FAQs
PT/OT
Question
My coworkers just informed me that under Medicare Part B insurance, if I bill for self care/home management, I can't bill for therapeutic activities on the same day. I should just bill all the time under either self care/home management or therapeutic activities. Please advise.
Answer
Your coworkers are incorrect. Self care/home mamagement (CPT code 97535) is considered a component of the more comprehensive code, therapeutic activities (CPT code 97530). Both interventions may be provided to the Medicare beneficiary on the same date of service, be billed to your Medicare contractor, and be reimbursed by your Medicare contractor. However, to be reimbursed for CPT code 97535, you would have to append modifier-59 to CPT code 97535 on the claim form. In addition, documentation would have to support the medical necessity of both interventions and that the interventions were provided at separate and distinct times of each other.
Question
Under Medicare Part B outpatient therapy services, can you bill the Medicare contractor for custom fitted and custom fabricated orthotics using L codes?
Answer
The answer depends on the setting in which you practice in. If you are a physicial or occupational therapist that practices in a non-private practice setting - hospital outpatient department, rehabilitation agency, comprehensive outpatient rehabilitation facility, skilled nursing facility Part B, and home health agencies when the patient is not under a home health plan of care - you do not currently require a durable medical equipment (DME) supplier number to bill your Medicare contractor for L codes. These settings bill the appropriate L codes on the claim form that contains the other therapy charges and submit it to their Medicare fiscal intermediary or Medicare Administrative Contractor. Reimbursement for the L code covers the assessment of the patient that includes, but is no limited to, the following: determining the need and type of orthotic the patient requires; sensation, range of motion, strength and skin integrity; the time it takes the therapist to fabricate the orthotic, supplies associated with fabricating the orthotic; and fitting the orthotic. The L code reimbursement doesn't include training the patient to use the orthotic, education regarding exercises to be performed with the orthotic or wearing schedule. The time providing these skilled interventions should be billed under CPT code 97760.
If you are a physical or occupational therapist in private practice, you do need a DME supplier number to bill for L codes and these charges would be submitted to your respective DME Medicare Administrative Contactor on a 1500 claim form or the electronic equivalent.
Excellent resources for the above answer can be found in CPT Assistant December 2005 and February 2007 as well as CPT Changes 2006-An Insiders View. In addition, APTA has an excellent resource on its website that provides a comprehensive overview on billing of orthotics to the Medicare program depending on your practice setting
Question
I've heard that Medicare has imposed a condition that the referring physician must make "hands on" contact with the patient every 30 days. In the past, we've used this wording on recertifications: "In accordance with Medicare requirements, I have reviewed the plan of care established for therapy services and certify that services are required and that they will be provided while the patient is under my care for a maximum of 30 days". Do I need to amend this wording to include "hands on" contact?
Answer
The mandatory physician office visit was eliminated by the Centers for Medicare & Medicaid Services effective June 6, 2005 unless the physician or non-physician practitioner requires/requests the visit or if the patient is receiving electrical stimulation or electromagnetic therapy to treat wounds. If it's the latter, the patient must physicially see their physician every 30 days, per the national coverage decision policy.
In terms of initial certifications, they're valid for 30 calendar days or one month, whichever is longer (60 calendar days for a CORF) from the initial treatment. Recertifications are due every 30 calendar days for all settings except a CORF , where it is 60 calendar days.
To reference this information, go to CMS Pub 100-02, Chapter 15, Section 220.1.3 B & C for all settings besides a CORF and CMS Pub 100-02, Chapter 12, Section 30 E if you are a CORF
Question
How does Medicare define a re-evaluation and what is the criteria for performing and billing for a re-evaluation?
Answer
The professional assessment indicates a significant improvement or decline or change in the patient's condition or functional status that was not anticipated in the plan of care for that interval. In addition, a re-evaluation may be warranted in the case of new clinical findings or failure of the patient to respond to the treatment outlined in the current plan of care. A re-evaluation may also be appropriate at a planned discharge. A re-evaluation is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment, or terminating services. A re-evaluation requires the same professional skills as an evaluation. The reference for this answer can be found in CMS Publication 100-02, Chapter 15, Sections 220 and 220.3 C. The link is posted below.
Medicare Benefit Policy Manual
Question
Is it possible to provide a timed modality and/or therapeutic procedure for less than 8 minutes and bill for it under Medicare Part B therapy services?
Answer
Expect further clarification from The Centers for Medicare & Medicaid Services (CMS) in the near future. CMS has addressed this question in CMS Publication 100-04, Chapter 5, Section 20.2. The last paragraph in section 20.2 states "It does not imply that any minute until the eighth should be excluded from the total count. The timing of active treatment counted includes all direct treatment time." CMS also released Transmittal 47 on February 15, 2006 and attempted to further clarify the billing of timed CPT codes. On page 29 of this Transmittal, CMS states "Contractors shall not count each minute for each therapy service relative to each billed treatment code, but shall ascertain that the total number of minutes of treatment for services represented by timed codes is consistent with the number of units billed for those services and that the total minutes of treatment, including un-timed codes, is consistent with the documentation that the services were provided for a reasonable amount of time."
For example, the therapist provides 33 minutes of therapeutic exercise (CPT code 97110), 7 minutes of manual therapy (CPT code 97140), and 15 minutes of mechanical pelvic traction. The total time of timed therapeutic procedures is 40 minutes. Using Medicare's "8 minute rule" scale, 40 minutes falls between at least 38 minutes, but less than 53 minutes so the therapist would bill for 3 units of timed CPT codes. The correct billing would be 2 units of 97110 and 1 unit of 97140. The total treatment time would be 55 minutes as this includes the summation of timed and un-timed CPT codes. In addition, the therapist would bill for 1 unit of mechanical traction (CPT code 97012).
To read section 20.2, follow this link and open up Chapter 5:
Medicare Claims Processing Manual
To read Transmittal 47, click on this link: Transmittal 47
Question
For Medicare outpatient therapy service, must we document the minutes spent providing each modality and therapeutic procedure?
Answer
According to Transmittal 47 on page 29 (last page) released by CMS on February 15, 2006, you do not have to document the minutes spent on each CPT code. You have to document the total minutes spent providing modalities, therapeutic procedures, and evaluations/assessments (where applicable) that are timed codes. In addition, providers must also document the total treatment time that is the summation of timed and un-timed CPT codes. As always, check with your specific Medicare contractor regarding their documentation requirements of timed and un-timed CPT codes.
Here is the link to Transmittal 47:
http://www.cms.hhs.gov/transmittals/downloads/R47BP.pdf
Question
How do you determine which CPT code requires modifier-59 to be appended to it in order for both CPT codes to be reimbursed?
Answer
Using the CCI Edit table on my website, it is the CPT code that appears in either the mutually exclusive column or column 2 column when provided on the same day by the same provider as the CPT code in the column on the far left hand side. For example, if a patient received both therapeutic exercise and aquatic therapy on the same day by the same provider, therapeutic exercise is considered a component of the more comprehensive code, aquatic therapy. In this example, therapeutic exercise would need to have modifier-59 appended to it on the claim form in order for it to be reimbursed. Aquatic therapy will be reimbursed regardless of whether or not you append modifier-59 to therapeutic exercise. Documentation must support that both procedures were medically necessary and that they occurred at separate and distinct times.
Question
How do you document to show your Medicare contractor that modalities and/or procedures were performed at separate and distinct times and that the use of modifier-59 was appropriate?
Answer
I recommend one of two ways. The first is to document the time period that each service was provided. For example, 9:00AM-9:30AM Aquatic exercises of (list exercises), 9:45AM-10:10AM, therapeutic exercises on land of (list exercises). The second way would be aquatic therapy of (list treatment provided) followed by land-based therapeutic exercises of (list exercises). It is the words "followed by" that lets the Medicare contractor see you provided aquatic therapy first followed by land-based exercises.