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Coding and Payment Guideelpegapm2018aSFor the Physical TherapistAn essential coding, billing and reimbursement resourcefor the physical therapistPOWER UP YOUR CODING with Optum360, your trustedcoding partner for 32 years. Visit optum360coding.com.SPT SPT18 CVR.indd 112/19/16 4:53 AM
ContentsGetting Started with Coding and Payment Guide .1Sample Page and Key .1Reimbursement Issues .3Procedure Codes .7Appropriate Codes for Physical Therapists .7Definitions and Guidelines: Procedures .9Skin .13Casting and Strapping .15Neurostimulators .26Biofeedback.28Evaluative and Therapeutic Services.30Cardiovascular .36Pulmonary .39Muscle and Range of Motion Testing .53Electromyography .57Ischemic Muscle Testing .66Nerve Conduction Tests .67Motion Analysis .73Central Nervous System Tests.79PM&R: Evaluation and Re-evaluation .83PM&R: Supervised Modalities .88PM&R: Constant Attendance Modalities.97PM&R: Therapeutic Procedures. 103PM&R: Active Wound Care Management . 120PM&R: Tests and Measurements. 129PM&R: Orthotic/Prosthetic Management. 131Acupuncture . 133Education and Training for Patient Self-Management. 134Telephone Services. 135Online Medical Examination . 136Medical Team Conference . 137HCPCS Level II . 138Appendix. 143egapCorrect Coding Initiative Update 23.3 .145CPT Index .153HCPCS Level II Definitions and Guidelines .157Introduction . 157HCPCS Level II—National Codes . 157Structure and Use of HCPCS Level II Codes . 157HCPCS Level II Codes and the Physical Therapist . 159Medicare Official Regulatory Information .177The CMS Online Manual System . 177Pub. 100 References . 177elpGlossary .195maSCPT 2017 American Medical Association. All Rights Reserved.Coding and Payment Guide for the Physical Therapist 2017 Optum360, LLCContents — 1
Getting Started with Coding and PaymentGuideThe Coding and Payment Guide for the Physical Therapist is designed tobe a guide to the specialty procedures classified in the CPT books. Itis structured to help coders understand procedures and translateprovider narrative into correct CPT codes by combining manyclinical resources into one, easy-to-use source book. The book alsoallows coders to validate the intended code selection by providingan easy-to-understand explanation of the procedure and associatedconditions or indications for performing the various procedures. Asa result, data quality and reimbursement will be improved byproviding code-specific clinical information and helpful tipsregarding the coding of procedures. For ease of use, Coding andPayment Guide for the Physical Therapist lists the CPT and HCPCS LevelII codes in ascending numeric order. Included in the code set are allsurgery and medicine codes pertinent to the specialty. Each CPTcode is followed by its official code description.Resequencing of CPT CodesThe American Medical Association (AMA) employs a resequencednumbering methodology. According to the AMA, there are instanceswhere a new code is needed within an existing grouping of codes,but an unused code number is not available to keep the rangesequential. In the instance where the existing codes were notchanged or had only minimal changes, the AMA has assigned a codeout of numeric sequence with the other related codes beinggrouped together. The resequenced codes and their descriptionshave been placed with their related codes, out of numeric sequence.Codes within the Optum360 Coding and Payment Guide series displayin their resequenced order. Resequenced codes are enclosed inbrackets for easy identification.ICD-10-CMare included the appendix with the official code description. Thecodes are presented in numeric order, and each code is followed byan easy-to-understand lay description of the procedure.CCI Edit UpdatesThe Coding and Payment Guide series includes the a list of codes fromthe official Centers for Medicare and Medicaid Services’ NationalCorrect Coding Policy Manual for Part B Medicare Contractors that areconsidered to be an integral part of the comprehensive code ormutually exclusive of it and should not be reported separately. Thecodes in the Correct Coding Initiative (CCI) section are from version23.3, the most current version available at press time. The CCI editsare located in a section at the back of the book. Optum360maintains a website to accompany the Coding and Payment Guideseries and posts updated CCI edits on this website so that currentinformation is available before the next edition. The website addressis https:// www.optum360coding.com/ProductUpdates/.The 2018 edition password is: SPEC18DLC. Please note that youshould log in each quarter to ensure you receive the most currentupdates. An email reminder will also be sent to you to let you knowwhen the updates are available.elpmaSOverall, the 10th revision goes into greater clinical detail than didICD-9-CM and addresses information about previously classifieddiseases, as well as those diseases discovered since the last revision.Conditions are grouped with general epidemiological purposes andthe evaluation of health care in mind. New features have beenadded, and conditions have been reorganized, although the formatand conventions of the classification remain unchanged for themost part.Detailed Code InformationSome procedure codes are presented in a less comprehensiveformat in the appendix. These codes are presented in numeric order,and each code is followed by an easy-to-understand lay descriptionof the procedure.IndexegapA comprehensive index is provided for easy access to the codes. Theindex entries have several axes. A code can be looked up by itsprocedural name or by the diagnoses commonly associated with it.Codes are also indexed anatomically.General GuidelinesProvidersThe AMA advises coders that while a particular service or proceduremay be assigned to a specific section, the service or procedure itselfis not limited to use only by that specialty group. Additionally, theprocedures and services listed throughout the book are for use byany qualified physician or other qualified health care professional orentity (e.g., hospitals, laboratories, or home health agencies). Keepin mind that there may be other policies or guidance that can affectwho may report a specific service.Sample Page and KeyOn the following pages are a sample page from the book displayingthe format of Coding and Payment Guide with each element identifiedand explained on the opposite page.Appendix Codes and DescriptionsSome procedure codes are presented in a less comprehensiveformat in the appendix. The CPT codes appropriate to the specialtyCPT 2017 American Medical Association. All Rights Reserved.Coding and Payment Guide for the Physical Therapist 2017 Optum360, LLCGetting Started with Coding and Payment Guide — 1
intervention and/or revise anticipated goals and expected outcomes.Reexamination may be indicated more than once during a plan of care.[97161, 97162, 97163,97164]97161 Physical therapy evaluation: low complexity, requiring thesecomponents: A history with no personal factors and/or comorbiditiesthat impact the plan of care; An examination of body system(s) usingstandardized tests and measures addressing 1-2 elements from anyof the following: body structures and functions, activity limitations,and/or participation restrictions; A clinical presentation with stableand/or uncomplicated characteristics; and Clinical decision makingof low complexity using standardized patient assessment instrumentand/or measurable assessment of functional outcome. Typically, 20minutes are spent face-to-face with the patient and/or family.97162 Physical therapy evaluation: moderate complexity, requiring thesecomponents: A history of present problem with 1-2 personal factorsand/or comorbidities that impact the plan of care; An examinationof body systems using standardized tests and measures in addressinga total of 3 or more elements from any of the following: bodystructures and functions, activity limitations, and/or participationrestrictions; An evolving clinical presentation with changingcharacteristics; and Clinical decision making of moderate complexityusing standardized patient assessment instrument and/or measurableassessment of functional outcome. Typically, 30 minutes are spentface-to-face with the patient and/or family.97164 Re-evaluation of physical therapy established plan of care, requiringthese components: An examination including a review of history anduse of standardized tests and measures is required; and Revised planof care using a standardized patient assessment instrument and/ormeasurable assessment of functional outcome Typically, 20 minutesare spent face-to-face with the patient and/or family.Physical therapy evaluation (97161-97163) is a dynamic process in which thephysical therapist makes clinical judgments based on data gathered duringexamination. Examination includes taking a comprehensive history, performinga systems review, and conducting tests and measures. The physical therapistevaluates the examination findings, establishes a physical therapy diagnosis,determines the prognosis, and develops a plan of care that includes goals andexpected outcomes, interventions to be used, and anticipated plans forconclusion of care. There are three levels of physical therapy evaluation—low,moderate, and high complexity. The level of evaluation performed isdependent on the degree of clinical decision making and on the patient’spresentation, measured by the number of elements determined present fromthe following components of the evaluation: history, examination of bodysystem(s), clinical presentation, and clinical decision-making. A physical therapyreevaluation (97164) should be reported when the physical therapistreexamines the patient to evaluate progress, and to modify or redirectCPT 2017 American Medical Association. All Rights Reserved.Coding and Payment Guide for the Physical TherapistegapFor the neuromuscular system, the provider conducts a general assessmentof the patient's balance, gait, locomotion, transfers, and transitions as part oftheir gross coordinated movements as well as the patient's motor function,including motor control and motor learning.In assessing the cardiovascular and pulmonary body systems, the providerreviews the patient's heart and respiratory rates and blood pressure, and looksfor signs of edema.For the integumentary system, the provider reviews the skin's color, texture,and integrity, and whether any scars have formed.In addition to assessing body systems, the physical therapy evaluation shouldinclude the general condition of the patient, such as the ability to communicateneeds; level of consciousness; being oriented to persons, place, and time; andanticipated emotional and behavioral responses.The provider should identify which learning or educational needs the patientshows a preference for over another. Personal factors that exist but do notimpact the plan of care should not be considered when selecting the level ofevaluation. However, factors that influence how a disability is experienced bythe individual should be considered. Examples include sex, age, coping styles,social background, education, profession, past and current experience, overallbehavior pattern, and character.Coordinating, consulting, and collaborating with other clinicians or agenciesregarding the patient's care is rendered as appropriate to the needs of thepatient, family, and/or caregivers. Report 97161 for a physical therapyevaluation of low complexity, 97162 for moderate complexity, and 97163 forhigh complexity. Report 97164 for re-evaluation of an established physicaltherapist plan of care.Coding TipsThese codes are new for 2017. They replace 97001 and 97002, which havebeen deleted. These codes are resequenced codes and will not display innumeric order.These services can be performed at multiple places of service (e.g., patient'shome, physical therapist’s office, outpatient hospital). The correct place ofservice should be indicated on the claim form.It is appropriate to report the reevaluation if the patient’s status should changeand the reevaluation is medically reasonable and necessary. It may be necessaryto append modifier 59, if performing 97164 with other 97000 series codes.Check with payers to determine their specific guidelines.A therapeutic procedure may be reported on the same day as an evaluationor reevaluation (97161–97164) when the medical record documentationsupports the medical necessity of both services.Muscle and range of motion testing are reported with 95831–95852.Electromyography is reported with codes 95860–95872, which includesre-sequenced codes [95885, 95886, 95887]. If a separate procedure is provided 2017 Optum360, LLCPM&R: Evaluation and Re-evaluation — 83PM&R: Evaluation and Re-evaluationpExplanationA review of the musculoskeletal system comprises assessing gross symmetry,gross range of motion (ROM), gross strength, and the patient's height andweight.le97163 Physical therapy evaluation: high complexity, requiring thesecomponents: A history of present problem with 3 or more personalfactors and/or comorbidities that impact the plan of care; Anexamination of body systems using standardized tests and measuresaddressing a total of 4 or more elements from any of the following:body structures and functions, activity limitations, and/orparticipation restrictions; A clinical presentation with unstable andunpredictable characteristics; and Clinical decision making of highcomplexity using standardized patient assessment instrument and/ormeasurable assessment of functional outcome. Typically, 45 minutesare spent face-to-face with the patient and/or family.maSThe physical therapist conducts tests and measures, and modifies the plan ofcare as indicated in support of the medical necessity of skilled intervention.For the purpose of a physical therapy evaluation, body systems are definedas musculoskeletal, neuromuscular, cardiovascular, pulmonary, andintegumentary. Body structures are the structural or anatomical parts of thebody, such as organs, limbs, and their components, classified according tobody systems. Body regions are the head, neck, back, lower and upperextremities, and the trunk.
HCPCS Level II Definitions and GuidelinesHCPCS Level II Codes: Sections A–VOne of the keys to gaining accurate reimbursement lies inunderstanding the multiple coding systems that are used to identifyservices and supplies. To be well versed in reimbursement practices,coders should be familiar not only with the American MedicalAssociation’s (AMA) Physicians’ Current Procedural Terminology(CPT ) coding system (HCPCS Level I) but also with HCPCS Level IIcodes, which are becoming increasingly important toreimbursement as they are extended to a wider array of medicalservices.The HCPCS coding system is arranged in 16 sections:Level II codes consist of one alphabetic character (letters A throughV) and four numbers. Similar to CPT codes, they also can havemodifiers, which can be alphanumeric or two letters. Nationalmodifiers can be used with all levels of HCPCS codes.A codes A0021–A9999Transportation Services IncludingAmbulance, Medical/SurgicalSupplies, and Administrative,Miscellameous, and InvestigationalHCPCS Level II—National CodesB codesB4034–B9999Enteral and Parenteral TherapyHCPCS Level II codes commonly are referred to as national codes orby the acronym HCPCS (pronounced “hik-piks”), which stands forthe Healthcare Common Procedure Coding System. HCPCS codesare used for billing Medicare and Medicaid patients and have beenadopted by some third-party payers.C codesC1204–C9899Outpatient PSSE codesE0100–E8002Durable Medical EquipmentThese codes, updated and published annually by the Centers forMedicare and Medicaid Services (CMS), are intended to supplementthe CPT coding system by including codes for nonphysician services,administration of injectable drugs, durable medical equipment(DME), and office supplies.G codes G0008–G9862Procedures/Professional Services(Temporary Codes)H codes H0001–H2037Alcohol and Drug Abuse TreatmentServiceselpJ codesJ0120–J9999Drugs Administered Other Than OralMethod, Chemotherapy Drugs(Exception: Oral ImmunosuppressiveDrugs)K codesK0001–K0902Durable Medical Equipment forMedicare Administrative Contractors(DME MACs) (Temporary Codes)L codesL0112–L9900Orthotic and Prosthetic Procedures,DevicesWhen using HCPCS Level II codes, keep the following in mind: CMS does not use consistent terminology for unlisted services orprocedures. The code descriptions may include any one of thefollowing terms: unlisted, not otherwise classified (NOC),unspecified, unclassified, other, and miscellaneous. If billing for specific supplies and materials, avoid CPT code 99070General supplies, and be as specific as possible unless theMedicare administrative contractor or local payer directsotherwise. Coding and billing should be based on the service provided.Documentation should describe the patient’s problems and theservice provided to enable the payer to determinereasonableness and necessity of care. Refer to the Online CMS Manual e/Guidance/Manuals/Internet-Only-Manuals-IOMs.html or third-partypayment policy to determine whether the care provided is acovered service. When bot
Coding and Payment Guide for the Physical Therapist Optum360, 2017 LLC Getting Started with Coding and Payment Guide — 1 Getting Started with Coding and Payment Guide The Coding and Payment Guide for the Physical Therapist is designed to be a guide to
5. The batch will close and so will the OPIE Billing application. 6. To return to OPIE Billing, create a new batch. Get Started in Billing - Set up Global Settings in Billing Admin Rights in OPIE are required to access Billing Settings. 1. Log into OPIE Billing, go to the top left part of the Window to the menus: File, Windows, Help and click .
Consolidated Billing 3 Medicare Part B 3. SNF Billing Requirements 4. Billing Tips 5 Special Billing Situations 6 Readmission Within 30 Days 6 Benefits Exhaust 7 No Payment Billing 8 Expedited Review Results. 9 Noncovered Days 10 Other SNF Billing Situations 10. Resources 12. The American Hospital Association (the " AHA
This streamlines your medical billing beyond what a single in-house biller can do. PrognoCIS EHR software is integrated with Practice Management, meaning that billing and electronic medical records can be managed in a single solution. The company that already organizes your electronic medical records will also handle your medical billing.
The process for an AIA billing in Foundation has a few basic steps: 1. Create an AIA billing record 2. Create a schedule of values for Application 1 3. Print and post the application 4. Repeat as needed 5. Release retainage Create an AIA Billing Record Setting up an overall billing record for your progress billing job in Foundation means two .
Part 2 – Medical Supplies: Billing Examples Page updated: August 2020 Tracheostomy Supplies: Contracted Figure 1. Tracheostomy supplies, contracted. This is a sample only. Please adapt to your billing situation. In this example, a Durable Medical Equipment (DME) company is billing for contracted tracheostomy supplies.
billing and collecting fees for services. To maintain a regular cash flow —the move-ment of monies into or out of a business—specific medical billing tasks must be com-pleted on a regular schedule. Processing encounters for billing purposes makes up the pre-claim section of the medical billing cycle. This chapter discusses the important
Billing Notes Effective Date of Change Description of Change Publication Date Medical Supplies Billing Codes, Units and Quantity Limits This spreadsheet contains medical supply billing codes, unit of measure (UOM) and quantity limits. Refer to the Medical Supplies section of the provider manual for additional information and program coverage.
The UB04 is suitable for use in billing multiple third party liability (TPL) payers. When submitting claims, complete all items required by each payer who is to receive a copy of the form. These billing instructions use "Form Locators" to detail only those data elements required for Medical Assistance paper claim billing.
