Coding and Payment Guide for the Physical Therapist

Coding and Payment Guide forthe Physical TherapistAn essential coding, billing, and payment resourcefor the physical therapist2014

Coding and Payment Guide for the Physical TherapistHCPCS Level II codes, published annually by CMS, are intended tosupplement the CPT coding system by including codes for durablemedical equipment, prosthetics, orthotics, and supplies (DMEPOS);drugs; and biologicals. These Level II codes consist of one alphabeticcharacter (A through V) followed by four numbers. In manyinstances, HCPCS Level II codes are developed as precursors to CPTcodes. A complete list of the HCPCS Level II codes and the quarterlyupdates to this code set may be found at http://www.cms.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp.Claim FormsInstitutional (facility) providers use the UB-04 claim form, alsoknown as the CMS-1450, to file a Medicare Part A claim to Medicarecontractors for service providers in hospital outpatient settings or inthe electronic format using the 837I format.Noninstitutional providers and suppliers (private practices or otherhealth care providers offices) use the CMS-1500 form or the 837Pelectronic format to submit claims to Medicare contractors forMedicare Part B-covered services. Medicare Part A coverage includesinpatient hospital, skilled nursing facilities (SNF), hospice, and homehealth. Part A providers also include rehabilitation agencies andcomprehensive outpatient rehabilitation facilities (CORF). MedicarePart B coverage provides payment for medical supplies, physicianservices, and outpatient services delivered in a private practicesetting (PTPP).Not all services rendered by a facility are inpatient services. Providersworking in facilities routinely render services on an outpatient basis.Outpatient services are provided in settings that includerehabilitation centers, certified outpatient rehabilitation facilities,SNFs, and hospitals. Outpatient and partial hospitalization facilityclaims might be submitted on either a CMS-1500 or a UB-04depending on the payer.For professional component billing, most claims are filed usingICD-9-CM diagnosis code to indicate the reason for the service, CPTcodes to identify the service provided, and HCPCS Level II codes toreport supplies on the CMS-1500 paper claim or the 837P electronicformat.Contents and Format of This GuideThe Coding and Payment Guide for the Physical Therapist containschapters that address payment, official Medicare regulatoryinformation, and a glossary.PaymentThe first section of the guide provides comprehensive informationabout the coding and payment process. It contains four chapters:an introduction, “The Payment Process,” “Documentation—AnOverview,” and “Claims Processing.” These chapters arepredominantly narrative in nature; however, the claims processingchapter provides step-by-step explanations to complete theCMS-1500 and UB-04 claim forms and a crosswalk for electronicsubmissions.Procedure Codes for Physical TherapistsThe next chapter, “Procedure Codes,” contains a numeric listing ofprocedure codes most commonly used by a physical therapist. Eachpage identifies the information associated with that procedure (or inIntroductionsome cases, related procedures) including an explanation of theservice, coding tips, and associated diagnoses. Please note that thislist of associated ICD-9-CM codes is not all inclusive. The proceduremay be performed for reasons other than those listed that supportthe medical necessity of the service. Only those conditionssupported by the medical record documentation should bereported.The procedure code page contains related terms and the CMSManual System references that designate the official references tothe service, which is identified by the procedure code and found inthe online manual system. The full excerpt from the online CMSManual System pertaining to the reference is provided in theMedicare official regulatory information appendix. The full text of allof the Internet-Only Manuals (IOM) may be found athttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html. The procedure codepages also have a list of codes from the official Centers for Medicareand Medicaid Services National Correct Coding Policy Manual for Part BMedicare Contractors that are considered to be an integral part ofthe comprehensive or mutually exclusive coding system and shouldnot be reported separately. Please note that the CCI edits will beupdated quarterly and posted on Optum’s website athttp://www.optumcoding.com/cciedits. Finally, all relative valueinformation pertaining to the code is listed at the bottom of thepage.Indexes and AppendixThe chapter containing applicable procedure codes is followed by aprocedure code index, an index of diagnosis codes commonlyreported by physical therapists, and HCPCS Level II definitions andguidelines. An appendix, “Medicare Official RegulatoryInformation,” and a glossary follow.How to Use This GuideThe chapters: “The Payment Process,” “Documentation—AnOverview,” and “Claims Processing” may be read in their entiretyand/or used as references. When using this Coding and PaymentGuide for code assignment, follow these important steps to improveaccuracy and experience fewer overlooked diagnoses and services:• Step 1. Carefully read the medical record documentation thatdescribes the patient’s diagnosis and the service provided.Remember, more than one diagnosis or service may bedocumented.• Step 2. Locate the main term for the procedure or servicedocumented in the CPT index. This will identify the procedurecode that may be used to report this service.• Step 3. Locate the procedure code in the chapter titled“Procedure Codes.” Read the explanation and determine ifthat is the procedure performed and supported by the medicalrecord documentation. The Terms to Know section may beused ensure appropriate code assignment.• Step 4. At this time, review the additional informationpertinent to the specific code found in the coding tips, IOMreference, and CCI sections or the Medicare physician feeschedule references.• Step 5. Peruse the list of ICD-9-CM codes to determine if thecondition documented in the medical record is listed and thecode identified. If the condition is not listed refer to the© 2012 OptumInsight, Inc. CPT codes only © 2012 American Medical Association. All Rights Reserved. 3

Procedure Codes95869-958709586995870Needle electromyography; thoracic paraspinal muscles (excludingT1 or T12)limited study of muscles in 1 extremity or non-limb (axial)muscles (unilateral or bilateral), other than thoracic paraspinal,cranial nerve supplied muscles, or sphinctersExplanationNeedle electromyography (EMG) records the electrical properties ofthoracic paraspinal muscles, excluding T1 or T12 (95869) using anoscilloscope. Recordings, which may be amplified and heard througha loudspeaker, are made during needle insertion, with the muscle atrest, and during contraction. Report 95870 for a limited study ofmuscles in one extremity or non-limb (axial) muscles other than thoracicparaspinal or cranial supplied muscles or sphincters.Coding TipsCode 95870 should be used to report a needle EMG study of a limbthat has fewer than five muscles tested per limb. Report this code once,or once per each extremity examined. Append modifier 59 Distinctprocedural service, to any subsequent codes reported. Report 95870once when performed on the thorax or abdomen, regardless of if thestudy is performed bilaterally. When performed on the cervical orlumbar paraspinal muscles, report 95870 only once regardless of thenumber of levels examined or if performed bilaterally.When no nerve conduction studies are performed on the same date ofservice, the appropriate EMG code (95860–95864 and 95866–95870)should be reported. To report nerve conduction studies, see95907–95913.Do not report code 95870 in addition to code 95860, 95861, 95863,or 95864 since the testing of paraspinal muscles corresponding to anextremity are included in these codes. However, when a different limbis tested, append modifier 59 Distinct procedural service, to indicatethe involvement of the second limb.Physical therapists in private practice may bill for the technical andprofessional component of certain diagnostic tests in the 95860–95937code range, such as electromyograms and nerve conduction studies.These codes have both a technical and professional component. Toreport only the professional component, append modifier 26. To reportonly the technical component, append modifier TC. To report thecomplete procedure (i.e., both the professional and technicalcomponents), submit without a modifier.The professional component is covered by Medicare as outpatientphysical therapy when performed by a PT who meets the followingcriteria:1) The PT is certified by the American Board of Physical TherapistSpecialties (ABPTS) as a clinical electrophysiologic-certified specialist2) The PT is personally supervised by an ABPTS-certified PT; only thecertified PT may bill for the serviceMedicare will permit a PT without ABPTS certification to provide certainelectromyography services if that PT was not ABPTS-certified as of July1, 2001, and had been furnishing such diagnostic tests prior to May1, 2001. The requirements vary depending on the CPT code billed.Some third-party payers, such as Medicare, reimburse only for thetechnical portion of many procedures whose codes are in this subsectionof the CPT book. It is important for each therapist to determine howinsurers require physical therapists to bill services. Therapists shouldkeep track of experiences with each insurance company and policy,providing data for future claims.Single-fiber EMG testing is the innervation of one or more nerve cellsand some of the muscles stimulated. Code 95872 describes testing ofeach muscle studied. Normally, 20 pairs of nerves must be studied tosignificantly study each muscle. Each muscle is coded only once.However, if another muscle is studied, then the code is reported again.These codes can be used in addition to the standard evaluation.Terms To Knowelectromyography. (EMG). Examining and recording the electrical activityof a muscle.technical component. Portion of a health care service that identifies theprovision of the equipment, supplies, technical personnel, and costs attendantto the performance of the procedure other than the professional services.Synonym(s): TC.ICD-9-CM Diagnostic CodesThe application of this code is too broad to adequately presentICD-9-CM diagnostic code links here. Refer to your ICD-9-CM book.IOM References100-2,15,230.4; 100-4,5,10.2CCI Version 18.395873-95874Coding and Payment Guide for the Physical TherapistAlso not with 95869: 90901, 95870, 95887-95904, 95920Also not with 95870: 95885-95904Note: These CCI edits are used for Medicare. Other payers mayreimburse on codes listed above.Work ValueNon-Fac PEFac PEMalpracticeNon-Fac TotalFac Total95869........................ 0.3795870........................ 0.372.172.302.172.300.020.022.562.692.562.69134CPT only © 2012 American Medical Association. All Rights Reserved.© 2012 OptumInsight, Inc.

HCPCS Level II Definitions and GuidelinesA4452A4455A4456A4461A4463A4465A4466A4490A4495A4500A4510A4556A4558A4559A4565A4566Tape, waterproof, per 18 sq inMED: Pub. 100-2, Chapter 15, Section 120Adhesive remover or solvent (for tape, cement orother adhesive), per ounceMED: Pub. 100-2, Chapter 15, Section 120Adhesive remover, wipes, any type, eachSurgical dressing holder, nonreusable, eachSurgical dressing holder, reusable, eachNonelastic binder for extremityGarment, belt, sleeve or other covering, elastic orsimilar stretchableSurgical stocking above knee length, eachMED: Pub. 100-2, Chapter 15, Section 100, 130; Pub.100-3, Section 280.1Surgical stocking thigh length, eachMED: Pub. 100-2, Chapter 15, Section 100, 130; Pub.100-3, Section 280.1Surgical stocking below knee length, eachMED: Pub. 100-2, Chapter 15, Section 100, 130; Pub.100-3, Section 280.1Surgical stocking full length, eachMED: Pub. 100-2, Chapter 15, Section 100 , 130; Pub.100-3, Section 280.1Electrodes (e.g., Apnea monitor), per pairConductive gel or paste, for use with electricaldevice (e.g., TENS, NMES), per ounceCoupling gel or paste, for use with ultrasounddevice, per ounceSlingsShoulder sling or vest design, abduction restrainer,with or without swatheCoding TipThe initial casting of the fracture is considered part of the fracturecare, inherent in the fracture care code. The sling, however, is notincluded in the global package for fracture care. Some contractorswill pay for this additional patient care item; some will not. If theprovider ordered the sling secondary to high probability of patientself-harm with a flailing, casted limb, or if the patient is a child whorequires immobilization of the casted limb to avert further injury,reimbursement may be considered by some contractors. Clearevidence of these situations must be reflected in the medicaldocumentation and should be submitted with the claim. In any case,it would be prudent to secure an advance beneficiary notice ofnoncoverage (ABN) from the patient in case a medical necessitydenial is received.A4570A4580SplintMED: Pub. 100-2, Chapter 15, Section 100Cast supplies (e.g., plaster)MED: Pub. 100-2, Chapter 15, Section 100A4590A4595A4600A4630A4635A4636A4637A4649Coding and Payment Guide for the Physical TherapistSpecial casting material (e.g., fiberglass)Electrical stimulator supplies, 2 lead, per month,(e.g. TENS, NMES)MED: Pub. 100-3, Section 270.3Sleeve for intermittent limb compression device,replacement only, eachReplacement batteries, medically necessary,transcutaneous electrical stimulator, owned bypatientUnderarm pad, crutch, replacement, eachReplacement, handgrip, cane, crutch, or walker,eachReplacement, tip, cane, crutch, walker, eachSurgical supply; miscellaneousCoding TipDetermine if an alternative national HCPCS Level II code betterdescribes the supply being reported. Code A4649 should be usedonly if a more specific code is unavailable.A5113A5114Leg strap; latex, replacement only, per setMED: Pub. 100-2, Chapter 15, Section 120Leg strap; foam or fabric, replacement only, per setMED: Pub. 100-2, Chapter 15, Section 120DressingsMedicare claims fall under the jurisdiction of the durable medicalequipment Medicare administrative contractor (DME MAC) unlessotherwise noted.A6000Non-contact wound warming wound cover for usewith the non-contact wound warming device andwarming cardMED: Pub. 100-3, Section 270.2Coding TipNoncontact normothermic wound therapy (NNWT) encourageswound healing by warming a wound to a preset temperature. Thedevice consists of a noncontact wound cover that contains a flexible,battery-powered infrared heating card. Benefits are not availableunder Medicare for this therapy based on a national coveragedetermination (NCD).s A6021s A6022s A6023A6024Collagen dressing, sterile, size 16 sq in or less, eachMED: Pub. 100-2, Chapter 15, Section 100Collagen dressing, sterile, size more than 16 sq inbut less than or equal to 48 sq in, eachMED: Pub. 100-2, Chapter 15, Section 100Collagen dressing, sterile, size more than 48 sq in,eachMED: Pub. 100-2, Chapter 15, Section 100Collagen dressing wound filler, sterile, per 6 inMED: Pub. 100-2, Chapter 15, Section 100200 ● New Codes ▲ Revised Codes MED: Medicare Reference © 2012 OptumInsight,