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

Transcription

1 Coding and Payment Guide for the Physical Therapist An essential coding, billing, and payment resource for the physical therapist 2016

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...41 General Guidelines for Documentation Principles of Documentation Guidelines: Physical Therapy Documentation of Patient/Client Management Compliance Claims Processing...57 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 Definitions and Guidelines: Procedures...97 CPT Codes...99 Appendix Correct Coding Initiative Update 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 Procedure Codes...95 Appropriate Codes for Physical Therapists Optum360, LLC CPT 2014 American Medical Association. All Rights Reserved. iii

3 Coding and Payment Guide for the Physical Therapist 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 some other third-party payers. These codes may also be used as nonpaying codes to report claims-based functional outcomes and PQRS measures. 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 Medicare/Coding/HCPCSReleaseCodeSets/HCPCS_Quarterly_ Update.html. 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. The CMS-1500 claim form was approved in 2013 for 2014 claims. Among other things, it accommodates reporting needs for ICD-10-CM. 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: Introduction 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 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. Mutually exclusive codes are identified with an icon. 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 Optum360, LLC CPT 2014 American Medical Association. All Rights Reserved. 3

4 Procedure Codes Plethysmography for determination of lung volumes and, when performed, airway resistance Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes Airway resistance by impulse oscillometry Explanation Pulmonary function testing the lungs' volume, airway resistance, and diffusing capacity is performed in multiple ways. In 94726, the lung volume and possibly the airway resistance are evaluated using a variety of methods. In the oldest method, the patient is enclosed in a pressurized small room and the volume of air and air resistance are measured as the patient breathes. In a newer method, two belts with sensors are wrapped around the patient at the rib cage and the abdomen to measure the lung volumes, referred to as respiratory inductance plethysmography. In 94727, lung volumes are tested in a pulmonary lab using helium, nitrogen open circuit, or another method to check lung functions to include residual capacity or residual volume, the volume of air remaining in the lung after a patient exhales. The physician interprets results. This code applies to the distribution of inspired gas using multiple breath nitrogen washout curves and including alveolar nitrogen or helium equilibration time. In 94728, the patient breathes into an apparatus called a pneumotachograph. This device uses sound waves to detect and analyze airway changes. In 94729, diffusing capacity is tested. In this test, the patient takes a deep breath, holds it for 10 seconds, and releases the first half. The second half is collected and analyzed for the amount of carbon dioxide it contains. Coding Tips Do not report codes in addition to gas dilution or washout (94727) or airway resistance by impulse oscillometry (94748). Do not report code in addition to spirometry (94010), respiratory flow volume loop (94375), or plethysmography (94726). ICD-9-CM Diagnostic Codes Malignant neoplasm of parietal pleura Malignant neoplasm of visceral pleura Amyotrophic lateral sclerosis Paraplegia Kyphoscoliotic heart disease Other chronic pulmonary heart diseases Left heart failure (Code, if applicable, heart failure due to hypertension first: , with fifth-digit 1 or with fifth digit 1 or 3) Other diseases of respiratory system, not elsewhere classified (Use additional code to identify infectious organism) Systemic lupus erythematosus (Use additional code to identify manifestation: , , , ) V12.60 V12.61 V12.69 V42.1 Coding and Payment Guide for the Physical Therapist Rheumatoid lung Abnormal arterial blood gases Late effect of adverse effect of drug, medical or biological substance Toxic effect of liquefied petroleum gases (Use additional code to Toxic effect of other hydrocarbon gas (Use additional code to Toxic effect of nitrogen oxides (Use additional code to Toxic effect of sulfur dioxide (Use additional code to Toxic effect of freon (Use additional code to specify the nature of the toxic effect) Toxic effect of lacrimogenic gas (Use additional code to Toxic effect of chlorine gas (Use additional code to Toxic effect of hydrocyanic acid gas (Use additional code to Toxic effect of other specified gases, fumes, or vapors (Use additional code to specify the nature of the toxic effect) Toxic effect of unspecified gas, fume, or vapor (Use additional code to Personal history, unspecified disease of respiratory system Personal history, Pneumonia (recurrent) Personal history, Other diseases of respiratory system Heart replaced by transplant 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. Work Value Non-Fac PE Fac PE Malpractice Non-Fac Total Fac Total CPT 2014 American Medical Association. All Rights Reserved Optum360, LLC

5 HCPCS Level II Definitions and Guidelines Coding and Payment Guide for the Physical Therapist A6220 A6221 A6222 A6223 A6224 A6228 A6229 A6230 A6231 A6232 A6233 A6234 A6235 Gauze, non-impregnated, sterile, pad size more than 16 sq in but less than or equal to 48 sq in, with any size adhesive border, each Gauze, non-impregnated, sterile, pad size more than 48 sq in, with any size adhesive border, each saline, or hydrogel, sterile, pad size 16 sq in or less, without adhesive border, each saline, or hydrogel, sterile, pad size more than 16 sq in but less than or equal to 48 sq in, without adhesive border, each saline, or hydrogel, sterile, pad size more than 48 sq in, without adhesive border, each pad size 16 sq in or less, without adhesive border, each pad size more than 16 sq in but less than or equal to 48 sq in, without adhesive border, each pad size more than 48 sq in, without adhesive border, each Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq in or less, each Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq in, but less than or equal to 48 sq in, each Gauze, impregnated, hydrogel for direct wound contact, sterile, pad size more than 48 sq in, each size 16 sq in or less, without adhesive border, each size more than 16 sq in but less than or equal to 48 sq in, without adhesive border, each A6236 A6237 A6238 A6239 A6240 A6241 size more than 48 sq in, without adhesive border, each size 16 sq in or less, with any size adhesive border, each size more than 16 sq in but less than or equal to 48 sq in, with any size adhesive border, each size more than 48 sq in, with any size adhesive border, each Hydrocolloid, wound filler, paste, sterile, per fluid ounce Hydrocolloid, wound filler, dry form, sterile, per gram A6242 Hydrogel, wound cover, sterile, pad size 16 sq in or less, without adhesive border, each A6243 A6244 Hydrogel, wound cover, sterile, pad size more than 16 sq in but less than or equal to 48 sq in, without adhesive border, each Hydrogel, wound cover, sterile, pad size more than 48 sq in, without adhesive border, each A6245 Hydrogel, wound cover, sterile, pad size 16 sq in or less, with any size adhesive border, each A6246 A6247 A6248 A6250 Hydrogel, wound cover, sterile, pad size more than 16 sq in but less than or equal to 48 sq in, with any size adhesive border, each Hydrogel, wound cover, sterile,pad size more than 48 sq in, with any size adhesive border, each Hydrogel, wound filler, gel, per fluid ounce Skin sealants, protectants, moisturizers, ointments, any type, any size 220 l New Codes s Revised Codes MED: Medicare Reference 2015 Optum360, LLC