Coding

Healthcare Common Procedure Coding System (HCPCS)

can processes claims in an efficient manner

level 1: CPT

level 2: non-physician supplies and some services (mostly orthotics)

level 3: local codes (MediCal): elevation and treatment

Common Procedure Terminology (CPT)

used for reporting medical procedures and services to governmental and third party payers for payment; developing medical review guidelines; medical research; education

5 digit numeric code that is used to describe medical. surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals and other health care providers

provide a uniform language that describes medical, surgical and diagnostic services

Codes and OT

shorthand to the payer to describe what we do and why we do it in a medical model

first step of medical necessity

selected code must be a logical solution to the care process initiated y the patient diagnosis

CPT Editorial Panel

the American medical association (AMA) assembles a panel that maintains, revives, deletes and modifies CPT codes

made up of 17 members, 11 are nominal by the AMA the others are nominated by various other entities such as BC/BS and CMS (physicians, health care professional advisory committee representatives, payer and coding representatives)

makes decisions about inclusion of codes in future CPT editions

Healthcare Professions Advisory Committee (HCPAC)

physicians assistants

chiropractors

nurse practitioners

occupational therapist

optometrist

physical therapist

podiatrists

psychologists

audiologists

speech language pathologists

social workers

registered dietitians

Doctoring Profession

power, autonomy, scope, reimbursement

chiropractors

nurse practitioners

optometrist

physical therapist

podiatrists

psychologists

Caregiver Training

3 new CPT codes will allow OT to bill for training sessions provided to one or more caregivers for an individual or groups of caregiver for several patients without the patient present

Relative Values Scale Update Committee (RUC)

expert panel of expert providers who make recommendations to CMS on behalf of the AMA (provider time, clinical labor, supplies, equipment involved in patient care)

regularly reviews medical services to determine whether they are appropriate or misvalued

CMS makes all final decisions about payments for each service under the Medicare program in the physician fee schedule final rule for each new calendar year

Components of Code Value

work

practice expense

malpractice/liability insurance

Work

time to perform service

technical skill and physical effort

required mental effort and judgement

stress due to potential risk

Time

pre-service time spend preparing to see the patient: review medical record, prepare space and materials

intra-service time performing service/procedure: provide intervention and clinically indicated

post-service time receiving patient feedback: providing instruction/plans for future treatment, documenting the service

bill in 15 minute increments

when counting time for timed codes, count intra-service time only unless code states report is included

Practice Expense

resources needed to perform the service: clinical labor, medical supplies, equipment

administrative costs: office space, clerical staff, computers

Liability Insurance

valued based in the resources needed to purchase malpractice insurance

Report Correct Code

payment integrity: insurance fraud (know insurance doesn’t pay for a service so provide that service but bill it as something else; pick a code that pays higher but doesn’t necessarily represent what uo did with the client)

ethical choice for the profession

valuable data for future changes to codes, to better represent full scope of OT practice

Codes Promote OT

evaluation costs set the stage for promoting optimal OT by requiring and occupational profile, requiring standardized assessments and other tests/measures, describing the full scope of OT

correct coding promotes “distinct value”

3 Components to Evaluation

high complex or broad the OT profile and medical/therapy history must be

how many performance deficits will be addressed, which standardized or non standardized assessment to be given

degree of clinical decision making used

Determining Appropriate Level

each comment must be separately determined as low, moderate, or high

each component must meet or exceed the complexity requirement to appropriately quality at the level of evaluation

higher code cannot be used unless all 3 components meet the higher level (always use the lower complexity level)

Low Complexity: Occupational Profile

an occupational profile and medical/therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem

Moderate Complexity: Occupational Profile

an occupational profile and medical/therapy history, which includes a expanded review of medical and/or therapy records and additional review of physical, cognitive or psychosocial history related to current functional performance

High Complexity: Occupational Profile

an occupational profile and medical/therapy history, which includes a expanded review of medical and/or therapy records and extensive additional review of physical, cognitive or psychosocial history related to current functional performance

Occupational Profile

clients background

contexts/environment

meaningful interests

needs and goals

past level and types of occupational participation

MUST be completed at the beginning of every evaluation

CMS, CPT, ACOTE and the framework agreement

Low Complexity: Occupational Performance

and assessment that identifies 1-3 performance deficits (related to physical, cognitive or psychosocial skills) that result in activity limitations and/or participation restrictions

Moderate Complexity: Occupational Performance

and assessment that identifies 3-5 performance deficits (related to physical, cognitive or psychosocial skills) that result in activity limitations and/or participation restrictions

High Complexity: Occupational Performance

an assessment that identifies 5 or more performance deficits (related to physical, cognitive or psychosocial skills) that result in activity limitations and/or participation restrictions

Performance Deficits

related to: activity limitations, participation restrictions

refer to OTPF: use the general categories as well as the specific occupations, occupations not specified may be identified as performance deficits if appropriate to the client, identified performance deficits must be assessed in the intervention plans

Physical Skills

refer to body structures or body functions

ex: balance, mobility, strength, endurance, fine/gross motor coordination, sensation, dexterity

Cognitive Skills

refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn and remember resulting in the ability to organize occupational performance in a timely and safe manner

observed when: a person attended to and selects, interacts with and uses task tools and materials; carries out individual actions and steps; modifies performance when proven are encountered

Psychosocial Skills

refer to interpersonal interactions, habits, routines and behaviors, active se of coping strategies and/or environmental adaptations to develop skills necessary to successfully and appropriately participate in everyday task and social situations

Counting Deficits

the number of performance deficits identified is very important and will likely receive scrutiny as these new codes are used

clinical judgement about the overall needs of the client, the expectations for this episode of care and the overall complexity of the presenting client situation will dictate the number identified

use the framework list of occupations as a guide

this supports the independent reasoning and judgment of the therapist

Low Complexity: Decision Making

clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem focused assessments and considerations of a limited number of treatment options

patient presents with no comorbidities that affect occupational perfjoamcne

modification of task/assistance with assessments is not necessary to enable completion of evaluation components

Moderate Complexity: Decision Making

clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessments and considerations of a several treatment options

patient presents with comorbidites that affect occupational performance

minimal to moderate modifications of tasks or assistance with assessment is necessary to enable completion of evaluation components

High Complexity: Decision Making

clinical decision making of high analytic complexity, which includes an analysis of the occupational profile, analysis of data from comprehensive assessments and considerations of a multiple treatment options

patient presents with comorbidities that affect occupational perfjoamcne

significant modifications of tasks or assistance with assessment is necessary to enable completion of evaluation components

Defending Appropriate Codes

components must be identified and justified in the documentation

therapists must be clear with administrators that evaluations is a process not defined by the same amount of time or level for each client but rather but the needs and complexity of the client’s individual performance deficits

arming oneself with knowledge of the evaluation code components will enable defense of approbate evaluation code selection in any outside review

Plan of Care

CPT identifies the development of the patient as part of the evaluation process

written after all information from the history and profile, assessment and clinical decision making is gathered and intervention strategies are identified