Physical Therapy 12/4/2014. Agenda. Time Based Billing. Presented by Regan Tyler, CPC, CPC-H, CPC-I, CPMA, CEMC Senior Consultant & NAMAS Instructor

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1 Physical Therapy Presented by Regan Tyler, CPC, CPC-H, CPC-I, CPMA, CEMC Senior Consultant & NAMAS Instructor Agenda Time based billing Therapeutic procedure(s) documentation Group therapy documentation Legibility Signature requirements Physical therapy assistants Time Based Billing Documented Time (Minutes) Number Units Must reach the half-way point of the time unit (15 min) to reach the next unit 1

2 Therapeutic Exercise Therapeutic exercises to develop strength and endurance, range of motion and flexibility Documentation must explain the actual exercise(s) done Time for each separate exercise should be documented and/or repetitions Therapeutic Exercise Treadmill Bike Elliptical Lunges Jumps Weights / weight machine 2

3 Therapeutic Exercise Majority of therapists will document start and end times, and individual exercises are counted in reps/weight Verify time is accurate for units billed and documentation of specific exercise is found Neuromuscular Reeducation Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/or standing activities Examples: Proprioceptive neuromuscular facilitation (PNF) Feldenkreis Bobath BAP s boards PNF Stretching Set of stretching techniques commonly used in clinical environments to enhance both active and passive range of motion with the ultimate goal being to optimize motor performance and rehabilitation o Stretching then contracting the isolated muscle 3

4 Feldenkreis The practitioner directs attention to habitual movement patterns which are inefficient or strained, and teaches new patterns using gentle, slow, repeated movements Bobath Bobath concept is to promote motor learning for efficient motor control in various environments, thereby improving participation and function. This is done through specific patient handling skills to guide patients through initiation and completion of intended tasks o Commonly utilized after stroke Biomechanical Ankle Platform System Used to improve balance and proprioception in the ankle, knee, and hip 4

5 Aquatic Therapy Aquatic therapy with therapeutic exercises Any type of exercise performed in a water environment Do not report a code for the water modality (Hubbard Tank, whirlpool) Gait Training Gait training (including stair climbing) Training the manner or style of walking, including rhythm and speed o Stance phase o Swing phase o Double support phase Massage Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Effleurage: Petrissage: Tapotement: light massage stroke used in Swedish massage prior to deep tissue work deep and compressing massage movements rhythmic percussion used in massage 5

6 Therapeutic Procedures All codes in range ( ) billed in 15 minute units 7 minutes or less is not reportable In and out times not required but individual modality times are Manual Therapy Manual Therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Hands-on therapy techniques. Manual Therapy Connective tissue massage Joint mobilization and manipulation Manual lymphatic drainage Manual traction Passive range of motion Soft tissue mobilization 6

7 Supervised Modalities hot or cold packs traction, mechanical electrical stimulation (unattended) vasopneumatic devices paraffin bath whirlpool diathermy (microwave) infrared ultraviolet Supervised Modalities PT remains in the room and available but does not need to be one-on-one No time associated with these services Constant Attendance Modalities electrical stimulation (manual) iontophoresis contrast baths ultrasound Hubbard tank 7

8 Constant Attendance Modalities All codes are billed in 15 minute increments Require one-on-one attendance by provider Group Therapy Therapeutic procedure(s), group (2 or more individuals) The health care provider supervises group activities (two or more patients/clients) during therapeutic procedures on land or in the aquatic environment. The patients/clients do not have to be performing the same activity simultaneously; however, the need for skilled intervention must be documented. This code can be reported once for each group participant. Group Therapy No time associated with group therapy Can be reported on the same day as one-on-one services 8

9 Group Therapy Per CMS: Group therapy consists of simultaneous treatment of two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, it is appropriate to bill each patient one unit of group therapy, Group Therapy In order to bill for therapeutic exercise/activities that require one-on-one care from the PT, time must not be split between patients. It is appropriate to spent time in chunks, for example 4 minutes on one exercise, have that patient do a unsupervised modality for 10 minutes, return and do 8 additional minutes of exercise. If time cannot be directed one-on-one, group therapy should be reported Legibility All documentation must be legible o If not legible one could dictate for clarity and submit both notes when requested Create an approved acronym and symbol list Have a standard for documenting times and repetitions o Are you capturing in and out times? Is everyone? 9

10 Legibility If you don t know what an acronym is, just ask If you don t know if it s a time (minutes) or a repetition, just ask Physician Order During an audit you should be verifying there is an appropriate physician referral for services Verify appropriate communication occurs between the PT and physician 10

11 Signature Requirements Like all medical records, PT records must be appropriately signed If handwritten notes, verify a signature log is available Physical Therapy Assistants Licensed to work in all states Licensed in some states to work unsupervised CMS requires PTAs to be supervised Physical Therapy Assistants Per CMS: A physical therapist must supervise PTA s. The level and frequency of supervision differs by setting and by state or local law. General supervision is required for PTA s in all settings except private practice, which requires direct supervision, unless state practice requirements are more stringent. In these cases, state or local requirements must be followed. See specific settings for details 11

12 Physical Therapy Assistants General supervision The procedure is furnished under the physician s overall direction and control in the office setting. The physician s presence is not required during the performance of the procedure. The physician is responsible for ensuring that the non-physician personnel who actually perform the diagnostic procedure are trained and are responsible for ensuring the maintenance of the necessary equipment and supplies to perform the tests. Physical Therapy Assistants Direct supervision A physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure in the office setting. The physician does not have to be present in the room when the procedure is performed. Physical Therapy Assistants The services of PTAs used when providing covered therapy benefits are included as part of the covered service. These services are billed by the supervising physical therapist. PTAs may not provide evaluation services, make clinical judgments or decisions or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws. 12

13 Physical Therapy Assistants A physical therapist must supervise PTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless state practice requirements are more stringent, in which case state or local requirements must be followed. See specific settings for details. For example, in clinics, rehabilitation agencies, and public health agencies, 42CFR indicates that when a PTA provides services, either on or off the organization s premises, those services are supervised by a qualified physical therapist who makes an onsite supervisory visit at least once every 30 days or more frequently if required by state or local laws or regulation. Physical Therapy Assistants The services of a PTA shall not be billed as services incident to a physician/npp s service, because they do not meet the qualifications of a therapist. PT Modifiers GN GO GP KX: Services delivered under an outpatient speechlanguage pathology plan of care; Services delivered under an outpatient occupational therapy plan of care; or, Services delivered under an outpatient physical therapy plan of care. Cap exception 13

14 Therapy Cap Outpatient financial limitations are listed on the CMS website Publication , Chapter 5, Section 10.2 $1920 PT and SLP combined $1920 OT Modifier KX Documentation must be found to support the requirement of continued therapy services over the therapy cap Use of modifier KX does not require documentation to be sent Patients receiving over $3840 total in therapy services will prompt a manual review by CMS Can we correlate time per service to the breakdown of activities? 14

15 Audit Reminders Verify referral from MD Verify continuation of plan from MD Notes complete, legible and signed and include progress Timed codes supported (Including 1 patient at a time) PTA s used appropriate CMS modifiers supported by documentation AAPC CEU # 38875RGS 15

16 National Alliance of Medical Auditing Specialists Kingston Pike, Knoxville, TN P: F: Web: