Review the different reasons for documentation and goals for each Discuss strategies to prove medical necessity for treatment Review documentation



_{There are no conflicts of interest and information will be presented fairly}

and without bias



No commercial support has been given for this presentation



The focus of this presentation is on Medicare guidelines, which is the

“Gold Standard” for documentation and coding

 _{Each payer may have their own requirements for reimbursement}

 The information included in this presentation does not guarantee third party reimbursement



_{Review the different reasons for documentation and goals for each}

Discuss strategies to prove medical necessity for treatment

Continuity and Quality of Care Risk Management



_{Documentation needs to tell the story of current treatment as well as}

outline a roadmap for where the course of treatment is heading



Ensure that a colleague can pick up your notes and seamlessly treat your

patient



_{Make sure to track progress}

 _{Identify interventions that work/don’t work}



_{If it isn’t documented, it did not happen}



Patient concerns/complaints are investigated by outside entities- make

sure they can follow your thoughts and rationale

 _{Risk Management Department}  _Attorneys

 Managers

 _{Business Office}

 _{Customer Service Department}



_{Documentation that describes rationale for treatment can improve}



_{Prove Medical Necessity}



Justify treatment interventions



Explain why progress may deviate from the norm



Make sure to write in professionally language, yet make it so a lay person

can also understand

 _{Claims are often reviewed by processors with no therapy background, nurses,} etc.

Diagnosis Codes Treatment Codes

 ICD-9-CM

 International Classification of Diseases, 9th _{Revision, Clinical Modification}  Describes the diagnosis or condition being treated

 Medicare has a list of ICD-9 Codes that support medical necessity for Physical Medicine and Rehabilitation

 ICD-10 CM will become the standard by Oct. 1, 2015  Code to the highest level of specificity

 Should be specific and relevant to the problem being treated

 Medical Dx

 Only provided by referring physician or non-physician practitioner

 Treatment Dx

 Should reflect specific conditions being addressed



_{Example: Post-op ACL}

 Referral (Medical) Diagnoses

 _{844.2- ACL Sprain}

 _{V58.43- Aftercare following surgery}  _{Treatment Diagnoses}

 _{719.46- Knee pain}

 _{719.56- Knee joint stiffness}  728.87- Muscle weakness



_{Primary vs. Secondary Dx}

 Insurance companies look at Primary Dx for each procedure

 _{Should be the most relevant Dx for the condition being treated}

 Make sure to link the appropriate Dx with the appropriate procedure

 _{Example: Crutch Training}

 Primary Dx should be 719.7- Difficulty Walking

 _{CPT® Codes}

 _{Current Procedural Terminology Codes}

 _{Developed by the AMA as a listing of descriptive terms and identifying codes for}

reporting medical services and procedures

 Unless otherwise specified, the codes do not restrict who can bill, it describes the particular service

 _{ATC’s will primarily use Physical Medicine and Rehabilitation Codes (97005-97725)}  _{HCPCS Level II Codes}

 _{Healthcare Common Procedure Coding System}

 _{Used to describe supplies, services, and products not identified by CPT codes}

 Often used to report medical items or services that are regularly billed by suppliers other than physicians



_{Documentation should prove the need for skilled rehabilitative therapy}

 Skill of the clinician is required to safely and effectively perform a recognized therapy service whose goal is improvement of an impairment or functional limitation



_{Prove the need for skilled therapy by documenting:}

 Rationale for treatment

 _{Why interventions are necessary and require your skill}  _{Treatment changes made due to your assessment}

 The skilled intervention you are performing (ex. cueing)  _{Objective measures to track progress}



_{The Episode of Care should have documentation that:}

 _{Describes the patient’s impairments and functional limitations requiring} skilled intervention

 _{Describes prior level of function to assist in establishing the patient’s} potential and prognosis

 _{Justifies that the type, frequency and duration of therapy is medically} necessary for the individual patient’s condition

 _{Identifies each specific intervention/modality and describes the skilled} nature of that treatment

 _{Clearly reflects both Timed Code Treatment Minutes and Total Treatment} Time in order to justify the units billed



_{Treatment Notes are required for every treatment day and must include:}

 Date of service

 _{Identification of each specific intervention that corresponds to each CPT} code that was billed

 _{Record of total treatment time to justify CPT codes that were billed}

 _{Present a breakdown and sum of minutes spent with both Timed and Untimed Codes}



_{Recommended elements:}

 _{Patient’s subjective comments}

 _{Positive or negative changes in condition}

 _{Description of skilled components of interventions}  _{Instructions and equipment given to the patient}



_{Treatment modality or procedure that is not defined by a specific time}

frame, rather the service provided



Generally can only bill 1 unit per day



Evaluation/Re-evaluation (97005-97006)



_{Supervised Modalities (97010-97024)}

_{Group Therapy (97150)}



_{Establishes baseline data necessary for assessing rehab potential,}

prognosis, goal setting, and Plan of Care



_{Patient should exhibit a significant change from their “usual”}



List the conditions being treated and the complexities that impact

treatment length or prognosis

 _{i.e. age, time since onset and reasons for delays in seeking treatment, cognitive}

ability, etc.



_{Presenting condition or complaint}

 _{Objective description of changes in function}  _{Mechanism of injury}

 _{Subjective complaints and date of onset}

 _{Onset date for acute conditions or “acute exacerbation” date for chronic conditions}



_{Relevant medical history}

 _{Medications and co-morbidities that support increased severity or complexity}

 _{Prior therapy history for this condition and rationale of why additional treatment is}

necessary



_{Social/Support Environment}

 _{Living arrangements, level/type of support, home obstacles, usual home} responsibilities/level of independence required for safety, patient’s

responsibilities in the home



_{Prior Level of Function}

 _{Functional status just prior to onset of condition}

 _{Should be recorded in objective, measurable, and functional terms}

 _{Information should be used to establish rehab potential, prognosis, and} functional goals of treatment



_{Functional Testing}

 _{Objectively measure or describe impact that impairments have on current} level of functioning

 Ex: mobility status, pain and how it limits function, etc.



_{Objective Testing}

 _{Determine source or cause of the limitation}  _{ROM, MMT, Special Testing}

 _{Use concise, objective measurements}

 DO NOT use descriptions when more precise measurements are available



_Assessment

 Therapist’s analysis of the condition

 Prognosis for return to prior functional status or maximum expected condition



_{Plan of Care}



_{Part of the initial evaluation that addresses specific therapeutic}

goals

 _{Goals should:}

 Pertain to functional impairment findings

 Be realistic with a predicted date of achievement

 Be function based and written in objective, measurable terms



_{Must contain:}

 _{Treatment diagnoses}

 Type of treatment (discipline)

 _{Amount of treatment (number of sessions/day)}  _{Frequency of treatment (number of times/week)}

 _{Duration of treatment (number of weeks or sessions)}



_{Some insurance companies may require signature certifying POC}



_{Documentation must include clear justification of the need for further}

tests and measurements

 _{Ex. New clinical findings, unanticipated change in the patient’s condition,} failure to respond to the current POC



Clinicians should asses for progress at each therapy session; however, this

is not considered a formal re-evaluation



_{Re-evaluations should contain all the applicable components of the Initial}



_{When used alone to reduce discomfort, considered to be “unskilled”}



When used in conjunction with a modality (bundled), charge is included

in the associated treatment



_{Medically necessary if used for radiculopathy}

 Cannot be used as a stand-alone treatment



Can be billed for the time devoted to teaching a patient to use a home

traction device



_{Documentation required:}

 _{Body part being treated (cervical or lumbar)}  Etiology of symptoms



_{Medically necessary when used for control of pain/swelling, retraining}

weak muscles

 _{Should not be used as a stand-alone treatment}  _{Objective/subjective improvement within 6 visits}



_{Documentation required:}

 Area being treated



_{Medically necessary if used for the application of pressure to an extremity}

to reduce edema



Documentation required:

 _{Effects of edema on function}

 _{Area being treated/location of edema}

 Objective measurements with contralateral comparison  _{Type of device used}



_{Medically necessary when therapy treatment is provided simultaneously}

for 2 or more patients who may/may not be doing the same activities

one-on-one contact

 _{May bill 1 unit for each member of the group}



_{Documentation required:}

 _{Purpose and number of participants in the group}

 Description of the skilled activity provided by the clinician in this setting



_{Billed based on the time spent in patient contact}



Requires direct, one-on-one contact with the patient

 _{Non-billable = 0-7 min}  1 unit = 8-22 min

 _{2 units = 23-37 min}  _{3 units = 38-52 min}  _{4-units = 53-67 min}



_{Pre- and post-delivery time cannot be counted when recording treatment}



_{Constant attendance is required}

 _{i.e. motor point stim, NMES with Exercise}

 _{Can be used for instruction on home TENS use}



_{Medically necessary when used for control of pain/swelling,}

retraining weak muscles

 _{Should not be used as a stand-alone treatment}  _{Objective/subjective improvement within 6 visits}



_{Documentation required:}

 Area being treated

 _{Type of e-stim being applied}

 _{Subjective/objective improvement}

 Strength and pain ratings, progression of functional deficits

 _{Medically necessary when used for limited joint motion that requires an}

increase in tissue extensibility, symptomatic soft tissue calcification, and neuromas

 _{Phonophoresis is billable as ultrasound, with no reimbursement given separately for}

drugs

 _{Ultrasound/E-stim Combo should be billed as Ultrasound}  _{Objective/subjective improvement within 6 visits}

 Documentation required:

 _{Area being treated}

 _{Frequency and Intensity}

 _{Subjective/objective improvement}

 Strength and pain ratings, progression of functional deficits  _{Justification needed for continued use after 12 visits}



_{Medically necessary to restore strength, endurance, ROM, flexibility, etc.}

 Must require the skill of the clinician for assessment and progression



Documentation Required:

 _{Measureable impairments and their effects on function}  _{ROM/strength measures with contralateral comparison}

 _{Metrics of progress that are functionally and clinically meaningful}

 _{Information that shows the condition is responsive to the therapy chosen}  Evidence that exercises are being transitioned to an independent home

exercise program

 _{Specific exercises performed, purpose of exercise as related to function, and} clinical intervention/instructions given



_{Medically necessary for restoring balance, coordination, kinesthetic sense,}

posture, and proprioception

 _{Can be used to bill for time using McConnell Taping or Kinesiotaping} techniques to enhance proprioception



Documentation required:

 _{Objective measures of coordination, balance, postural deficits, etc. and their} effects on function

 _{Specific exercises performed, purpose of exercise as related to function, and} clinical intervention/instructions given



_{Medically necessary for a patient that cannot tolerate land-based therapy}

and requires the buoyancy and resistance properties of water



_{Documentation requirements:}

 _{Justification for use of aquatic environment}

 Measureable impairments and their effects on function

 ROM/strength measures with contralateral comparison, balance, coordination, etc.

 Specific exercises performed, purpose of exercise as related to function, and clinical intervention/instructions given



_{Medically necessary for training patients and instructing caregivers in}

ambulating patients whose walking abilities have been impaired



Documentation requirements:

 _{Objective measurements of balance/gait disturbance, assistive device used,} amount of assistance required, gait deviations and limitations being

addressed, description of verbal cueing

 _{Presence of complicating factors (pain, balance/gait deficits, environmental} or safety concerns)

 _{Specific techniques used, clinical intervention/instructions given and} patient’s response



_{Medically necessary to manage pain, address restricted joint}

motion/dysfunction, and effect change in soft tissues, articular structures,

neural or vascular system to restore normal function



Documentation requirements:

 _{Soft tissue or joint mobilization technique used}

 Measureable impairments and their effects on function

 _{ROM/strength measures with contralateral comparison, balance, coordination, etc.}  Specific exercises performed, purpose of exercise as related to function, and



_{Medically necessary for patients needing a broad range of rehab}

techniques that involve movement

 _{Involves the use of functional activities to restore functional performance in a} progressive manner



Documentation requirements:

 _{Clear correlation between the type of therapeutic activity performed and the} patient’s underlying condition geared toward a specific outcome that is listed within the POC



_{Medically necessary when specialized testing is required that is above and}

beyond the normal evaluative process (i.e. isokinetic testing)



_{Documentation required:}

 _{Problem requiring the testing and the tests performed}  Separate measurement report including graphical data  _{Application to functional activity}

National Correct Coding Initiative Modifier -59



_{National Correct Coding Initiative}



Implemented to prevent abusive and fraudulent billing



Primarily applies to Medicare outpatient therapy; however, the use of CCI

Edits for non-Medicare payers varies by the payer and the State



_{CCI Denial reasons:}

 _{Mutually Exclusive Codes}

 Codes that cannot be reasonably billed together because they would not normally be performed together

 Code billed is considered a component of a more comprehensive code and is not reimbursed separately



_{Indicates that a service or procedure was distinct from other services}

performed on the same day



Used to report procedure/services that are not normally reported

together, but are appropriate under the circumstances (i.e. cervical

traction followed by manual therapy)

 _{Documentation must reflect that the services/procedures were provided} separately and were medically necessary



_{Also signifies that multiple disciplines of therapy are working with the}



_{Know your insurance contracts}

 Each payer requires different elements  _{Each payer may reimburse differently}



_{Medicare is the “Gold Standard”}

 _{Medicare is the most stringent/restrictive}

 If you follow Medicare guidelines, you will most likely meet the requirements of all other payers

 http://www.cms.gov/Medicare/Billing/TherapyServices/index.html  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf  http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?lcd_id=10214&lcd_version=61&basket=lcd%25253A10214%25253A61%25253AOutpati ent+Physical+Therapy%25253AFI%25253APalmetto+GBA+(00380)%25253A  www.gawendaseminars.com

Thank You

Contact Info:

Alclark@quincymedgroup.com