2014 aptanj spring mtg coding, billing and...

4/10/2014

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Coding, Billing and Documentation

Beth Sarfaty, PT, MBAVP Clinical Services and Quality

ManagementSelect Medical Hospital Based OP

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Official Disclaimer

The views expressed in this presentation and the accompanying materials are solely that of the author and should not be represented asthe author and should not be represented as the policy or opinion of either APTAnj, Kessler Rehabilitation Institute or Select Medical.

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Start the Story…

• Diagnosis Coding ‐ is the code that defines the condition

– Classifies information for statistical purposes

Describes and communicates the person’s health– Describes and communicates the person s health care condition

– Is the basis for medical necessity of services

– Impacts reimbursement

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Diagnosis coding specification

• The code is considered the title or heading for a category of codes

d f h d fi d i h i ifi i• Codes are further defined in their specificity and detail by additional digits

– If there is additional digits assigned, they should be used as appropriate

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Keep in mind…

• A V Code (surgical code) or Medical Diagnosis code should not be the only ICD9 code chosen for therapy

• Therapist should include a functional (or• Therapist should include a functional (or treatment) diagnosis code to further define the need for therapy

• Codes chosen must be clearly supported in the documentation

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• If no medical diagnosis given, or if not the primary reason for rehab, a therapeutic or functional diagnosis code that describes the patient’s signs and symptoms is OK to use

• Is there a correct order to use?– If available: medical diagnosis current condition current problem (or reason for the need of therapy) any additional code that describes a coexisting condition that will impact need for rehab or expected outcome

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Choosing the best codes

• Identify the codes that best match the diagnosis

• 1st code chosen should be the one that best describes the cause of symptomsdescribes the cause of symptoms

• Then chose a code that describes any manifestations, complications, late effect symptom that may impact treatment time, prognosis, outcomes, etc.

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• Include medical diagnosis from the MD when appropriate to the condition being treated

• Include any and all treatment and functional diagnoses (assessment) codes that is pertinentdiagnoses (assessment) codes that is pertinent to the care being furnished

– Make sure all is supported in the documentation

– Should reflect signs and symptoms being treated

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Functional Diagnosis code

• Identifies the result or reason the patient is being referred for therapy

• Needs to be specific to what is found during the evaluationthe evaluation

• Examples

– Joint stiffness, difficulty walking, hemiparesis, joint contracture, muscle wasting, pain in limb

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Continuing the Story…

• CPT codes – define the treatment intervention being provided

Bill f h t th th i t i idi NOT h t– Bill for what the therapist is providing, NOT what the patient is doing

– Select the code that best describes the clinical intent of the treatment

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Service vs. Time Based Codes

• Service Based

– Reimbursed same amount regardless of time spent delivering the service

– Unlimited body parts

– Direct contact not required throughout the service

• Time Based

– Billed in per unit increments

– Documentation must support the time billed

– Includes more than just the delivered treatment time

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Included in Time‐based codes TIME for billing

• The provider’s total time required to perform the service including skilled:

i k (P)pre‐service work (P)

intra‐service work (I)

post‐service work (P)

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Pre‐Service Work may include

– Chart reviews for medical treatment – Set‐up of activities, equipment and area to be used– Positioning patient on equipment or table– Education of the patient relating to his/her condition or treatment

– Review of previous documentation p– Communication with other health care professionals (i.e., case manager)

– Discussions with family– Calls to the referring physician for additional information or clarification of direction

– Pre‐service work that is skilled may only be considered billable if the patient is present

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Intra‐Service Work includes

• Direct contact (visual, verbal or manual) delivery of the treatment procedure, status check of the patient’s symptoms andcheck of the patient s symptoms and assessment of response to treatment

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Post‐Service work may include:

• Repositioning patient off table

• Assessing patients response to treatment

• Discharging the patient from treatment

• Calls to referring physician to report progress and i i i h h bcommunication with other team members.

• Documentation of treatment or report writing time must be skilled time and performed while the patient is present in order to be billable

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NOT Included in Time‐based time for billing

• Rest time / non‐treatment time‐– cell phones, texting, restroom breaks

• Time spent delivering service‐basedTime spent delivering service based modalities or procedures

• Time spent by patient performing independent activities‐ unsupervised/ unskilled

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What code should I use?

• Consider the goal of your activity to determine which CPT code to select

• Choose a code based on the intent of the treatment –inclusive of physiologically what is involved as well as the actual service performed and the anticipated outcome

• Documentation must support the code

• Billable time is direct one‐on‐one time

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Therapeutic Exercise 97110

• Therapeutic procedure to develop strength and endurance, ROM, and flexibility to one or more body areas (ea code 15 min)

• Generally used to describe services delivered• Generally used to describe services delivered to improve a single parameter such as strength, or ROM

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TE 97110

• Considered reasonable & necessary if the patient has an identified impairment such as

– Weakness, pain, contracture, muscle imbalance

Limitations in mobility strength dexterity ROM– Limitations in mobility, strength, dexterity, ROM, endurance

• Novitas Solutions LCD L27513 printed 2/27/14

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Neuromuscular Re‐education 97112

• Addresses movement, balance, fine or gross motor coordination, kinesthetic sense, posture, motor skill and/or proprioception for sitting and/or standing activities (ea 15 min)sitting and/or standing activities (ea 15 min)

• Desensitization

• Kinesiotaping/patellar taping

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Aquatic Therapy 97113

• Uses therapeutic properties of water (buoyancy, resistance)

• Use for restrictions of joint motion, strength, mobility or functionmobility or function

• 1:1 contact code

• Do not use for Hubbard Tank or WP

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Gait Training 97116

• Training the biomedical and kinesiologicalcomponents of walking, including balance, cadence, symmetry, motor control, speed, energy and efficiencyy

• Includes stair climbing

• May be reasonable and necessary to improve/restore or compensate for impairment of walking ability due to neurological, muscular or skeletal abnormalities

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Massage Therapy 97124

• Designed to facilitate healing of muscle, reduce edema, improve joint motion and/or relieve muscle spasm (ea 15 min)

– Includes effleurage petrissage and/or tapotement– Includes effleurage, petrissage and/or tapotement(stroking compression, percussion)

• Documentation must support the need for medical necessity

• May be used for desensitization

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Manual Therapy Techniques 97140

• Includes but not limited to mobilization/manipulation, manual lymphatic drainage, manual traction (ea 15 min)– Joint/soft tissue mobs, MFR, scar mobilization, transverse friction, lymphatic taping

• Documentation must include the specific techniques performed, the tissues/area treated and the total time the intervention occurred

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Be specific with Manual Therapy

What are the goals of the treatment?

• Modulate pain

• Increase joint range of motion

• Reduce/eliminate soft tissue swelling, inflammation or soft tissue restriction

• Induce muscular relaxation

• Improve contractile and non‐contractile extensibility

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Group Therapy 97150

• For Medicare ONLY

• Constant attention but not 1:1 contact

• Therapist working with more than one patient iat a time

• Providing SKILLED services

• Patients do not need to be receiving same type of treatment/procedure

• Service based code

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Community/Work Reintegration 97527

• Shopping, transportation, money management, vocational activities, work environment/modification analysis, work task analysis, use of assistive technology de ices/adapti e eq ipmentdevices/adaptive equipment

• Not typically used to describe HEP instruction

• Describe all aspects of training, level of understanding

• How the intervention is related to functional goals

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Community/Work Reintegration 97537

• Shopping

• Transportation

• Money management

• A‐vocational activities

• Work environment modification analysis

• Work task analysis

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Therapeutic Activity 97530

• Using dynamic activities to improve, restore or compensate for loss of one’s functional performance ability (ea code 15 min)

• Describes the activities that use multiple pparameters (strength, ROM, balance, coordination, etc) simultaneously to achieve a functional activity or movement

• Can be for a specific body part or multiple body parts

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Development of Cognitive Skills 97532

• Interventions used to enhance cognitive skills

– Attention

– Memory

– Problem solving

• Not covered

– Use of memory aids such as memory books, memory boards or communication books is sole treatment plan

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Sensory Integrative Techniques 97533

• Used to enhance sensory processing and to promote adaptive responses to environmental demands– Often denied if used for desensitization in Hand Therapypy

• Documentation must include the patient’s deficit in processing input from a sensory system (vestibular, proprioceptive, tactile) that may decrease their ability to make adaptive sensory, motor and behavioral responses appropriately within the environmental demand

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Self‐Care/Home Management 97535

• ADL and compensatory training, meal prep, safety procedures and instructions in use of assistive technology devices/adaptive equipment (ea 15 min)

• Must be documented as part of an active treatment plan directed at a specific outcome

• Patient and/or caregiver must have the capacity to learn from instruction

• Excessive use of the code may be denied as not medically necessary

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TENS Fitting for home use

• Charge for your time to instruct the patient

– 64550 ‐ Application of surface (transcutaneous) neurostimulatorneurostimulator

– Treatments > Modalities > TENS placement / application

– Service based code

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Wheelchair Management 97542

• Assessment for need

• Determination of type of WC and components

• Measuring and fitting

• Making adjustments

• Training in use‐for safety, mobility and transfers

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Work Hardening/Conditioning 97545/97546

• 97545 initial 2 hours

• 97546 each additional hour

R l l l k kill• Relate solely to work skills

• Not covered by Medicare

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Wound Care Management

• 97597 ‐ Debridement open wound, including topical applications, wound assessment, use of WP, when performed and instructions for ongoing care, per session, total wound(s) surface area, first 20 sq cm or less

• 97598 ‐ as above, each additional 20 cm, or part thereof(list separately in addition to 97597

• 97602 ‐ Removal of devitalized tissue, nonselective debridement

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Wound Care Management

• 97605 – negative pressure wound therapy (vacuum assisted drainage collection), include topical application, wound assessment, instructions for ongoing care Charge perinstructions for ongoing care. Charge per session, total surface area < or = 50 sq cm

• 97606 – total wound area > 50 sq cm

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Documenting Wound Care

• Document wound size, condition

• Document specific method of intervention (selective tech, non selective, VAC) and tools used (high pressure water jet, forceps, ( g p j , p ,scissors)

• Document outcome of interventions on the wound and how the wound is addressed following the intervention (dressing, medications applied, etc)

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Physical Performance Test 97750

• Used to provide additional objective documentation of a patient’s condition or status

• Require a separate report from the other l i devaluations done

• Must document problem requiring the test, specific test performed, time to administer test, test results and how the information affects the treatment plan

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Orthotic Management and Training 97760

• Assessment and determination of most appropriate device

• Design and fabrication

• Fitting and Training

• L Code‐includes assessment, fabrication, fitting and supplies. Education and training billed separately under orthotic management code

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Prosthetic Training 97761

• Includes training and education

• Upper/lower extremities

• Pre and post Prosthetic

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Checkout for Orthotic/prosthetic 97762

• An end‐service for established Patient

• Time spent to ensure correct fit, adjust or repair device when using device duringrepair device when using device during functional activity

• Reasonable & Necessary when a modification or re‐issue of a device or re‐assessment of a newly issued device

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Canalith repositioning 95992

• Epley, Semont manuever

• Do not report with 92531 (spontaneous nystagmus including gaze) or with 92532 (positional nystagmus test)(positional nystagmus test)

• 95992 is a separately reportable service by PT’s per 2011 PFS

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Assistive Technology Assessment 97755

• Assess the need for a technological interface b/w the patient and their environment or mobility system

• Patient’s voluntary motions (oral motor• Patient s voluntary motions (oral motor strength, head/neck ROM and strength, ocular motor control, quality of voice output) are identified and assessed

• Not covered if provided by a therapy assistant

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Assistive Tech 97755

• Written report must include:

– Goal of the assessment

– Technology/component/system involved

A description of the process involved in assessing– A description of the process involved in assessing the patient’s response

– Outcome of the assessment

– Documentation of how this information affects the treatment plan

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Reporting Timed Codes and Documenting Effectively

• “The work of a QHCP consists of face to face time with the patient (or caregiver if applicable) delivering skilled services Forapplicable) delivering skilled services. For determining total time of a service, incremental intervals of treatment at the same visit can be accumulated.”

• AMA CPT 2013

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Documenting

• Each DOS should indicate total treatment time

• 8 minute rule can be used to determine total units for all payors

i f bill d i• Documentation of un‐billed services not part of total treatment time not required but recommended for liability services

» CMS MPBM Ch 15 Sec 220‐230

» MR Claims Policy Manual Ch 5 Part B OP

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Total Time Intervalsfor Federal Funded Payors

• 1 unit = 8 to 22 minutes

• 2 units = 23 to 37 minutes


• 4 units = 53 to 67 minutes• 4 units = 53 to 67 minutes





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FSC

FFP Billing rules CPT/AMA Billing Rules

Total Time Rounding Rules15 min increments =

1 unit

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Reporting Timed Codes

• Total Treatment Time: 47 min

• Direct Contact Time: 24 min of NMR 97112, 23 i f 9 023 min of TE 97110

• Total Direct Treatment time: 47 min

• Number of units = 3» CMS MPBM Ch 15 sec 220‐230 and MR Claims Policy Manual Ch 5 Part B OP

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• Direct Contact Time: 10 min of TE 97110, 10 i f 9 0 8 i f S 9 03min of MT 97140, 8 min of US 97035

• Total Direct Treatment Time: 28 min

• Number of Units = 2» CMS MPBM Ch 15 sec 220‐230 and MR Claims Policy Manual Ch 5 Part B OP

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• Direct Contact Time: 20 min of TE 97110, 20 i f 9 0min of MT 97140

• Total Direct Treatment time: 40 min

• Number of units = 3» CMS MPBM Ch 15 sec 220‐230 and MR Claims Policy Manual Ch 5 Part B OP

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Documenting Direct 1:1 contact

• Should include specific treatment and direct patient interaction

• Include area of body treated, technique used, patient response and outcome of treatmentpatient response and outcome of treatment

• Cannot be provided simultaneously with more than one patient at a time

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Stretch Break

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Accurate Documentation

• Select the code that most accurately identifies the service performed

h d h b d ib h• Report the code that best describes the outcome to be achieved or the intent of the intervention

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What else do I need to include?

• Time to support the units billed when reporting direct contact 1:1 codes

• Flow sheets are part of the medical record

N d t h kill– Need to show skill

– Proper ID of provider

– Should describe therapists intervention not just patient doing activity

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Consider treating environments

• Direct Contact (1:1 care)

• Intermittent

• Group

• When you are billing 1:1 interventions with a FFP patient no other patient can be billed during that same time interval

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What if I am seeing more than one patient?

FFP patient

• 1:1 treatment

FFP patient

• No Charge or supervised modality

• Group

• 1:1 treatment

(minus the time you are instructing the other patient)

• Group

• Bill only the time it takes you to instruct them in the exercise

Vise versa

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Non‐FFP with a FFP

Non‐ FFP Patient

• NC or supervised modality

FFP patient

• 1:1 Intervention time

• 1:1 intervention time

• 1:1 treatment

(minus the time you are

instructing the other patient)

• Group

• Bill only the time it takes you to instruct them in the exercise

Vise versa

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What code? What’s the Intent?

• 97110‐ THERAPEUTIC PROCEDURE– Strength, endurance, ROM, flexibility

• 97112‐ NEUROMUSCULAR RE‐EDUCATION– Balance, coordination, kinesthetic sense, posture, proprioception

• 97530‐ THERAPEUTIC ACTIVITIES “functional activities”– Improved functional performance, lifting, pulling, function, steps, squatting, etc

• 97140‐MANUAL THERAPY– Mobilization‐ joint or soft tissue, manual traction, specific technique

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Wall Slides: Which code?

• Wall Slides to strengthen the LE

• Supporting Documentation: Decreased LE strength to support the need to perform LE strengthening

• Therapeutic Exercise

ll l d h h f h• Wall Slide with the intent of improving the patients squatting or transferring ability

• Supporting documentation: squatting or transferring deficit and specific skills/techniques used to improve this ability

• Therapeutic Activity

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UBE: Which code?

• UBE with intent of improving pushing/pulling• Supporting documentation: Decreased pushing/pulling ability and indication of how UBE is being used to address the deficit

• Therapeutic Activitiesp

• UBE to increase ROM• Supporting Documentation: Objective UE ROM goniometric measures demonstrate support for UBE to improve ROM


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BAPS board: which code?

• Baps board for improving ankle ROM

• Supporting Documentation: Decreased Ankle ROM to support the need to improve ankle ROM


• Baps Board for proprioception after ankle sprain

• Supporting documentation: Improper balance reactions for involved ankle. Specific techniques utilized.

• Neuromuscular Re‐education

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What about education?

• Currently, there is no CPT code for education…or is there…

• Professional time spent educating a patient inProfessional time spent educating a patient in issues pertaining to their diagnosis is skilled treatment and is billable.

• It should be billed under the intent of the education (ie, NMR for posture, etc.)

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Service based Modalities

• Hot/cold packs 97010

• Mechanical Traction 97012

• Unattended E‐Stim 97014

• Vasopneumatic Device 97016• Vasopneumatic Device 97016

• Paraffin 97018

• Whirlpool/ Fluidotherapy 97022

• Biofeedback 90901/90911

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Constant Attendance Modalities

Billed as 1:1 timed units

• Ultrasound 97035

• Iontophoresis 97032

• Manual E‐Stim 97032

• Contrast bath 97034

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Documenting Modalities

• Document the impact using the modality will have on the patients functional goals

• Document the parameters and desired effect of the applicationof the application

• Document body position

• Document to support the continued use (clinical decision making)

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Questions about coding? Billing? Scheduling l i l i h imultiple patients when treating

Medicare/FFP?

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Documenting Medical Necessity

• Therapy is designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functions that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital , gabnormalities or injuries.

• Therapy emphasizes a form of rehabilitation focused on treatment of dysfunction involving NM, MS, CV/P or integumentary systems through the use of therapeutic interventions to optimize functioning levels.

» Guide to PT Practice

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Documentation

• A basic need for the profession and required

• It is not real if it is not written

• It’s a justification of medical necessity which l i bequals reimbursement

• Must be objective and functional

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What is expected?

• Objective information in measurable terms –or a clear explanation as to the limited progress or function

• Must include baseline data• Must include baseline data

• Linked to functional status – include specific info that details residual problems that warrant treatment

• Individually based on patient outcomes

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Must haves…

• Sufficient info to IDENTIFY the patient

• SUPPORT the DIAGNOSIS

• JUSTIFY treatment

• Define the COURSE and RESULT of the treatment

• Explain the NEED and RESULTS from the CONTINUITY of care among all HCP

• SUPPORT for CHARGES – why each code used

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Evaluations• Reason for referral/Diagnosis

• Relevant medical history

• PLOF and CLOF and potential for improvement – indicate QOL

• Documentation to indicate patient’s social support

– Where they livey

– Who they live with

– In a new living environment

– Learn new ADLs

– Functional assessments

• Measure impairments, activity restrictions and outcomes expected – document a functional outcome measure

• Documentation to support the illness severity or complexity73

Evaluation

• Record of DC from Part A qualifying IPR, SNF, HHA (within 30 days of start of OP)

• Whether patient seen for same condition previously by same therapy discipline

• Describe goals from a functional perspective• Describe goals from a functional perspective• Write a plan for achieving the functional improvement

• Clinicians clinical judgment• Determination if treatment is or is not needed

• MPBM Ch 15 Sect 220.2 Rev 179 Issued 1/14/14

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Goal Writing

• Describe the outcome, not the means to get there

• Connected to the dysfunction, impairment or functional limitationfunctional limitation

• Need to be concrete and measurable

• Should predict a time frame for achievement

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Goals need to include

• Area of body

• Impairment

• Goal

• Functional activity• Functional activity

• Target performance

• Why they need to do it

• Target timeframe

• Be concrete and measurable

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Questions to identify functional goals

• Ask the patient about their desired outcome

• Determine which are most important

• Include self care, work, leisure activities and h i f hthe environment for each

• Establish goals with the patient

• Goals should be patient centered

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The patient’s bilateral UE strength will increase to at least 4‐/5 to allow her to reach for items in the kitchen cabinets to facilitatefor items in the kitchen cabinets to facilitate independent preparation of meals in 3 weeks

• Fearon & Levine APTA 2013

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The patient’s right shoulder flexion active ROM will increase to at least 135 degrees to allow improved ability to reach items in herallow improved ability to reach items in her closet to dress independently in 4 weeks


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The patient’s hip extensor strength will increase to 4‐/5 to allow independent transfers with improved control to avoidtransfers with improved control to avoid potential fall and further injury in 3 weeks


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The patient’s low back pain level will reduce to 2/ 0 bl h l i d f2/10 to enable her to sleep uninterrupted for 6 hours in 4 visits


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The patient’s sitting tolerance will increase to 45 minutes to allow for use of community transportation/driving to attend work andtransportation/driving to attend work and other obligations in 8 visits


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High Level Activity for Medicare

• Mowing the yard, running the vacuum, walking 3 miles daily, playing tennis

– May be PLOF but NOT essential to ADLs

Will be denied– Will be denied

• How document?

– Identify the impairment(s) or functional limitation associated with the high level activity

– Document the functional piece vs. the activity

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Examples

Patient to improve core stability, strength and flexibility to allow her to participate for 15 minutes a day in necessary home based sanitary requirements of cleaning andsanitary requirements of cleaning and maintaining a hazard free environment.

MPBM Ch 15

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• Patient to improve balance, endurance and safe independent gait pattern to allow for 1.5 mile walk to bus stop 2x a week to independently shop.p

• The patient’s shoulder limits her ability to maintain a clean home with vacuuming. Shoulder weakness/limited ROM/decreased stability and increased pain prevent vacuuming as she was able to do prior to injury.

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Focus on Function

• Functional goals are a meaningful activity that the patient can no longer perform

• Are necessary to show that we are not treating the dysfunction alone and that ittreating the dysfunction alone and that it impacts ADLs

• Shows that addressing and achieving the impairment alone may not lead to functional improvements

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Questions to identify functional goals

• Ask the patient about their desired outcome

• Determine which are most important

• Include self care, work, leisure activities and h i f hthe environment for each

• Establish goals with the patient

• Goals should be patient centered

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Contents of Plan of Care

• Diagnosis

• Long Term Treatment Goals

• Type, amount, duration and frequency of therapy services

• MPBM Ch 15 Sec 220.1.2 Rev 179 Issued 1/14/14

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Daily Note

• Document the description of the service provided

• Changes made to the treatment due to patient’s progressionpatient s progression

• Document the patient’s response to treatment

• Show parameters of treatment

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Observations noted…

• Describe type and amount of manual, visual and verbal cues needed

“ b l d il i f• “Constant verbal and tactile cues given for shoulder flexion without substitution. TE resulted in an increase of shoulder flexion to 120 degrees to comb hair. Still unable to reach into cupboards at home.”

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• Factors that will require modification of frequency, intensity or progression of treatment program– “performing shoulder flex and abd ex incorrectly

lti i i d i i t”resulting in increased impingement”

– “painted BR with repeated OH movements increased pain”

– “computer station ergonomic corrections not made, enhances poor posture and muscle imbalances, aggravating symptoms”

• BCBS of Kansas Documentation Guidelines

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Assessment

• Include a statement of clinical decision making and problem solving

– “poor control and contraction of transverse abdominal muscles resulting in continued compression and sheering, causing LS pain and radicular symptoms”

– “poor blood sugar control resulting in fatigue and avoidance of exercises (speak to MD)”

– “quad control in open chain good, transition into controlled functional closed chain in prep for running”

• BCBS of Kansas Documentation Guidelines

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Progress notes and Re‐certifications

• Progress notes not billable, part of regular documentation requirements

• Re‐certification also not billable but requiredRe certification also not billable but required if care if additional care needed beyond initial POC– Should include specifics in regards to patients progress made and rationale for extending the POC

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Progress Notes

• Includes assessment of improvement, extent of progress (or lack thereof) of each goal

• Plans for continuing treatment

• Changes to long or short term goalsChanges to long or short term goals

• Functional documentation (including G Codes)

Re‐eval should only come from this if changes not anticipated are noted


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Re‐evaluation

• Per the APTA definition– Is a focused evaluation process of examination of subjective and objective findings

– Results in the therapist making a professional judgment about continued care, altering goals, altering treatment or terminating services

– Process of performing selected tests and measures after the IE to evaluate progress and to modify or redirect interventions

– Reports significant change in the patient’s condition– Includes new clinical findings or failure to respond to interventions

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• A Re‐eval is a formal re‐assessment• Cannot just summarize objective findings• Need for continued care must come from your skilled assessment• Can be billed/charged when:

– New clinical findings exist– Significant deviation from the course of therapy or level of function asSignificant deviation from the course of therapy or level of function as

note in IE– A new body part added– Significant deterioration or improvement that was not expected and

thus necessitates change of treatment or LTG– Progress is significantly slower than expected, or absent– Lapse in care due to hospitalization– At planned d/c if documenting the progress the patient has made over

their episode of care

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Re‐evaluations

• Describe objective measurements which when compared to previous documentation, show

– Improvements in function

– Decrease in severity

– Progress toward goals

– Rationalization to justify continued treatment

– Modify/Update goals and/or treatment plan

• NOT routine or re‐occurring re‐assessment

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When can I charge a Re‐eval?

• Significant deviation for the course of therapy or function as projected at the initial eval

• Addition of a new body part or clinical condition to be treatedcondition to be treated

• Significant deterioration or improvement that was not expected that therefore necessitates change of treatment and long term goals

• Failure to respond to the therapeutic interventions outlined in plan of care

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Re‐evals

• A planned discharge to determine if goals have been met, or for use of the MD or treatment setting at which treatment will be continued

• Necessary to determine that frequency, durations and treatment durations are still – Reasonable

– Specific to the diagnosis and acuity level

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Re‐assessment

• A routine component of therapy

• Performed on a regular basis to assess a patient’s response to treatment and progression towards their stated goalsprogression towards their stated goals

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Capturing Re‐assessment time

• When not billable as a re‐evaluation

– Include your skilled assessment time in billable time for the treatment procedures provided

– Document as a separate treatment, but chargeDocument as a separate treatment, but charge as treatment procedure it corresponds to

• Additional detail should describe the measure that was performed; indicate purpose of the test, time spent and applicable charge option

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Discharge Summary

• Reason for DC

• Functional status at DC

• Identify patient progressed and achieved goals d i Oas stated in POC

• Future recommendations

• Communication with other HCP

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What do payors look for when they review the documentation?

• Evaluation supports all DOS and services provided

• Treatments changing as progress is met

f f kill d i i• Proof of skilled intervention

• Patients functional status

• How much time the therapist spends with the patient

• How modalities are used

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• What abbreviations mean

• How can I tell from flow sheets if progress being made

f i i fl h kill d• If interventions on flow sheet are skilled

• Are re‐evals done?

• DC summary or explanation if self DC

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What must be in each medical record?

• What is wrong with the patient?

• What do you plan to do with the patient?

• What skilled interventions are required that ill b f i ?you will be performing?

• What progress is being made?

• What is the final result?

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Don’t forget the basics…

• Services provided

• Services are skilled and medically necessary

• Services provided by QHCP

• Services require the skill of QHCP• Services require the skill of QHCP

• Interventions appropriate for DX

• Appropriate frequency and duration

• Patient expected to make significant functional improvement

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Reviewers want to see…

• Clinical reasoning is demonstrated

• Treatment interventions are related to functional limitations

• Functional goals identified• Functional goals identified

• Documentation supports codes chosen and billed

• Documented changes in functional limitations

• New clinical findings

• Lack of progress

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Why might I get denied or audited?

• Lack of reporting time in documentation

• Lack of support in documentation for interventions

k f d• Lack of progress noted

• Too much passive care (modalities)

• Lack of functional information

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So…to avoid denials…

• Create a complete POC

• Document when the POC is modified, including how it has been modified and why the previous goals were not or could not be met

• Confirm POC is certified

• Clearly document, in minutes, total treatment time for the timed codes and the total treatment time (timed and untimed codes) in the medical record

• MLN Fact Sheet Sept 2011

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Just because I have a RX…

• Does that mean it is medically necessary?

– PT determines medical necessity, not MD

– Based on functional status

We must be able to be effective in our treatment– We must be able to be effective in our treatment

– Goals must be to improve function, minimize loss of future function and/or decrease risk of injury and disease


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Don’t confuse unskilled and skilled care…

• Unskilled

– Repetitive procedures

– Reinforcing previously learned skills

Maintaining function aftermaintenance program– Maintaining function after maintenance program developed

– No POC developed

– Services don’t require the skills of a QHCP

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Reasonable & Necessary

• Patient’s condition will improve significantly in a reasonable time frame

• Improvement is evidenced by successive p yobjective measurements whenever possible. If the expected rehab potential is insignificant in relation to the extent and duration of therapy required to achieve such potential, rehabilitative services are not R&N

» MPBM Ch 15 Sect 220.2 Rev 179 Issued 1/14/14

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Skilled Rehabilitative Therapy

• Evaluations and Re‐evaluations• Establishment of treatment goals specific to the patient’s disability or dysfunction

• Design of a POC addressing patient’s disorder• Continued assessment and analysisContinued assessment and analysis • Instruction leading to establishment of compensatory skills

• Selection of devices to replace or augment a function• Training of patient and family to augment rehabilitative treatment


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Maintenance Program

A program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress s/he has mademaintaining the progress s/he has made during therapy or to prevent or slow further deterioration due to a disease or illness.

• MPBM Ch 15 Section 220 Rev. 179, Issued 1/14/14

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Skilled Maintenance

• Maintenance Therapy – no improvement expected but skilled care necessary to maintain the patient’s current level of function

• The performance of a safe and effective• The performance of a safe and effective maintenance program can only be established and carried out by a QHCP and PT only.

• CMS MM 8458 1/7/14

• CMS Transmittal 175 12/6/13

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Skilled Maintenance Program

• Skills of a therapist are necessary to maintain, prevent or slow further deterioration of the patient’s current functional status

• Services cannot be safely and effectively• Services cannot be safely and effectively carried out by the patient with the assistance of non‐therapists, including unskilled caregivers

• CMS MM 8458 1/7/14

• CMS Transmittal 175 12/6/13

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Documenting skilled care & medical necessity

• Assessed

• Added

• Cueing

• Demonstrated

• Modified

• Progressed

• Provided

• Reviewed• Demonstrated

• Educated

• Facilitated

• Instructed

• Reviewed

• Trained

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Remember…

• The person paying the claims makes the rules

• Decisions aren’t made by payment policies (not ok to withhold care just b/c won’t get paid)paid)

• No auth doesn’t = no care, pt can still get care w/o 3rd party payer

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Questions?

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References

• 2004 Coding and Payment Guide for the Physical Therapist• BCBS of Kansas, Documentation Guides for Physical Therapists, 9/21/09• Defensible Documentation Elements, PT Magazine, APTA• Documenting Medical Necessity of Physical Therapy, Retrieved from www.cgsmedicare.com,

3/21/13• Drummond‐Dye, R, Lee, G, Smith, H, Frohlich, M, “Emerging Issues in Medicare and Federal Affairs:

What Every PT Needs to Know”, January 21‐24 2013• Fearon, H, “CPT, ICD9 and Reporting Physical Therapy Services”, APTA 2013

G id t Ph i l Th P ti 2nd Editi 2003• Guide to Physical Therapy Practice, 2nd Edition, 2003• Guidelines for Medical Necessity Determination for Physical Therapy, Mass Health, 6/05• Lee, G, “Medicare Payment Policy Update” February 15, 2013• Levine, S, “Payment Policy and Compliance for Today and Tomorrow”, NY, NY 2/15/13• Medicare Benefits Manual, Chap 15, Sec 220 and 230• MLN, Fact Sheet, “OP Rehab Services: Complying with Documentation Requirements”, ICN 905365,

Sept 2011• Novitas LCD L27513 ‐ Physical Medicine & Rehabilitation Services, Physical Therapy and

Occupational Therapy

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