CPT Current Procedural Terminology A National Standard under HIPAA Transactions Rule CPT Assistant = AMA s Coding Guidelines and Instructions

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1 DISCLAIMER & TERMS THIS PRESENTATION WAS CREATED IN ORDER TO HELP HEALTH CARE PROFESSIONALS, MEDICAL BILLING PERSONNEL, CODERS AND OTHER SUPPORT PERSONNEL TO BETTER UNDERSTAND THE RAPIDLY CHANGING MEDICAL/HEALTHCARE ENVIRONMENT. DOCUMENTATION, BILLING AND CODING DECISIONS SHOULD NOT BE SOLEY BASED UPON INFORMATION CONTAINED IN THIS PRESENTATION. INDIVIDUAL CIRCUMSTANCES, LEGAL AND ETHICAL CONSIDERATIONS, STATE AND FEDERAL LAWS, AS WELL AS PAYER POLICIES SHOULD ALWAYS BE CONSIDERED WHEN DETERMINING A PARTICULAR COURSE OF ACTION. THIS PRESENTATION AND CONTENTS HERIN SHALL NOT BE CONSTRUED AS LEGAL ADVICE NOR AS ESTABLISHING A CLIENT-ATTORNEY RELATIONSHIP. RESOURCES ARE PROVIDED FOR EDUCATIONAL AND AWARENESS PURPOSES ONLY, AND AS SUCH, ARE PROVIDED STRICTLY AS SAMPLES. IF YOU HAVE QUESTIONS OF A LEGAL NATURE, YOU SHOULD CONTACT AN ATTORNEY AT LAW. THE PRESENTERS MAKES NO WARRANTIES, EXPRESS OR IMPLIED, REGARDING ANY SUCH RESOURCES. Presented by: Marty Kotlar, DC & David Klein, CPC, CHC ALL RESOURCES DISSEMINATED AT THIS SEMINAR ARE SUBJECT TO A COPYRIGHT. ALL OTHER RIGHTS RESERVED. RECORDING OF THIS SEMINAR IS STRICTLY PROHIBITTED. PLEASE TURN OFF ANY RECORDING DEVICES AND PUT THEM AWAY. 1 2 There Is Way Too Much Mis-Information The Code Definitions -- CPT-4 and ICD-9 became Federal Law as a result of the HIPAA Transactions Rule in See 45 CFR (a), Make sure you are using accurate sources CPT Current Procedural Terminology A National Standard under HIPAA Transactions Rule CPT Assistant = AMA s Coding Guidelines and Instructions Not currently a national standard AMA is striving to have the AMA Coding Guidelines and Instructions adopted as a national standard. We have a licensed access to the entire archives of CPT Assistant CPT is the primary coding authority. If it doesn t answer a particular question, look to CPT Assistant next

2 Instructions from CPT: Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or code. Question What is the appropriate CPT code to report for mechanical massage therapy? AMA Comment From a CPT coding perspective, no current CPT code specifically and accurately describes mechanical massage; therefore, code 97039, Unlisted modality (specify type and time if constant attendance), would be the most appropriate code to report for mechanical massage therapy. It would not be appropriate to report code Question We have recently begun using the AquaMed device, which is a water tank with pressurized water jets designed to move along a hydraulic track. A nylon net and heavy plastic barrier are fixed to the top surface of the tank. The patient is situated on top of this barrier, and the water jets are directed toward the body area to be treated. What CPT code should we use to report this service? Kinesio Taping AMA Comment CPT does not contain a code that accurately describes the AquaMed physical medicine device you have described in your question. Therefore, the unlisted code 97039, Unlisted modality (specify type and time if constant attendance), should be reported. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure, and the time, effort and equipment necessary to provide the service. 7 2

3 Kinesio Taping Kinesio taping is a taping technique that is designed to facilitate the body s natural healing process while providing support and stability to muscles and joints without restricting the body s range of motion. Kinesio taping can help alleviate pain and can facilitate lymphatic drainage by microscopically lifting the skin. It can be applied in hundreds of ways and has the ability to re-educate the neuromuscular system, reduce inflammation, enhance performance, prevent injury and promote good circulation and healing, and assist in returning the body to homeostasis. Kinesio Taping According to the AMA, Kinesio tape is a supply. Its application is included in the time spent in direct contact with a patient to provide either re-education of a muscle and movement or to stabilize one body area to enable improved strength or range of motion. The application of tape is usually performed in conjunction with educating the patient on various functional movement patterns. The tape is applied based on the patient s specific patterns of weakness or strength. The tape is left in place after instruction related to movements designed for improving strength, range, and coordination is provided and documented. However, if the purpose of the taping is to immobilize the shoulder, then the strapping codes may be appropriate as those codes describe the use of a strap or other reinforced material applied post-fracture or other injury to immobilize the joint. Kinesio Taping I have not read any insurance carrier policies recently that state it will cover Kinesio taping for alleviating pain, reducing inflammation, promoting good circulation and returning the body to homeostasis. Therefore, you should consider Kinesio taping a non insurance payable procedure. However, if you need to bill an insurance carrier for Kinesio taping I recommend you use CPT code (unlisted therapeutic procedure) or CPT code (unlisted physical medicine/rehabilitation service or procedure). You can also bill HCPCS code A4450 per 18 sq. inches of tape (non waterproof) or A4452 per 18 sq. inches of tape (waterproof). Kinesio Taping We do not recommend billing CPT codes 29200, 29240, 29260, 29280, 29520, 29530, or for Kinesio taping. These Casts and Strapping codes are meant to immobilize a joint or body part and are therefore should not be used for Kinesio taping. 3

4 Laser Therapy Laser Therapy According to Chiropractic Economics, 30% of chiropractors surveyed use Laser Therapy. Laser Therapy Laser Therapy COMMON CONDITIONS: Tendonitis, Sprains/Strains, Carpal Tunnel Syndrome, Bursitis, Plantar Fasciitis, Restricted ROM, Edema, Effusion, Inflammation, Muscle Spasm, Myofascitis, Fibromyalgia, Low Back Pain, Neck Pain, TMJ, Ligament Injury, Muscle Contusions, Disc Trauma GOOD BUSINESS MOVE: Adds another treatment option Can treat more conditions See more patients It s very marketable High-tech Patients love it! 4

5 Laser Therapy There are hundreds of studies and numerous books that have been written on the effectiveness laser therapy. Laser Therapy In general, you have 2 choices when it comes to billing for laser therapy. It can be billed as CPT code (unlisted modality). When reporting an unlisted code to describe a procedure or service, you should submit supporting documentation (e.g., procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure; and the time, effort, and equipment necessary to provide the service. Laser Therapy Laser Therapy Cold laser can also be billed as HCPCS code S this is the application of a modality (requiring constant provider attendance) to one or more areas; low level laser; each 15 minutes. Cash or insurance, you need to show "medical necessity" - this includes performing an exam, history, making a proper diagnosis, and report frequency and duration of care. The SOAP notes should include the clinical rationale for performing the service and if the functional goals are being reached. CPT code 97039: Unlisted modality (specify type and time if constant attendance) If used as a constant attendance modality, document the amount of time spent and the anatomic location where the laser therapy was applied. 5

6 Laser Therapy HCPCS code S8948: Application of a modality (requiring constant provider attendance) to one or more areas; low level laser; each 15 minutes BC/BS created the S8948 code to denote the actual procedure being performed. Coding & Fees for nutritional services Is the service Medically Necessary? Are you charging extra to give nutritional advice? Explain what and how are you charging for this service: Are you setting aside a separate time for nutritional advice or is it part of an office visit? Is there an additional fee for this service or is it just added value for them? * Nutritional advice is a valuable service, you should either paid or they should be aware of the added value you provide Tip: An attorney usually charges $ an hour for a consult In Most Cases it is not covered Two questions to ask yourself: 1. Is the Patient presenting with actual symptoms and/or an established illness that requires nutritional counseling? or 2. Is the patient is merely seeking/needs preventative services? According to Current Procedural Terminology (CPT): When physicians provide nutrition services, Evaluation and Management or Preventive Medicine service codes are used to report the service. Do not use the Medical Nutrition Therapy (MNT) codes they are for Nutritionists only 6

7 99401 Preventative medicine counseling and or risk factor reduction intervention(s) provided to an individual (separate procedure) approximately 15 minutes approximately 30 min approximately 45 min approximately 60 min Group setting 30 min approximately 60 min E/M When counseling and/or coordination of care dominates more than 50% or the total time spent face to face with the patient, time may be the controlling factor in determining the level of service. The documentation must include how much time was spent for the visit and how much time was spent counseling / coordinating care. This office submits services for Nutritional Counseling utilizing the preventative counseling codes( ) in anticipation of denial of payment from your insurance Carrier. The Provider will not submit the these services to your Carrier as a covered service because, based on carrier policies, the Nutritional Counseling service will likely be considered preventative in nature and not covered. Cash Plans The patient has read, understood and acknowledges that the Patient will be solely responsible for payment and will waive any future claims or demands against the Provider for payments made in connection with this service. 7

8 Cash Plans Is One Fee Really Possible? Normal Fees (standard fee, regular fee) Managed Care Fees (contracted fee): BC/BS, Aetna, CIGNA, United Healthcare, OptumHealth, ASH Mandated Fees (set by state or federal gov t): Medicare, Medicaid Workers Compensation Fees Personal Injury Fees Financial Hardship Fees Being part of all or some does NOT mean you have a dual fee schedule (they re contracted or mandated). Cash Plans Is One Fee Really Possible? Your fee schedule/policy should have this approach: I have one fee for my practice and the only time I provide a discount is when I m required to do so because of a contractual network agreement or because of a patient financial hardship. Cash Plans Is One Fee Really Possible? All patients should be aware of your normal fees. Integrated Practices Some providers give discounts only to cash patients and do not let them know the normal fees. This could cause unnecessary confusion if a cash patient returns as an insurance patient (sticker shock). 8

9 Integrated Practices Multi-specialty office: DC, MD, DO, NP, PA, PT, PTA, MT Employment contracts In-network credentialing In-network contracts NPI #s, PTANs Malpractice Contact existing plans - notify them of new providers Medicare 855R form Reason #1 Many major insurance entities appear to define the care NOT by the nature of the table (i.e., as a modality), but rather by the programmed systems and outcome (therapeutic procedure) associated with the care confusing??? Medical Policy: The common principle behind all these decompression therapy devices (whether they apply static, intermittent, or cycled distractive forces) is to create negative intra-discal pressure to induce disk and nerve root decompression, thereby resulting in pain relief. Policy: Vertebral axial decompression as a treatment of acute or chronic low back pain is considered investigational. CPT code 97012, Application of a modality to one or more areas; traction, mechanical, is intended to identify a procedure that creates a force to allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds or Newtons) allowed, duration (time), and angle of pull (degree) using mechanical means. Therefore, code would be the most appropriate code to report for various types of mechanical traction devices (e.g., computerized/ motorized) including vertebral axial [decompression]. Coding Communication: Vertebral Axial De[com]pression, CPT Assistant, American Medical Association, November 2004, Vol.14, Issue 11, p. 9. 9

10 Reason #2 -- Split of authority when it comes to coding Mechanical Traction S Vertebral Axial Decomp / Unlisted Modality/Service Reason #3 -- Is it really true that the carriers are mandating S9090??? Case in Point Most BCBS plans If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern. If you bill the service by Code, what is the carrier likely to do? Code Carrier Likely to (mechanical traction) Pay you (unlisted modality) Evaluate your documentation?? S9090 (vertebral axial decompression) Deny as investigational?? In light of the above, a provider could utilize an unlisted code to confirm that medical policy is consistent with benefit plan or contract. 1.Experiment try using an unlisted code Submit the procedure on paper claim form 3.Include attachments see next slide 4.Send by Certified Mail or other verifiable means 5.Keep a copy 6.When EOBs come back, attach them to the copy of the letter - File it. Treatment Plan not a schedule for care Daily Notes Identify the device Include pictures of the device from Manufacturer s web site Brief description of care don t give the care a name Cover Letter please process my claims promptly 10

11 Durable medical equipment (DME), also known as durable goods, medical supplies and home care products is defined as: items or appliances which can withstand repeated use are primarily and customarily used to serve a medical purpose are most useful to injured or disabled people are appropriate for home use are necessary for one or more daily living activities General Recommendations: Contact the carriers you bill and get their DME documentation and referral arrangement policies and guidelines. Do not create cookie-cutter DME orders. LO = Lumbar Orthotic LSO = Lumbar Sacral Orthotic Spinal orthotics are used to immobilize specific areas of the spine and designed to control gross movement of the trunk. Spinal orthotics reduce pain by restricting mobility of the trunk. They must support weakness and restrict motion. 11

12 They should have an intimate fit and are generally designed to be worn under clothing. Spinal orthotics can be rigid or semi-rigid devices. Elastic support garments do not meet the definition of a spinal orthotic because they are not rigid or semi-rigid devices. Therefore, flexible spinal support garments that are made primarily of elastic material are considered noncovered items. Flexible spinal orthotics that are made primarily of nonelastic material (e.g., canvas, cotton or nylon) or that have a rigid posterior panel are eligible for coverage. A spinal orthotic is designed to control gross movement of the trunk and intersegmental motion of the vertebrae in one or more of the following planes of motion: Lateral flexion, forward flexion or extension in the sagittal plane and axial rotation in the transverse plane. If the spinal orthotic does not provide control of motion in one or more planes or does not provide intracavitary pressure, then the item is not considered a spinal orthotic. The documentation must relate the patient s expected functional goals. The spinal orthotic should be part of an active treatment plan directed at a specific goal. HCPCS Code L0625 HCPCS code L0625 is a lumbar orthotic, flexible, provides lumbar support, posterior extends from L1 to below L5 vertebra, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment. 12

13 HCPCS Code L0627 HCPCS code L0627 is a lumbar orthotic, sagittal control, with rigid anterior and posterior panels, posterior extends from L1 to below L5 vertebra, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment. HCPCS Code L0631 HCPCS code L0631 is a lumbar-sacral orthotic, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment. HCPCS Code L0637 HCPCS code L0637 is a lumbar-sacral orthotic, sagittalcoronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment. REMINDER: The spinal orthotic must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve function of a condition. 13

14 Common diagnosis codes: Herniation or displacement of lumbar disc without myelopathy Low back pain Sciatica Lumbar spinal stenosis Lumbosacral or sacroiliac pain, instability Degeneration of lumbar or lumbosacral intervertebral disc IMPORTANT: The order/prescription must be created by the ordering provider. Make sure the order is signed and dated. Make sure your documentation creates a bread crumb trail leading up to the ordering of DME. A Letter of Medical Necessity (LOMN) may be required in order to get DME authorized and/or reimbursed. A LOMN also helps appeal denials. Closing Comments: You must check with all the carriers you bill prior to submitting claims based on the information provided in this presentation to ensure that it is compliant. Target Coding does not guarantee that the information provided in this presentation will guarantee payment from any insurance carrier or patient. Target Coding is not responsible for any insurance carrier or managed care organization laws, rules and guidelines that may change following this presentation. Please understand that insurance carrier rules, laws, guidelines and regulations change so it s important to do your best to stay on top of any changes that may occur by attending seminars, webinars and joining your National and State Professional Associations. 14

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