I do PT/OT billing, what is confusing you most?
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
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 contact97110 - therapeutic exercises97140 - manual therapy97014 - electrical stimulation97012 - mechanical traction97035 - ultrasoundJust 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