Wisconsin Physical Therapy Association -Reimbursement Frequently Asked Questions

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Reimbursement Frequently Asked Questions


Reimbursement Center FAQs are catagorized into these bins: Scope of Practice FAQs Practice Management FAQs Payment Policy FAQs Medicare FAQs Medicaid FAQs CPT Coding FAQs 2007 Q1 FAQs 2006 Q3 FAQs 2006 Q2 FAQs 2006 Q1 FAQs
Do you have a Frequently Asked Question for the WPTA Reimbursement Team?
Scope of Practice FAQS
Can a physical therapist dispense or recommend use of vitamins or other supplements? Can a physical therapist keep medications in their office and stock medications? Can a physical therapist treat animals? Can a physical therapist treat injuries at an athletic event without a physician referral? Can a PT and OT share a patient under one plan of care? Can a PT supervise a COTA or can an OT supervise a PTA? Can a therapist use a scalpel? What can be used to defend this position to an insurance company? Can I get reimbursed for services provided by students? Can physical therapists bill outside of the 97000 series? Do payers permit physical therapists to bill for manipulation? How can a therapist bill for participating in weight loss programs? Is this within our scope of practice? How can co-treatments with an OT be billed? How can physical therapists bill for health promotion and wellness programs? How will a PT know a payers policy on treatment of womens health problems? Please explain APTA policies on supervision of PTAs. Does this differ from Medicare policies? What should a physical therapist prepare for emergency situations? Will a payer reimburse for a physical therapist to perform EMG/NCV? Top of Page
Practice Management FAQS
Are there any good electronic documentation systems? Can a physical therapist opt-out of Medicare? Can I waive copays and deductibles? How can I find out more information regarding billing software? How can I maximize collection of copays and deductibles? How come I cannot get into a network? How do I bill for supplies? How should a therapist bill for home visits provided by hospital or out-patient clinic based PTs vs. home health PTs? I am still unsure how to bill one-on-one vs. group therapy. Is there a reference I can use? Please explain PTA supervision in different practice settings? Please explain the 60-day certification process. Please explain the 8-minute guidelines Should I consider first party pay? What are important considerations when establishing a contract with a payer? Top of Page
Payment Policy FAQS
Can I collect interest on claims that are paid late? How can a chapter submit comments for reconsideration of local coverage decisions? Medicaid usually offers poor reimbursement and there are restrictions by site of care. Do you have any advice? What can be done for a benefit that is limited by a specific number of calendar days? What can be done if a payer bundles more than one provider under a single cap? What can be done if a payer establishes a cap based on CPT code use vs. a provider cap (e.g. PA)? What if a payer has a specific payment policy to deny services for a specific condition (e.g. TMJ)? What if a payer will not pay for evaluation (97001) or reevaluation (97002)? What if a payer will only pay for one evaluation per year, regardless of number of episodes of care or number of diagnoses? What is a silent PPO. What should I do if a payer is not sending payment in a timely fashion? How should I construct my appeal? Why are copays increasing at such a fast rate? Im afraid the patients wont want to attend therapy as often as I recommend? Why are more companies not paying for services provided by PTAs? What can we do? Top of Page
Medicare FAQS
I am unsure when to use V-Codes with OP Medicare billing. I was at a recent billing course and I just want to run a couple billing scenarios by you and see what you would recommend billing MEDICARE: Are daily notes required for our Medicare patients? What do you know about this new progress report for Medicare after 10 visits requirements? Top of Page
Medicaid FAQS
Can I bill a patient if Medicaid denies a PA for the services? How must I inform the patient prior to billing if allowed? Can I limit the number of Medicaid patients my practice serves or can I totally eliminate my participation in the program (deny services to all Medicaid patients)? Can you give some hints about what to include in a PA/TA request to assure it passes through the review process successfully the first time? Does Medicaid impose CCI edits and require modifiers? How do I know when to use a Prior Authorization/Therapy Attachment versus a Prior Authorization/Spell Of Illness Attachment? What are the Initial 35 days in a Spell of Illness and what types of therapy visits count against the Initial 35 days? How do I submit my PA to Medicaid? How does Medicaid define a unit of service and can I bill all of the Physical Medicine CPT-4 codes to Medicaid? May I start treating the patient prior to receiving an approved prior authorization back from Medical Assistance? Must I record Time In/Time Out as with Medicare? What are the documentation requirements? What are the maximum units I can charge for a patient in one day and how does Evaluation billing differ for Medicaid from other payers? What are the physician prescription requirements for Medicaid and what is the difference between prescription and a certification/recertification of a plan of care? What are the supervision requirements for PTAS? What do hospital off site clinics have to do differently from outpatient hospital clinics? What do I have to do to become certified for Wisconsin Medical Assistance? Top of Page
CPT Coding FAQS
Coding for Specific Diagnoses: A major payer has announced that they will not pay for TMJ services. How should a therapist bill? Coding for Specific Diagnoses: A payer in Kentucky is not paying for treatment of plantar fasciitis. What can be done about this? Coding for Specific Diagnoses: How should we bill for vestibular rehabilitation CPT Coding Edits: A payer will not reimburse for manual therapy and/or therapeutic exercise when billed with any modalities. There appears to be no limit on the number of modalities that can be billed without procedures. Therapeutic exercise and manual therapy can be billed on the same date of service without modalities. CPT Coding Edits: Is there a way to modify or qualify 97140 so it is not considered inclusive under Medicare? CPT Coding Edits: A payer will not permit use of the sensory integration code (97533) and advises providers to use neuromuscular reeducation (97112) instead. CPT Coding Specifics: Please describe the Assistive Technology Assessment code (97755). When should it be used? CPT Coding Specifics: What are examples of correct use of the ADL code? Evaluation and Management Codes:: Is it appropriate to use 99201 or 99211 when a patient comes in for a visit and you spend time with them but end up not providing any therapy services for them? IDC-9 coding: How many digits are needed for an ICD-9 code? IDC-9 coding: What is the correct ICD-9 coding for obesity? Orthotics: When we cast for orthotics, how can we bill for supplies? Patient Education: Often we have a patient for 30 minutes and spend 10-15 of those minutes answering questions and providing education. What is the most appropriate way to bill these patients? How can our documentation reflect 30 minutes of direct one-on-one care if only 15 minutes were spent doing exercise and/or the patient questions a bill with charges for 30 minutes of exercise? Patient Education: The insurance company will not pay for patient education coded as 97535. Physical Performance Test or measurement (97750): When is it appropriate to use the physical performance test of measurement code? Physician Referrals: Is there a written/unwritten regulation regarding the duration of a physician prescription for commercial insurance or private pay patients. Does the prescription have to be updated once per month? Preauthorization Challenges: Payers want to pre-authorize the use of Biofeedback (90911) but we need to use the biofeedback evaluation to show the need for continued use. Pre-surgical training and education: A patient is referred to physical therapy for pre-operative total joint arthroplasty training in exercise and ambulation with assistive devices. How can this be billed? Can the therapist bill for an evaluation? Can the therapist bill for another evaluation post-operatively? Reevaluation Code (97002): When is it appropriate to use the reevaluation code? Therapeutic Procedure Codes: How much one-on-one time is needed to be spent with the patient to bill each unit of the timed codes in comparison to the group code (97150). Therapeutic Procedure Codes: Our state workers compensation department has denied 97112 for musculoskeletal diagnoses stating that 97112 was intended only for neurological diagnoses. What is the major difference between 97110, 97112 and 97530? Workers Compensation: Are there different codes for work conditioning and work hardening and reimbursement for same in each state? Top of Page
2007 Q1 FAQS
Can I see a homebound Medicare patient under the Medicare Part B Physical Therapy benefit? How can I find the CCI edits on the Internet? How do I bill for setting up a TENS unit for Medicare? How should I bill non-selective wound debridement? Is there a code that a Physical Therapist could use for weight loss counseling? Is there a difference between a PT and PTA performing the above procedure? If so, how would you define the difference? Question about the selective debridement code (97587 and 97598): according to Phys Med 009, this code may only be used for active selective debridement only (i.e. more than 8 minutes of removal of devitalized tissue), as it does not account for applying any medication or dressings to the wound. Is this correct? Regarding MA prior authorization, I have heard that if the patient has never had physical therapy or if the lifetime visits is less than 35,then prior authorization is not needed to continue services. Is this true? Do we have to submit the PA/TA and PA/RF paperwork for every MA patient regardless? Please clarify for me. Should we use the physical performance test and measures code instead for the above process? The concern is that charging re-assessments are a red flag to insurances and our coders have to use special modifiers when using this code. Have you come across this? What is required on a patient consent form? What is the easiest way to get the 2007 Medicare Fee Schedule for Wisconsin? Does UGS have it on their website? With the automatic exemption do we put the KX modifier on the initial bill and each line item there after or due we wait until we reach the cap limit then place KX modifiers from that point on? Top of Page
2006 Q3 FAQS
Are guidelines specified on a formal discharge document for Medicare patients? Can a chiropractor become a primary referring doctor for Medicare patients in the state of Wisconsin in referring Medicare patients to physical therapy? Medicare does not recognize Chiropractors as prescribing, certifying or recertifying physicians in WI. See Page 123 of the Medicare Transmittal. Can PT/OT students treat Medicare A patients that are inpatient acute care? Currently, we are trying to seek out information on standards that need to be met in order to be able to offer aquatic therapy at an off-site pool. What guidelines need to be met to be reimbursed for this service at our facility? How do I bill for theratogs and /kinesiotaping: If Medicare does not cover BPPV or vertigo, is there another code that I can use to get payment for services? If Medicare does not cover BPPV or vertigo, is there another code that I can use to get payment for services? It seems to me that the practice of waiving co-pays "under the table" has become rampant in WI. How does the APTA feel about this practice? Should I be coding hypertension, osteoarthritis for all my patients even though I personally did not diagnose them? Do we code these conditions as well if they affect the treatment? The potential for sharing Medicare patients does not violate the PT or OTs practice act; however, is there a Medicare regulation stating PTs cannot specifically treat another disciplines POC? If so, would the I concur form allow PTs to treat and OTs patient if there was a signed document stating the PT agrees with the OT POC? We follow a protocol from a spine surgeon post-op. He wants us to see his patients at 2 weeks, 6 weeks and 3 months post op. Do we need to do a recertification on his Medicare patients in the time that we don't see them in the 30-day window? Or can we put in the care plan that we will put the patient on hold to do the HEP and then recertify when we see them again (even though it might be after 30 Days)? What billing code do you use to prior authorize serial casting to Medicaid? What does Medicare expect in order to verify MD oversight for inpatient acute care PT/OT/SLP? What is CMS/UGS policy on how we should charge for a single visit instruction in and application of TENS for home use? What is the grace period for obtaining a cert/revert? When billing codes that are CCI comprehensive edits, do you use the 59 modifier on either codes, or just one of them? Top of Page
2006 Q2 FAQS
Are daily notes required for our Medicare patients? Are physical therapists allowed to bill consult visits to Medicaid? Can a physical therapist bill a therapy session to Medicaid if he/she does not provide direct/interactive therapy with a child? Can I bill my patients insurance company for the time I spent discussing the plan of care and how it may change given upcoming diagnostic testing? If so, what is the appropriate CPT code? Can Medicare patients receive aquatic therapy in a public pool? Can patient co-payments or deductibles be waived? Can physical therapists bill outside of the 97000 series? Can PTs in Wisconsin accept referrals from physician assistants for Medicare beneficiaries? Can PTs receive referrals from chiropractors for Medicare recipients? No. CMS clearly states that referrals from chiropractors for PT services are not covered under the Medicare benefit. Furthermore, a physician or non-physician provider (NPP) should not certify a plan of care if the care was not initiated by a physician or NPP. Steffes & Associates QTR 2, 2006 CPT Coding Edits: Is there a way to modify or qualify 97140 so it is not considered inclusive under Medicare? Does a PT initial plan of care or subsequent plans of care for a Medicare recipient in a hospital acute or inpatient rehab setting need to be certified/recertified by a physician at a particular interval? For the Medicare Automatic Exception Process, what is the difference between Complexities and Conditions? How come I cannot get into a network? How much one-on-one time is needed to be spent with the patient to bill each unit of the timed codes in comparison to the group code (97150)? How should we bill for vestibular rehabilitation? I am unsure when to use V-Codes with OP Medicare billing. IDC-9 coding: How many digits are needed for an ICD-9 code? If a chiropractor, podiatrist or physician bills a CPT code like 97035 (ultrasound) or 97014 (traction) when treating a Medicare beneficiary, will this count against that patients cap limit? Is there a written/unwritten regulation regarding the duration of a physician prescription for commercial insurance or private pay patients. Does the prescription have to be updated once per month? Is there any law or statute stating out of network providers are entitled to be reimbursed some amount of money for the services they provide? Patient Education: Often we have a patient for 30 minutes and spend 10-15 of those minutes answering questions and providing education. What is the most appropriate way to bill these patients? How can our documentation reflect 30 minutes of direct one-on-one care if only 15 minutes were spent doing exercise and/or the patient questions a bill with charges for 30 minutes of exercise? Please describe the Assistive Technology Assessment code (97755). When should it be used? Please explain the Medicare 60-day certification process. Pre-surgical training and education: A patient is referred to physical therapy for pre-operative total joint arthroplasty training in exercise and ambulation with assistive devices. How can this be billed? Can the therapist bill for an evaluation? Can the therapist bill for another evaluation post-operatively? Should I consider first party pay? The insurance company will not pay for patient education coded as 97535. What are examples of correct use of the ADL code? What are the definitions for the following ICD-9 codes? 719.7 781.2 781.92 What do you know about this new progress report for Medicare after 10 visits requirements? What if a payer will only pay for one evaluation per year, regardless of number of episodes of care or number of diagnoses? What is the correct ICD-9 coding for obesity? When is it appropriate to use the physical performance test and/or? measurement code? When is it appropriate to use the reevaluation code? When treating patients in the SNF or acute care setting, what are the regulations regarding the use of PT techs or aides? When we cast for orthotics, how can we bill for supplies? Why are more companies not paying for services provided by PTAs? What can we do? Top of Page
2006 Q1 FAQS
Hope you can answer an age old question-can PTAs do joint mobs? A Physical Therapist wanted to know if there is any law/regulation that states a provider cannot waive a patient co pay or deductible. Several patients wanting us to waive these items. Could you please tell me what the reimbursement is for cold laser for HMO's and Medicare. Estim (unattended- 97014) is non-covered for Medicare. Is there another code that can be billed for IFC-types treatments? How have hospital-based PT Providers extended Direct Access Practice without referral guidelines into the hospital setting which is NOT expressly mentioned in WI PT Statutory language? I have a patient with multiple medical problems including CP, chronic hip dislocation with fusion, scoliosis with multiple level fusions etc. She has difficulty with land based exercises and would like to begin an independent aquatic program to maximize independence and function, however, has limited resources and can not cover the membership fees at aquatic facilities. She does have Medicare (disability) and Medicaid for coverage. I was wondering if you knew if either would cover the cost of an independent program and if so how I could assist her with this? What is your experience with evaluating different "body part diagnoses" on the same day? For example, a patient comes in with a diagnosis of shoulder strain/RTC and ankle sprain. Can you bill 2 separate eval codes? And have 2 separate charts since the POCs/goals will be different? Wondering what procedure code would be used for a work ergo assessment? Top of Page
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