Coding and Billing

1. Coding and Billing October 19, 2019

2. Benefit Verification • Date benefits are being verified • Document the name of the person to whom you spoke • Majority of information is now available on line through various websites • If you aren’t sure – call! • Have a specific outline of the services and supplies you render in your office

3. Understanding Benefits and Collecting Correct Amounts • Deductibles • Initial out of pocket expense payable by the patient • Co-pays • A specific dollar amount • Co-insurance • A specific percentage of services rendered or the contracted rate

4. Completion of the HCFA1500 Understanding this will allow you to understand a more complete picture of insurance

5. TOP HALF • For the most part is self explanatory • Check your spelling! • Mailing address • Insured’s ID number • Careful not to transpose numbers! • Insured’s policy group or FECA number • Insurance plan or program name • Accident related • Medicare vs Commercial – not the same!

6. BOTTOM HALF • Needs to be a direct reflection of what is stated in your patient files • ICD Codes • What your patient is being treated for • CPT Codes • Type of treatment being rendered

7. Diagnostic Coding • ICDA (International Classification of Diseases, Adapted) are the codes used to report what condition the patient is being treated. • Document all diagnosis codes that pertain to the patient’s condition.

8. Proper Code Selection • Either find the GEM or find the correct chapter in your code book • Read your exclusions • Code specific to documentation • The more specific – the more you increase the necessity for service

9. Documentation must support • USE the most specific code that is SUPPORTED by your documentation. • LEGALLY responsible for EVERYTHING on the bill-on paper or electronically.

10. Condition Definitions • Acute • Chronic • If you have both Acute and Chronic DX to report, Acute gets reported first on the claim form • Exacerbation • Recurrence

11. Acute Condition A patient’s condition is considered to be acute when the onset of the condition and/or symptoms has occurred or has substantially become worse within a six-week period prior to presentation in your office. Typically caused by some intervening trauma whether known or unknown

12. Chronic Condition A patient’s condition is considered chronic when the condition or symptoms have existed for longer than six weeks. Classification of a condition as chronic in no way effects the expectation or whether the condition can be resolved or improved with treatment

13. Exacerbation Exacerbation is sudden, marked deterioration of the condition being treated, which causes a marked worsening in the patient’s functional status, and which is caused by some intervening event or trauma whether known or unknown

14. Recurrence A recurrence is the return of an acute condition which was previously treated and resolved or stabilized and which hasn’t been causing any trouble or symptoms for a period of time

15. Updating/Changing your DX • When an acute condition becomes chronic • Strain or Sprain after 6 weeks • New Conditions/New Injury • Change in condition • Improvement • Exacerbation It all goes back to documentation

16. CPT Codes & Modifiers

17. Coding for Treatment Rendered: Box 24 • CPT’s • Current Procedural Terminology • MODIFIERS

18. CPT’s • CMT’s • Chiropractic Manipulative Therapy • Modalities • Procedures • E&M’s • Evaluation & Management • X-rays

19. CMT’s • 98940 1-2 areas • 98941 3-4 areas • 98942 5 areas • 98943 Extremities • The work value of CMT codes includes preservice, intraservice, and post-service work, such as palpation and routine range of motion testing. This is why E/M codes and CMT codes get bundled together.

20. S Codes • S8948 • Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes. • S9090 • Decompression Therapy • S8990 • Physical or manipulative therapy performed for maintenance rather than restoration.

21. Modalities • Any physical agent applied to produce therapeutic changes to biologic tissues • Two categories: • Unattended/Passive Care • Attended/Active Care Georgia Rule 100-15-.01 does not allow a CA to place a patient on therapy without the doctor being present/somewhere in the building

22. Unattended/Passive • 97010 thru 97028 • No time involved • Supervised, constant attendance not needed. Does not require direct one on one patient contact.

23. Attended/Active • 97032 through 97039 • Time involved - Needs to be documented - Reduced time can include with another timed code otherwise it is unbillable • Can be reported in units • Direct one on one contact by provider

24. Procedures • 97110 through 97546 A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. • Time is involved • Must be documented • Can be reported in units • Direct one-on-one contact by provider

25. Procedures Defined • 97110 Therapeutic Exercises, each 15 minutes, one or more areas • Incorporates one parameter (strength, endurance, range of motion, flexibility) to one or more areas of the body. Examples include, treadmill (endurance), isokinetic exercise (range of motion), lumbar stabilization exercise (flexibility), and gymnastic ball (stretching and strengthening). • Documentation should include goals which focus on improvement of functional deficiencies. • Diagnoses: Loss or restriction of joint motion, strength, flexibility, functional capacity, or mobility from a specific disease or injury

26. Procedures Defined • 97530 Therapeutic Activities (Dynamic Activities to Improve Functional Performance) • Include the use of multiple parameters, such as balance, strength, range of motion. Examples include lifting stations, closed kinetic chain activity, hand assembly activity, transfers (chair to bed, lying to sitting, etc) and throwing, catching, or swinging • The service requires the skill of a provider or therapist who designs the activities to address a specific functional need and who instructs the patient • 97110 addresses a single parameter (ie. Loss of range of motion). 97530 differs in that it addresses multiple parameters involved in the performance of an activity (ie. Patient is unable to lift a box, it may involve strength, range of motion, as well as balance) • Diagnoses: Loss of restriction of mobility, strength, balance, or coordination

27. Procedures Defined • 97112 Neuromuscular Re-education, each 15 min, one or more areas • Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception. Examples include proprioceptive neuromuscular facilitation, feldenkreis, bobath, bap’s boards, and desensitization techniques • Goals should include an increase in functional ability in self care, mobility, or patient safety • Diagnoses: Loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain to the extremities. Nerve palsy, or injury that leads to muscle weakness or flaccidity. Inability to sit or stand unassisted, loss of gross and fine motor coordination, and hypo/hypertonicity.

28. Procedures Defined • 97124 Massage, each 15 minutes, one or more areas • Effleurage, petrissage, stroking, compression, percussion • Use of a machine, such as a massage chair or mechanical device may not be considered a cover service • Some payers may not cover massage as an isolated treatment or when performed for more than 30 minutes (2 units)

29. Procedures Defined • 97140 Manual Therapy Techniques, each 15 min, one or more regions • Manual therapy techniques consist of, but are not limited to; soft tissue mobilization, joint mobilization and manipulation, manual lymphatic drainage, manual traction, craniosacral therapy, myofascial release, and neural gliding techniques • This code should not be used interchangeably with codes 98940 – 98942 for joint manipulation • Modifier required when billing the same visit as a 98940 - 98942

30. Time • Reported in Units • Time must be documented • 8 minute rule or 15 minute rule • 8-22 (1), 23-37 (2), 38-52 (3), 53-68 (4) • Reduced time: Not billable!

31. CPT’s Policy for Unlisted Codes • Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code • In addition, don’t bill out under a specific CPT code just because a particular vendor tells you (i.e., infrared for low level laser)

32. E & M’s • New Patient- 99201 through 99205 • Established Patient- 99211 through 99215 • The difference between a new patient and an established patient is three years.

33. New Patient • Must meet or exceed three out of three key components to qualify for a particular level of service. • History • Examination • Medical Decision Making

34. History • 4 subcomponents: • Chief complaint (CC) • History of present illness (HPI) • Review of Systems (ROS) • Personal, Family and Social History (PFSH) • Problem Focused (99201) • Expanded Problem Focused (99202) • Detailed (99203) • Comprehensive (99204) • Comprehensive (99205)

35. Examination • Uses either the 1995 or 1997 Guidelines • 1997 Guidelines are better suited for a specialist because they outline more specific elements for particular body systems. • Problem Focused (99201) • Expanded Problem Focused (99202) • Detailed (99203) • Comprehensive (99204) • Comprehensive (99205)

36. Medical Decision Making • Essentially recognizes the clinical expertise required to appropriately manage patient care. That management of a case is assessed by answering the following questions: How many problems does the patient have (DX)? How much information needs to be reviewed to properly understand the case? How risky is the patient’s problem? (Risk of significant complications, morbidity and/or mortality) • Straight Forward (99201) • Straight Forward (99202) • Low Complexity (99203) • Moderate Complexity (99204) • High Complexity (99205)

37. Established Patient • Must meet or exceed two of the three key components to qualify for a particular level of service. • History • Examination • Medical Decision Making

38. History • Minimal (99211) • Problem Focused (99212) • Expanded Problem Focused (99213) • Detailed (99214) • Comprehensive (99215)

39. Examination • Minimal (99211) • Problem Focused (99212) • Expanded Problem Focused (99213) • Detailed (99214) • Comprehensive (99215)

40. Medical Decision Making • Minimal (99211) • Straight Forward (99212) • Low Complexity (99213) • Moderate Complexity (99214) • High Complexity (99215)

41. E & M’s and Time • If counseling and coordinating care dominates greater than 50 percent of the encounter, time may be a controlling factor to determine the level of service billed. Time must be documented. The progress note should show how much time was spent for the visit and how much time was spent counseling/coordinating care.

42. E & M Face to Face Time Guidelines • 99201 10 min • 99202 20 min • 99203 30 min • 99204 45 min • 99205 60 min • 99211 5 min • 99212 10 min • 99213 15 min • 99214 25 min • 99215 40 min

43. Re-exams: Denied?! • Payer Policy • A lot of Payers have incorporated policies where they only allow for 1 Evaluation & Management (exam) code every 6 months/12 months • When verifying benefits – ask! • Shared components with manipulation so essentially a portion of E&M is being done every time the patient is adjusted. • The preservice work includes: Physician review of the patient’s records to establish a treatment plan and to familiarize himself or herself with the previous treatment. The review of prior imaging, test interpretation, and test results. Consideration of the range of potential manipulative treatments that may be performed in the appropriate number of body regions for the current date of service. The explanation of the potential procedures to the patient and obtaining verbal consent. Answering any additional questions, comments, and/or concerns. • The intra-service work includes: Performing a pre-manipulation patient assessment, which includes: an assessment of the patient’s pain level; evaluation of interval changes in objective signs; and evaluation of functional changes that may include: identifying asymmetry, assessing segmental mobility, evaluating changes in tissue and tone in the affected regions. A treatment procedure that best fits the patient’s condition is finalized that day. • The post-service (after the patient leaves) period includes: Chart documentation Follow-up consultation e.g., arrangement of additional services or discussion/referral to another provider Reporting e.g., written and telephonic communications with the patient, family, and other providers.

44. X-rays – 2016 change out in 72081 Radiology exam, spine, entire survey study, AP & Lat; one view 72082 Radiology exam, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed; 2-3 views 72083 Same as 72082 except 4-5 views 72084 Same as 72082 except 6 views • 72010 • Deleted; use 72082 • 72020 • Radiology of spine & pelvis –single view • 72069 • Deleted, use 72081, 72082, 72083, or 72084 • 72090 • Deleted, use 72081, 72082, 72083, or 72084

45. Modifiers -21 Prolonged E&M Time must be documented -25 Significant Separate Identifiable E&M service -59 Distinct Procedural Service DX to support Must be documented -76 Repeat Procedure by same physician

46. -59 Modifier • The -59 modifier is used to indicate that a procedure is distinct and separate from another procedure • Medicare has introduced a modifier subset to be used when the -59 modifier would otherwise be used • This change took place January 5, 2015 • Check your Local Coverage Determination • Know which Payers are using which modifiers

47. The -59 modifier subset codes: • XE – separate encounter, a service that is distinct because it occurred during a separate encounter • XS – separate structure, a service that is distinct because it was performed on a separate organ/structure • XP – separate practitioner, a service that is distinct because it was performed by a different practitioner • XU – unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service

48. Modifiers - Continued The Affordable Care Act requires coverage of certain health benefits, two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. The following are informational modifiers in order to differentiate as to which type of outcome is anticipated for the type of therapy being performed: • 96 Habilitative: services that help a person DEVELOP skills or functions they didn’t have before • 97 Rehabilitative: services that help a person RESTORE functions which have become either impaired or lost

49. GP Modifier • Description: Services are delivered under an outpatient physical therapy plan of care • Palmetto (Medicare) requires GP to be reported with a GY when reporting therapy services. • Therapy service will continue to be non-covered by Medicare, in order to receive a correct to denial to forward to a secondary carrier you will need to append as GP GY. • Ambetter is currently requiring the GP modifier and supposedly other Payers will also be requiring

50. Payer Policies • Payer policies can cover everything from how they interpret codes to which codes are considered to be covered services • Payer policies dictate any daily limits/caps • Payer policies dictate what you can collect from your patients