"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Wednesday, October 17, 2007

Group Coding for Dummies

If you don’t use the group code (CPT 97150) in outpatient physical therapy billing and you dovetail treatments (every :30 minutes) then your company’s behavior sends a message to your employees

The message is this:

We don’t believe our charts and documentation are sufficiently well-written to survive a Medicare (Part B) audit. Also, we aren’t sophisticated or intelligent enough to learn and understand how to correctly code and document the group code.

Fly Below the Radar

Your employees will correctly perceive your corporate compliance strategy is ‘flying below the radar’ – don’t bill it so we don’t get caught. The unspoken secret is that there may be other areas where your Medicare compliance is less than optimum. You would rather give up group code revenue rather than invite suspicion on your other, ‘less risky’ coding patterns.

Rather than give up any revenue why not just learn the appropriate billing strategy and the appropriate way to chart the visit?

The reader can look to the Center for Medicare and Medicaid Services (CMS) Part B PT/OT group coding scenarios at this link: CMS Group Billing Scenarios.

This link has Center for Medicare and Medicaid services official interpretation of many physical and occupational therapy treatment scenarios.

Medicare vs. Everyone Else

What if you bill group code to Medicare patients but not to any other patients?

The Common Procedural Terminology (CPT) codes, created and defined by the American Medical Association (AMA), are not the exclusive province of Medicare. Therefore, you should apply the group code without regard to who pays for the physical therapy service.

The AMA is a professional association that generates revenue from creating, designing and promulgating CPT codes. They don't enforce the codes.

A legal issue probably arises in the insurance contracts that each physical therapist signs with each (non-Medicare) insurance company. The contract may contain language that states the eligible beneficiaries are not to be discriminated from any other patients.

For example, one of my contracts with an insurance company states the following:

"Responsibilities of the Provider:

1) Provide Medically Necessary Health Services to Covered Individuals in a manner similar and within the same time availability in which health care provider provides such services to any other individual and XYZ Co. Provider will not discriminate or differentiate against Covered individuals"

In other words, neither the AMA, the American Physical Therapy Association (APTA) or CMS will care if you treat Medicare patients better than non-Medicare patients. That is, if you are compliant with Medicare ‘rules’ then there are no grounds for CMS to take action.

You may, however, be in violation of your contractual obligations to the insurance company. You may also be in violation of the APTA Code of Ethics.

Principle 2 states the following:

“A physical therapist shall act in a trustworthy manner towards patients and in all other aspects of physical therapy practice”

Principle 3 states this:

“A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients”

Red Flags

Many of my friends and peers, physical therapists in private practice, have admitted to under-billing the group code because of its perceived ‘red flag’ status.

I think this is a mistake. Know the rules. Follow the rules.

Knowledge is power. Use it.

Tim Richardson, PT

6 comments:

  1. I never looked at any of the contracts expect medicare.

    which section of the contract would I find this information?

    the way that the medicare thin was explained to me, was that regardless what anyone says the law/rule is, you are legally responsible for the correct interpertation of the rules. is this the case with the other insurances?

    thanks.

    ReplyDelete
  2. You signed a legal contract to accept payment for and to provide a certain standard of care for patients referred to you for physical therapy.

    Just like any legal contract (lease, buy-sell, bank loan, whatever) you are obligated by the terms of that contract.

    You need to read all of the contract.

    Make sure you understand the contract.

    Get a lawyer if you need one (don't worry about the cost - after you've had the first contract explained to you, the rest of the contracts are all pretty much the same).

    You will find the anti-discrimination clause in the 'boilerplate' language at the back of the contract, usually.

    Tim

    ReplyDelete
  3. I'm not sure I understand 100% how to use the group code. If patients are booked every 30 minutes and stay for an hour, how should the patients be billed? My understanding is that each patient should only be billed 2 units of ther ex or manual therapy (or whatever else was done) and not bill for the remaining 30 minutes. Is this correct?

    ReplyDelete
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    Physical Therapy Billing

    ReplyDelete
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Free Tutorial

Get free stuff at BulletproofPT.com

Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"


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