Coding and Payment Guide for the Physical Therapist
Coding and Payment Guide for the Physical Therapist
Coding and Payment Guide for the Physical Therapist
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<strong>Coding</strong> <strong>and</strong> <strong>Payment</strong> <strong>Guide</strong> <strong>for</strong><strong>the</strong> <strong>Physical</strong> <strong>Therapist</strong>An essential coding, billing, <strong>and</strong> payment resource<strong>for</strong> <strong>the</strong> physical <strong>the</strong>rapist2014
<strong>Coding</strong> <strong>and</strong> <strong>Payment</strong> <strong>Guide</strong> <strong>for</strong> <strong>the</strong> <strong>Physical</strong> <strong>Therapist</strong>HCPCS Level II codes, published annually by CMS, are intended tosupplement <strong>the</strong> CPT coding system by including codes <strong>for</strong> durablemedical equipment, pros<strong>the</strong>tics, orthotics, <strong>and</strong> supplies (DMEPOS);drugs; <strong>and</strong> 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 <strong>the</strong> HCPCS Level II codes <strong>and</strong> <strong>the</strong> quarterlyupdates to this code set may be found at http://www.cms.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp.Claim FormsInstitutional (facility) providers use <strong>the</strong> UB-04 claim <strong>for</strong>m, alsoknown as <strong>the</strong> CMS-1450, to file a Medicare Part A claim to Medicarecontractors <strong>for</strong> service providers in hospital outpatient settings or in<strong>the</strong> electronic <strong>for</strong>mat using <strong>the</strong> 837I <strong>for</strong>mat.Noninstitutional providers <strong>and</strong> suppliers (private practices or o<strong>the</strong>rhealth care providers offices) use <strong>the</strong> CMS-1500 <strong>for</strong>m or <strong>the</strong> 837Pelectronic <strong>for</strong>mat to submit claims to Medicare contractors <strong>for</strong>Medicare Part B-covered services. Medicare Part A coverage includesinpatient hospital, skilled nursing facilities (SNF), hospice, <strong>and</strong> homehealth. Part A providers also include rehabilitation agencies <strong>and</strong>comprehensive outpatient rehabilitation facilities (CORF). MedicarePart B coverage provides payment <strong>for</strong> medical supplies, physicianservices, <strong>and</strong> 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, <strong>and</strong> hospitals. Outpatient <strong>and</strong> partial hospitalization facilityclaims might be submitted on ei<strong>the</strong>r a CMS-1500 or a UB-04depending on <strong>the</strong> payer.For professional component billing, most claims are filed usingICD-9-CM diagnosis code to indicate <strong>the</strong> reason <strong>for</strong> <strong>the</strong> service, CPTcodes to identify <strong>the</strong> service provided, <strong>and</strong> HCPCS Level II codes toreport supplies on <strong>the</strong> CMS-1500 paper claim or <strong>the</strong> 837P electronic<strong>for</strong>mat.Contents <strong>and</strong> Format of This <strong>Guide</strong>The <strong>Coding</strong> <strong>and</strong> <strong>Payment</strong> <strong>Guide</strong> <strong>for</strong> <strong>the</strong> <strong>Physical</strong> <strong>Therapist</strong> containschapters that address payment, official Medicare regulatoryin<strong>for</strong>mation, <strong>and</strong> a glossary.<strong>Payment</strong>The first section of <strong>the</strong> guide provides comprehensive in<strong>for</strong>mationabout <strong>the</strong> coding <strong>and</strong> payment process. It contains four chapters:an introduction, “The <strong>Payment</strong> Process,” “Documentation—AnOverview,” <strong>and</strong> “Claims Processing.” These chapters arepredominantly narrative in nature; however, <strong>the</strong> claims processingchapter provides step-by-step explanations to complete <strong>the</strong>CMS-1500 <strong>and</strong> UB-04 claim <strong>for</strong>ms <strong>and</strong> a crosswalk <strong>for</strong> electronicsubmissions.Procedure Codes <strong>for</strong> <strong>Physical</strong> <strong>Therapist</strong>sThe next chapter, “Procedure Codes,” contains a numeric listing ofprocedure codes most commonly used by a physical <strong>the</strong>rapist. Eachpage identifies <strong>the</strong> in<strong>for</strong>mation associated with that procedure (or inIntroductionsome cases, related procedures) including an explanation of <strong>the</strong>service, coding tips, <strong>and</strong> associated diagnoses. Please note that thislist of associated ICD-9-CM codes is not all inclusive. The proceduremay be per<strong>for</strong>med <strong>for</strong> reasons o<strong>the</strong>r than those listed that support<strong>the</strong> medical necessity of <strong>the</strong> service. Only those conditionssupported by <strong>the</strong> medical record documentation should bereported.The procedure code page contains related terms <strong>and</strong> <strong>the</strong> CMSManual System references that designate <strong>the</strong> official references to<strong>the</strong> service, which is identified by <strong>the</strong> procedure code <strong>and</strong> found in<strong>the</strong> online manual system. The full excerpt from <strong>the</strong> online CMSManual System pertaining to <strong>the</strong> reference is provided in <strong>the</strong>Medicare official regulatory in<strong>for</strong>mation appendix. The full text of allof <strong>the</strong> Internet-Only Manuals (IOM) may be found athttp://www.cms.gov/Regulations-<strong>and</strong>-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html. The procedure codepages also have a list of codes from <strong>the</strong> official Centers <strong>for</strong> Medicare<strong>and</strong> Medicaid Services National Correct <strong>Coding</strong> Policy Manual <strong>for</strong> Part BMedicare Contractors that are considered to be an integral part of<strong>the</strong> comprehensive or mutually exclusive coding system <strong>and</strong> shouldnot be reported separately. Please note that <strong>the</strong> CCI edits will beupdated quarterly <strong>and</strong> posted on Optum’s website athttp://www.optumcoding.com/cciedits. Finally, all relative valuein<strong>for</strong>mation pertaining to <strong>the</strong> code is listed at <strong>the</strong> bottom of <strong>the</strong>page.Indexes <strong>and</strong> AppendixThe chapter containing applicable procedure codes is followed by aprocedure code index, an index of diagnosis codes commonlyreported by physical <strong>the</strong>rapists, <strong>and</strong> HCPCS Level II definitions <strong>and</strong>guidelines. An appendix, “Medicare Official RegulatoryIn<strong>for</strong>mation,” <strong>and</strong> a glossary follow.How to Use This <strong>Guide</strong>The chapters: “The <strong>Payment</strong> Process,” “Documentation—AnOverview,” <strong>and</strong> “Claims Processing” may be read in <strong>the</strong>ir entirety<strong>and</strong>/or used as references. When using this <strong>Coding</strong> <strong>and</strong> <strong>Payment</strong><strong>Guide</strong> <strong>for</strong> code assignment, follow <strong>the</strong>se important steps to improveaccuracy <strong>and</strong> experience fewer overlooked diagnoses <strong>and</strong> services:• Step 1. Carefully read <strong>the</strong> medical record documentation thatdescribes <strong>the</strong> patient’s diagnosis <strong>and</strong> <strong>the</strong> service provided.Remember, more than one diagnosis or service may bedocumented.• Step 2. Locate <strong>the</strong> main term <strong>for</strong> <strong>the</strong> procedure or servicedocumented in <strong>the</strong> CPT index. This will identify <strong>the</strong> procedurecode that may be used to report this service.• Step 3. Locate <strong>the</strong> procedure code in <strong>the</strong> chapter titled“Procedure Codes.” Read <strong>the</strong> explanation <strong>and</strong> determine ifthat is <strong>the</strong> procedure per<strong>for</strong>med <strong>and</strong> supported by <strong>the</strong> medicalrecord documentation. The Terms to Know section may beused ensure appropriate code assignment.• Step 4. At this time, review <strong>the</strong> additional in<strong>for</strong>mationpertinent to <strong>the</strong> specific code found in <strong>the</strong> coding tips, IOMreference, <strong>and</strong> CCI sections or <strong>the</strong> Medicare physician feeschedule references.• Step 5. Peruse <strong>the</strong> list of ICD-9-CM codes to determine if <strong>the</strong>condition documented in <strong>the</strong> medical record is listed <strong>and</strong> <strong>the</strong>code identified. If <strong>the</strong> condition is not listed refer to <strong>the</strong>© 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), o<strong>the</strong>r than thoracic paraspinal,cranial nerve supplied muscles, or sphinctersExplanationNeedle electromyography (EMG) records <strong>the</strong> electrical properties ofthoracic paraspinal muscles, excluding T1 or T12 (95869) using anoscilloscope. Recordings, which may be amplified <strong>and</strong> heard througha loudspeaker, are made during needle insertion, with <strong>the</strong> muscle atrest, <strong>and</strong> during contraction. Report 95870 <strong>for</strong> a limited study ofmuscles in one extremity or non-limb (axial) muscles o<strong>the</strong>r than thoracicparaspinal or cranial supplied muscles or sphincters.<strong>Coding</strong> 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 per<strong>for</strong>med on <strong>the</strong> thorax or abdomen, regardless of if <strong>the</strong>study is per<strong>for</strong>med bilaterally. When per<strong>for</strong>med on <strong>the</strong> cervical orlumbar paraspinal muscles, report 95870 only once regardless of <strong>the</strong>number of levels examined or if per<strong>for</strong>med bilaterally.When no nerve conduction studies are per<strong>for</strong>med on <strong>the</strong> same date ofservice, <strong>the</strong> appropriate EMG code (95860–95864 <strong>and</strong> 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 <strong>the</strong> testing of paraspinal muscles corresponding to anextremity are included in <strong>the</strong>se codes. However, when a different limbis tested, append modifier 59 Distinct procedural service, to indicate<strong>the</strong> involvement of <strong>the</strong> second limb.<strong>Physical</strong> <strong>the</strong>rapists in private practice may bill <strong>for</strong> <strong>the</strong> technical <strong>and</strong>professional component of certain diagnostic tests in <strong>the</strong> 95860–95937code range, such as electromyograms <strong>and</strong> nerve conduction studies.These codes have both a technical <strong>and</strong> professional component. Toreport only <strong>the</strong> professional component, append modifier 26. To reportonly <strong>the</strong> technical component, append modifier TC. To report <strong>the</strong>complete procedure (i.e., both <strong>the</strong> professional <strong>and</strong> technicalcomponents), submit without a modifier.The professional component is covered by Medicare as outpatientphysical <strong>the</strong>rapy when per<strong>for</strong>med by a PT who meets <strong>the</strong> followingcriteria:1) The PT is certified by <strong>the</strong> American Board of <strong>Physical</strong> <strong>Therapist</strong>Specialties (ABPTS) as a clinical electrophysiologic-certified specialist2) The PT is personally supervised by an ABPTS-certified PT; only <strong>the</strong>certified PT may bill <strong>for</strong> <strong>the</strong> serviceMedicare will permit a PT without ABPTS certification to provide certainelectromyography services if that PT was not ABPTS-certified as of July1, 2001, <strong>and</strong> had been furnishing such diagnostic tests prior to May1, 2001. The requirements vary depending on <strong>the</strong> CPT code billed.Some third-party payers, such as Medicare, reimburse only <strong>for</strong> <strong>the</strong>technical portion of many procedures whose codes are in this subsectionof <strong>the</strong> CPT book. It is important <strong>for</strong> each <strong>the</strong>rapist to determine howinsurers require physical <strong>the</strong>rapists to bill services. <strong>Therapist</strong>s shouldkeep track of experiences with each insurance company <strong>and</strong> policy,providing data <strong>for</strong> future claims.Single-fiber EMG testing is <strong>the</strong> innervation of one or more nerve cells<strong>and</strong> some of <strong>the</strong> 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 ano<strong>the</strong>r muscle is studied, <strong>the</strong>n <strong>the</strong> code is reported again.These codes can be used in addition to <strong>the</strong> st<strong>and</strong>ard evaluation.Terms To Knowelectromyography. (EMG). Examining <strong>and</strong> recording <strong>the</strong> electrical activityof a muscle.technical component. Portion of a health care service that identifies <strong>the</strong>provision of <strong>the</strong> equipment, supplies, technical personnel, <strong>and</strong> costs attendantto <strong>the</strong> per<strong>for</strong>mance of <strong>the</strong> procedure o<strong>the</strong>r than <strong>the</strong> 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 18.395873-95874<strong>Coding</strong> <strong>and</strong> <strong>Payment</strong> <strong>Guide</strong> <strong>for</strong> <strong>the</strong> <strong>Physical</strong> <strong>Therapist</strong>Also not with 95869: 90901, 95870, 95887-95904, 95920Also not with 95870: 95885-95904Note: These CCI edits are used <strong>for</strong> Medicare. O<strong>the</strong>r 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 <strong>and</strong> <strong>Guide</strong>linesA4452A4455A4456A4461A4463A4465A4466A4490A4495A4500A4510A4556A4558A4559A4565A4566Tape, waterproof, per 18 sq inMED: Pub. 100-2, Chapter 15, Section 120Adhesive remover or solvent (<strong>for</strong> tape, cement oro<strong>the</strong>r adhesive), per ounceMED: Pub. 100-2, Chapter 15, Section 120Adhesive remover, wipes, any type, eachSurgical dressing holder, nonreusable, eachSurgical dressing holder, reusable, eachNonelastic binder <strong>for</strong> extremityGarment, belt, sleeve or o<strong>the</strong>r 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, <strong>for</strong> use with electricaldevice (e.g., TENS, NMES), per ounceCoupling gel or paste, <strong>for</strong> use with ultrasounddevice, per ounceSlingsShoulder sling or vest design, abduction restrainer,with or without swa<strong>the</strong><strong>Coding</strong> TipThe initial casting of <strong>the</strong> fracture is considered part of <strong>the</strong> fracturecare, inherent in <strong>the</strong> fracture care code. The sling, however, is notincluded in <strong>the</strong> global package <strong>for</strong> fracture care. Some contractorswill pay <strong>for</strong> this additional patient care item; some will not. If <strong>the</strong>provider ordered <strong>the</strong> sling secondary to high probability of patientself-harm with a flailing, casted limb, or if <strong>the</strong> patient is a child whorequires immobilization of <strong>the</strong> casted limb to avert fur<strong>the</strong>r injury,reimbursement may be considered by some contractors. Clearevidence of <strong>the</strong>se situations must be reflected in <strong>the</strong> medicaldocumentation <strong>and</strong> should be submitted with <strong>the</strong> claim. In any case,it would be prudent to secure an advance beneficiary notice ofnoncoverage (ABN) from <strong>the</strong> 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 100A4590A4595A4600A4630A4635A4636A4637A4649<strong>Coding</strong> <strong>and</strong> <strong>Payment</strong> <strong>Guide</strong> <strong>for</strong> <strong>the</strong> <strong>Physical</strong> <strong>Therapist</strong>Special casting material (e.g., fiberglass)Electrical stimulator supplies, 2 lead, per month,(e.g. TENS, NMES)MED: Pub. 100-3, Section 270.3Sleeve <strong>for</strong> intermittent limb compression device,replacement only, eachReplacement batteries, medically necessary,transcutaneous electrical stimulator, owned bypatientUnderarm pad, crutch, replacement, eachReplacement, h<strong>and</strong>grip, cane, crutch, or walker,eachReplacement, tip, cane, crutch, walker, eachSurgical supply; miscellaneous<strong>Coding</strong> TipDetermine if an alternative national HCPCS Level II code betterdescribes <strong>the</strong> 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 <strong>the</strong> jurisdiction of <strong>the</strong> durable medicalequipment Medicare administrative contractor (DME MAC) unlesso<strong>the</strong>rwise noted.A6000Non-contact wound warming wound cover <strong>for</strong> usewith <strong>the</strong> non-contact wound warming device <strong>and</strong>warming cardMED: Pub. 100-3, Section 270.2<strong>Coding</strong> TipNoncontact normo<strong>the</strong>rmic wound <strong>the</strong>rapy (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 <strong>for</strong> this <strong>the</strong>rapy 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,