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Ready or Not Here They Come! Prepping the Women’s Health Physical Therapist for the New Evaluation Codes

Posted on: January 7th, 2017 by Aika Barzhaxynova No Comments

By Kelly Huestis, MPT; Nakisha Jackson, DPT; and Katie Pring, MPT

As women’s health physical therapists, changes in health care policy always evoke the question, “But how does this apply to MY patients?” We often march to our own drum in terms of treatments and types of patients seen. This is no different for the new evaluation codes that started January 1, 2017.

Codes 97001, PT Evaluation, will no longer be used and will be replaced by three new codes of varying patient complexity:

97161 (PT evaluation low complexity)

97162 (PT evaluation moderate complexity)

97163 (PT evaluation high complexity)

To determine the correct code, the four components of History, Examination, Clinical Decision Making, and Development of Plan of Care must be documented clearly. See the APTA’s page as an excellent resource on the basics of the new codes:  http://www.apta.org/PaymentReform/NewEvalReevalCPTCodes/.

The following are three case examples for classic women’s health patients and our suggested evaluation code for each, based on the four elements.

Case #1

A 65-year-old female presents with stress urinary incontinence (UI) for the past 10 years, 1 pantiliner per day. New onset of urge UI with 3 episodes of complete loss of control over the last 6 months and frequent dribbling on the way to the restroom. Voiding eight to 10 times per day, 1 time per night. PMH: HTN, 2 C-sections. Medication: Lisinopril. Examination finds normal lumbar, SIJ and lower quadrants, pelvic floor weakness.

History Examination Presentation Decision-Making
None to affect current POC Pelvic Floor Weakness Stable, uncomplicated Low Complexity

We would consider this a Low Complexity Evaluation, Coded 97161.  

Case #2

A 76-year-old female is referred for cystocele, unimproved with pessary. History of frequent urinary tract infections. Presents with urinary retention, urge UI, frequency, nocturia. Functional limitations: bathroom mapping, sleep disruption, inability to travel, and pain with sitting. Patient is retired but volunteers regularly in a hospital. PMH: IBS, HTN, arthritis. Outcome Tools: UDI-6 25/100, PFIQ 86/300. Objective findings: Pelvic floor weakness and tension, low endurance, pelvic floor and core incoordination, poor bladder habits.

History Examination Presentation Decision-Making
Frequent UTIs

IBS

Pelvic Floor Weakness & Dysfunction

Nocturia and urgency/frequency

Pain in sitting

Unstable due to frequent UTIs Moderate. Use of outcome tools shows QOL impact.  Behavioral modifications impact success. Combination of weakness, retention, and incontinence.

We would consider this a Moderate Complexity Evaluation, Coded 97162.

Case #3

A 48-year-old female referred for pelvic pain. She presents with complaints of mild UI and pelvic pain that increases throughout the day. Worse with prolonged seated and stance activities. Recently underwent bladder suspension surgery with continued pain and UI. She reports having a lumbar fusion five years ago, with chronic LBP that requires pain management intervention. Pelvic girdle pain is located at the right SI joint. PMH includes MS, DM, smoking, depression, two C-sections, gall bladder removal. Exam Findings: decreased PFM extensibility and inability to relax, 4/5 Positive SI Joint Provocation Tests, decreased hip strength for hip extension and abduction, decreased core stability and coordination, poor posture and body mechanics, difficulty with gait, trouble with transfers, no current attempt at self-management or exercise. Outcome Tools: Oswestry LBP Questionnaire 72%, PFIQ 201/300.

History Examination Presentation Decision-Making
MS, DM, recent bladder suspension, smoking, depression, lumbar fusion Pelvic Floor Tension, SI Dysfunction, Gait dysfunction and trouble with transfers,

Hip and core weakness, sitting intolerance

Unstable, Progressive.  S/p recent surgery High. Use of outcome tools shows QOL impact.  Complicating co-morbidities will impact success of interventions, many inter-related active impairments.

We would consider this a High Complexity Evaluation, Coded 97163.

Keep an eye on the SOWH Payment, Policy, and Advocacy Page for more examples and helpful links on the topic: http://www.womenshealthapta.org/practice-payment-policy-and-advocacy. For more information about outcome measures, please refer to the Practice section of the SOWH website under Functional Outcome Measures:  http://www.womenshealthapta.org/fom/. Send your questions to [email protected].

AUTHORS: Kelly Huestis, MPT; Nakisha Jackson, DPT; and Katie Pring, MPT, serve on the SOWH Reimbursement Committee.

 

 


 

 

 

Getting Paid: What’s on the Horizon for 2017?

Posted on: October 28th, 2016 by Aika Barzhaxynova No Comments

BKelly Huestis, chair of the SOWH Reimbursement Committeey Kelly Huestis

As Section on Women’s Health Reimbursement Committee chair, I am fortunate to attend the APTA State Policy and Payment Forum annually. For therapists of women’s and men’s health, let’s be honest–payment can be one of the most aggravating and unfamiliar aspects of our job. Indeed, this forum changes my perspective on payment every year! I’m especially thankful for the latest payment updates. Here are some of the hot topics:

  • Workers compensation rates are decreasing in some states in an effort to allow more people to grow their businesses. Emerging trends in this area include opioid misuse and encouragement to wear activity and location trackers. Often associated with low back pain, opioid prescriptions can lead to other costlier interventions rather than physical therapy. Thus, the #ChoosePT campaign was born!
  • The Health Care Exchange has been a frustration for many payers with too much risk. Payers see providers paying premiums for clients; loss due to the “grace period;” and too many opportunities for people to go on and off the exchanges, particularly when they are sick.
    • For 2017, Humana and UHC/Aetna will be reducing their participation. Cigna and Anthem sustained losses and are continuing with caution. Centene (which just acquired Healthnet) and Molina are doing well and plan to continue. Expect a volatile environment in 2017, since there will be premium hikes, payers coming on and off, and reduced out-of-network coverage.
  • Manual Therapy Charges. Some issues have arisen in a few states around denial of CPT 97140. Some overutilization has drawn increased scrutiny to this code. This seems to be payer- and state-specific. If you experience an issue, contact your state APTA reimbursement chair.
    • MACRA Act of 2015 (Medicare Access and CHIP Reauthorization Act of 2015). This is the legislation that repeals the sustainable growth rate formula (SGR), ties in merit-based incentives for quality reporting, and encourages alternative payment models such as accountable care organizations and bundled payment. Those participating in alternative payment models will receive a 5% bonus payment if participating from 2019 to 2024. However, there are stipulations: They must be risk-based and have no fee-for-service (think Joint Replacement Program), and it requires an increasing percentage of patients in the Advanced Alternative Payments Models annually.
    • Targeted Manual Medical Review also is implemented through MACRA and looks at providers with aberrant billing practices, high claims denial percentages, and newly enrolled providers. The emphasis is on the number of units/hours of therapy provided in a day and looks at 40 claims per provider.
  • New evaluation codes are coming in 2017! Episodic care is the payment model of the future. The American Physical Therapy Association will be launching an educational campaign to help physical therapists comply with the new codes. Be aware that although CMS will accept the codes for 2017, they will reimburse all new codes at the same rate. They are concerned about upcoding. Each new code has four components of complexity and severity. Remember that your documentation must show consistency on all four levels to determine the level of complexity. More to come on this in future blog posts by the SOWH Reimbursement Committee!
  • Tricare Reorganization. Humana Military and Health net services will manage the Tricare system. Look for significant reductions in PT payment rates.

Keep an eye on the SOWH Reimbursement website page for ongoing payment updates and guidelines.

Got a question? Submit it to [email protected].

AUTHOR: Kelly Huestis, MPT, is chair of the Section on Women’s Health Reimbursement Committee.

 

 


 

 

 

Ringing in 2017 with New Physical Therapy Evaluation and Re-evaluation Codes

Posted on: October 22nd, 2016 by Aika Barzhaxynova No Comments

Katie PringBy Katie Pring, MPT

Starting January 1, 2017, physical therapists will have three new evaluation codes and one new re-evaluation code. The new evaluation codes will replace the 97001, PT initial evaluation, and 97002, PT reevaluation codes.

In addition, the three new physical therapy evaluation codes are further divided into three levels of complexity: low, moderate, and high. Listed are the new evaluation codes for 2017:

  • 97161: Physical Therapy Evaluation–Low Complexity Evaluation
  • 97162: Physical Therapy Evaluation–Moderate Complexity Evaluation
  • 97163: Physical Therapy Evaluation–High Complexity Evaluation
  • 97164: Re-evaluation

The new initial evaluation codes are based on four components: patient history, examination, clinical presentation, and clinical decision making. Together, these four components of the evaluation determine which evaluation code to use.

The following charts can be used to help guide a therapist in determining the complexity of the evaluation. Please note when choosing the complexity of the evaluation, all components must be met and documented. If one of the four components is not met and documented, the therapist must default to a lower complexity evaluation code.

97161:  PT Evaluation Low Complexity Evaluation

Patient History Examination Clinical Presentation Clinical Decision Making
No documented comorbidities or personal factors that impact the plan of care. Documented 1-2 elements from any of the following:  body structures and functions, activity limitations, and/or participation restrictions Stable and/or uncomplicated characteristics Low complexity

97162:  PT Evaluation Moderate Complexity

Patient History Examination Clinical Presentation Clinical Decision Making
Documented 1-2 comorbidities and/or personal factors  that impact the plan of care Documented 3 or more elements from any of the following:  body structures and functions, activity limitations, and/or participation restrictions Evolving clinical presentation with changing characteristics Moderate complexity

97163: PT Evaluation High Complexity

Patient History Examination Clinical Presentation Clinical

Decision-making

Documented 3-4 comorbidities and/or personal factors  that impact the plan of care Documented 4 or more elements from any of the following:  body structures and functions, activity limitations, and/or participation restrictions Unstable and unpredictable characteristics High complexity

The new evaluation codes will be accepted by all insurances with the exception of workman compensation and/or auto insurance providers. It is recommended to follow-up with workman comp and auto insurance providers to see if they will be accepting the new evaluation codes.

At this time, all three initial evaluation codes will be reimbursed at the same fee scale. Reimbursement will not increase based on the complexity of the evaluation code. In 2017, CMS will study the utilization of the evaluation codes to determine if there different fees should apply for different evaluation codes.

In upcoming months, APTA will continue to educate physical therapists on the usage of the new evaluation codes. In addition, APTA is planning to have patient case scenarios that will allow therapists to review the case and practice determining which evaluation code to use. The Section on Women’s Health will have several patient examples on our reimbursement webpage in months to come.

Author: SOWH Reimbursement Committee member Katie Pring, MPT, works in the outpatient orthopedic practice of Mendelson Kornblum Orthopedics in Warren, Mich. The women’s health program she developed there includes treatment of lymphedema, pregnancy and postpartum care, and pelvic floor therapy.

 

 


 

 

 

Reimbursement Q & A: ICD-10 and Pregnancy

Posted on: August 30th, 2016 by Aika Barzhaxynova No Comments

By Kelly Huestis, PT, MPT

Confused about physical therapy reimbursement coding related to your pregnant patients? Here’s one example:

Question: I work with several pregnant patients for sciatica, low back pain, and pelvic pain. Do I need to code for the patient being pregnant and then code for the pain and functional problems or just the pain and functional problems?

Unsure how to code for reimbursement related to pregnant patients? Kelly Huestis has your back.

Unsure how to code for reimbursement related to pregnant patients? Kelly Huestis has your back.

Answer: As a physical therapist, you should always code for the primary diagnoses that you are treating first. This includes codes such as weakness, pain, balance, and functional limitations. Pregnancy should be considered like a medical diagnosis or secondary diagnosis.

As the therapist, you are not actually treating the pregnancy per se but rather the musculoskeletal symptoms associated with it.  Unless you have a confirmed, detailed ICD-10 code from the physician, you would not bill an ICD-10 code for the pregnancy.

These codes can be complex and can be broken down as far as weeks and complications. Document the pregnancy in your notes to assist with reimbursement and submit ICD-10 codes for the impairments you are actually addressing.

Some common ICD-10 codes used during pregnancy include the following:

M54.4_                 Lumbago with sciatica (be sure to specify side to assure payment)

M53.3                   Sacral disorders, not elsewhere classified (coccygodynia, pain in sacrum)

M25.50                 Pain in unspecified joint

M25.55_              Pain in hip (specify side)

M62.838               Muscle spasm, other

M62.81                 Muscle weakness

R29.3                     Posture abnormality

R26.2                     Difficulty in walking, not elsewhere classified

R26.89                   Other abnormalities of gait and mobility

For more resources on ICD-10 coding for the women’s health patient, check out the SOWH ICD-10 page located under the “Practice” tab at www.womenshealthapta.org or email your inquiries to the Reimbursement Committee at [email protected].

Author: Kelly Huestis, PT, MPT, is chair of the Reimbursement Committee for the Section on Women’s Health.

 

 


 

 

 

Goodbye, 97001 & 97002

Posted on: July 26th, 2016 by Aika Barzhaxynova No Comments
Monica White

Monica White

By Monica White, DPT, PRCP

As you may have heard, Centers for Medicaid & Medicare Services (CMS) is changing how we code for physical therapy evaluations in 2017. There will be three new evaluation codes– 97X61, 97X62, and 97X63–that will replace 97001, and one new re-evaluation code, 97X64, that will replace 97002.

How will this change the reimbursement rate?

At this point we’re not sure. CMS will publish the final ruling on payment rates in late October or early November. CMS has proposed to keep the same reimbursement rate whether you are evaluating a relatively simple or a complex patient or whether you spend 20 minutes or 45 minutes evaluating a patient. Check out what the new codes will look like below:

New Physical Therapy CPT Codes

CodeCPT Long Form Descriptors for Physical Medicine and Rehabilitation
97X61Physical therapy evaluation: low complexity, requiring these components:
A history with no personal factors and/or comorbidities that impact the plan of care;
An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
A clinical presentation with stable and/or uncomplicated characteristics; and
Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family
97X62Physical therapy evaluation: moderate complexity, requiring these components:
A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following body structures and functions, activity limitations, and/or participation restrictions;
An evolving clinical presentation with changing characteristics; and
Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family.
97X63Physical therapy evaluation: high complexity, requiring these components:
A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;
An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
A clinical presentation with unstable and unpredictable characteristics; and
Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family
97X64Reevaluation of physical therapy established plan of care, requiring these components:
An examination including a review of history and use of standardized tests and measures is required;
and
Revised plan of care using a standardized patient assessment instrument and/or measurable assessment
of functional outcome
Typically, 20 minutes are spent face-to-face with the patient and/or family.
97X65 Occupational therapy evaluation, low complexity, requiring these components...

https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16097.pdf

 Change is just around the corner! Keep an eye on the SOWH Blog and the SOWH Payment, Policy, and Advocacy web page for more updates:  http://www.womenshealthapta.org/practice/payment-policy-and-advocacy/

AUTHOR: Monica White, DPT, PRCP, is a CAPP-Pelvic certified member of the SOWH Reimbursement Committee.

 

 

 


 

 

 

Reimbursement Q & A: Billing for Electrodes

Posted on: June 28th, 2016 by Aika Barzhaxynova No Comments

By Kelly Huestis, PT, MPT

The Section on Women’s Health receives many payment reimbursement questions from physical therapists providing a range of services. Here is one of the most common, according to the SOWH ReimburseKelly Huestis, chair of the SOWH Reimbursement Committee, addresses a common question on electrode reimbursement codes. ment Committee:

Question:  Our physical therapists do internal vaginal biofeedback and/or electrical stimulation. The electrode probes we use are $40 each, and we want to ensure we are using the most appropriate CPT codes to charge for this intervention. Do you have any advice for us? “90911” seems like an appropriate code. Is anyone else using it?

Answer: The Reimbursement Committee regularly receives questions regarding proper billing for incontinence patients and how to maximize payment to cover the cost of equipment, probes, and electrodes. Recapturing the cost of the intra-vaginal probes can be a huge expense issue for many outpatient clinics.

Regarding this question, yes, some clinics are still using the “90911” CPT code (biofeedback services and procedures) for biofeedback. However, I would caution you since many payers do not reimburse for that code, and coverage determinations can vary by state. Talk to each individual payer about what they allow. Several stipulations and criteria must still be met for billing Medicare, and you also should look at your state’s local coverage determinations as related to biofeedback billing.

See the following link for Medicare guidelines and National Coverage Determinations (section 30.1.1 and section 230.8): https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r10ncd.pdf.

Other clinics use EMG feedback as a tool to assist with neuromuscular re-education or therapeutic exercise and to document and bill as such. If a clinic believes these charges are not adequate to compensate for the cost of the probe, here are other options:

  1. Have the patient purchase their own electrodes.
  2. Consider the use of surface electrodes, when possible, rather than intra-vaginal probes. These are significantly less expensive and can be just as effective for many patients.
  3. Check out corporate deals. For instance, cmtmedical.com will let you set up an account where patients go to purchase electrodes at a discount.
  4. Buy the electrodes and sell them to patients but consider DME licensing and sales tax.

Stay tuned this year to the Section on Women’s Health’s Payment, Policy, and Advocacy webpage for regular updates on billing for pelvic floor muscle dysfunction. For more payment questions, email the Reimbursement Committee at [email protected].

AUTHOR: Kelly Huestis, PT, MPT, is chair of the Section on Women’s Health Reimbursement Committee. She can be reached at [email protected]

 

 


 

 

 

Alternative Payment Models: Not just an “Ortho Thing”

Posted on: May 31st, 2016 by Aika Barzhaxynova No Comments

By NaKisha Jackson, PT, DPT

The new craze is all about “alternative payment models” (APM). In January 2015, the Department of Health and Human Services (HHS) announced a plan to move aggressively on its goal to transition 30% of

NaKisha Jackson shares an update on PT reimbursement actions.

NaKisha Jackson shares an update on PT reimbursement actions.

traditional fee-for-service Medicare payments to APMs such as the Comprehensive Care Joint Replacement (CJR) program by the end of 2016, and 50% by the end of 2018.

HHS noted it has reached the 30% goal ahead of schedule and will move toward the next milestone.1 The concept seems instinctive for the move toward the “fee-for-outcomes” model that no one could argue is unreasonable. As physical therapists we are a very intricate detail in the overall picture of these clients’ recoveries. However, according to the American Physical Therapy Association, physical therapists are not as strongly considered in this model as we should be in comparison to our impact on those outcomes.

At first glance this may appear to be an “ortho thing.” In our Section, we could assume that this may not have as drastic of an effect on us as it does our other colleagues, whose caseloads are inundated with clients pre- and post-joint replacement surgery.

While orthopaedic surgeries may be on the forefront of this experiment, does it not seem fathomable that other specialties may be on a short list of the HHS? The first two suspects that come to mind are the ever so popular bladder and urethral suspension/sling procedures for incontinence and hysterectomies for complaints of pelvic pain.  How many of these have you seen with poor outcomes and thought to yourself, “I could have helped prior to surgery, and she may have had a better recovery?”

Complications vary from mesh erosion and worsening urgency to increased pain and a host of other issues. What about the other very common and easily justifiable radical prostatectomy? With quality of life being a major outcome focus of most insurers, stress incontinence that was unresolved or not even addressed may also be a red flag for scoring the success level of this surgery.

While our specialty is flying under the radar, this is the perfect time to make sure you are crossing your t’s and dotting your i’s. If this comes down the pike, as all things usually do, to begin to incorporate all major surgical areas that cost insurers and beneficiaries enormous amounts of money, we need to be ready to stake our claim as major players in these outcomes.

Have your personal therapy outcomes ready and in a readable format, so when surgeons and general physicians need convincing that you are the missing piece to the puzzle, you have your ammunition. Use your results as marketing tools, not only to physicians, but to clients and their families and friends as well.

This is especially necessary for those therapists striving for a cash-based practice. What better way to ask clients to forego their insurance and pay you cold hard cash up-front, with no tangible evidence that you know what you are doing?

We are in a prime situation to be proactive and able to advocate for ourselves in a system that continues to underestimate the undeniable benefits of physical therapy to clients and insurers in the form of quality of care and cost control.

References

  1. APTA Statement on Transition to Alternative Payment Models (Including CJR). 04/16/2016

Author: NaKisha Jackson, PT, DPT, practices in Arlington, Texas, in an outpatient setting solely devoted to enhancing the pelvic health of men and women. She can be reached at [email protected].

 

 

 


 

 

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