Re: Physical,occupational, and speech therapy

[Reichl2014]

Hello,

Help!  I have many years experience in surgical and internal med billing.  Just started Assisting new therapy practice with therapy billing and it seems so complicated.  Anyone familiar with this type of billing mainly to commercial and MA insurances. 

Thanks, Gayle

[shanbull]

I do PT/OT billing, what is confusing you most?

[Merry]

Much more complex than regular physician billing. I would suggest at least for Medicare..go to your MAC's site and download their info about therapy services. Many of the MACS have free webinars so check under educational services on the Medicare site

[Reichl2014]

It is a new practice and the owner is a physical therapist. She has no idea about coding and billing.  In the midatlantic area. What are normal % paid to biller and does it include auths etc. statements?
How do u keep track of auths???   She  Wants to use 96111 all the time because it pays more. Told her she needed eval code like 97003. And treatment codes. She isn't doing modalities yet
Thanks

[Reichl2014]

I do PT/OT billing, what is confusing you most?

practice is brand new and owner is therapist. She knows nothing about billing or coding.  What is normal% paid to billers (pa). Does it include auths, sending statements?
What procedure do u have in place for auths.  Anywhere to find forms.
She wants to code 96111 all time but told her needs to do eval first like 97001or 97003 first. Is there a time  for this code.  And then auth patient for modalities or treatment   For future visits. When should you do 96111?
Thanks gayle

[Reichl2014]

Much more complex than regular physician billing. I would suggest at least for Medicare..go to your MAC's site and download their info about therapy services. Many of the MACS have free webinars so check under educational services on the Medicare site

Owner is therapist and know nothing about billing.  Any info on fee schedule. This is pediatric therapy practice.  No medicare yet.Any procedures on doing auths. Any example of forms. Super bills. I will be doing this at home and not at therapy office
Thanks.

[PMRNC]

You want to be careful, if she's not doing coding and your not a certified coder you might want to think of having them get a certified coder or you will be in for a real mess. If you are not working in the office your liability is a bit higher if your doing coding since you will need the actual documentation to code.

[shanbull]

I have never billed CPT 96111. Based on the description is looks like it's intended for extended screening for autism, "Developmental testing, extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, eg, Bayley Scales of Infant Development) with interpretation and report." So it's more of an SLP code and should not be used for PT or OT. It's definitely not something to use as a standard code, but for children who need extra screening beyond 96110 and are suspected of having a developmental issue. Also the owner will need to get used to the idea that you do not bill a code because it pays more. You bill a code because it is the most appropriate description of the services rendered and all documentation must match up with the code billed or the money will be taken back during an audit, or worse, her clinic will be kicked out of the insurer's network, or even worse, she could be convicted of fraud, have her license revoked, and never be able to work in healthcare again. It's a big deal. I actually found an article about how 96111 is commonly fraudulently billed by providers attempting to get higher reimbursement: https://hcfraudshield.wordpress.com/tag/cpt-96111/, this means that frequently billing this code will most likely be a red flag to insurance companies and prompt audits.

For the first visit 97001 should be billed for an initial PT evaluation.  97002 is for a PT re-evaluation (often done to justify extending authorization for more treatment). 97003 is for OT evaluation, 97004 is for OT re-evaluation. We also bill a lot of modality types like:

97530 - therapeutic activities, direct patient contact
97110 - therapeutic exercises
97140 - manual therapy
97014 - electrical stimulation
97012 - mechanical traction
97035 - ultrasound

Just make sure you're aware of mutually exclusive procedures and become familiar with the National Correct Coding Initiative edits because most of these codes are on it. Most cannot be paid with 97002 in particular.

You should also research the modifiers required in PT/OT coding as well as when it's appropriate to use modifier 59 to report distinct services (note, modifier 59 will not override NCCI edit rules and if an insurer accidentally pays because modifier 59 because it was inappropriately used, they will recoup payment).

Finally, if you do ever get into it, Medicare has a completely different system because of its functional limitation reporting requirements. I found this guide really helpful: http://www.functionallimitationreporting.com/#q01 Medicare does cover children with disabilities so you may run into it sooner than you'd think.

Sorry, I can't answer your questions about rates because the clinic employs me hourly and I do other stuff besides billing.

Prior Authorization forms are usually provided by the insurance companies, and they are now supposed to be publishing their fee schedules on their websites. We track the prior authorizations by claims, if a claim is ready to go out but we don't have prior authorization yet, the claim is assigned to a specific person who makes sure to bill as soon as the authorization number is received. We only have one insurance company we bill for that requires prior authorization. We treat mostly adults though.

[kristin]

As far as a fee schedule goes, my suggestions are:

1. Have one fee schedule for all payers
2. Set the fees by taking the Medicare allowable and adding a percentage to that fee, or round up to what your highest payer allows. You will find that in MOST instances, payers will be at or below the Medicare allowable, with few exceptions. Contact your biggest payers and get their fee schedules for your codes, if you are unsure who pays the most. I like to round up to the nearest even dollar amount. Example(made up numbers, not actual): 97014 Medicare allowable is 18.00, and BCBS(highest payer) allowable is 19.65. I make the fee $20. I don't like inflated fees that I just have to contractually adjust off...I like my A/R to be as accurate as possible.
3. For self pay patients, read up on what is allowed, and what isn't in that situation...but make sure the SAME fee is being charged to all self pay patients, and hardship exemptions are documented.

[Reichl2014]

I have never billed CPT 96111. Based on the description is looks like it's intended for extended screening for autism, "Developmental testing, extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, eg, Bayley Scales of Infant Development) with interpretation and report." So it's more of an SLP code and should not be used for PT or OT. It's definitely not something to use as a standard code, but for children who need extra screening beyond 96110 and are suspected of having a developmental issue. Also the owner will need to get used to the idea that you do not bill a code because it pays more. You bill a code because it is the most appropriate description of the services rendered and all documentation must match up with the code billed or the money will be taken back during an audit, or worse, her clinic will be kicked out of the insurer's network, or even worse, she could be convicted of fraud, have her license revoked, and never be able to work in healthcare again. It's a big deal. I actually found an article about how 96111 is commonly fraudulently billed by providers attempting to get higher reimbursement: https://hcfraudshield.wordpress.com/tag/cpt-96111/, this means that frequently billing this code will most likely be a red flag to insurance companies and prompt audits.

For the first visit 97001 should be billed for an initial PT evaluation.  97002 is for a PT re-evaluation (often done to justify extending authorization for more treatment). 97003 is for OT evaluation, 97004 is for OT re-evaluation. We also bill a lot of modality types like:

97530 - therapeutic activities, direct patient contact
97110 - therapeutic exercises
97140 - manual therapy
97014 - electrical stimulation
97012 - mechanical traction
97035 - ultrasound

Just make sure you're aware of mutually exclusive procedures and become familiar with the National Correct Coding Initiative edits because most of these codes are on it. Most cannot be paid with 97002 in particular.

You should also research the modifiers required in PT/OT coding as well as when it's appropriate to use modifier 59 to report distinct services (note, modifier 59 will not override NCCI edit rules and if an insurer accidentally pays because modifier 59 because it was inappropriately used, they will recoup payment).

Finally, if you do ever get into it, Medicare has a completely different system because of its functional limitation reporting requirements. I found this guide really helpful: http://www.functionallimitationreporting.com/#q01 Medicare does cover children with disabilities so you may run into it sooner than you'd think.

Sorry, I can't answer your questions about rates because the clinic employs me hourly and I do other stuff besides billing.

Prior Authorization forms are usually provided by the insurance companies, and they are now supposed to be publishing their fee schedules on their websites. We track the prior authorizations by claims, if a claim is ready to go out but we don't have prior authorization yet, the claim is assigned to a specific person who makes sure to bill as soon as the authorization number is received. We only have one insurance company we bill for that requires prior authorization. We treat mostly adults though.

I have never billed CPT 96111. Based on the description is looks like it's intended for extended screening for autism, "Developmental testing, extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, eg, Bayley Scales of Infant Development) with interpretation and report." So it's more of an SLP code and should not be used for PT or OT. It's definitely not something to use as a standard code, but for children who need extra screening beyond 96110 and are suspected of having a developmental issue. Also the owner will need to get used to the idea that you do not bill a code because it pays more. You bill a code because it is the most appropriate description of the services rendered and all documentation must match up with the code billed or the money will be taken back during an audit, or worse, her clinic will be kicked out of the insurer's network, or even worse, she could be convicted of fraud, have her license revoked, and never be able to work in healthcare again. It's a big deal. I actually found an article about how 96111 is commonly fraudulently billed by providers attempting to get higher reimbursement: https://hcfraudshield.wordpress.com/tag/cpt-96111/, this means that frequently billing this code will most likely be a red flag to insurance companies and prompt audits.

For the first visit 97001 should be billed for an initial PT evaluation.  97002 is for a PT re-evaluation (often done to justify extending authorization for more treatment). 97003 is for OT evaluation, 97004 is for OT re-evaluation. We also bill a lot of modality types like:

97530 - therapeutic activities, direct patient contact
97110 - therapeutic exercises
97140 - manual therapy
97014 - electrical stimulation
97012 - mechanical traction
97035 - ultrasound

Just make sure you're aware of mutually exclusive procedures and become familiar with the National Correct Coding Initiative edits because most of these codes are on it. Most cannot be paid with 97002 in particular.

You should also research the modifiers required in PT/OT coding as well as when it's appropriate to use modifier 59 to report distinct services (note, modifier 59 will not override NCCI edit rules and if an insurer accidentally pays because modifier 59 because it was inappropriately used, they will recoup payment).

Finally, if you do ever get into it, Medicare has a completely different system because of its functional limitation reporting requirements. I found this guide really helpful: http://www.functionallimitationreporting.com/#q01 Medicare does cover children with disabilities so you may run into it sooner than you'd think.

Sorry, I can't answer your questions about rates because the clinic employs me hourly and I do other stuff besides billing.

Prior Authorization forms are usually provided by the insurance companies, and they are now supposed to be publishing their fee schedules on their websites. We track the prior authorizations by claims, if a claim is ready to go out but we don't have prior authorization yet, the claim is assigned to a specific person who makes sure to bill as soon as the authorization number is received. We only have one insurance company we bill for that requires prior authorization. We treat mostly adults though.

Thanks so much for all the info. Really helped. Also sent fraud info to the owner.  Do u have any issues with coding  for instance 97003 with 97530 and using modifier 59 on same day. ?  Anything to be aware of when therapists do documentation besides time. Gayle

[shanbull]

Thanks so much for all the info. Really helped. Also sent fraud info to the owner.  Do u have any issues with coding  for instance 97003 with 97530 and using modifier 59 on same day. ?  Anything to be aware of when therapists do documentation besides time. Gayle

There is no conflict billing 97530 with modifier 59 along with either 97001 or 97003. There is a conflict billing it with re-evaluation (97002 or 97004.)

This is the Medicare page where you can download the code pair edits: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/
Here is a document on how to read the edits: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf

As for documentation aside from time, make sure all measures used in the evaluation are updated with current status at each appointment (so for example, pain levels always should be documented, functional limitation status should be updated including range of motion and other objective measures that apply), the patient's "homework" until the next treatment should be included. Basically, anything that is done during the appointment should be documented so that if an insurance company requests records, it's very easy to show that what was billed for was actually done. An evaluation generally contains one section on "History" which will explain what led the patient to need therapy, any relevant symptoms/medical history and information from previous treating providers, baseline pain levels and limitations, and probably anything a parent mentions that might be helpful information to refer to later. Next would be the "Physical Exam" section which would go into more specific measures like range of motion, strength, gait, balance, reaction to palpation, and special testing. Next section would be "Therapeutic Interventions" where the provider will document what treatment was done, on what body part(s) and for how long. Next section would be "Diagnosis/Assessment" and the provider will note all relevant diagnoses made during the evaluation, and then write out a treatment plan including objective goals to be measures at further appointments, including long-term and short-term. The final section would be "Treatment" where the provider will document for each diagnosis what treatment will take place, plus frequency and duration prescribed for each treatment. At subsequent appointments most of this info will be exactly the same, with an update on how things went on each particular date for the patient and any necessary changes to the treatment plan of course can be made. At the discharge appointment the "Physical Exam" section will need to be updated with the patient's status as of the end of treatment, and documentation addressing whether each of the goals in the "Diagnosis/Assessment" section have been met.

You can probably find several different formats for initial evaluation and appointment notes on Google, all providers have their own style and order in which they like to do things. I just outlined the general structure our providers prefer to use.

[medwave]

Codes and modifiers are listed for the three that you've questioned.

Physical Therapy
Occupational Therapy
Speech Therapy

New CPT Codes for Physical Therapy
97161 – Physical Therapy Evaluation – Low Complexity
97162 – Physical Therapy Evaluation – Moderate Complexity
97163 – Physical Therapy Evaluation – High Complexity
97164 – Physical Therapy Re-evaluation

Hope that helps! :-)