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Physical therapy is a dynamic profession characterized by constant change and progress. It helps to restore, maintain, and promote optimal physical function of the patient. Physical therapists are essential participants in the health care delivery system and assume leadership roles in rehabilitation. Physical therapy is a covered benefit by federal, state, and private insurance plans.
It is mandatory to report quality coding and billing for the services performed to sustain in the healthcare industry. Information on the medical record and the claim form must be consistent and accurate enough to get paid for all the covered therapy services.
Rely on us healthcare services provide effective solutions minimizing your attention to RCM and maximizing your focus more on the patient care.
Payment rates for physical therapy services are on the decline but the payer is not the problem. After all, in healthcare or in any business, cutting cost is the name of the game. If we know the payers playbook rules very well, it’s easy winning the game.
Functional reporting along with Evaluation and Re-evaluation services: Medicare uses non-payable G-codes and related modifiers to convey information about the patient’s functional status at specified points during therapy. Claims without G-codes and related modifiers will lead to denials and delayed payments.
Visits or Treatment sessions: Session begins at the time the patient enters the treatment area and continue until all the services are completed. All minutes in the treatment sessions are not billable (e.g., rest periods). Reporting the correct time units is essential for getting paid. Inaccurate/missing documentation would reduce payments or might lead to recoupment of incorrectly billed services.
Therapy caps: Medicare Part B pays for medically necessary outpatient rehabilitation services. Medicare law does not limit payment for medically necessary therapy services in a calendar year, provided there is complete information on therapy claims and medical record if therapy services reach below amounts in 2018:
✔ $2,010 for physical therapy and speech-language pathology services combined
✔ $2,010 for occupational therapy (OT) services
Once therapy services reach the amounts listed above, a special modifier “KX” must be applied to the therapy claims. Adding this modifier confirms that the services are reasonable and necessary and medical record includes information to explain why the services are medically necessary.
An ABN is required when services which are not medically necessary are provided.
Efficient Coding: Correct coding for the services rendered would help in proper reimbursement. Code selection plays a prominent role to get paid for the services rendered.
An example of incorrect coding where reimbursement drops, and an audit might be triggered -
Selection of CPT® 97110 for the therapeutic activities rendered rather than using CPT® 97530.
Here in this case we need to use CPT® 97530 when the therapeutic activities are rendered for the patient. CPT® 97110 is used when therapeutic exercises to develop strength and endurance are rendered.
The loss per claim is nearly $10.10
Modifiers and proper usage: Modifiers signify a specific line item is either covered or not for many different reasons. GP modifier is used to represent services that are considered as “always therapy” for Medicare patients.
Missing to append required modifiers or incorrect modifier usage would lead to denials.
Fixed rate payment: Paying a capped maximum per day still requires billing certain number of timed units per day to qualify for the maximum capped amount for the day. Payment would not be in proportion to the services billed.
Time documentation is a must as most of the codes used for rehabilitation services are time based. Units are calculated based on the time spent rendering the service. Time needs to be documented for every service that is rendered. Practices may incur reduced reimbursements if units are not correctly calculated.
✔ Lack of medical necessity – Insufficient Documentation to support the services billed
✔ No initial evaluation documented
✔ No progress notes available to check the medical necessity
✔ Time spent on the services rendered is not documented
✔ Specific goals of treatment are not documented
✔ Insufficient information present to indicate the progress toward goals
✔ Individual therapeutic measures and treatment modalities/exercises are not documented to support the number of units billed.
✔ Missing valid signature
✔ Documentation is illegible
You may want to improve reimbursement for physical therapy services and coming across more denials, we help you to improve your first pass ratio and decrease the AR.