follow these important steps to improve accuracy and experience fewer overlooked diagnoses and services: Step 1. Carefully read the medical record documentation that describes the patient s diagnosis and the service provided. Remember, more than one diagnosis or service may be documented. Step 2. Locate the main term for the procedure or service documented in the CPT index. This will identify the procedure code that may be used to report this service. Step 3. Locate the procedure code in the chapter titled Procedure Codes. Read the explanation and determine if that is the procedure performed and supported by the medical record documentation. The Terms to Know section may be used ensure appropriate code assignment. Step 4. At this time, review the additional information pertinent to the specific code found in the coding tips, IOM reference, and CCI sections or the Medicare physician fee schedule references. Step 5. Peruse the list of ICD-9-CM codes to determine if the condition documented in the medical record is listed and the code identified. If the condition is not listed refer to the 2012 OptumInsight, Inc. CPT codes only 2012 American Medical Association. All Rights Reserved. 3
4 Procedure Codes Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12) limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters Explanation Needle electromyography (EMG) records the electrical properties of thoracic paraspinal muscles, excluding T1 or T12 (95869) using an oscilloscope. Recordings, which may be amplified and heard through a loudspeaker, are made during needle insertion, with the muscle at rest, and during contraction. Report for a limited study of muscles in one extremity or non-limb (axial) muscles other than thoracic paraspinal or cranial supplied muscles or sphincters. s Code should be used to report a needle EMG study of a limb that has fewer than five muscles tested per limb. Report this code once, or once per each extremity examined. Append modifier 59 Distinct procedural service, to any subsequent codes reported. Report once when performed on the thorax or abdomen, regardless of if the study is performed bilaterally. When performed on the cervical or lumbar paraspinal muscles, report only once regardless of the number of levels examined or if performed bilaterally. When no nerve conduction studies are performed on the same date of service, the appropriate EMG code ( and ) should be reported. To report nerve conduction studies, see Do not report code in addition to code 95860, 95861, 95863, or since the testing of paraspinal muscles corresponding to an extremity are included in these codes. However, when a different limb is tested, append modifier 59 Distinct procedural service, to indicate the involvement of the second limb. Physical therapists in private practice may bill for the technical and professional component of certain diagnostic tests in the code range, such as electromyograms and nerve conduction studies. These codes have both a technical and professional component. To report only the professional component, append modifier 26. To report only the technical component, append modifier TC. To report the complete procedure (i.e., both the professional and technical components), submit without a modifier. The professional component is covered by Medicare as outpatient physical therapy when performed by a PT who meets the following criteria: 1) The PT is certified by the American Board of Physical Therapist Specialties (ABPTS) as a clinical electrophysiologic-certified specialist 2) The PT is personally supervised by an ABPTS-certified PT; only the certified PT may bill for the service Medicare will permit a PT without ABPTS certification to provide certain electromyography services if that PT was not ABPTS-certified as of July 1, 2001, and had been furnishing such diagnostic tests prior to May 1, The requirements vary depending on the CPT code billed. Some third-party payers, such as Medicare, reimburse only for the technical portion of many procedures whose codes are in this subsection of the CPT book. It is important for each therapist to determine how insurers require physical therapists to bill services. Therapists should keep track of experiences with each insurance company and policy, providing data for future claims. Single-fiber EMG testing is the innervation of one or more nerve cells and some of the muscles stimulated. Code describes testing of each muscle studied. Normally, 20 pairs of nerves must be studied to significantly study each muscle. Each muscle is coded only once. However, if another muscle is studied, then the code is reported again. These codes can be used in addition to the standard evaluation. Terms To Know electromyography. (EMG). Examining and recording the electrical activity of a muscle. technical component. Portion of a health care service that identifies the provision of the equipment, supplies, technical personnel, and costs attendant to the performance of the procedure other than the professional services. Synonym(s): TC. 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. IOM References 100-2,15,230.4; 100-4,5,10.2 CCI Version Coding and Payment Guide for the Physical Therapist Also not with 95869: 90901, 95870, , Also not with 95870: 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 CPT only 2012 American Medical Association. All Rights Reserved OptumInsight, Inc.
5 HCPCS Level II Definitions and Guidelines A4452 A4455 A4456 A4461 A4463 A4465 A4466 A4490 A4495 A4500 A4510 A4556 A4558 A4559 A4565 A4566 Tape, waterproof, per 18 sq in Adhesive remover or solvent (for tape, cement or other adhesive), per ounce Adhesive remover, wipes, any type, each Surgical dressing holder, nonreusable, each Surgical dressing holder, reusable, each Nonelastic binder for extremity Garment, belt, sleeve or other covering, elastic or similar stretchable Surgical stocking above knee length, each, 130; Pub. Surgical stocking thigh length, each, 130; Pub. Surgical stocking below knee length, each, 130; Pub. Surgical stocking full length, each, 130; Pub. Electrodes (e.g., Apnea monitor), per pair Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per ounce Coupling gel or paste, for use with ultrasound device, per ounce Slings Shoulder sling or vest design, abduction restrainer, with or without swathe The initial casting of the fracture is considered part of the fracture care, inherent in the fracture care code. The sling, however, is not included in the global package for fracture care. Some contractors will pay for this additional patient care item; some will not. If the provider ordered the sling secondary to high probability of patient self-harm with a flailing, casted limb, or if the patient is a child who requires immobilization of the casted limb to avert further injury, reimbursement may be considered by some contractors. Clear evidence of these situations must be reflected in the medical documentation and should be submitted with the claim. In any case, it would be prudent to secure an advance beneficiary notice of noncoverage (ABN) from the patient in case a medical necessity denial is received. A4570 A4580 Splint Cast supplies (e.g., plaster) A4590 A4595 A4600 A4630 A4635 A4636 A4637 A4649 Coding and Payment Guide for the Physical Therapist Special casting material (e.g., fiberglass) Electrical stimulator supplies, 2 lead, per month, (e.g. TENS, NMES) MED: Pub , Section Sleeve for intermittent limb compression device, replacement only, each Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient Underarm pad, crutch, replacement, each Replacement, handgrip, cane, crutch, or walker, each Replacement, tip, cane, crutch, walker, each Surgical supply; miscellaneous Determine if an alternative national HCPCS Level II code better describes the supply being reported. Code A4649 should be used only if a more specific code is unavailable. A5113 A5114 Leg strap; latex, replacement only, per set Leg strap; foam or fabric, replacement only, per set Dressings Medicare claims fall under the jurisdiction of the durable medical equipment Medicare administrative contractor (DME MAC) unless otherwise noted. A6000 Non-contact wound warming wound cover for use with the non-contact wound warming device and warming card MED: Pub , Section Noncontact normothermic wound therapy (NNWT) encourages wound healing by warming a wound to a preset temperature. The device consists of a noncontact wound cover that contains a flexible, battery-powered infrared heating card. Benefits are not available under Medicare for this therapy based on a national coverage determination (NCD). s A6021 s A6022 s A6023 A6024 Collagen dressing, sterile, size 16 sq in or less, each Collagen dressing, sterile, size more than 16 sq in but less than or equal to 48 sq in, each Collagen dressing, sterile, size more than 48 sq in, each Collagen dressing wound filler, sterile, per 6 in 200 New Codes Revised Codes MED: Medicare Reference 2012 OptumInsight,