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CommonErrors– AuditingthePhysMed Record

CommonErrorsandFraudRiskinPhysicalMedicine(Chiro/PT)Coding

AuditingthePhysMed Record

Lecturer:MichaelD.MiscoeJD,CPC,CASCC,CUC,CCPC,CPCO,CPMA


DISCLAIMERThispresentationisforgeneraleducationpurposesonly.Theinformationcontainedinthesematerials,lecture,ideasandconceptspresentedisnotintendedtobe,andisnot,legaladviceorevenparticularbusinessadvicerelevanttoyourpersonalcircumstances.Thelaws,regulationsandcontractualtermsregardingbillingofanyservicetoathirdpartypayeraspresentedinthisseminarareaspublishedbytheauthoringfederalorstategovernmentorinrelevantcarrierpolicies/contracts.Suchlaws,regulations,contractsandpoliciesareopentointerpretation.Itisyourresponsibilitytoidentifyandevaluateanyrelevantlaw,regulation,contractorpolicyaswellastoseekprivatecounselwithyourattorneytodeterminehowtheselaws,regulations,policiesandcontractualtermsandanyconceptdiscussedhereapplytoyourspecificcasebeforeapplyingtheconceptsaddressedinthisseminar.

Attendanceatthispresentationshouldnotbeconstruedascreatinganattorney– clientrelationshipwiththespeakernorshouldtheinformationpresentedbeconstruedaslegaladvice.Remainingforthispresentationindicatesyouracknowledgementandagreementwiththeabove.

NOTICESCurrentProceduralTerminology(CPT®)iscopyright©2016AmericanMedicalAssociation.AllRightsReserved.CPT®isaregisteredtrademarkoftheAmericanMedicalAssociation(AMA).

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• Howtoproperlydeterminetheappropriatecodeforanyphysicalmedicinetherapyservice.

• Commonerrorsinthereportingofphysicalmedicinetherapyservices.

• RecenttrendsinpostpaymentandfalseclaimsanalysistargetingchiropracticandPTproviders.

Whatyouwilllearn

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• Analysis– Identifywhatthetherapyis

• Identifyingcreativenamingissues

– Identifytheamountofcontactprovidedandnecessary

– Identifythedurationoftheservice

TherapeuticServiceIdentification

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• ModalityDefinition:“Anyphysicalagent appliedtoproducetherapeuticchangestobiologictissue;includesbutnotlimitedtothermal,acoustic,light,mechanical,orelectricenergy.”– WherePhysicalAgentCausesChange– ThePhysical

Agent AppliedDefinestheCode.– IdentifytheLevelofContactREQUIRED

• Supervised(97010‐97028)– Notunitable• ConstantAttendance(97032‐97036)– Unitable basedontime

– Unlisted(97039)Contact/TimeRelevant?

Modalitiesvs.Procedures

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• FundamentalsofModalityCoding– Supervision:“Theapplicationofamodalitythatdoesnotrequire direct(one‐on‐one)patientcontactbytheprovider.”i.e.– stayinthebuilding.Appliestocodes97010‐97028.

– ConstantAttendance:“Theapplicationofamodalitythatrequires direct(one‐on‐one)patientcontactbytheprovider.”Note:AMAhasclarifiedthatyoucanprovideconstantattendancetomorethanonepatientincertaincircumstances.Forconstantattendancemodalities,theremustbeaneed tostaywiththepatientinordertodeliverthetherapyservice.Appliestocodes97032– 97036.


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• FundamentalsofProcedureCoding• ProcedureDefinition:“Amannerofeffectingchangethroughtheapplicationofclinicalskills and/orservicesthatattempttoimprovefunction.Physicianortherapistrequiredtohavedirect(one‐on‐one)patientcontact.”Appliestocodes97110‐97546.

• Clinicalskillisnecessarytoachievethespecifictherapeuticchangeandmustbeappliedduringtheentiretyoftheservice;hence,thedirectone‐on‐onecontactrequirement.

• ThePrimaryTherapeuticOutcomeIntendedDefinestheCode• Howdowedeterminetheintendedtherapeuticoutcome?


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Istheserviceamodalityorprocedure?• Lookatwhatiscausingthetherapeuticchange.

– APhysicalagent?• Light,Sound,Thermal,Electrical,MechanicalForce,etc.

– TheClinicalSkillofthePhysicianorTherapist?• Evidencethatclinicaldirectionisnecessarytoachievea

particulartherapeuticresult.

• Whatlevelofcontactprovided?


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• Ifamodality,whatisthephysicalagentandwhatlevelofcontactisrequired?– MatchthephysicalagentandlevelcontactwithintheappropriatemodalitysectionofCPT®.Ifthereisnomatch,report97039.

• Ifaprocedure,whatistheprimarytherapeuticoutcomeandwhatlevelofcontactwasprovided?– If1‐on‐1,matchtheprimaryoutcomewithacodewithintherangeof97110‐97546.Ifthereisnomatch,code97139.

– Ifnot1‐on‐1butskilledandconstantattendancewasprovided,bill97150.

– Whatifonlysupervisionisprovided?


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• Definitionof“Contact”– “FromaCPT® codingperspective,… Therapeuticprocedure,oneormoreareas,each15minutes;… requiresthetherapisttomaintaindirectpatientcontact(ie,visual,verbaland/ormanualcontact)duringprovisionoftheservice.”AMA,CPT® Assistant,p.11(December,1999)• Contactmustbesufficientlyskilledtoassurethattheprocedurewillcausetheintendedspecifictherapeuticchange.e.g.havinganunskilledtherapistsimplywatchapatientdoanexerciseisinsufficient.

• ConnectionbetweenCPT“contact”requirementsandCMS(andotherpayer)requirementsfor“skilled”intervention.

UnderstandingContact

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• ElectricalStimulation– TMR

• TherapeuticMagneticResonanceTreatment

– PENS• PercutaneousElectricNerveStimulation

TherapyCodingExercise

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• LightTherapy– ClassI‐II(LED)

– ClassIII(ColdLaser)

– ClassIV(HotLaser)


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• HandsFreeUltrasound– PulsedUltrasound

• Phonopheresis– Ultrasound+Medication(Hydrocortisone,Dexamethasone,SalicylatesorLidocaine).


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• Kinesiotaping– CPTAssistant

• 3/2012


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• DecompressionTractionTherapyCodingExercise

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• PneumaticTraction(PosturePump)

• VibratoryMassage/MassageChairs


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• NeuromuscularMassage• RehabilitativeExercise

– BalanceBoards– ExerciseMachines(Isotonic/Isometric/Isokinetic)– SwissBalls


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• 97110‐ Therapeuticprocedure,1ormoreareas,each15minutes;therapeuticexercisestodevelopstrengthandendurance,rangeofmotionandflexibility– CPT® Assistant(Summer1995,Vol7):Therapeuticexerciseincorporatesoneparameter(strength,endurance,rangeofmotionorflexibility)tooneormoreareasofthebody.Examplesinclude,treadmill(forendurance),isokineticexercise(forrangeofmotion),lumbarstabilizationexercises(forflexibility),andgymnasticball(forstretchingorstrengthening).

• 97530‐ Therapeuticactivities,direct(one‐on‐one)patientcontact(useofdynamicactivitiestoimprovefunctionalperformance),each15minutes– CPT® Assistant(Summer,1995,p.9)Dynamicactivitiesincludetheuseofmultipleparameters,suchasbalance,strength,andrangeofmotion,forafunctionalactivity.Examplesincludeliftingstations,closedkineticchainactivity,handassemblyactivity,transfers(chairtobed,lyingtositting,etc),andthrowing,catching,orswinging:Functionalactivitiesspecificallyrelatedtowork(hardening/conditioning)shouldbecodedusing97545

97110/97530

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• CPTKnowledgeBase(2013):Code97530isatherapeuticprocedurethatrequiresdirectone‐on‐onepatientcontactbyaphysicianortherapist.Dynamicactivitiesincludetheuseofmultipleparameters,suchasbalance,strength,andrangeofmotion,forafunctionalactivity.Examples ofwhentousethiscodewouldbewhenthefollowingactivities/functionsaretakingplace:liftingstations,closedkineticchainactivity,handassemblyactivity,transfers(chairtobed,lyingtositting,etc),andthrowing,catching,orswinging.Additionalexamplesincludedexteritytasks,writing,functionalmobilityorpurposefulactivitiessuchasplacingobjectsoutofreach,manipulationtasksusingsmalltools,crossingmidline,orweight‐shiftingtaskswiththeupperbodytoimprovesafetywithunsupportedsittingorstanding.Code97530differsfrom97110inthat97110,Therapeuticprocedure,oneormoreareas,each15minutes;therapeuticexercisestodevelopstrengthandendurance,rangeofmotionandflexibility,describesservicesaimedatimprovingaparameter,suchasstrength,rangeofmotion,etc.Therapeuticactivities,asincode97530,pullalltheseparameterstogethertofocusonachievingafunctionalactivity.Thefocusincode97530isonactivityvsexercise.

97110/97530

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• 97112:Therapeuticprocedure,1ormoreareas,each15minutes;neuromuscularreeducationofmovement,balance,coordination,kinestheticsense,posture,and/orproprioceptionforsittingand/orstandingactivities.

– CPT® Assistant(Summer1995,Vol7):Examplesinclude,ProprioceptiveNeuromuscularFacilitation(PNF),Feldenkreis,Bobath,BAP'SBoards,anddesensitizationtechniques).

97112

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• AetnaPolicy(asanexample):NeuromuscularRe‐education‐ Thistherapeuticprocedureisprovidedtoimprovebalance,coordination,kinestheticsense,posture,andproprioceptiontoapersonwhohashadmuscleparalysisandisundergoingrecoveryorregeneration.Goalistodevelopconsciouscontrolofindividualmusclesandawarenessofpositionofextremities.Theproceduremaybeconsideredmedicallynecessaryforimpairmentswhichaffectthebody'sneuromuscularsystem(e.g.,poorstaticordynamicsitting/standingbalance,lossofgrossandfinemotorcoordination,hypo/hypertonicity)thatmayresultfromdiseaseorinjurysuchasseveretraumatonervoussystem,cerebralvascularaccidentandsystemicneurologicaldisease.[EmphasisAdded]

97112

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• CPT®97150‐ Therapeuticprocedure(s),group(2ormoreindividuals)– CPT®Assistant(Summer1995)GrouptherapeuticproceduresincludeCPT® codes97110‐97139.Ifanyoftheseproceduresareperformedwithtwoormoreindividuals,thenonly97150isreported.Donotcodethespecifictypeoftherapyinadditiontothegrouptherapycode.

– Mixedcontact?

NotOne‐on‐One?

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GroupandOne‐on‐One‐ CCI

• UnderCCI,alldirectone‐on‐onecontactproceduresareconsideredexcludedbythegroupcode(97150)butcanbereportedseparatelywhenaone‐on‐onecontactprocedureisperformedseparateintimefromtheexercisesperformedinagroup.

• Whereappropriatetobillbothaone‐on‐oneprocedure(e.g.97110)andagroupcode(97150)theone‐on‐oneproceduregetsthemodifier59.


• CPTEDITORIALPANELAPPROACH– 1ST UNIT– 50%(SeeCPT®Instructions)– MORETHANONEUNIT– Lessthan8minutes‐MODIFIER52?– ConcurrentPerformanceofTimeBasedTherapies

• CMSAPPROACH– Part1– Individualtimeanalysisunderthe8minuterule.– Part2– Totaltimeanalysis(wheremorethanonetimebasedserviceisperformed).

ReportingTimeBasedServices

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Whattimecounts?

• CPT:Allnecessarypre,intraandpostserviceworkassociatedwiththeservice.

• CMS:Onlytheactualtimeinvolvedinperformanceoftheservice(intraservicetime).Pre,andpostserviceworkdoesnotcount.


UnderstandingTimeRules• CPTEditorialPanelGuidance

– SingleServiceAnalysis– 1st UnitBillableif50%ofServicePerformed

• Iflessthanwhole15minutes,but7.5minutesormore,reportsingleunit.

• Whattodowhenserviceisperformedforlessthan8minutes?

• Whentoreportthe2nd Unit?

– FollowCarrierPolicy!

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UnderstandingTimeRules• CMS

– TwoPartAnalysis• EachService:8MinuteRule

– 8‐22=1Unit– 23‐37=2Units– 38‐52=3Units– 53‐67=4Units

• WhereMultipleTimeBasedServicesarePerformed,EvaluateTotalTimevs.TotalUnits


UnderstandingTimeRules• CMS– SpecialRules

– Lessthan8Minutes• Can’tBillbutSavetheTime…

– BundlingServicesofSameTime• LowerValueBundlestoHigherValue

– BundlingServicesofDifferentTime• LowerTimeBundlestoHigherTime

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PracticalExercise‐ AMA

• 97012– 15minutes• 97032– 5minutes• 97140– 10minutes• 97110– 12minutes

• 97012x1unit• Notreported• 97140x1unit• 97110x1unit


PracticalExercise– CMS– Step1

• 97012– 15minutes• 97032– 5minutes• 97140– 10minutes• 97110– 12minutes

• 97012x1unit• Notreported(savetime)• 97140x1unit• 97110x1unit

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PracticalExercise– CMS– Step2• 97012– 15minutes• 97032– 5minutes• 97140– 10minutes• 97110– 12minutes

• TotalTime=?a. 22Minb. 27Minc. 42Min

• TotalUnits=?a. 2Unitsb. 3Unitsc. 4Units


PracticalExercise– CMS– Result

• 97012– 1Unit• 97140– 1Unit• 97110– 1Unit

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• 97012– 15minutes• 97140– 10minutes• 97110– 12minutes

• 97012x1unit• 97140x1unit• 97110x1unit



• 97012– 15minutes• 97140– 10minutes• 97110– 12minutes

• TotalTime=?– 22Min

• TotalUnits=?– 2Units

IsitEnough?– No!

NowWhat?

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PracticalExercise– CMS– Result

• 97012– 1Unit• 97110– 1Unit

– Sincetherewasnotenoughtotaltime(intime‐basedservices)tojustify2totaltime‐basedunits,thelowertimeservicebundlesintothehighertimeservice.As97110wastheservicewithhighertime,97140bundlesinto97110.


PostPaymentIssues

• Miscodingoftherapyservices:– TMR:

• 76498(Unlistedmagneticresonanceprocedure(eg,diagnostic,interventional)

– PENS:• 64555‐ Percutaneousimplantationofneurostimulatorelectrodearray;neuromuscular

• 64999– Unlistedprocedure,nervoussystem

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PostPaymentIssues• CorrectCodingofTMR/PENS:

– TMR:• 97032‐ Applicationofamodalityto1ormoreareas;electricalstimulation(manual),each15minutes

– PENS:• 97014‐ Applicationofamodalityto1ormoreareas;electricalstimulation(unattended);or

• G0283‐ Electricalstimulation(unattended),tooneormoreareasforindication(s)otherthanwoundcare,aspartofatherapyplanofcare


PostPaymentIssues• Reportingone‐on‐oneserviceswhenonlyconstantattendanceorsupervisionprovided– IfConstantAttendance– Entireencounter=1unit97150– IfSupervision– Nocode.

• Why?• AuditConsiderations

– Documentationoftherapyservicedetails– Documentationoftime.– Documentationofcontact– Identityofpersonprovidingcontact

• Unfortunately,mostcommercialcarriermedicalpoliciesrequirenoneoftheabove.

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PostPaymentIssues• ContactRequiredforWorkHardening

– CPT– DirectOne‐on‐One– CPTAssistant– reprintedAPTAguidancesuggestingthatonlysupervisionisrequired.

• Whereonlysupervisionisprovided,howdoyoujustifythattheservicewasa“skilled”service?


PostPaymentIssues• ReportingServiceperformedforlessthan8minutes

– CriminalfelonyfraudconvictioninOhioforreportingmanualtherapy(97140)withmodifier52

– Serviceperformedfor40‐60secondsinmostcases.– $13Kofrelevantbilling.– Ambiguouspolicy

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PostPaymentIssues• MedicalNecessityRedFlags

– Morethan4totalunitsofservice– Morethan1hourofservice– Morethan4differentcodesperencounterassociatedwiththesamediagnosis/injury.

• ProcedureMis‐Coding– 4unitsof97112?– 4unitsof97140?


Questions?

CEUCode:

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PhysMed Coding Errors - …aapcperfect.s3.amazonaws.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315fa0/...dynamic activities to improve functional performance) ... , lying to sitting, etc),