Module 5 Coding and Billing Practices in PT

What is Healthcare Common Procedure Coding System (HCPCS)?

Two level system used for billing medical services, supplies and products NOT included in the CPT codes

What is Level I of the HCPCS?

Comprised of Current Procedural Terminology (CPT - 4)

What is Level II of the HCPCS?

Standardized coding system primarily for products, supplies, and services when used outside a physicians office (ex. ambulance services, prosthetic devices)

What is Current Procedural Terminology (CPT)?

Uniform coding system consisting of descriptive terms and identifying codes used to identify medical services and procedures furnished by physicians and other health care professionals

Who owns and maintains CPT?

American Medical Association

What is Category I of CPT?

Procedures consistent with contemporary medical practice and are widely performed. Used by physicians and most outpatient providers

What is Category II of CPT?

Supplementary tracking code used for performance measures; intended to facilitate the collection of information about quality of care

What is Category III of CPT?

Temporary codes (about 5 years) for emerging technology, services, and procedures. Procedures may not have FDA approval.

Category I of CPT is divided into ____ major sections

6

What are the 6 Sections of CPT Category I?

Evaluation/Management

Anesthesia

Surgery

Radiology

Pathology

Laboratory

Physical Therapists typically use which Section from CPT Category I?

Evaluation and Management

What are CPT Modifiers?

Two-digit codes appended to CPT code to provide additional information about a medical services or procedure

True or False: Medicare does not require CPT Modifiers

False

What are some circumstances under which a CPT Modifier may be used?

- If PTA was provider

- Billing two services performed separately

What is CPT Modifier 59?

Indicates that a procedure was separate and distinct from another procedure performed on the same day. (Prove we didn’t “double dip” for extra money)

Why was the National Corrective Coding Initiative (NCCI) developed?

Promote correct coding methodologies and prevent improper payments for Medicare and Medicaid Claims

National Corrective Coding Initiative (NCCI) has 3 types of edits…

Procedure-to-Procedure Edits (PTP)

Medically Unlikely Edits (MUEs)

Add-On Code Edits

What is the NCCI Procedure-to-Procedure edit for?

Prevent inappropriate payment of services that should not be reported together

What is the NCCI Medically Unlikely Edits (MUEs) for?

Prevent improper payment for an inappropriate number/quantity of the same service on a single day

What is the NCCI Add-On-Code Edits for?

Consist of a listing of CPT and HCPCS add-on codes with their respective primary codes

What is an example of a PTP edit in physical therapy?

Code 97140 (manual therapy) has many codes that are considered “linked services” and when billed in combination, you will receive payment for only 97140. So must use PTP Edit and documentation to show these two procedures were independent of each other.

How do we support NCCI PTP Edits and show we are billing distinct services?

Documentation!

True or False: Frequent and excessive use of PTP edits may flag for audit

True

We can bill either CPT or HCPCS Level II codes for services delivered to Medicare patients, but…

Look to CPT codes first and use HCPCS Level II when there is not an appropriate CPT code

CPT Category I?

Procedure codes in current medical practice

CPT Category II?

Non-billable tracking codes

CPT Category III?

Temporary codes for experimental treatments and research

What is a “hik-piks”

Supplement CPT codes for non-physician services, admin injectable drugs, DME, office supplies

True or False: Supervised modalities, such as thermal agents, are not timed services

True

True or False: Manual electric stimulation is a code that counts as “constant attendance” so it is timed and can be billed

True

What is the Medicare “8-Minute Rule”?

1 Unit - 8 to 22 Minutes

2 Units - 23 to 37 Minutes

3 Units - 38 to 52 Minutes

4 Units - 53 to 67 Minutes

5 Units - 68 to 82 Minutes

The language accompanying most of the therapeutic procedure codes requires…

Direct one-on-one time

True or False: Group therapy procedures are a way for Medicare patients to be treated together, no requiring one-on-one patient contact

True

When using Group Therapy Codes, how is it possible to add direct contact 1-1 time to group therapy services?

Use a 59 modifier and document that direct codes were provided during separate time intervals than the group therapy

True or False: You can bill group therapy if you provide 1-1 care independently to each patient, alternating between them

False; must be notable difference in care between patients

True or False: You can bill group therapy if you are providing simultaneous therapy and give constant feedback to all patients

True

Your patient completes:

25 minutes of Neuro Re-ed

10 minutes of gait training

What can I bill under Medicare?

What can I bill under commercial?

Medicare = 2 units (35 total time; 2 units as threshold is 38 for 3 units and did not reach that)

Commercial = 3 units (10 minutes allows for 1 unit; 25 minutes allows for 2 units as its over 23 minutes)

Your patient completes:

10 Minutes of Manual Therapy

10 Minutes of Therapeutic Activity

25 Minutes of Therapeutic Exercise

What can I bill under Medicare?

What can I bill under Commercial?

Medicare = 3 units (45 minutes total; 3 units as time would have to be 53 to have 4)

Commercial = 4 units (1 unit (was at least 8 minutes), 1 unit, (was at least 8 minutes) then 2 units (at least 23 minutes)

Your patient completes:

8 Minutes of Manual Therapy

10 Minutes of Therapeutic Exercise

What can I bill under Medicare?

What can I bill under Commercial?

Medicare = 1 unit (18 minutes; doesn’t reach 23 min mark so only gets 1)

Commercial = 2 units (8 minute allows for 1 unit; separate service for 10 minute allows for 1 more unit)