IS IT A MODALITY OR PROCEDURE?
Avoid common PMR coding errors
By Michael D. Miscoe, CPC, CHCC, CRA
Coding can be confusing. Vague code descriptions and varying carrier rules for how and when codes should be used cause some errors.
Most coding mistakes in physical medicine and rehabilitation (PMR), however, can be traced to a fundamental misunderstanding of the difference between modalities, procedures, and contact requirements for each.
DEFINITIONS AND DIFFERENCES
Modalities and procedures are distinct and separate as defined in the AMA CPT Manual:
• Modalities. The AMA CPT Manual defines a modality as any physical agent applied to produce therapeutic changes to biologic tissues. Types of physical agents include, but are not limited to, thermal, acoustic, light, mechanical, or electrical energy.
Modalities are further subdivided into “supervised” and “constant attendance” modalities based on the degree of contact necessary to perform the service.
Supervised modalities (CPT 97010-97028) do not require direct one-on-one patient contact by the provider. Constant-attendance modalities (CPT 97032-97039), however, do require direct one-on-one patient contact by the provider.
You should note that the definitional requirement for direct “one-on-one” contact is somewhat of a misnomer, since you can provide constant attendance to more than one patient at a time.
To avoid problems, it is best to take a literal definition of constant attendance — that is, the provider or therapist must be in constant attendance with the patient, and such attendance is necessary for effective or safe delivery of the therapy.
• Procedures. The AMA CPT Manual defines procedure as “a manner of effecting change through the application of clinical skills and or services that attempt to improve function.”
Procedures require a physician or therapist to have direct one-on-one patient contact.
Two parts are key to distinguishing between a modality and a procedure. The first part involves a “gizmo” analysis; the second part involves reporting.
• Modality/procedure determination (gizmo analysis). If the therapy is delivered by some device (a gizmo) and the clinical skill is limited to determining the settings of the device and/or location and duration of application, the service is clearly a modality.
When the effect of the therapy is more dependent on the clinical skill of the practitioner (even if a device is used), the service is more likely a procedure.
• Specific code selection. For modalities, the code is selected based on method of performance, or more accurately, the physical agent (gizmo) used and level of contact necessary; the specific outcome is irrelevant.
For procedures, the code is selected based on the therapeutic outcome intended — the method of performance is irrelevant provided that one-on-one contact is provided and necessary.
CORRECT MODALITY CODING
Here are some common modality-coding errors:
• Laser therapy. Laser therapy is clearly a modality (a gizmo delivers the physical agent of light) and requires constant attendance (someone has to hold the laser probe).
This modality is often incorrectly coded as infrared therapy. Although it is true that laser falls within the infrared spectrum, using the CPT code for infrared therapy (97026) when reporting laser therapy is incorrect because laser therapy requires constant attendance, not supervision.
When you perform laser therapy, use HCPCS code S8948 or if S-codes are not permitted (for instance, with Medicare claims), report CPT 97039 and document the time of performance.
• Electric stimulation. Three codes exist that relate to electric stimulation — CPT 97014/G0283, supervised electric stimulation; CPT 97032, attended manual electric stimulation; and CPT 97033, iontopheresis.
CPT 97014/G0283 is appropriate for pad-based e-stim, which requires supervision only. Although this is not a time-based service, accepted protocols require 15 minutes to as much as 30 minutes of treatment.
CPT 97032 can only be used when stimulation is manually applied. The requirement for constant attendance is derived from the manual-application requirement.
Usually a probe or other hand-held device is used and must be held for the entire therapy. This is a time-based service reported in 15-minute units.
CPT 97033 is appropriate only when iontopheresis — the introduction of ions of soluble salts into the body by an electric current — is applied. Applying topical gels to the skin prior to application of the electric stimulation pads is not considered iontopheresis.
Although the pads used in this treatment are similar to those used in supervised e-stim, constant attendance is required because of the potential for burning the patient’s skin during therapy.
• Ultrasound and phonopheresis. Ultrasound is a constant-attendance modality, which, according to the AMA CPT Assistant, is provided to increase tissue temperature for treating arthritis, neuromas, and adhesive scars, or for conditions in which increasing tissue temperature is the desired effect.
Continuous ultrasound clearly provides such a thermal effect, whereas pulsed ultrasound is generally a nonthermal form of ultrasound. Reporting of pulsed ultrasound, however, using CPT 97035 may be inaccurate.
Some pulsed ultrasound units, which have ultrasound heads attached to a mechanical arm placed over the patient, are marketed as hands-free devices. Constant attendance is not required, and CPT 97035 is therefore inappropriate. The appropriate code for hands-free forms of ultrasound is CPT 97039.
Phonopheresis is ultrasound treatment that uses a steroidal cream in place of the usual types of conductive gels. Report the ultrasound with CPT 97035 and the steroidal cream with the supply code 99070. Phonopheresis is often misreported as an unlisted procedure (97039).
• Vasopneumatic therapy. Many providers incorrectly report vibratory massage with CPT 97016. Because vibromassage devices require constant attendance (not supervision), the correct code for vibratory therapy is 97039.
CORRECT PROCEDURE CODING
Modalities are coded on the basis of the physical agent applied or how they are performed. Procedures are reported on the basis of the therapeutic outcome intended, not the method of performance.
With the exception of the group-therapy procedure (CPT 97150), all therapeutic procedures are time-based and require direct one-on-one contact.
As a result, validation of your code selection (and units) depends on having evidence of the therapeutic outcome, time of performance, and level of contact needed/provided.
The requirement of clinical skill, the intended outcome, and direct one-on-one contact are tied together. For most musculoskeletal problems, either CPT 97110 or 97530 is appropriate for your skilled rehabilitation services. The problem is deciding the appropriate code. As you likely have discovered, the descriptions for these codes provide little help.
• Strength, endurance, range of motion, and flexibility. CPT 97110 and 97530 both address these outcomes, are time-based, and require direct one-on-one contact by the provider. Despite these similarities, there is a difference between these procedures.
CPT 97110 is appropriate when the outcome of the exercise is one of the following: strength, endurance, range of motion, or flexibility.
CPT 97530 is appropriate when the outcome of the exercise involves multiple parameters.
While the AMA provides a number of examples of how each of these procedures might be performed, don’t be fooled — they are just examples. Remember, the method
of performance does not determine the code.
Without a local carrier policy stating otherwise, to select an exercise or activity code correctly, you must determine (and hopefully document) how many therapeutic outcomes are served by the particular procedure or technique performed.
This should be defined in the treatment plan. For example: If you prescribe an elliptical walker exercise to improve strength and cardiovascular endurance, use 97530. If endurance is the only goal, use CPT 97110.
Simply put: If you are aiming at one outcome (strength, endurance, range of motion, or flexibility), use 97110. For more than one outcome, use 97530.
• Neuromuscular re-education and gait training. CPT 97112 and 97116 are commonly misreported. While both are time-based (in 15-minute units) and require direct one-on-one contact of the provider, they are not appropriate for most musculoskeletal rehabilitation scenarios.
CPT 97112 involves neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting or standing activities.
This code gets a lot of attention from fraud investigators because this service gets used to represent manual proprioceptive techniques or neuromuscular massage techniques.
This code is used correctly when the relationship of the procedure to sitting or standing activities is evident. Many carriers have placed restrictions on the use of 97112. These restrictions generally involve significant neurologic deficits, such as muscular dystrophy, stroke, and cerebral palsy, thereby establishing the primary neurologic emphasis of this service.
CPT 97116 is used to report gait training, including stair climbing, stance, swing, and double-support. Again, most carriers restrict use of this service to patients with substantial gait anomalies in which the gait deficiency is neurologically centered rather than due to relatively minor problems with activation patterns.
• Massage therapy. Massage is often miscoded and providers should exercise caution before attempting to bill for massage services.
Massage is a therapeutic procedure and, therefore, requires skilled application. It is also a time-based service that requires one-on-one contact. Given the near universal bundling of this service with manipulation, this service is not reportable is in many circumstances.
When massage is provided, CPT 97124 should be reported.
As with all procedures, your documentation must be clear concerning the service performed and therapeutic outcome to be achieved in order to select the correct procedure code.
Michael D. Miscoe, CPC, CHCC, CRA, is a certified professional coder, certified healthcare compliance consultant, certified rehab assistant, the president of Practice Masters Inc. (www.codingexperts.com), and a member of the National Advisory Board of the American Academy of Professional Coders. He can be reached at 814-754-1550 or by e-mail at firstname.lastname@example.org.
The numbers tell the story
By William Berkowitz, DC
When doctors don’t understand their numbers, they have a problem. The familiar adage, “If you don’t know where you’re going, you won’t know when you get there” can easily be restated, “If you don’t have a method of measuring your progress, you won’t know how far you have gone.”
The costs of doing business, from rent to payroll to insurance, are steadily rising, while insurance reimbursements are progressively dwindling. To manage and succeed, you need to know where you stand at all times. That calls for an understanding of basic business statistics.
TWO IMPORTANT STATISTICS
The single most important statistic for your practice is the total amount of case fees collected per patient — that is, the total amount of money a patient spends in your office during his or her lifetime. In a chiropractic practice, the case-fees-collected statistic is calculated in two steps:
1. Calculate all collections for a given number of months (preferably at least 12 months), and
2. Divide that figure by the total number of new patients for that same time period.
For example: Dr. Smith’s practice collects approximately $10,000 per month and sees 10 new patients. The case-fees-collected calculation is $1,000. This means the average patient in this practice spends $1,000 on his or her care before terminating care.
The second most important statistic to understand is case-fee costs — that is, your costs to service a patient during the same period of time you are collecting your case fee.
Calculating case-fee costs is similar to calculating the case fees collected:
1. Compile total overhead for the same time period used to calculate case fees collected. (Be sure to include your personal salary in this figure.)
2. Divide this figure by the total number of new patients for the same time period.
For example: If Dr. Smith’s total overhead is $10,000 per month and the average number of new patients is 10, then Dr. Smith’s case-fee costs are $1,000. This means it costs Dr. Smith on average $1,000 to provide care to each new patient.
WHAT THE STATISTICS TELL
When you look at these two statistics, Dr. Smith appears to be breaking even on each patient he sees. In fact, he is probably losing money, when you factor in taxes not included in the initial calculation.
If Dr. Smith wants to do more than break even, and, in fact, put money into a wealth-building account, he needs to increase the ratio between case fees collected and case-fee costs. This ratio should be at least 3-to-1.
Many doctors think if they could just increase the number of new patients to their practice, they could turn the numbers in their favor. The reality is that doubling the number of new patients does not necessarily net more income.
The reason is because when you have a larger number of new patients, your costs also rise. If your case-fees-collected statistic stays static or even falls slightly, you will not make any more money, regardless of how many new patients you attract.
The solution to this problem is increased volume. However, increased volume does not necessarily mean acquiring more new patients. Increased volume also refers to improving the ratio of your case fees collected to case-fee costs.
Remember: Volume per patient is king, so the challenge is in generating more volume per patient, measured by the third most important practice statistic: Patient visit average (PVA).
To calculate PVA:
1. Determine the average number of patient office visits per month during the same time period used earlier; then,
2. Divide the average number of office visits by the average number of new patients per month.
For example: If Dr. Smith has, on average, 230 office visits per month and during the same period of time has 10 new patients, his PVA is 23. This means the average new patient returns to see Dr. Smith 23 times.
The way to increase PVA is to create a lifetime-maintenance practice.
Developing a maintenance practice takes work and dedication, but it is rewarding and makes practice fun. Maintenance patients have a greater understanding and appreciation of what chiropractic has to offer.
Start mapping your path to a maintenance practice by tracking the three most important statistics — case fees collected, case-fee costs, and patient visit average. Keep tabs on these statistics, and aim for a minimum ratio of 3-to-1 for case fees collected to case-fee costs.
William Berkowitz, DC, is a success coach for the Personal Training Company, a chiropractic coaching program that helps doctors build lifetime maintenance practices. He can be reached at 800-886-1792, by e-mail at email@example.com, or through www.personaltrainingcompany.com.
TELL A GOOD ‘STORY’
Don’t cheat yourself on therapeutic procedures
By Bharon Hoag
Numbers — specifically, numbers used in coding — tell a story. And good “storytellers” — coders — get paid properly.
Those who do not know how to tell their stories correctly do not get paid fully and fairly. There are two reasons for this breakdown:
• Ignorance. Historically, doctors have not been trained adequately in business procedures. Because they lack a sound understanding of the coding process, many doctors fail to recognize billable treatment elements and thus overlook things that can and should be billed.
• Fear. The second reason for poor coding is fear. Doctors cheat themselves because they are afraid of denials, audits, paybacks, and even the fear of losing their license to practice. (Losing a license to practice almost never happens. On the few occasions it does, it is a severe penalty for a serious infraction.)
Projecting problems that may never occur, these doctors deliberately undercode to avoid risk and settle for less to avoid problems.
This fear spreads like a virus through the profession. Insurance companies know it and take advantage of it.
Both problems can be avoided simply by gaining a better understanding of codes and how to properly apply them. Ignorance can be overcome by education; fear can be defeated with information and confidence.
As you gain this understanding and awareness, it is important to recognize that codes cannot enumerate and codify every eventuality and you must use professional judgment, find the code that works best in the given situation, and apply it.
THE PROBLEM: THERAPEUTIC PROCEDURES
Practitioners usually do not have a problem coding modalities because the Food and Drug Administration (FDA) clearances provide easily understood guidance concerning what can be done with a given modality and how it can be used. Coding them is similarly precise.
Code 97014 (electrical stimulation), for example, clearly identifies what the code is for and both prescribes and limits when it can and should be used.
The gray areas have to do with therapeutic procedures — what doctors and therapists do with their hands — and the problem often begins with the first patient visit.
The procedures most often undercoded are 97110 (therapeutic exercises), 97140 (manual therapy), 97530 (therapeutic activities), and 97535 (activities for daily living).
Although these procedures are imprecisely defined, they are not difficult to justify. In fact, it is quite the opposite. All that is required is for you to identify in advance — either in the initial diagnosis or during subsequent outcome assessments — the conditions the codes are intended to treat.
As long as you do this, the door is open to major new income opportunities that rarely have to be defended. If the codes are challenged, you have the evidence on hand to win an appeal.
Coding therapeutic procedures correctly relies on documenting your intent — that is, why you perform the treatment to achieve a result because of the symptoms the patient presents.
SOME EXAMPLES OF THERAPEUTIC CODES
Let’s look at some examples of therapeutic procedures, code by code:
• Code 97110 (therapeutic exercises). These are constant-attended exercises in which the intent is to increase the patient’s range of motion, flexibility, strength, and/or endurance.
In rehabilitation scenarios, results are typically achieved by having the patient use such aids as elastic bands, exercise balls, treadmills, and recumbent bicycles, individually and in combination.
When to use this code: Code and bill for each activity administered intended to achieve a specific rehab goal. This code is also appropriate for services to improve range of motion, flexibility, strength, and/or endurance in nonrehab situations.
• Code 97140 (manual therapy). Similar to procedures used in 97110, these procedures are intended to develop strength, endurance, range of motion, and flexibility. And, once again, they can represent opportunities frequently overlooked by doctors who do things during treatment that fall outside the adjustment process.
When to use this code:A doctor who is treating a trigger point may, for example, identify a related problem, such as a disk compression or muscle spasm. He may then apply manual traction to the patient’s calves to alleviate the compression, or use soft-tissue mobilization on the muscle spasm.
In such circumstances, the doctor can bill these and similar treatments within this code as long as the diagnosis supports the treatment.
• Code 97530 (therapeutic activities). This code refers to the use of dynamic activities to improve functional performance.
When to use this code: Essentially, this code is for treatments that can range in complexity from isometrics using elastic-band resistance, to stretching on an exercise ball, to a treatment on a flexion/distraction table.
When multiple parameters are assigned to the treatment, such as stimulating movement by isolating disk space while also generating a neuromuscular effect, the parallel intents can be coded and billed separately.
• Code 97535 (activities of daily living — ADL). This code is used to help patients accelerate recovery and alleviate pain.
When to use this code: Use this code when you discuss how to do icing, elevation, posture exercises, stretching, and similar activities with your patient. All of these activities fall under the ADL code. They are inherent to the treatment plan, and you can bill for them up to twice a month.
MEDICAL NECESSITY A MUST
Getting reimbursed for the codes you use depends upon intent. When codes have only a generic definition, it us up to you to find the code that best fits the service performed with regard to its appropriateness under the diagnosis.
The key to establishing medical necessity is accurate diagnosis. Make sure the initial exam clearly identifies the pain, functional abnormalities, and structural problems — what is wrong, why, and how long it will take to fix.
Then, code to fit — exercising judgment and understanding that one size does not fit all. When you understand the philosophy of codes, it’s easier to tell a convincing story.
Bharon Hoag is senior consultant in the ACOM Chiropractic Consulting Group (www.acomconsulting.com) and is certified as a professional coder by the American Academy of Professional Coders. He can be contacted at 866-286-5315, ext. 601 or by e-mail at firstname.lastname@example.org.