Objectives. Objectives. Conversion Factor-Final Rule Physical Medicine & Rehab Coding & Regulatory Update

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1 2008 Physical Medicine & Rehab Coding & Regulatory Update Presented by: Rick Gawenda, PT President Section on Health Policy & Administration, APTA Objectives Understand 2008 Medicare Payment Methodology Understand the outpatient therapy cap and exception process for 2008 Identify and understand new CPT Codes for Not to be Re-printed 2 Objectives Identify new ICD-9 Codes Understand qualification standards for therapists and assistants under Medicare Identify and understand 2008 Physician Quality Reporting Initiatives applicable to Physical Therapy Conversion Factor-Final Rule In 2007, conversion factor was $ In 2008, conversion factor is $ Change is a minus 10.1% To prevent this decrease, congressional action was required and did occur Not to be Re-printed 3 Not to be Re-printed 4 Medicare, Medicaid, and SCHIP Extension Act of 2007 Passed by the Senate on December 18, 2007 and the House of Representatives on December 19, 2007 Signed by President Bush on December 29, 2007 Contains many important items for the therapy profession Medicare, Medicaid, and SCHIP Extension Act of 2007 Replaces the scheduled 10.1% reduction to the conversion factor with a.5% increase through June 30, 2008 Conversion factor approximately $ Extends the exception process for therapy caps until June 30, 2008 Extends the geographic price cost index floor of 1.0 through June 30, 2008 Not to be Re-printed 5 Not to be Re-printed 6 1

2 Geographic Price Cost Index (GPCIs) Measures area cost differences in work, practice expenses, and malpractice insurance Currently, there are 92 localities These are reviewed and revised, if necessary, every 3 years CMS includes new values for GPCIs in the 2008 final rule that will be implemented over 2 years Medicare, Medicaid, and SCHIP Extension Act of 2007 Permanently freezes the IRF compliance threshold at 60% effective for cost reporting periods starting July 1, 2006 Allows co-morbid conditions to count towards this threshold Extends the State Children s Health Insurance Program through March 31, 2009 Not to be Re-printed 7 Not to be Re-printed 8 Budget Neutrality Adjustor Reduced all work RVU s by 10.1% in 2007 For 2008, CMS has proposed a work adjustor of.8806 which corresponds to a minus 11.94% to all work RVU s What does this mean? Budget Neutrality Adjustor CMS will take the work RVU for each CPT code reimbursed under the Medicare Physician Fee Schedule and multiply that value by.8806 to determine the new work RVU value prior to multiplying it to the geographic practice cost index Not to be Re-printed 9 Not to be Re-printed 10 Budget Neutrality Adjustor Payment formula is [(RVU work x.8806) x GPCI work) + (RVU PE x GPCI PE) + (RVU malpractice x GPCI malpractice)] x conversion factor Example for therapeutic exercise in Detroit, Michigan [(.45 x.8806) x 1.037) + (.29 x 1.048) + (.02 x 2.300)] x [(.40 x 1.037) + (.29 x 1.048) + (.02 x 2.300)] x Budget Neutrality Adjustor = ( ) x =.7647 x = $29.12 per unit in 2008 In 2007, 1 unit reimbursed $28.97 in Detroit Please refer to the CMS website or your specific Medicare contractors website for exact payment for your locality per CPT code Not to be Re-printed 11 Not to be Re-printed 12 2

3 2008 Therapy Cap Amount will be $1,810 for physical therapy and speech-language pathology combined Separate $1,810 for occupational therapy Therapy cap exception process extended through June 30, 2008 as a result of the Medicare, Medicaid and SCHIP Extension Act of 2007 Not to be Re-printed 13 Outpatient Therapy Certification Requirements Beginning January 1, 2008, CMS extends the initial certification requirement from 30 days to 90 days Recertification s would be required every 90 days thereafter Do not forget your State Practice Act or other applicable State laws and regulations Progress Reports must still be completed by a clinician (therapist) every 10 visits or once during each certification interval, whichever is less Not to be Re-printed 14 Speech Central Nervous System Assessments/Tests (New Code for 2008) Standardized cognitive performance testing (eg. Ross Information Processing Assessment) per hour of a qualified health care professional s time, both face-to-face time administering tests to the patient and time interpreting these tests results and preparing the report Speech Central Nervous System Assessments/Tests (New Code for 2008) Compromised functional abilities due to acute neurological events such as CVA or TBI must be assessed to determine if functional abilities such as orientation, memory, and high-level language have been compromised and to what extent Not to be Re-printed 15 Not to be Re-printed 16 Speech Central Nervous System Assessments/Tests (New Code for 2008) Tests evaluate memory, reasoning, sensory processing, visual perceptual status, orientation, social pragmatics, and elements of decision making and executive function Speech Central Nervous System Assessments/Tests (New Code for 2008) This code can be used by speechlanguage pathologists and occupational therapists. Involves both face-to-face time with the patient and non face-toface time. Not to be Re-printed 17 Not to be Re-printed 18 3

4 New 2008 CPT Codes Telephone Services Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion New 2008 CPT Codes Telephone Services Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; minutes of medical discussion Not to be Re-printed 19 Not to be Re-printed 20 New 2008 CPT Codes Telephone Services Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; minutes of medical discussion New 2008 CPT Codes On-line Medical Evaluation Online assessment and management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network Not to be Re-printed 21 Not to be Re-printed 22 CPT Codes Are non-covered by Medicare If provided to Medicare beneficiaries, would recommend patient sign ABN. Check with other payers regarding whether they will reimburse for these CPT codes 2008 New CPT Codes Medical Team Conferences Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional. Not to be Re-printed 23 Not to be Re-printed 24 4

5 2008 New CPT Codes Medical Team Conferences Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more, participation by nonphysician qualified health care professional 2008 New CPT Codes Medical Team Conferences & Reporting participants shall have performed face-to-face evaluations or treatments of the patient, independent of any team conference, within the previous 60 days. Requires involvement of at least 3 different disciplines in the team conference. Not to be Re-printed 25 Not to be Re-printed New CPT Codes Medical Team Conferences & The team conference starts at the beginning of the review and ends at the conclusion of the review. Time related to record keeping and report generation is not reported. The reporting participant shall be present for all time reported New CPT Codes Medical Team Conferences & For team conferences where the patient is present for any part of the duration of the conference, nonphysician qualified health care professionals report the team conference face-to-face code These codes are considered bundled by CMS and are not separately reimbursed Not to be Re-printed 27 Not to be Re-printed New CPT Codes Medical Team Conferences & Non-physician health care providers include speech-language pathologists, audiologists, physician assistants, pharmacists, physical therapists, occupational therapists, registered dieticians, geneticists, genetic counselors, psychologists, and social workers. ICD-9 Changes Effective October 1, 2007 Deleted Dysphagia Replaced with 6 new ICD-9 codes Not to be Re-printed 29 Not to be Re-printed 30 5

6 ICD-9-CM Dysphagia (Valid 10/01/2007) Dysphagia, unspecified Dysphagia, oral phase Dysphagia, oropharyngeal phase Dysphagia, pharyngeal phase Dysphagia, pharyngoesophageal phase Other dysphagia ICD-9-CM Effective 10/01/ Acquired auditory processing disorder Conductive hearing loss, unilateral Conductive hearing loss, bilateral Neural hearing loss, unilateral Central hearing loss Not to be Re-printed 31 Not to be Re-printed 32 ICD-9-CM 389 Effective 10/01/ Sensory hearing loss, unilateral Sensorineural hearing loss, bilateral Mixed hearing loss, unspecified Mixed hearing loss, unilateral Mixed hearing loss, bilateral Deaf, nonspeaking, not elsewhere classifiable Test & Measurements Physical performance test or measurement (eg, musculoskeletal, functional capacity) with written report, each 15 minutes (Biodex, Cybex, BTE, Tinetti, Berg Balance Test, ROM testing, MMT testing, etc.) Includes the time required to analyze and interpret the resulting data while the patient is present (CPT Assistant February 2004) Not to be Re-printed 33 Not to be Re-printed 34 Muscle & ROM Testing Un-timed Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk Muscle testing, manual (separate procedure) with report; hand with or without comparison with normal side Muscle & ROM Testing Un-timed Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands (Limited to 1 unit) Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands (Limited to 1 unit) Not to be Re-printed 35 Not to be Re-printed 36 6

7 Muscle & ROM Testing Un-timed Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side MMT & ROM & Physical Performance Testing Reports A separate and distinctly identifiable, signed written report is required when billing 97750, , and Report should include the provider s interpretation of the results Not to be Re-printed 37 Not to be Re-printed 38 MMT & ROM versus Physical Performance Testing If the only intent of the therapist is performing a complete ROM and/or MMT, it would be appropriate for the therapist to choose the appropriate codes listed between If the therapist s services are more comprehensive and include performance testing, then use of CPT code is appropriate Muscle, ROM, and Physical Performance Testing References CPT Assistant December 2003 CPT Assistant February Not to be Re-printed 39 Not to be Re-printed 40 Orthotic Management & Prosthetic Management Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s), and/or trunk, each 15 minutes Prosthetic training, upper and/or lower extremities, each 15 minutes Checkout for orthotic/prosthetic use, established patient, each 15 minutes Orthotic Management & Prosthetic Management Orthotic management may include: Assessing the patient Determining the type of orthotic Designing, selecting, and fabricating the orthotic Orthotic fitting and training Does not include the supplies Not to be Re-printed 41 Not to be Re-printed 42 7

8 97760 versus is used for the assessment, fabrication, fitting, and training of an orthotic. Training includes wear time, skin care, and safety precautions as well as Pt instruction in exercises to be performed while the orthotic is in place Reference is CPT Assistant February versus is used for established patients who have already received the permanent or temporary orthotic or prosthetic. Includes patient s response to wearing the device, whether the patient is donning/doffing the device correctly, patient s need for padding, underwrap, or socks, and of the patient s tolerance to any dynamic forces being applied. Reference is CPT Assistant February 2007 Not to be Re-printed 43 Not to be Re-printed 44 Orthotic Management & Prosthetic Management If you bill an L code for the pre-fabricated or custom fabricated orthotic, you may only bill the appropriate number of units of for the orthotic training based on the number of minutes spent providing the training The L code reimbursement includes the assessment, fabrication time, fitting, and supplies, NOT the training component CPT Assistant December 2005 & February 2007 and CPT 2006 Changes: An Insiders View L Codes - Medicare Orthotic procedures and devices Includes braces, trusses, and artificial legs and arms Stump stockings and harnesses are covered Adjustments, repairs and replacements are covered so long as the devices continues to be medically required Hospital outpatient departments, SNF s Part B, Rehab Agencies, and CORF s can bill their FI without needing a DME supplier # Private practices require a DME supplier number to bill Medicare for L codes Read section 10 Make sure your state practice act and/or state laws do not prohibit PT and OT from billing for these services Not to be Re-printed 45 Not to be Re-printed 46 L Codes Non-Medicare Is payer specific whether or not they reimburse for L codes provided under a therapy plan of care Some payers may require you have a DME supplier number while others may not in order to be reimbursed for L codes Type in orthotics in the search box and click go. Click on the first link that comes up. Excellent 7 page reference on the billing of orthotics and DME Not to be Re-printed 47 Prosthetic Training Includes preparation of the stump, strengthening of the remaining musculature, modification of prosthetic fit using stump socks or socket liners, mobility training, use during functional activities as well as skin care and overall conditioning Once a patient begins gait training with the prosthesis, it is appropriate to report such training with Reference is CPT Assistant February 2007 Not to be Re-printed 48 8

9 Qualification Standards Physical Therapist Beginning in 2010, a physical therapist is one who is licensed, if applicable by the State in which practicing, has passed a national examination for physical therapists approved by the State and meets one of the following requirements on the next slide: Qualification Standards Physical Therapist ) Graduated from a CAPTE approved physical therapist education program 2) Graduated from a PT program approved by a successor organization of CAPTE or 3) If educated outside the U.S., graduated from a program determined to be substantially equivalent to a PT entry level education in the U.S. by a credentials evaluation organization approved by APTA or an organization identified in 8 CFR (e) as it relates to PT s Not to be Re-printed 49 Not to be Re-printed 50 Qualification Standards Physical Therapist Prior to 2010 On or before December 31, 2009, graduated after successful completion of a physical therapy curriculum approved by the Commission on Accreditation in Physical Therapy Education; or meets both of the following requirements on the next slide. Qualification Standards Physical Therapist Prior to ) Graduated after successful completion of an education program determined to be substantially equivalent to a PT entry level education in the U.S. by a credentials evaluation organization approved by APTA or an organization identified in 8 CFR (e) as it relates to PT s 2) Passed a national examination for PT s approved by the State in which physical therapy services are provided Not to be Re-printed 51 Not to be Re-printed 52 Qualification Standards Physical Therapist Assistant-2010 A person who is licensed, registered, or certified as a physical therapist assistant, if applicable, by the State in which practicing, unless licensure does not apply and meets one of the following requirements on the next slides: Not to be Re-printed 53 Qualification Standards Physical Therapist Assistant ) Graduated from a CAPTE approved physical therapist assistant education program or 2) If educated outside the U.S. or trained in the U.S. military, graduated from a program determined to be substantially equivalent to a PTA entry level education in the U.S. by a credentials evaluation organization approved by APTA or an organization identified in 8 CFR (e) and 3) Passed a national examination for PTA s 4) This is effective January 1, 2010 Not to be Re-printed 54 9

10 Qualification Standards Physical Therapist Assistant 1) On or before December 31, 2009, meets one of the following requirements: a) Is licensed, or otherwise regulated in the State in which practicing, or b) In States where licensure or other regulations do not apply, graduated before December 31, 2009 from a 2-year collegelevel program approved by the APTA Qualification Standards Physical Therapist Assistant 1) Before January 1, 2008, where licensure or other regulations do not apply, graduated a 2-year collegelevel program approved by the APTA Not to be Re-printed 55 Not to be Re-printed 56 Certification/Re-certification SNF Part A & Inpatient Hospital In inpatient hospitals and SNF s, a physician s review and certification of the therapy plan of care is implied by the physician s review and approval of a facility plan that includes therapy services No additional certification requirements for the inpatient hospital setting or SNF setting are required Not to be Re-printed 57 Documentation CMS discussed their plans to improve consistency in the standards and conditions for Medicare Part A and B therapy services CMS stated that many, but not all, of the policies described for therapy in Part B settings are also appropriate to Part A settings Not to be Re-printed 58 Documentation In the final rule, CMS did not state which Part B policies would be applied to Part A settings CMS anticipates addressing these issues further in manual instructions expected to be released in 2008 What does this mean? Stay tuned for an Exciting 2008 Not to be Re-printed 59 Screening for Future Fall Risk Pain Assessment Prior to Initiation of Patient Therapy Patient Co-Development of Treatment Plan/Plan of Care Adoption/Use of health Information Technology (Electronic Health Records) Universal Weight Screening and Follow Up Universal Documentation and Verification of Current Medications in the Medical Record Not to be Re-printed 60 10

11 Only provides who bill on the HCFA claim form or electronic equivalent (837-P) are eligible This includes physical therapists in private practice and physician owned physical therapy practices Tied to the therapists NPI number on the claim form Must report on at least 3 of the 6 measures Must meet the 80% threshold on the 3 initiatives you measure for eligible Medicare patients based on their age CPT category II codes are placed in box 24D on the claim form with either a $0.00 or $0.01 charge amount Not to be Re-printed 61 Not to be Re-printed 62 Screening for Future Fall Risk Patients 65 years of age or older Reported a minimum of once per reporting period Applies when CPT codes 97001, 97002, 97003, and are billed Screening for Future Fall Risk-CPT II Codes 1100F: Patient screened; documentation of 2 or more falls in the past year or any fall with injury in the past year 1101F: Patient screened; documentation of no falls in the past year or only one fall without injury in the past year Not to be Re-printed 63 Not to be Re-printed 64 Screening for Future Fall Risk-CPT II Codes Modifier 1P: Append to 1100F or 1101F when future fall risk not performed for medical reasons and documentation is present to justify Modifier 8P: Append to 1100F when future fall risk not performed for medical reasons and reason is not specified Pain Assessment Prior to Initiation of Therapy Patients 18 years of age or older Reported each initial evaluation per reporting period Applies when CPT codes and are billed Not to be Re-printed 65 Not to be Re-printed 66 11

12 Pain Assessment CPT II Codes G8440: Documentation of pain assessment prior to initiation of treatment or documentation of absence of pain as a result of the assessment G8442: Pain assessment not documented; patient not eligible G8441: Pain assessment not documented; reason not specified Patient Co-Development of Treatment POC Patients 18 years of age or older Reported at least one time for each unique episode of care for patients seen during the reporting period Applies when CPT codes 97001, 97002, 97003, and are billed Not to be Re-printed 67 Not to be Re-printed 68 Pt Co-Development of POC - CPT II Codes G8437: Active participation documented. Includes signature of the practitioner and either a co-signature by the Pt or documented verbal agreement obtained from the patient or an authorized representative G8438: Active participation not documented, Reason not specified. G8439: Active participation not documented, patient not eligible Adoption/Use of Health Information Technology Reported at each visit occurring during the reporting period for patients seen during the reporting period Applies when CPT codes 97001, 97002, 97003, and are billed Not to be Re-printed 69 Not to be Re-printed 70 Adoption/Use of Health Information Technology Must be either a Certification Commission for Healthcare Information Technology (CCHIT) certified EMR or, System must be capable of all of the following: generating a medication list, generating a problem list, entering laboratory tests as discrete searchable data elements Adoption/Use of Health Information Technology - CPT II Codes G8447: Patient encounter was documented using a CCHIT certified EMR G8448: Patient encounter was documented using a non-cchit certified EMR G8449: Patient encounter not documented using CCHIT certified or qualified EMR for system reasons Not to be Re-printed 71 Not to be Re-printed 72 12

13 Universal Weight Screening & Follow Up Patients 65 years of age or older Reported a minimum of once per reporting period for patients seen during the reporting period Applies when CPT codes and are billed Universal Weight Screening CPT II Codes G8417: BMI 30 was calculated and a follow-up plan was documented in the medical record G8418: BMI < 22 and a follow-up plan was documented in the medical record G8419: BMI 30 or < 22 was calculated, but no follow-up plan documented in the medical record Not to be Re-printed 73 Not to be Re-printed 74 Universal Weight Screening CPT II Codes G8420: BMI < 30 and 22 was calculated and documented G8421: BMI not calculated G8422: Patient not eligible for BMI calculation Universal Documentation and Verification of Current Medications in the Medical Record Patients 18 years of age or older Reported at each visit occurring during the reporting period for patients seen during the reporting period Includes prescription, over-the-counter, herbals, vitamin/mineral/dietary supplements Applies when CPT codes 97001, 97002, 97003, and are billed Not to be Re-printed 75 Not to be Re-printed 76 Universal Documentation & Verification of Current Medications CPT II Codes G8427: Written provider documentation was obtained confirming that current medications, with dosages, were verified with the patient or authorized representative or patient assessed and is not currently on any medications G8430: Documentation that the patient is not eligible for medication assessment Universal Documentation & Verification of Current Medications CPT II Codes G8428: Current medications, with dosages, were verified were documented without documented patient verification G8429: Incomplete or no documentation that patient s current medications with dosages were assessed Not to be Re-printed 77 Not to be Re-printed 78 13

14 - APTA Excellent page reference on APTA Website References & Resources 1. American Medical Association Current Procedural Terminology; CPT 2008; Standard Edition 2. Ingenix St. Anthony Publishing/Medicode ICD-9-CM Expert for Hospitals-Volumes 1,2, & th Edition Not to be Re-printed 79 Not to be Re-printed 80 References & Resources Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, and Other Part B Payment Policies for CY jan /edocket.access.gpo.gov/2007/ pdf/ pdf Pages of importance are for CORF Issues, for therapy standards, and a summary from pages References & Resources 1. CPT Changes 2008: An Insider s View 2. CPT Changes 2006: An insiders View Not to be Re-printed 81 Not to be Re-printed 82 References & Resources CPT Assistants 1) December ) February ) December ) February Resources Section on Health Policy & Administration Not to be Re-printed 83 Not to be Re-printed 84 14

15 References and Resources Medicare Physician Fee Schedule Medicare Physician Fee Schedule arch.asp?agree=yes&next=accept Click Accept and then choose either Single HCPC Code, List of HCPC Codes, or Range of HCPC Codes Under Type of Information, choose Pricing Information and then click Next References and Resources Medicare Physician Fee Schedule Under Select Carrier Option, choose Specific Locality Under Select field options, choose All Fields, then click Next Enter HCPC code or range or list of HCPC codes that you want pricing on Not to be Re-printed 85 Not to be Re-printed 86 References and Resources Medicare Physician Fee Schedule Under Modifier drop down box, choose All modifiers Under Carrier Locality, choose the correct locality based on where you do business then click submit You are reimbursed 80% of the nonfacility rate. Patients secondary insurance or the patient pays the other 20% References & Resources Cigna nal/coverage_positions/index.html#medp Aetna Tricare Not to be Re-printed 87 Not to be Re-printed 88 References and Resources United Healthcare Click on Tools & Resources at the top of the page and then choose the appropriate policies on the left hand side BCBS Do search typing in state BCBS. State BCBS links available on HPA website for members of HPA Medicaid Refer to your state government website. State Medicaid links available on APTA and HPA websites for members Rick Gawenda, P.T. (313) Cell phone: (734) Not to be Re-printed 89 Not to be Re-printed 90 15

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