PPTA Payer Summit Medical Review Challenges and Red Flags in Documentation. CPT Coding for Physical Therapy Services Series and Beyond

Transcription

1 PPTA Payer Summit Medical Review Challenges and Red Flags in Documentation November 19, 2014 Presented by Sandra McCuen, PT PPTA Reimbursement Specialist CPT Coding for Physical Therapy Services Series and Beyond CPT Definitions Supervised Does not require direct (one on one) patient contact Constant attendance Does require direct (one on one) patient contact One or more areas If not timed bill once per date of service Unit = 1 Mechanical traction If timed, aggregate delivery time to determine billable units Unit = 1 or more Ultra sound PPTA Payer Summit 3 1

2 CPT Definitions Time Is not intended to describe and/or prescribe the therapeutic dose Is face to face time with the patient 15 minutes is the most commonly described unit in the series A unit of time is attained when the mid-point is passed AMA CPT coding manual Introduction section Time attributed to a specific CPT code is aggregated across the treatment session 2014 PPTA Payer Summit 4 Physical Medicine and Rehabilitation Series Physical Medicine and Rehabilitation through within the scope of practice of licensed Physical Therapists (PT) Some within the scope of a Physical Therapist Assistant (PTA) 2014 PPTA Payer Summit 5 Evaluation Services PT evaluation Outside scope of a PTA Required to develop a physical therapist plan of care (POC) Not timed PT re-evaluation Outside scope of a PTA Required to update a physical therapist plan of care (POC) New tests and measurements Change to long term goals At discharge to summarize episode of care Not timed 2014 PPTA Payer Summit 6 2

3 Modalities Modalities Physical agents to change biologic tissue Supervised Skilled services that do not require one on one patient contact Units = 1 per date of service During the same time interval the same caregiver (PT or PTA) could bill patient A an unattended e-stim (97014) and patient B minutes of therapeutic exercise (97110) 2014 PPTA Payer Summit 7 Modalities Constant Attendance Skilled services that do require one on one patient contact Time based Units = 1 or more During the same time interval the same caregiver (PT or PTA) could not bill patient A minutes of ultrasound (97035) and patient B minutes of therapeutic exercise (97110) 2014 PPTA Payer Summit 8 Therapeutic Procedures Application of clinical skills and/or services to attempt to improve function Skilled services that do require one on one patient contact Time based Units = 1 or more During the same time interval the same caregiver (PT or PTA) could not bill patient A minutes of manual therapy (97140) and patient B minutes of therapeutic exercise (97110) 2014 PPTA Payer Summit 9 3

4 Therapeutic Procedures Exception Group Application of clinical skills and/or services to attempt to improve function Skilled service that does not require one on one patient contact Requires constant attendance One caregiver with more than one patient PT or PTA Not time based Units = 1 to each patient in the group During the same time interval the same caregiver (PT or PTA) could bill one unit of to more than one patient 2014 PPTA Payer Summit 10 Active Wound Care Management Performed to remove devitalized and/or necrotic tissue and promote healing Skilled services that do require one on one patient contact Wound surface area based first 20 sq cm or less each additional 20 sq cm or part thereof 2014 PPTA Payer Summit 11 Tests and Measurements Tests in addition to routine evaluation tests and measures Data gathering within the scope of a PTA Report done by PT Skilled services that do require one on one patient contact PPTA Payer Summit 12 4

5 Orthotic Management and Prosthetic Management Skilled services that do require one on one patient contact PPTA Payer Summit 13 Other Procedures Unlisted physical medicine/rehabilitation service or procedure PPTA Payer Summit 14 CPT Codes outside the Series Muscle and Range of Motion (ROM) Testing Muscle ROM Electromyography EMG Nerve Conduction tests PPTA Payer Summit 15 5

6 CPT Codes outside the Series Biofeedback for urinary incontinence Vestibular rehabilitation Canalith repositioning PPTA Payer Summit Modifier Distinct Procedural Service National Correct Coding Initiative (NCCI) coding edits Commonly used on Physical Therapy claims Definition for rehabilitation Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute intervals. /modifier59.pdf Updated to include the new subset of modifiers related to 59 My most current information is that physical therapists will not be required to use the subset at this time 2014 PPTA Payer Summit 17 Red Flags in Coding and Documentation 6

7 CPT Coding Red Flags No evaluation billed at beginning of episode Required to identify medical necessity for physical therapy Required to develop a plan of care Billing modalities only Excessive billing of modalities in absence of symptoms/impairments that respond to modalities Too many (redundant) Too long Routine billing of re-evaluation PPTA Payer Summit 19 CPT Coding Red Flags Miscoding unattended e-stim (97014) (G0283) as manual e-stim (97032) and G0283 are set up and supervise May treat another patient during the same time interval Units = is one on one with the patient during treatment May not treat another patient during the same time interval Units = 1 or more 2014 PPTA Payer Summit 20 CPT Coding Red Flags Aquatic therapy aquatic therapy with therapeutic exercise Skilled service that does require one on one patient contact Time based Units = 1 or more If more that one patient with one caregiver codes to group code Therapeutic procedure(s), group (2 or more individuals) Represents both land based and aquatic therapeutic procedures Not time based Units = 1 for each individual in the group 2014 PPTA Payer Summit 21 7

8 CPT Coding Red Flags Documentation does not support the CPT codes on the claims therapeutic exercises to develop strength and endurance, range of motion and flexibility You should see Evaluation identifying qualified and quantified deficits in strength, endurance, range of motion or flexibility Goals related these deficits Interventions (narrative or flow sheet) to address these deficits Periodic reassessments of these deficits and progress to related goals 2014 PPTA Payer Summit 22 CPT Coding Red Flags Treatment sessions routinely coded to exceed 90 minutes of service Documentation of treatment time does not validate the CPT units billed 2014 PPTA Payer Summit 23 Validation of Claims Eval Dysfunction/problem Re-eval Progress reports Decreasing dysfunction Goal achievement POC interventions CPT language Documentation of POC delivery CPT/time Functional measurable goals 2014 PPTA Payer Summit 24 8

9 Question Low Level Laser Therapy - what exactly is it? LLLT Low level frequency on the light spectrum (red). Does not produce heat, sound or vibration. Laser scalpel, LASIK eye surgery, laser angioplasty, cosmetic and dental laser assisted treatments. In physical therapy can be Super Pulsed or Continuous Wave. Mail goals are tissue repair and pain relief. Efficacy research level >>>>>> information PPTA Payer Summit 25 Question What are key differences between coding for Medicare and Medicaid claims? 2014 PPTA Payer Summit 26 Medicare vs Medicaid CPT Coding Coding principals remain the same Payment policies differ Under age 21 Paid as fee for service with a range of CPT codes Unit limit per visit 21 through 64 Follow managed care plan policies 65 and over as secondary to Medicare Generally not an issue as Medicaid fee schedule is lower than the 80% of the Medicare fee schedule paid to the provider 2014 PPTA Payer Summit 27 9

10 Beyond into the Future Payers and regulators have been seeking a alternative payment model for therapy services APTA and AOTA have been developing CPT codes to represent PT and OT evaluation and treatment services Concepts have been introduced to payers, regulators and AMA during the development process Focus on representing the clinical skill and judgment to evaluate and treat the patient Visit/session based payment Collapse the series Select services remain as separately reportable 2014 PPTA Payer Summit 28 PT, OT Evaluations: 3 Initial, Development of POC: 1 Re- Eval, est. POC - (4 total) Clinical Considerations & Complexity of the Examination Level of Evaluation Problem - Focused Expanded Comprehensive Limited Moderate Significant 1 CPT 1 CPT 1 CPT Established POC (re-eval) 1 CPT 2014 PPTA Payer Summit 29 Evolution of Model Collapsing Levels of Interventions (5 total) Severityof Visit / Intensity of Intervention Low/Low Moderate/Low Moderate/ Moderate High/Moderate High/High 1 CPT 1 CPT 1 CPT 1 CPT 1 CPT Patient s presentation Clinical decision- making Selection of interventions / Risk to the patient 2014 PPTA Payer Summit 30 10

11 Timeline to Implementation Feb 2015 Presentation to CPT editorial Panel Upon approval referred to Relative Value Committee Member surveys to establish values for the various levelsof service Jan 2016 Potential implementation through Medicare Fee Schedule Stay Tuned! 2014 PPTA Payer Summit 31 11