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Use of Physical Medicine and Rehabilitation Codes

November 1, 2016

Blue Cross and Blue Shield of Oklahoma (BCBSOK) periodically reviews claims submitted by providers as part of our commitment to ensure our members have access to quality and affordable health care. The issues addressed in this article represent common documentation and coding errors found during our recent audits of physical therapy claims. This is not an all-inclusive list, but is intended to assist providers and their staff with documentation and coding requirements for the most common areas of concern that .

Subjective complaint: The patients’ complaint must be documented in each therapy note. This complaint should correspond with the patients’ treatment.

CPT® 97140 (manual therapy techniques, 1 or more regions, each 15 minutes): To bill this code, the documentation must include (1) the area being treated, (2) the therapy technique being used and (3) the start and stop times of the treatment or at a minimum, the direct one-on-one contact time spent on each individual activity. The manual therapy performed should require the skills of a physical therapist. An auditor should also be able to discern the expected functional performance improvement.

CPT® 97530 (therapeutic activities, direct patient contact, each 15 minutes): To bill this code, your documentation must include (1) the area being treated, (2) the specific activity or technique being used and (3) the start and stop times of the treatment or at a minimum, the direct one-on-one contact time spent on each individual activity. These activities should require the skills of a physical therapist. An auditor should also be able to discern the expected functional performance improvement.

CPT® 97110 (therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility): To bill this code, your documentation must include (1) the specific exercises performed, (2) the purpose of the exercises as related to function and (3) the start and stop times of the treatment or at a minimum, the direct one-on-one contact time spent on each individual activity. These exercises should require the skills of a physical therapist. Supervising patients who are exercising independently is not a skilled service. An auditor should also be able to discern the expected functional performance improvement.

CPT® 97112 (therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities): To bill this code, your documentation must include (1) the specific exercises/activities performed, (2) the purpose of the exercises/activities as related to function and (3) the start and stop times of the treatment or at a minimum, the direct one-on-one contact time spent on each individual activity. These activities should require the skills of a physical therapist. Supervising patients who are performing activities independently is not a skilled service. An auditor should also be able to discern the expected functional performance improvement.

Modifier 59: This modifier should only be used when the therapy is applied to separate anatomic locations or provided during different sessions.

Direct patient contact: The above listed codes require direct one-on-one contact throughout the procedure. The provider is required to maintain visual, verbal, and/or manual contact with the patient.

Reporting units for timed codes: When multiple units of therapies or modalities are provided, the 8-minute rule must be followed when billing for these services. A provider should not report a direct treatment service if only one attended modality or therapeutic procedure is provided in a day and the procedure is performed for less than 8 minutes.

  • The time reported should be the time actually spent in the delivery of the modality and/or therapeutic procedure. This means that pre and post-delivery services should not be counted in determining the treatment time.
  • The time that the patient spends not being treated, due to resting periods or waiting for a piece of equipment to become available, is not considered treatment time.
  • All treatment time, including the beginning and ending time of the direct treatment, must be recorded in the patient’s medical record, along with the note describing the specific modality or procedure. Each minute of time may only be counted once. Any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.
  • Each minute of time may only be counted once. Any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.

The following unit of service billing guideline has been published by Medicare. It is the standard when billing multiple units of service with timed procedures defined as per each 15 minutes.

  1. unit: ≥ 8 minutes through 22 minutes
  2. units: ≥ 23 minutes through 37 minutes
  3. units: ≥ 38 minutes through 52 minutes
  4. units: ≥ 53 minutes through 67 minutes
  5. units: ≥ 68 minutes through 82 minutes
  6. units: ≥ 83 minutes through 97 minutes
  7. units: ≥ 98 minutes through 112 minutes
  8. units: ≥ 113 minutes through 127 minutes

If any 15 minute timed service that is performed for 7 minutes or less on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total time of the two is 8 minutes or greater, then bill one unit for the service performed for the most minutes. The same logic is applied when three or more different services are provided for 7 minutes or less.

For example, if a provider renders:

5 minutes of 97035 (ultrasound),

6 minutes of 97110 (therapeutic procedure), and

7 minutes of 97140 (manual therapy techniques)

Then claim should be filed with 1 unit of 97140 since the total minutes of direct treatment is 18 minutes. The patient’s medical record should document that all three modalities and procedures were rendered and include the direct treatment time for each.

If any direct patient contact timed service is performed on the same day as another direct patient contact timed service, then the total units billed cannot exceed the total treatment time for these services.

For example, if a provider renders:

  • 8 minutes of 97530 (therapeutic activities),
  • 8 minutes of 97110 (therapeutic procedure), and
  • 8 minutes of 97140 (manual therapy techniques)

Then claim should be filed with a total of 2 units since the total minutes of direct treatment is 24 minutes. The patient’s medical record should document that all three modalities and procedures were rendered and include the direct treatment time for each.

Records submitted with “cut and paste” or cloned documentation: Documentation is considered “cut and paste” or cloned when each entry in the medical record for a patient is worded exactly alike or similar to the previous entries. This also occurs when medical documentation is exactly the same from patient to patient. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter.

Templates certainly are useful tools, but providers must use caution when applying “templated” language. Specifically, (although it may seem obvious) providers must ensure that what is being represented in the medical record actually took place and isn’t something the provider normally does, but may not have done for that particular patient.

Illegible documentation: During our audit, we received records with illegible documentation. Unfortunately, documentation that is not legible cannot be used to support services rendered. We make every effort to decipher the hand-written records, but if it is not possible, the claim will be denied for services not documented.

Split-Billing: We also identified split-billing during the audit. As a reminder, BCBSOK’s participating provider agreement requires that providers bill all services from the same provider and same date of service on a single claim.

Unsigned/improperly signed records: Each medical record must be signed and dated by the provider performing the services. A legible physical signature or electronic signature is required. The medical record should also be signed at the time services are rendered. You may not add late signatures to medical records.

Abbreviations: The medical record should contain only those terms and abbreviations easily comprehended by peers of similar licensure. If a legend is needed to review your records, please submit it with your records. Abbreviations should not be the only documentation when describing care. The documentation must also include a clear description of the treatment provided and how the patient tolerated the treatment.

Insufficient documentation: Checkmarks, small entries and other commonly illegible notations seldom provide adequate documentation to support services billed. Please ensure that the medical record documentation is concise and complete.

Maintenance therapy: Therapy performed for maintenance rather than restoration is considered not medically necessary.

Medical Policies and physical therapy information: BCBSOK has medical policies regarding physical therapy services. You may review these policies on our website at www.bcbsok.com. Please familiarize yourself with the website as policies are updated on a regular basis. The most common medical policies related to physical therapy are listed below:

 
Title Policy Number
Non Covered Physical Therapy Services THE803.008
Physical Therapy (PT) and Occupational Therapy (OT) Services THE803.010

BCBSOK relies on our providers to bill and document appropriately for all services submitted. It is imperative that providers and their staff are aware of documentation requirements and BCBSOK medical policies for all services provided. Claims filed with documentation that does not meet the above listed requirements will be denied and are not billable to the patient. If you have any questions please contact your provider network representative. For assistance locating your network rep please see http://www.bcbsok.com/provider/network/reps.html