Annual Therapy Threshold And Targeted Medical Review Threshold
In the final rule, CMS did not publish the 2021 therapy threshold dollar amount for outpatient therapy services. On December 3, 2020, CMS re-communicated Transmittal 10464 and announced the 2021 therapy threshold dollar amount would be $2,110 for physical therapy and speech therapy combined and a separate $2,110 for occupational therapy. The targeted medical review threshold remains at $3,000 for physical therapy and speech therapy combined and a separate $3,000 for occupational therapy in CY 2021.4
The Billing Black Hole
I remember my first few months of trying to figure out how to properly bill in order to please the insurance companies and to meet my own clinics expectations.
It was odd to me that there was so much widespread uncertainty involved in such a vital part of what we do on a daily basis as clinicians.
- How could this topic be so sensitive and debatable?
- Dont insurance companies want to clearly define what procedures they will be paying for?
- How will I know how to bill for my patients time in the clinic if I dont truly understand what the codes even mean?
Those tasked with the job of creating and modifying Medicare legislation and reimbursement must have some idea of what they are doing. Payable criteria for each billing code must remain vague and undefined in order to give the insurance company the power to deny our claims if they feel our services arent necessary or warranted. To them, if a patient is considered functional, they no longer require skilled physical therapy intervention.
When it comes down to it, insurance companies are businesses. Their main job isnt to provide affordable, high quality healthcare services to all who sign up for their services. Rather, their goal is to turn a profit.
The net profit of the industry over the past 10 years has equaled almost half a trillion dollars. Aetna alone reported a revenue of over $60.3 billion in 2015, a record for the company despite insurance companies sobbing over the passing of the Affordable Care Act in 2010.
Final Changes To The Medicare Physician Fee Schedule For Calendar Year 2021
- Conversion factor: $32.4085 a reduction of $3.6811 from the CY 2020 conversion factor
- RVU for CPT codes 97061, 97062, 97063, 97065, 97066, 97067: increase 1.2 to 1.54
- RVU for CPT codes 97064 and 97068: increase 0.75 to 0.96
- RVU for CPT code 92521: increase from 1.75 to 2.24
- RVU for CPT code 92522: increase from 1.5 to 1.92
- RVU for CPT code 92523: increase from 3.0 to 3.84
- work RVU of CPT code 92524: increase from 1.5 to 1.92
- 2021 Medicare $ Amount for the thermometer: $2110
So what does this mean?
The reduction is being implemented through application of the budget neutrality adjustment to the conversion factor to satisfy the budget neutrality requirements of 1848 of the Social Security Act. The combined impact of the reduction slated for physical therapy, occupational therapy, and speech-language pathology services in 2021 is -9%.
A bill to offset the cuts is still in play! Check out this APTA article for great updated information.
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So Everything Is Billed In Eight
No, that would be too easy. Medicine PT billing is handled in increments of 15. The good news is that if you work with a patient one-on-one for eight minutes or 10 minutes, you can bill for one 15-minute unit. If you work with a patient for two eight-minute segments , youd actually end up billing for one 15-minute unit.
If you work for 23 minutes with a patient, then youd get to bill for two 15-minute units.
It sounds confusing and it kind of is but this little table-list below should help clarify things.
- 822 minutes = 1 unit
- 2337 minutes = 2 units
- 3852 minutes = 3 units
- 5367 minutes = 4 units
- 6882 minutes = 5 units
- 8397 minutes = 6 units
- 98112 minutes = 7 units
- 113127 minutes = 8 units
So if you work with a patient for 22 minutes or less, youll bill for one unit. If you do 23 to 37 minutes, 2 units, and so on.
It may look frustrating, but it rewards the patient and the PT when you spend a little more time helping the patient. After all, if you engage with a patient for 16 or 17 minutes, and you end up not being compensated for one or two minutes of work, thats not going to break your bank . But because you probably dont want to work for free for, say, seven minutes, you would want to try to avoid working for, say, 22 minutes and try to spend at least one more minute with the patient, so you can bill for two units.
So How Can I Make Sense Of The 8
Much of it, unfortunately, involves practice simply doing enough billing and mastering it. But if you become a Hands-On Diagnostics franchise, youd have the billing software that would automate everything, tracking your time and instituting the 8-Minute Rule for you, so you can have accurate and higher PT insurance reimbursements.
In other words, as weve stated more than a few times on this blog, if you team up with Hands-On Diagnostics, we can alleviate your financial migraines and billing suffering which will give you more time and energy to focus on healing your patients.
We hope youll give us a call. It may take a little longer than eight minutes for you to figure out whether you want to be a HODS franchise, but we promise we wont bill you in units or otherwise.
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Maintenance Therapy Provided By Ptas And Otas
CMS finalized their proposal to make permanent their Part B policy for maintenance therapy services that CMS adopted on an interim basis for the PHE in the May 8th COVID-19 IFC that grants a physical therapist and occupational therapist the discretion to delegate the performance of maintenance therapy services, as clinically appropriate to a PTA or an occupational therapy assistant . This will align CMS Part B policy with that paid under Part A in skilled nursing facilities and the home health benefit where maintenance therapy services may be performed by a physical or occupational therapist or a PTA/OTA.1
When Should I Use Modifier 59
Modifier 59 can monumentally impact your Medicare reimbursements, and unfortunately, its the modifier physical therapists struggle with most. Perhaps thats because the CPT Manual doesnt offer the most helpful guidance. Therefore, we recommend asking the following questions to decide if and when you should use modifier 59.
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The Current Procedural Terminology
Developed by the American Medical Association , the Current Procedural Terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. According to the APTA, When billing most third parties for servicesit is necessary to utilize CPT-4 codes to describe the services that were rendered. Although CPT is not an exact description of physical therapists interventions, it does provide a reasonable framework for billing.
Most of the CPT codes that are relevant to rehab therapists are located in the 97000 section . However, you can bill any code that best represents the service you provide as long as you can legally provide that service under state law. Be forewarned, though: just because you can legally bill for a code doesnt automatically mean that a payer will reimburse you for it. When in doubt, always check with your payers before providing the service in question.
All physical and occupational therapists should get to know the following CPT categories before billing for their services:
- PT evaluations and OT evaluations , which are tiered according to complexity:
- 97161: PT evaluation low complexity
- 97162: PT evaluation moderate complexity
- 97163: PT evaluation high complexity
- 97165: OT evaluation low complexity
- 97166: OT evaluation moderate complexity
- 97167: OT evaluation high complexity
The International Classification Of Diseases
In order to successfully bill for your services, youll need to diagnose your patients conditions in a manner that demonstrates the medical necessity of those servicesand youll need to do so using the latest version of the International Classification of Diseases , which, as of October 2015, is ICD-10. Given the complexity of the new coding system, it can be difficult to decide which codeor codesto use. However, you should select the most specific code that most accurately reflects the condition. See the most common ICD-10 codes used in PT here.
If youre ever in doubt as to whether your codes are reimbursable under your payers payment policy, call the payer before submitting the claim. According to the APTA, Your goal is to maximize the number of claims that are paid on the first submission and to minimize the need for appeals. In other words, in this case, its much better to ask for permission than for forgiveness.
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Medicare Physician Fee Schedule Conversion Factor
In the final rule, CMS announced the MPFS conversion factor would be 32.4085.1 This is a 10.2% decrease compared to the 2020 MPFS CF of 36.0896. Due to increases in some of the relative value units of CPT codes billed by physical therapists, occupational therapists and speech-language pathologists, the overall decrease in payment for outpatient therapy services was estimated to be approximately 9% in CY 2021.
On December 21, 2020, The United States House of Representatives and United States Senate passed The Consolidated Appropriations Act, 2021 and this legislation was signed into law by President Trump on December 27, 2020. The legislation ordered the Secretary of Health and Human Services to increase the MPFS by 3.75% for services furnished on and after January 1, 2021 through December 31, 2021.2
In addition, the legislation placed a moratorium on the payment for G2211 from January 1, 2021 through December 31, 2023.2 G2211 is a new Medicare-specific add-on code to report office/outpatient E/M visit complexity.
G2211 Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patients single, serious, or complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established2
How Do You Bill For Speech
According to the American Speech-Language-Hearing Association , Medicare will only allow speech-language pathologists to bill for telehealth services during the federal pandemic emergency. The Biden administration renewed the public health emergency declaration in April 2021. However, private insurance companies have their own rules about telehealth billing for SLPs.
SLPs may use the codes above along with modifier 95 to indicate telehealth services and GN to designate services provided by an SLP. They should also use the place of service code for the setting where the patient received services prior to the pandemic . Our downloadable cheat sheet for telehealth SLP services provides easy access to the telehealth codes you need, plus tips on billing correctly for telehealth services.
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Physical Therapy Evaluation Cpt Codes
Evaluation in physical therapy is a dynamic process in which the physical therapist makes clinical judgments based on data gathered during examination.
Examination does include conducting a comprehensive history, by performing a systems review, and directing tests and measures.
After that, physical therapist or physician evaluates the findings of examination, do establish any physical therapy diagnosis if identified properly, determine the prognosis and then develop complete plan care that include future goals and expected or unexpected outcomes, interventions to be used and anticipated plans for conclusion of care.
Underneath are the coding guidelines for physical therapy evaluation.
Baylor Internal Medicine Residency
Michael Rojas, PT, DPT is a Physical Therapist based in Phoenix, Arizona. Michael Rojas is licensed to practice in Arizona and his current practice location is 3342 E Greenway Rd Ste 1090, Phoenix, Arizona.He can be reached at his office via phone at 648-5444. NPI number for Michael Rojas is 1861122947 and his current.
2020. 9. 30. ·PTOT-1.1: Criteria/Guidelines for Provision of Physical Therapy and Occupational Therapy 11 PTOT-1.2: Applicable Federal and State Mandates 16 PTOT-1.3: eviCores Evidence Based Guidelines 16 PTOT-1.4: Medicare Coverage Policies 17 PTOT-2.0: General Medical Rehabilitation 18 PTOT-2.1: Lymphedema 19. February 3, 2022. /. Rick Gawenda. /. 21 Comments. /. For those physical therapists that perform dry needling on Medicare beneficiaries, they understand that the Medicare program does not reimburse PTs for dry needling when billing CPT codes 20560 and 20561. What has been confusing is must the PT provider issue a mandatory advance. 2022. 8. 1. ·UnitedHealthcare Medicare Advantage Policy Guideline Update Bulletin: August 2022 . Access a policy listed below for complete details on the latest updates. … Jul. 13, 2022 : Thermogenic Therapy Retired : Jul. 13, 2022 . Treatment of Psoriasis Retired . Jul. 13, 2022 : Ultrasonic Surgery .
. Get important info on occupational & physicaltherapy coverage. Learn about therapy caps, skilled nursing care, speech-language pathology services, more.
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Win: Cms Will Lift Several Code Pairing Restrictions
Therapy services have required the 59 or X modifier which means that if both services are performed on the same day only the first is paid for, and a modifier is needed to indicate both codes are distinct and separate. In the new edit set that will take effect on Jan. 1, many of these problematic code pairs have been resolved. The retroactive change applies to both office and facility-based settings.
The code pairing restrictions deleted in both office and facility-based settings include:
- 97110 with 97164
- 97140 with 97530
- 97530 with 97113
Per the APTA website, in its announcement, CMS says that some of the positive changes are retroactive to Oct. 1, 2020, with others retroactive to Dec. 31, 2019. APTA has reached out to CMS and its NCCI contractor to get more answers on the deletion dates and provisions that could allow reprocessing of previously denied claims. The association also will update the code pairing chart available on its Medicare National Correct Coding Initiative webpage.
Medicare Changes Impacting Physical Therapy Services
On December 2, 2020, the Centers for Medicare and Medicaid Services released the calendar year 2021 final rule for services paid under the Medicare Physician Fee Schedule as well as the Quality Payment Program, better known as the Merit-Based Incentive Payment System .
On December 27, 2021, President Trump signed The Consolidated Appropriations Act, 2021 into law and this legislation had positive implications for outpatient therapy services. In this article, I will highlight aspects of the final rule and The Consolidated Appropriations Act, 2021 as they pertain to outpatient therapy services.
Supervision Requirements Of A Physical Therapist Assistant
Under normal circumstances, CMS requires the physical therapist provide direct supervision to the physical therapist assistant when they are treating a Medicare beneficiary for outpatient therapy services in a private practice setting. Due to the public health emergency due to COVID-19, CMS has eased the direct supervision requirements of a PTA or an OTA in the private practice setting. During the public health emergency, CMS is revising the definition of direct supervision to include a virtual presence through the use of interactive telecommunications technology for services paid under the MPFS.
The news got even better on December 2, 2020 when CMS released the CY 2021 final rule for services paid under the MPFS. In the final rule, CMS finalized their proposal to allow direct supervision to be provided using real-time, interactive audio and video technology through the later of the end of the CY in which the public health emergency ends December 31, 2021.1 For example, if the public health emergency ends April 20, 2021, this revised direct supervision requirement would end December 31, 2021. However, if the public health emergency did not end until January 20, 2022, this revised direct supervision requirement would end December 31, 2022.
Which Cpt Codes Should Pts Ots And Slps Use To Bill For Remote And Virtual Care Services
In light of the COVID-19 pandemic, CMS and many commercial payers began allowing rehab therapists to provide and bill for certain remote care services. In most cases, therapists bill for true telehealth services using the same CPT codes they would bill for services provided in the clinic .
Outside of true telehealthand based on temporary, crisis-related regulatory provisionstherapists may bill the following codes when providing remote patient care:
For more details on these codesincluding payer coverage and required modifiersdownload this free Telehealth Billing Quick Guide for PTs, OTs, and SLPs.
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What Are Cpt Codes
If you arent too familiar with medical billing yet, you might be wondering what the heck CPT means. Let me explain.
CPT stands for Current Procedural Terminology. Theyre numerical codes used by healthcare providers to report the services performed for the patient.
Think of it this way. When doctors evaluate their patients, they know all of the services that they need to perform. But an insurance agent looking at the bill? Not so much. To improve communication between healthcare organizations and insurance agencies, numerical codes represent every different procedure and service.
A healthcare provider encodes all of the services performed into a medical bill using these CPT codes. When the bill reaches the insurance provider, they decode these so that it makes sense in the insurance world.
In essence, the codes describe what happened in the doctors office, making it a fundamental part of the billing process. The CPT codes must match the services provided so that the entire workflow and communication are coherent.