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National Athletic Trainers’ Association

64th Annual Meeting & Clinical Symposia

Las Vegas

Paul A. Ullucci, Jr., DPT, ATC, SCS, CSCS President

Ullucci Sports Medicine & Physical Therapy, Inc.

Disclaimer I am a member of the

NATA Board of Directors.

Disclaimer 2013 NATA Board of Directors

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Disclaimer However this presentation is based on my thoughts,

experiences and opinions and does not reflect those of the NATA, NATA BOD or anyone else of importance.

Journey to the Future It’s 2014, CMS has recognized ATs and we can now bill for services rendered to clients of Medicare Age.

Other third parties are compelled to reimburse for AT services as well, due to the fact that CMS now recognizes AT services and public demands…

Legal and Ethical Responsibilities of Billing

Medicare (CMS)

Third Parties (BCBS, United, Tufts)

Patients

Discounts (No you CAN NOT provide them)

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Carriers Legal and ethical obligation to bill

Correct diagnostic codes

Appropriate CPT codes and units

Discharge when skilled services no longer necessary

Must honor deductibles and copays

Obtain and comply with authorizations

Authorizations Most carriers:

Require prescriptions

Require prior authorization

Limit visits

Per week

Per year

Life time

Patients Bound by contract with carrier to bill patients

Discounts are a violation of the contract

CMS can and will prosecute

Must accept rate set by carrier

CAN NOT balance bill patient

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Contracting with third party carriers how and why

IN Network VS. OUT of Network

Benefits

Patients

Providers

Understanding Limits

Maximum billable amounts

Copays & deductibles

What form do I bill on and how will it effect me?

HCFA 1500

UB42 (no not the music group)

Using EBM to justify your treatment program

Contracting with carriers Often require you to be Credentialed by CMS

In Network

Saves patients’ money

Expedites provider – carrier relationship

Authorizations

Payment

Out of Network

Coverage limited or nonexistent

Patient Benefits Patients contract with carriers to pay for medically necessary rehabilitative services.

This may include

Preoperative care

Functional (ADL level) care

Restorative care

Preventative services

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Provider Benefits Providers contract with carriers to gain access to their clients in order to provide services for their clients. This contract stipulates reimbursement levels for the provider as well as establishes rules and regulations that the provider and patient must abide.

• Scope and breath of services are based upon

• CMS guidelines

• Carrier policies / prerogatives

• Research (EBM)

Accepting Assignment CMS 1500 form allows provider to accept or not accept

assignment.

Accepting assignment

Contracted providers - Accept rates and payments from carrier and patient as stipulated in the patient’s health plan

Not Accepting assignment

Billing patient directly at time of treatment

Carrier may ore may not reimburse patient based upon the patient’s health plan

Maximums Daily maximums: max provider can be reimbursed in a

single day

Annual Maximum benefit: max carrier will pay out in a single 12 mo. period for services rendered

Out of pocket maximum: max patient can be responsible for in a single 12 mo. period.

Life time benefit: max carrier will pay over the lifetime of the patient, often related to specific diagnosis

Visits: number of visits, regardless of costs, a patient can have in a given period.

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Special populations

Workers Compensation

Motor vehicle Accidents (MVA)

Attorney Cases

Liability

Slip and fall, MVA, etc

Malpractice

Workers compensation Injured workers typically can be treated by any appropriate and recognized medical professional regardless of network status

Require physician referral

Medical Necessity Preferred

Require authorization(s)

Prior to evaluation

Treatment

Stringent documentation requirements

Work Comp Cont…

Contracting with insurers

Expedite authorization and payment process

May reduce reimbursement!

States may dictate timeframe for payment

Report data as regulated by state regulations

Extra income….

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Motor Vehicle Accidents Patients who were injured in a MVA have multiple payment/coverage options

The defendants car Insurance

Their car Insurance

Their health Insurance

Their attorney

Combination of the above

MVA Imperatives Physician letter of Medical Necessity

Signed Lean (Secured!!)

Excellent documentation

Updated script from MD every 30 days

Visits

Cancellations

No Shows

Payments (EOBs)

MVA Issues Payment may take YEARS

Health insurance can audit the claim years later and take back money

Require you to reimburse them

Withhold payments on other clean claims

See liability for more dysfunction

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Liability Patients who are using an attorney to represent them in a liability claim (i.e. slip and fall, MVA, malpractice or assault) may request/require you to submit all of their bills to their attorney.

You MUST

Have a signed lean by the patient

Have that signed lean recognized by the attorney

Physician letter of medical necessity

Patient’s health insurance information

Explain to the patient that if they loose their case that they are financially responsible for all of their bills

Be prepared to accept significant reductions in amount owed to you

Lean Legal document which details the specifics about a

person’s debt to you and that they and all pertinent parties to the matter agree to the fact that the person owes it to you…..

Secured Lean : Leans should always be filed with the appropriate state and local agencies, ex secretary of state, State Attorney General, city/town Clerk….

Understanding bad debt and collections procedures

Bad debt by definition is income which you can not collect.

May pay taxes on it

Should track

It can not be used as a means of discounting services….

Collections (best performed by a professional)

Have staff make calls to try and avoid this step

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Documentation Basics You must prove through your documentation that your

interventions are designed to meet specific treatment goals and objectives

Should demonstrate sound clinical reasoning

Evidenced based diagnostics and interventions essential

Document everything you did and how they responded

Which is Better • Wall squat held for 10 seconds for 20 reps

• Wall squat held for 10 seconds for 20 reps – to increase strength in the quadriceps and gluteal muscles in order to increase strength and endurance in same, in order to achieve previously stated therapeutic and patient specific goals

Which is safer Grade 2+ lateral ankle sprain

+ Talar tilt Grade 2+

Pt has no pain with palpation of the navicular, base of the 5th metatarsal or bilateral malleoli and was able to bear weight on the injured ankle immediately following the injury with a + Talar Tilt, Grade 2+ Laxity and no other laxity noted in the ankle complex.

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Diagnostic Codes ICD 9 – current set of diagnostic codes

Numeric code of 3 to 5 numbers

ICD 10 ICD 10 CM – All healthcare settings

3–7 alpha and numeric digits

ICD 10 PCS – inpatient hospital ONLY

7 alpha or numeric digits

Take effect no later than 10/1/2013

Why switch Much more specific

Location

Severity

Appropriate medical terminology

Allows better tracking

Reimbursement

Public health surveillance

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844.2 Anterior Cruciate S83.511A - Sprain of anterior cruciate ligament of right knee, initial encounter S83.512A - Sprain of anterior cruciate ligament of left knee, initial encounter

Knee ligament ICD-9 CODE ICD-9 CODE DESCRIPTION

717.85 OLD DISRUPTION OF OTHER LIGAMENTS OF KNEE

844.0 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE

844.1 SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEE

844.2 SPRAIN OF CRUCIATE LIGAMENT OF KNEE

844.3 SPRAIN OF TIBIOFIBULAR (JOINT) (LIGAMENT) SUPERIOR OF KNEE

Billing Code Basics Legal and ethical responsibilities

Definitions

Time per unit

Supervised vs. unsupervised services

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Billing codes CPT Description CPT Description

97010 Hot and cold packs 97110 Therapeutic exercises

97012 Mechanical traction therapy

97113 Neuromuscular reeducation

97022 Whirlpool therapy 97116 Gait training therapy

97032 Electrical stimulation

97124 Massage therapy

97035 Ultrasound therapy

97140 Manual therapy

97036 Hydrotherapy 97530 Therapeutic activities

CPT • 29540 Strapping; ankle and/or foot

97005 Athletic Training Evaluation

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97006 Athletic Training Re-Evaluation

97110 Therapeutic Exercise The clinician and/or patient perform therapeutic exercises to one or more body areas to develop strength, endurance, and flexibility.

This code requires direct contact and may be billed in 15-minute units.

97140 Manual Therapy The clinician performs manual therapy techniques including soft tissue and joint mobilization, manipulation, manual traction, and/or manual lymphatic drainage to one or more areas.

This code requires direct contact with the patient and can be billed in 15-minute units.

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97112 Neuromuscular Re-education of Movement, Balance, Coordination The clinician and/or patient perform activities to one or more body areas that facilitate re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception.

This code requires direct contact and may be billed in 15-minute units.

97530 Therapeutic Activities – Direct The clinician uses dynamic therapeutic activities designed to achieve improved functional performance (e.g., lifting, pulling, bending).

This code requires direct contact and can be billed in 15-minute units.

97124 Massage, Including Effleurage, Petrissage, Tapotement The clinician uses massage to provide muscle relaxation, increase localized circulation, soften scar tissue, or mobilize mucous secretions in the lung via tapotement and/or percussion.

This code requires direct contact and can be billed in 15-minute units, regardless of number of body parts treated.

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97116 Gait Training The clinician instructs the patient in specific activities that will facilitate ambulation and stair climbing with or without an assistive device. Proper sequencing and safety instructions are included when appropriate.

This code requires direct contact and may be billed in 15-minute units.

97016 Vasopneumatic Devices The clinician applies a vasopneumatic device to treat extremity edema. A pressurized sleeve is applied. Girth measurements are taken pre- and post treatment.

This code can only be billed one unit per day.

97022 Whirlpool The clinician uses a whirlpool to provide superficial heat in an environment that facilitates tissue debridement, wound cleaning, and/or exercise. The clinician decides the appropriate water temperature, provides safety instruction, and supervises the treatment.

This code can only be billed one unit per day.

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97035 Ultrasound The clinician applies ultrasound to increase circulation to one or more areas. The delivery of corticosteriod medication via ultrasound is called phonophoresis.

Ultrasound or phonophoresis requires constant attendance and can be billed in 15-minute units.

97033 Iontophoresis The clinician uses electrical current to administer medication to one or more areas. Iontophoresis is usually prescribed for soft tissue inflammatory conditions and pain control.

This code requires constant attendance by the clinician and can be billed in 15-minute units.

97010 HP/CP (not reimbursed!)

HP/CP (including ice massage) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a therapist

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97113 Aquatic Therapy The clinician directs and/or performs therapeutic exercises with the patient/client in the aquatic environment. This code requires skilled intervention by the clinician and documentation must support medical necessity of the aquatic environment.

This code can be billed in 15-minute units.

97012 Mechanical Traction The clinician applies sustained or intermittent mechanical traction to the cervical and/or lumbar spine. The mechanical force produces distraction between vertebrae thereby relieving pain and increasing tissue flexibility.

Once applied, the treatment requires supervision and one unit may be billed per day.

97024 Diathermy The clinician uses diathermy as a form of superficial heat for one or more body areas. After application and safety instructions have been provided, the clinician supervises the treatment.

This code can only be billed one unit per day.

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97026 Infrared The clinician uses infrared light as a form of superficial heat that will increase circulation to one or more localized areas. Once applied and safety instructions have been provided, the treatment is supervised.

This code can only be billed one unit per day.

97028 Ultraviolet The clinician applies ultraviolet light to treat dermatological problems. Once applied and safety instructions have been provided, the treatment is supervised.

This code can only be billed one unit per day.

97018 Paraffin Bath The clinician uses the paraffin bath to apply superficial heat to a hand or foot. The part is repeatedly dipped into the paraffin forming a glove.

This code can only be billed one unit per day.

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97014 Unattended Electrical Stimulation ( G0283 for Medicare) The clinician applies electrical stimulation to one or more areas in order to stimulate muscle function, enhance healing, and alleviate pain and/or edema. The treatment is supervised after the electrodes are applied and only one unit may be billed per day.

State specific codes RI workers comp bills X codes

X7001 evaluation

X7002 re-evaluation

X7003 treatment

Common Modifiers GP – refers to services provided as part of an

outpatient physical therapy plan of care

25 – used when performing and billing for a re-evaluation and treatment on the same day. (Medicare functional outcomes).

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KX Modifier Used when a Medicare patient has exhausted their benefits for rehab services.

The clinician is “certifying that the services rendered are medically necessary”

Documentation must demonstrate medical necessity

Audit indicator

Select Treatments

Today’s Treatment (Please indicate the number of minutes spent performing ALL therapeutic

exercises described below. 30 minutes)

Therapeutic Exercises consisting of Exercise Bike x 10 minutes

The following Lower Extremity Stretches were performed; Hamstring stretch in supine (to increase flexibility of the hamstring muscles and posterior thigh soft tissue in order to reduce the stress on the lumbar spine, pelvis, hip and knee) 5 repetitions with 30 seconds hold, Lateral hamstring stretch in supine (to increase flexibility of the hamstring muscles and posterior thigh soft tissue in order to reduce the stress on the lumbar spine, pelvis, hip and knee) 10 repetitions with 30 second hold, Distal ITB stretch in sitting (to improve flexibility in the iliotibial band to improve patellar mobility and tracking as well as hip and knee mobility) 10 repetitions with 30 second hold, ITB stretch in standing (to improve flexibility in the iliotibial band to improve patellar mobility and tracking as well as hip and knee mobility) 10 repetitions with 30 second hold, standing on slant board gastroc and soleus stretches (to increase calf flexibility improving gait, knee/ankle mobility) 10 repetitions with 30 second hold, Lower Extremity Stretching Flexibility Exercises x 15 minutes

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Today’s Treatment Functional Strengthening Techniques utilizing Progressive Resistance Exercises

(PRE's) The following Lower Body Strengthening exercises were performed; bridge with adduction held for 20 seconds x (to increase hip ADD, EXT and knee EXT strength to promote lumbo-pelvic stability, patellar tracking and balance), bridge with abduction held for 20 seconds x using silver theraband 3x15 reps(to increase hip ADD, EXT and knee EXT strength to promote lumbo-pelvic stability, patellar tracking and balance), Shuttle leg press (2 legs) using 4 Large cord 6 Medium cord for 3 sets of 20 repetitions, , Multihip machine for hip flexion, extension, abduction, and adduction using 50 lbs., (to increase hip ADD, EXT and knee EXT strength to promote lumbopelvic stability, patellar tracking and balance)

The following Core Strengthening exercises were performed; Crunches with ball between legs using a 50 lbs. medicine ball for added resistance 3 sets of 20 repetitions, (to increase abdominal and groin strength to promote trunk stabilization), and Oblique Crunches with ball between legs using a 50 lbs. medicine ball for added resistance 3 sets of 20 repetitions, (to increase abdominal and groin strength to promote trunk stabilization), all x 15 minutes

Today’s Treatment Balance training standing on wobble board with medial-lateral foot

placement for 10 repetitions with 30 second hold, (to increase bilateral LE strength, balance and endurance), Single leg stance on dyna disc 10 repetitions with 30 second hold, (to increase ankle and LE strength, balance and endurance), Direct one-on-one Manual Therapy Techniques consisting of Patellar Mobilizations: Medial and STM to lateral retinaculum for 15 minutes

The above skilled interventions was performed in order to achieve AT functional goals per evaluation

The following modalities were provided at the end of the patient's PT session in order to reduce current edema and/or pain and inflammation from the diagnosis or treatment provided: Hi Volt Galvanic Electrical Stimulation to the Knee x 20 minutes with cold pack, and Russian Stimulation to the rectus femoris and VMO x 20 minutes with cold pack

CMS’ New Documentation Requirements As of July 1, 2013 all providers wishing to bill CMS (Medicare) for services rendered must report functional outcome data to CMS.

These functional outcome measures must be appropriate for the provider and the providers’ settings.

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Suggested FOD Pain

Function

BMI

Slip and fall risk

Requires additional coding for intervention

Smoking history (re-eval only)

A special Thank You to

Kathy Dieringer, EdD, ATC, LAT, District 6 Director

ICD 9 and 10 Resources http://www.cms.gov/medicare-coverage-

database/staticpages/icd-9-code-lookup.aspx

General ICD-10 Information

http://www.cms.gov/ICD10

Websites ICD-10-PCS Coding System, Mappings, and Related Training Manual

http://www.cms.gov/ICD10/13_2010_ICD10PCS.asp

ICD-10-CM Coding System, Mappings, and Guidelines

http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

http://www.cms.gov/ICD10/12_2010_ICD_10_CM.asp

Report on Use of Health Information Technology to Enhance and Expand Health Care Anti-Fraud Activities

http://www.hhs.gov/healthit/documents/ReportOnTheUse.pdf

CMS-0013-P—HIPAA Administrative Simplification: Modification to Medical Data Code Set Standards to Adopt

ICD-10-CM and ICD-10-PCS

http://edocket.access.gpo.gov/2008/pdf/E8-19298.pdf

Transactions and Code Sets Regulations

http://www.cms.gov/TransactionCodeSetsStands/02_TransactionsandCodeSetsRegulations.asp