1. 2010 UBO/UBU Conference
Health Budgets &
Financial Policy
Briefing: Physical Therapy Coding
Date: 25 March 2010
Time: 1010–1100
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2. 2010 UBO/UBU Conference
Turning Knowledge Into Action
Objective
To standardize Physical Therapy coding practices
throughout the AFMS…and the rest of the MHS
– PT coding issues
– Confusing coding problems
– Questions
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3. 2010 UBO/UBU Conference
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PT Coding Issues
Acronyms
AAROM = Active Assistive Range of Motion
– ABD* = Abduction
– ADD* = Adduction
– ADL = Activities of Daily Living
– B = Bilateral/Both
– CP = Cold Pack
– DTR = Deep Tendon Reflex
– ext = extension
– FWP = Full Weight Bearing
– GT = Gait Training
– HEP = Home Exercise Program
– HP = Hot Pack, or MHP = Moist Hot Pack
*(careful, more than one meaning)
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PT Coding Issues
Acronyms
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IM* = Ice Massage
LBP = Low Back Pain
mob = Mobilized, Mobilization
OMT = Osteopathic Manipulative Therapy
POC* = Plan of Care
PROM = Passive Range of Motion
US = Ultra Sound, Ultrasonography
VO = Verbal Order
WP* = Whirlpool, Warm Pool, Wet Pack
*(careful, more than one meaning)
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PT Coding Issues
Activities of Daily Living
Gait Training
Osteopathic Manipulative Therapy
Incident-to services (aka Technician services)
When are PT evaluations/re-evaluations coded
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PT Coding Issues
Activities of Daily Living
– CPT® Code 97535
– Self–care/home management training (e.g., activities
of daily living (ADL) and compensatory training, meal
preparation, safety procedures, and instructions in
use of assistive technology devices/adaptive
equipment) direct one-on-one contact by provider,
each 15 minutes
– APTA advises - This code should be utilized when a
patient is trained in the use of assistive technology to
assist with mobility, seating systems and
environmental control systems for use in the home
environment (e.g., wheelchair mobility using a mouth
control)
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PT Coding Issues
97535 – Self Care Management
Designed for ADL training/return to function at home
– Cooking
– Cleaning
– Transfers in/out of vehicle or bathroom
– Transfers out of actual hospital bed (not plinth)
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PT Coding Issues
Gait Training
– CPT® Code 97116
– Watching, evaluating and training on the manner or
style of walking, including rhythm and speed. Three
phases of gait include the stance phase, the swing
phase, and the double support phase.
Crutch training included
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PT Coding Issues
Osteopathic Manipulative Treatment
– CPT® codes 98925-98929
– Generally performed by Doctors of Osteopathy (DO)
More appropriate in PT is CPT® code 97140 Manual
therapy techniques (e.g., mobilization/ manipulation,
manual lymphatic drainage, manual traction), one or
more regions, each 15 minutes
– Manual therapy based on time (use units of service)
as well as regions
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PT Coding Issues
98925-98929 OMT codes
Civilian PTs do not use this code
DoD guidelines allow PTs to utilize OMT when appropriate
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As of:
PT Coding Issues
V57.1 Encounter for other physical therapy
– Per BDQAS – for the first quarter of FY10 utilized
85,679 times for the AF
– To be assigned in primary/first listed position
– Condition diagnoses coded secondarily
Don’t assign V57.1 when patient presents for evaluation or
re-evaluation – even when treatment starts that day
– Assign referred condition in primary/first listed position
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PT Coding Issues
Incident-to Services (aka Technician services)
– UBO restricts use of conventional incident-to services
– Appointment made to the technician if they are the
provider of that therapeutic service
– PT co-signatures are not required as services will not
be billed although still generates RVUs for the clinic
Still needs a supervising provider named on
encounter (not necessarily a co-signature)
– All tech services are provided under a therapist or
physician documented plan of care
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PT Coding Issues
When are PT evaluations re-evaluations coded
– CPT® Code 97001 evaluation
– CPT® Code 97002 re-evaluation
– Evaluations may occur when a new diagnosis is
present to develop plan of care
– Re-evaluations may occur when improvement or
decline of patient condition was not anticipated to
determine any changes to plan of care
Patient not meeting documented long and/or short
term goals
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PT Coding Issues
Documentation
– All methods of therapy must be documented in the
patient record
– Timed codes are coded per units of at least 8 minutes
for one unit (see slide 17 for table)
– Do not combine timed codes in separate
modalities/therapeutic procedures to get one unit of
service – if under 8 minutes that modality/procedure
will not be coded
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PT Coding Issues
What is the most important thing to remember about
coding?
If it wasn’t documented…
it wasn’t done!
#1 issue from the coder’s is supporting documentation
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PT Coding Issues
Rule of 8’s
Most CPT codes are based on units of time
– Rule of 8’s (>8 or multiples of 15+8)
• 1 unit= ≥ 8 minutes but < 23 minutes
• 2 units
= ≥ 23 minutes but < 38 minutes
• 3 units
= ≥ 38 minutes but < 53 minutes
• 4 units
= ≥ 53 minutes but < 68 minutes
MUST validate number of units against total treatment time
– If in clinic for 3 different modalities…
– 97110 x 12 min; 97112 x 10 min; 97010 x 20 min
– How many units can you charge???
Answer: 1 Unit of 97110: Timed 1-on-1 services = 22 min, 1
Unit of 97010: Supervised services (untimed)
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17. PT Coding Issues
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Unit of
Service
1
Greater than or
equal to
08 minutes
2
23 minutes
3
38 minutes
4
53 minutes
5
68 minutes
6
83 minutes
7
98 minutes
8
113 minutes
And fewer than
23 minutes total for all time-based
modalities
38 minutes total for all time-based
modalities
53 minutes total for all time-based
modalities
68 minutes total for all time-based
modalities
83 minutes total for all time-based
modalities
98 minutes total for all time-based
modalities
113-minutes total for all time-based
modalities
128-minutes total for all time-based
modalities
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PT Coding Issues
Documentation
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Physical Therapy Evaluations:
Initial Evaluations (97001) include:
Therapist evaluates the patient
– History
– Examination
– Assessment
– Treatment plan
Re-evaluations (97002) include:
Re-examination
Assessment of progress
Modifications to plan
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PT Coding Issues
Documentation
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Elements inclusive to examination or re-examination that
are not coded separately
Muscle testing 95831-95834
Range of motion 95851-95852
Health and Behavior Assessment/Intervention 9615096155
Physical Performance Test 97750
Assistive Technology Assessment 97755
Orthotic/Prosthetic checkout 97762
MNT 97802-97804
MTMS 99605-99607
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20. PT Coding Issues (Q&A)
2010 UBO/UBU Conference
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Is there a limit to re-evaluation codes per pt?
(If I have to do re-evaluation 3 x wk due to changes, is it
alright to charge it each time?)
If these changes were…
◦ Unanticipated
◦ Due to complications,
additional surgeries and/or
procedures, or the instability
of the pt’s condition
◦ Require you to adjust your
goals/treatment plan
YES
If these changes were…
◦ Expected
◦ Normal progression w/
course of care
◦ Built into your POC
◦ Require minimal
modification of your plan
◦ No changes to your goals
NO
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PT Coding Issues
Modalities – Supervised
– The “supervised modalities” (97010-97028) do not
require direct one-on-one contact by the provider.
Only one unit can be coded per visit, regardless of the
number of body parts treated
– Direct supervision – must be physically present and
available in the clinic
Modalities – Constant Attendance
– The “constant attendance modalities” (97032-97039)
require that a provider have direct one-on-one contact
with the patient for the minutes represented by the
code
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PT Coding Issues
Therapeutic Procedures (97110-97546)
– Therapist required to have direct (one-on-one) patient
contact
– Constant attendance required unless group therapy
(97150)
– Personal supervision requires that the provider is in
the same room of the patient during the entire
procedure and in the immediate vicinity of the patient.
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23. 2010 UBO/UBU Conference
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PT Coding Issues (Q&A)
T or F: We code what our patients do during their
treatment session.
FALSE
– Technicians and therapists code what THEY do in the
clinic…NOT what their PATIENTS do in the clinic.
– Remember…the following are necessary in order to
code for workload/reimbursement
REASONABLE
& MEDICALLY NECESSARY
ADEQUATELY DOCUMENTED
Rendered by a QUALIFIED PROFESSIONAL
SKILLED services provided under a PLAN of CARE
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24. PT Coding Issues (Q&A)
2010 UBO/UBU Conference
Turning Knowledge Into Action
How can I bill for the time one patient is exercising in the
gym doing exercises on the equipment?
If, while exercising, the PT or PTA
is monitoring the pt’s pulse and
BP and instructions are given
related to target HR and
adjustments are made to the
speed/angle of the treadmill…
observations are being made and
recorded, the service would be
considered skilled and billable.
All of the components of the
service that represent skilled care
must be documented.
YES
Supervision of one patient
performing exercises in the
absence of provision of skilled
services is not billable.
NO
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25. 2010 UBO/UBU Conference
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PT Coding Issues (Q&A)
Can joint mobilization be coded and charged by techs?
YES, there is nothing in the DoD coding guidelines
preventing military technicians from using 97140.
– Military technicians need to have this training
documented in their AFTR.
– The supervising therapist is the final authority and
responsibility in educating/training/certifying that the
technician working under their plan of care is qualified
to provide joint mobilizations.
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26. PT Coding Issues
2010 UBO/UBU Conference
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Modalities (97010 – 97039)
Supervised
– Codes 97010-97028
– Does not require direct
patient contact (1-to-1)
– Time is NOT a factor
– Only 1 unit/visit
Constant Attendance
– Codes 97032-97039
– Requires 1-on-1
• Provider maintains
visual, verbal, and/or
manual contact with
the patient throughout
procedure
Time based—include time
required to perform all
aspects of service
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27. PT Coding Issues
2010 UBO/UBU Conference
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Supervised Modalities
CPT Code
Definition
97010
Hot / Cold pack
97012
Traction, mechanical
97014
E-stim (unattended)
[Indications other than wound care]
97016
Vasopneumatic device therapy
97018
Paraffin Bath
97022
Whirlpool / Fluidotherapy
97024
Diathermy treatment
Untimed codes Do not require 1-on-1
May only be used once per visit (regardless of number of areas treated)
*Disposable electrodes are included and cannot be billed separately
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PT Coding Issues
Supervised Modalities
– Documentation Requirements
– Use codes 97010-97028
– Supervised by provider but does not require direct
patient contact (one-to-one)
– Time is not a factor—only 1 unit can be reported for
each encounter
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29. PT Coding Issues
2010 UBO/UBU Conference
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Constant Attendance Modalities
CPT Code
Definition
97032
Electrical Stimulation (attended)
97033
Electric current
therapy/Iontophoresis
97034
Contrast bath therapy
97035
Ultrasound therapy
97036
Hydrotherapy
Requires 1-on-1
Provider maintains visual, verbal, and/or manual contact with the patient
throughout procedure
Time based—include time required to perform all aspects of service
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PT Coding Issues
Constant Attendance
– Documentation Requirements
Use CPT codes 97032–97039
Requires one-on-one contact
– Provider maintains visual, verbal, and/or
manual contact with the patient throughout
procedure
– Time based—include time required to perform
all aspects of service
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31. PT Coding Issues
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CPT Code Definition
97110
97112
Neuromuscular reeducation
97113
Aquatic therapy/exercises
97116
Gait training therapy
97140
Manual therapy
97150
Group therapeutic procedures
97530
Therapeutic activities
97532
Cognitive skills development
97533
Sensory integration
97535
Self care/management training
97537
As of:
Therapeutic exercises
Community/work reintegration
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PT Coding Issues
Documentation Requirements
– Skilled services that affect change through the
application of clinical skills and/or services that
attempt to improve function
– Requires direct, one-on-one patient contact by
provider—maintain visual, verbal, manual contact
with patient throughout procedure
– For technicians, must be working under guidance
of privileged provider – plan of care
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PT Coding Issues
Therapeutic Procedures (97110-97546)
Codes represent the majority of what is done
Requirements as follows:
– Skilled services
– Requires 1-on-1
– Time-based codes
– Provider maintains visual, verbal, and/or manual
contact with the patient throughout the procedure
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PT Coding Issues
Do we need to document the specific amount of time
spent performing each timed procedure?
– Yes
– 97110 (Therex) x 12 min
SLR x 3 (3x15); SAQ (3x15); Wall Slides 3x25
– 97112 (Neuromuscular Re-Ed) x 13 min
Single Leg stand Rebounder (3x25 tosses w/2#
ball)
3 Dir hip kicks w/Tband on uninvolved (3x10)
– 97010 (ice) x 15 min (untimed-use only once/visit)
Total 1-on-1 time = 25 min
Total treatment time (timed + untimed) = 40 min
Documenting the time required to perform each
individual exercise is NOT mandatory
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As of:
PT Coding Issues
Can I code for treatment during an evaluation?
– YES, Documentation is the critical component
– For example, if you evaluated a low back pain
patient, you can code 97001 (eval) and then
97110 (10 minutes of therapeutic exercise
instruction…if you instruct the patient and have
them demonstrate proficiency in the same visit).
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PT Coding Issues (Q&A)
Why would we use assisted exercises for ROM
(97110) with PT neuromuscular re-education
(97112)?
– 97110
Exercises
to develop strength, endurance, ROM, and
flexibility
–
97112
Activities
to facilitate re-education of movement, balance,
coordination, kinesthetic sense, posture, and
proprioception
Ankle rehab to restore ROM (97110) and Single leg
standing on a foam pad +/- Rebounder (97112)
As of:
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As of:
PT Coding Issues
Orthotics and Prosthetics
97760-97762 replaced codes 97504/97520/97703 in 2006
– AMA says: “Orthotic management (97760) includes
assessing the patient; determine the most appropriate
orthotic (e.g., Static vs. dynamic); and designing, selecting,
and fabricating the orthotic.”
– “Also includes further orthotic training during follow-up visits
including exercises performed in the orthotic, instruction in
skin care, and orthotic wearing time.”
Extracted from APTA publication
– Physical Therapy Reimbursement News
– Volume 13, Number 2 (March/April 2006)
Do not use with HCPCS Level II codes (L- and K-section) if in
the description the assessment and fabrication is listed.
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PT Coding Issues
Can we use 97530? How is this different form 97110?
– Yes
– Therapeutic exercise (97110)
Includes activities related to strengthening, endurance training,
ROM, and flexibility. These activities can include use of free
weights, exercise machines such as treadmills or ergometers,
and AROM/PROM
– Therapeutic activities (97530)
Utilize dynamic activities to improve functional performance.
Think of this as the “-ing” code, for example “lifting,” “pulling,”
“pushing,” “running,” and “jumping.” If you are providing
instruction in activities related to an actual activity, then the
therapeutic activity code would be appropriate.
Reimbursement, Coding, and Compliance for Physical Therapists
The ABCs of CPT Coding, By Rhea Cohn, PT, MA // APTA Web site
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PT Coding Issues
Direct Access – Initial Evaluation (situations requiring E
code)
Requirement for E-Codes (2.2.9)
If performing DIRECT ACCESS and this is the first time
the patient has been seen at the MTF for the current injury
(due to external causes) E 800-999 & V71.3 – V71.6 Used
to describe where, why, & how injury occurred
– Coding
724.2 Low
back pain
Exxx.x injury due to fall from ladder
–
Documentation
Should
include DOI, location, if MVA related (state) or if work
related (name of employer)
As of:
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V Codes
Use V-codes when the initial treatment of a disease or injury has
been completed (via surgical or wound healing), but requires
continued care during the healing phase or long term consequences
of the condition/disease
Aftercare Codes for Injury/Fractures
–
V53.7
V54.89
V54.81
V58.78
–
V67.89
–
–
–
As of:
PT Coding Issues
Orthopedic device fitting and adjustment
Aftercare for healing fracture (NOS)
Aftercare following joint replacement
Aftercare following surgery of the
musculoskeletal system (NEC)
Follow up visit after all treatment is complete and
patient no longer has diagnosis/problem for which
they sought care
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PT Coding Issues
Patient Education
Capture patient education…which is critical component
is under the one-on-one codes
– 97110
– 97112
– Etc…based on what you are teaching
– Key is to document what was covered
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As of:
PT Coding Issues
Group Therapy - 97150
Area of significant controversy
Key issues
– PT/OT services provided simultaneously to two or
more individuals by a practitioner as group therapy.
The individuals can be, but need not be performing the
same activity. The PT/OT or PM Tech involved in the
group therapy must be in constant attendance
[providing feedback/actively involved], but one-on-one
contact is not required.
PM Technician codes = 97150
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As of:
PT Coding Issues (Scenario)
Patient is a “regular”
She grabs her flow sheet and begins exercising
independently (Bike x 10 min; Hamstring Curls 3 x 15; Leg
Press 3 x 15; Fitter x 10 min) in gym.
The PM tech is working with another patient across the
room.
Patient finishes the treatment and asks the tech for some
ice.
Independent exercise in the clinic is NOT a “skilled
service” and cannot be billed/coded
PM Technician codes = 97010 (1 unit)…THAT’S IT!
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44. 2010 UBO/UBU Conference
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PT Coding Issues
Why can’t I get more than 4 CPT codes…& they’re
missing my units of service?
Problems with SADR
Unable to capture the following:
– Units of service
– Modifiers
– Any CPT or ICD-9 beyond four
CAPER is coming soon to an MTF near you…
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This and the next slide are some common acronyms…definitely not an all inclusive list
From the PT Bulletin APTA;
Q: How can I bill for patient education?A: The time spent providing patient education is billable time although there is not one specific CPT code for "patient education." APTA recommends that you determine your desired outcome of care related to that education. For example, if you are instructing the patient in a home program of strengthening exercises for the quadriceps, that time can be billed under 97110, therapeutic exercise. If your instruction is related to ergonomic issues in the workplace, the time can be billed under 97537, community/work reintegration training.
By definition, this type of training should be provided in a more real life situation…for example having a simulated kitchen, etc.
Plinth is a base for a column, or support
We’ve had questions regarding a tech performing this service without a therapists plan of care. A plan of care could come as a prescription from a surgeon getting ready to do knee surgery on the patient, or it could come from the patient’s PCM…not always an official POC from a therapist.
This diagnosis code is usually in the top three to five most utilized every month. We perform a lot of physical therapy, which makes this so important to understand and ensure the documentation is adequate which hopefully will help the coding to be more accurate.
Our DoD “incident to” is not the same as CMS/Medicare rules. Our PT, OT, orthotic and Nutrition techs do have count workload so the rules for these techs are not the same as in the rest of the clinics.
Code 97001, Physical therapy evaluation, would be reported for the comprehensive evaluation performed at the first visit. This code is not a time-based code and should be reported once per episode, regardless of how many body parts are involved.
CMS says (Pub 100-02) it’s okay to treat under two separate plans of care (evaluations) on the same day for different problems as long as there are two referrals or requests from different providers. There must be two separate plans of care if this occurs
The intent of a reevaluation is to assess progress and modify or redirect future interventions. May have consecutive re-evaluations if referred for multiple problems and unable to complete in one evaluation
First bullet…whether timed or not, documentation must support each modality or therapeutic procedure. Group therapy documented needs to be coded as group therapy, even if patients are not performing the same exercise…example: three people attending group aquatic therapy, 1 may exercise shoulder, one knee, and one ankle.
First indented bullet…for instance: 10 minutes of unattended e-stim, 20 minutes of aquatic exercises. Total time 40 minutes.
Last bullet…example: 4 minutes of US and e-stim for 3
REMEMBER: document those therapeutic procedures (we’ve got exercises and neuromuscular education) and hot/cold packs
Performed by the PT only
Performed by the PT, not techs
MNT = Medical Nutrition Therapy
MTMS = Medication Therapy Management Services
DOCUMENT!!
Reimbursement, Coding, and Compliance for Physical Therapists
The ABCs of CPT Coding
Documenting in the record doesn’t count for the time in the timed codes.
Documentation must support the service provided.
Total time documented performing the modality
Therapeutic Exercises
My caveat to the last bullet is that even time doesn’t have to be documented for each exercise, documentation still needs to describe what happened-exercises prescribed to patient…with total treatment time
The diagnosis for this would only be the condition the patient was being evaluated for.
For those PT clinics that are direct access, meaning the patient see the PT as a provider in a clinical setting
This is to say…when teaching/educating on a procedure for instance to teach the patient home exercises
Not sure what PM tech is??? Physical Medicine, Preventive Medicine,
CAPER = Comprehensive Ambulatory Professional Encounter Record