Physical Therapy/Occupational Therapy
Webinar Question and Answers
Q. Is
there any limitation for Physical and Occupational therapy this year?
A. There is no price cap for 2005.
Q.
What happened to the 60 days from initial physician order?
A. It was changed effective
Q. Are you saying the 60 day rule
changed? Where do I find the new ruling?
A. Yes, it was changed effective
Q. How
do I obtain the CR 3648?
A. Please use the following address: http://www.cms.hhs.gov/manuals/pm_trans/R36BP.pdf
Q. With recertification changing from 60 to
30 days, what happens if the month has 31 days in it?
A. Re-certification should occur every 30 days,
regardless of how many days are in the month.
Q.
Does PT classify as NPP?
A. No.
Q. Is
a prescription sufficient as initial certification?
A. Certification of a plan of care requires a
dated signature of the treatment plan determined by the physical or
occupational therapist. Therapy
services being provided must relate specifically and directly to a treatment
plan. The physician can certify the plan
during the interval of therapy or through delayed certification, if all
requirements of delayed certification are met.
Refer to page 11 of the Physical Therapy and Occupational Therapy
Billing Guide for delayed certification guidelines.
Q. A
re-certification from the physician is needed after 30 days, but the patient is
not required to see the doctor every 30 days, the physician just needs to
review plan of care and sign & date the re-certification?
A. That is correct.
Q. If
the original prescription for physical therapy has expired (example; 2 days a
week for 4 weeks), do we need a new prescription to continue if the physician
has already signed off on a re-certification extending the duration?
A. Signing off and dating the re-certification
is sufficient.
Q. For
recertification, can we fax to the physician?
A. Yes.
However, if a physician feels it is necessary to see the patient prior
to re-certifying the plan, he/she can do so.
Q.
What are the criteria for the delay in certification?
A. Delayed certification should include one or more
certifications and re-certifications on a signed and dated document. Also include any evidence the provider or
supplier feels is necessary to justify the delay. Please refer to page 12 of the Physical
Therapy and Occupational Therapy Billing Guide.
Q. Can
a physician’s assistant certify a plan of care?
A. The physician or Non-physician practitioner
can certify the plan of care.
Q. Can
employees perform physical therapy under the supervision of a physician?
A. Any one providing therapy services “incident
to” a physician must meet the qualifications of a qualified physical or
occupational therapist.
Q. How
do we find out if a patient is enrolled in a home health?
A. If the patient in unsure or won’t disclose
that information, contact our Customer Service department and ask if the
patient is enrolled in a home health which is not available on the IVR. You will have to verify the privacy act in
order to obtain the home health information.
Q. How
do we bill for maintenance in order to get a denial to bill secondary
insurance?
A. The GA modifier is used when providers want
to indicate that they expect that Medicare will deny a service as not
reasonable and necessary and they do have on file an ABN signed by the
patient. The GZ modifier must be used
when the provider expects Medicare to deny payment as unreasonable and
necessary but did NOT have the patient sign an ABN.
Q. Are
supplies for lymph edema treatment (wraps) included?
A. Most supplies are included in the cost of the
service. Please check with the CCI
section of the CMS website (http://www.cms.hhs.gov/physicians/cciedits/)
for specific CPT codes
Q.
When does the first 30 days start, with the date last seen or the
initial treatment date?
A. The 30 day count begins with the day
treatment begins.
Q. What does a new setting mean for
97002?
A. Procedure code 97002 does not require a new
setting.
Q. Will there be a therapy cap for 2006?
A. We have not
received official information from CMS regarding Therapy Caps. Please refer to our website for future
updates. Join our mail list at www.medicarenhic.com to receive the
most recent information.
Q. What if there is a change in frequency and
duration, does that now warrant a 97002 billing?
A. Re-evaluation is warranted when the
professional assessment indicates a significant improvement or decline in the
patient’s condition or functional status.
It may also be appropriate at a planned discharge.
Q. What is the service code for home therapy?
A. Refer to the CPT
and HCPCS codes book to find the appropriate codes for the procedures you are
billing.
Q. Is
97002 billed at recertification?
A. Yes,
a reevaluation is separately payable and is periodically
indicated during an episode of care when the professional assessment indicates
a significant improvement or decline in the patient's condition or functional
status.
Q. How
many units do I bill for 97003 or 97004?
A. One unit because these codes are not in time
increments
Q. On
the 1500 claim form is there a certain font and size? Also does it need to be in all caps?
A. The font type is to be either Arial or Pica
and font size either 10, 11 or 12, and all capital letters.
Q. How
and when do we need to provide you with our National Plan Provider Enumerator
number and will we use this number on the HCFA instead of the WPT number?
A. NPI’s will not be
required until 2007. Please watch our
website for continuing updates on NPI.
Q. If a physical therapist sees a patient with
Medicare and doesn’t know the requirements regarding physician certification
and recertification, evaluates the patient and provides therapy for months
before learning about the requirements, can the patient be sent back to their
physician for delayed certification if the physician deem to retro that
physical therapy was necessary and the plan of care was appropriate? And how should we document if so?
A. If the patient was under the care of their
physician you can provide
all the information required for delayed certification. Physical therapy and delayed certification
requirements indicate that you can submit, the initial certification and any
subsequent certifications, even if it is after 2 years. Be sure to include in any certifications and
re-certifications on a single signed and dated document and the reason for the
delay in the certification. Please
refer to http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3648.pdf
for more information.
Q. If a patient is seen by one physician for
a knee injury and two weeks later a different physician refers the same patient
for lower back, can we see the patient on the same day for both problems? Can this be billed on the same claim?
A. Since there are
two referring physicians, the claim should be spit due to item 19. Two different diagnosis from the same
physician can be used together as long as the appropriate modifiers are used
and Item 24e is linked correctly.
Q. If
a therapist has two patients on their schedule at the same time, then the only
billable code is the 97150 (group therapy)?
A. Two patients at
the same time qualify as group therapy, but this needs to be clarified that two
patients at once cannot have separate therapy.
Q.
What goes in Item 19?
A. The date the patient physically last saw and
the UPIN number of the referring physician
Q. Is
item 19 required? I heard Customer
Service say it wasn’t.
A. Item 19 billing requirements have not changed.
Q.
When billing Item 19, is the date last seen billed with 6 or 8 digits?
A. It can be billed with either 6 or 8 digits.
Q. For
Item 19, does the date the patient last physically saw the physician or the
date of the re-certification?
A. The date the patient last physically saw the
physician.
Q. If
a provider visit is not required and recertifies by fax after receiving a
progress note from the physical therapist, how does Medicare know we have
recertification if we do not use the recertification date in Item 19?
A. The information must be maintained in your
records and available upon request.
PT/OT Billing Requirements for Item 19
Effective for dates
of service on and after
This change in
coverage and policy has not changed the CMS-1500 claim form billing
requirements. Item 19 is used to
demonstrate the date the patient was last
seen by their attending physician,
and not necessarily the date of certification or re-certification. Instructions for completion are:
“Enter either the 6-digit (MM/DD/YY) or
8-digit (MM/DD/CCYY) date patient was last
seen and the UPIN (NPI when it becomes
effective) of his/her attending physician when an independent physical or
occupational therapist submits claims. For physical and occupational
therapists, entering this information certifies that the required physician
certification (or re-certification) is being kept on file.”
There is no billing
requirement on when the visit must take place in relation to the physician
certification or recertification. Enter
the date the patient was physically seen by the attending physician. The
following statements are a result of some of the questions raised: