Coding and Payment Guide for the Physical Therapist An essential coding, billing, and payment resource for the physical therapist 2013
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... 10 Calculating Costs... 12 Other Factors Influencing Medicare Payment... 12 Participation in Medicare Plans... 27 Workers Compensation... 33 Collection Policies... 33 Documentation An Overview...35 General Guidelines for Documentation... 35 Principles of Documentation... 35 Guidelines: Physical Therapy Documentation of Patient/Client Management... 37 Compliance... 42 Claims Processing...51 What to Include on Claims... 51 Clean Claims... 52 Medicare Billing for Physical Therapists in Private Practice... 52 The Health Insurance Portability and Accountability Act... 52 Processing the Claim... 55 The Appeals Process... 56 Medicare Benefit Notices... 65 The CMS-1500 Claim Form...69 The UB-04 Claim Form...82 Procedure Codes...91 Appropriate Codes for Physical Therapists...91 Definitions and Guidelines: Procedures...93 CPT Index...197 HCPCS Level II Definitions and Guidelines...201 Introduction...201 HCPCS Level II National Codes...201 Structure and Use of HCPCS Level II Codes...201 HCPCS Level II Codes and the Physical Therapist...203 ICD-9-CM Index...219 ICD-9-CM Coding Conventions...219 Manifestation Codes...219 Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital Based and Physician Office)... 220 ICD-9-CM Codes...221 Alphabetic Index to External Causes of Injury and Poisoning (E Code)... 297 Medicare Official Regulatory Information...313 Glossary...335 Index...345 2011 Optum CPT codes only 2011 American Medical Association. All Rights Reserved. iii
Coding and Payment Guide for the Physical Therapist 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, 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 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. Introduction 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 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 OptumInsight s website at http://www.shopingenix.com. 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 an index of HCPCS Level II codes for physical therapy. An appendix, Medicare Official Regulatory Information, follows the HCPCS Level II code index. How to Use This Guide The first three 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 ICD-9-CM index or your ICD-9-CM manual to locate the appropriate code. Step. 6. Finally, review the HCPCS Level II section to determine if there are applicable HCPCS Level II codes that may be reported. This section also includes HCPCS Level II modifiers as well as coding tips. 2011 Optum CPT codes only 2011 American Medical Association. All Rights Reserved. 3
Procedure Codes 95860-95864 95860 95861 95863 95864 Needle electromyography; 1 extremity with or without related paraspinal areas 2 extremities with or without related paraspinal areas 3 extremities with or without related paraspinal areas 4 extremities with or without related paraspinal areas Explanation Needle electromyography (EMG) records the electrical properties of muscle 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 95860 when one extremity (arm or leg) is tested; 95861 for tests of two extremities, 95863 for tests of three extremities and 95864 for tests of four extremities. 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 try 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. Coding Tips Single-fiber EMG testing is the innervation of one or more nerve cell(s) and some of the muscles stimulated. Code 95872 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. Physical therapists in private practice may bill for the technical and professional component of certain diagnostic tests in the 95860-95937 code range, such as electromyograms and nerve conduction studies. 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. 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, 2001. The requirements vary depending on the CPT code billed. Services reported by physical therapists that are in this code range (95860-95864) may need prior authorization or have other third-party payer reporting requirements or restrictions. Physical therapists are advised to have the information reviewed by the third-party payer before providing, documenting, or billing these services. These services may be billed in addition to the standard evaluation. Codes 95860-95864 are used when five or more muscles are tested and no nerve conduction studies are performed. When needle electromyography with nerve conduction, amplitude, and latency/velocity is performed, see codes 95885 and 95886. However, 95885 and 95886 may not be reported with 95860-95864. When four or less muscles are tested in a extremity, see codes 95870 or 95885. Paraspinal areas are included in these codes when performed and should not be reported separately. A fifth-digit is required when reporting spinal stenosis of the lumbar region. The fifth-digit subclassification indicates if neurogenic claudication is present. Terms To Know atrophy. Reduction in size or activity in an anatomic structure, due to wasting away from disease or other factors. electromyography. (EMG). Examining and recording the electrical activity of a muscle. myositis. Inflammation of a muscle with voluntary movement. neuropathy. Abnormality, disease, or malfunction of the nerves. 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. 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 17.3 95869-95870, 95873-95874 Also not with 95861: 95860 Coding and Payment Guide for the Physical Therapist Also not with 95863: 95860-95861, 95920 Also not with 95864: 95860-95863, 95920 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 95860... 0.96 95861... 1.54 95863... 1.87 95864... 1.99 1.82 2.50 3.01 3.30 1.82 2.50 3.01 3.30 0.04 0.06 0.08 0.08 2.82 4.10 4.96 5.37 2.82 4.10 4.96 5.37 134 CPT only 2011 American Medical Association. All Rights Reserved. 2011 Optum
HCPCS Level II Definitions and Guidelines G Codes: Procedures/Professional Services (G0255 G0329) Temporary G codes are assigned to services and procedures that are under review before being included in the CPT coding system. Payment for these services is under the jurisdiction of the local contractor. G0151 G0152 G0153 G0157 G0158 G0159 G0160 G0161 G0255 G0281 G0282 G0283 G0295 G0329 Services performed by a qualified physical therapist in home health or hospice settings, each 15 minutes therapist in home health or hospice settings, each 15 minutes Services performed by a qualified speech and language pathologist in home health or hospice settings, each 15 minutes Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes therapist assistant in the home health or hospice setting, each 15 minutes Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes therapist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes Current perception threshold/sensory nerve conduction test (SNCT), per limb, any nerve MED: Pub. 100-3, Section 220.7 Electrical stimulation, (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous statsis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses Electromagnetic therapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care Coding and Payment Guide for the Physical Therapist Coding Tips On November 18, 1997, the U.S. District Court in Massachusetts issued a preliminary injunction against CMS to the effect that CMS must cease enforcement of its national noncoverage determination that prohibited any Medicare coverage of, or reimbursement for, electrical stimulation (ES) therapy for the treatment of wounds. As a result of the injunction, Medicare contractors were authorized to cover and reimburse ES therapy in those cases in which they determined that such therapy is reasonable and necessary. After considerable study and review, the agency issued a decision memorandum on July 23, 2002, regarding electrical stimulation for the treatment of wounds. Another decision memorandum was issued on December 17, 2003, regarding electromagnetic stimulation for wound treatment. Effective July 1, 2004, Medicare will allow either one covered ES therapy or one covered electromagnetic therapy for wound treatment. Electrical stimulation and electromagnetic therapy for wound treatment will not be covered as an initial intervention (the NCD uses the term modality ); however, the use of electrical and electromagnetic stimulation will be covered as an adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard therapy. These interventions are applicable only for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers. ES and electromagnetic therapy are only covered when administered by a physician, physical therapist, or incident to a physician service. Wounds must be evaluated at least every 30 days by the treating physician during administration of ES or electromagnetic therapy. Continued treatment is not covered if measurable signs of healing have not been demonstrated within any 30-day period. These treatment modalities must be discontinued when the wound bed has completed epithelialization. For purposes of this NCD, the following wound stages are recognized. A chronic ulcer is defined as one that has not healed within 30 days of onset. Stage I: Observable pressure-related alteration of intact skin that may include one or more of the following: skin temperature (warm or cool), consistency of tissue (firm, boggy), and sensation (pain, itching). The ulcer presents as an area of persistent redness in patients with light skin, or as an area with red, blue, or purple hues in those with darker skin. Stage II: The ulcer is superficial and appears as an abrasion, blister, or shallow crater. There is partial skin loss that involves the dermis, epidermis, or both. Stage III: The ulcer appears as a deep crater with or without undermining of adjacent tissue. There is full-thickness skin loss that involves damage to or necrosis of subcutaneous tissue. It may extend to, but not through, the underlying fascia. Stage IV: The ulcer presents with full-thickness skin loss. There is widespread destruction including tissue necrosis or damage to muscles, bones, or supporting structures such as tendons and joint capsules. Undermining of adjacent tissue and sinus tracts also may be present. All other uses of ES and electromagnetic therapy not otherwise specified for wound treatment will be at the discretion of the local contractor. G0920 G8699 G8700 Type, anatomic location, and activity all documented Rehabilitation services (occupational, physical or speech) ordered at or prior to discharge Rehabilitation services (occupational, physical or speech) not indicated at or prior to discharge 212 New Codes Revised Codes MED: Medicare Reference 2011 Optum