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Physiotherapy bill format for Procurement

hello everyone welcome to this month's webinar new year new codes how to bill for PT and ot evaluations in 2017 we're so happy to have you all join us I'm Charlotte Bonet and I'm the content marketing and communications manager here at web PT now before I pass the mic over to our host doctor Heidi janiga and our special guests Rick Glenda I wanted to cover a few housekeeping items this webinar will last 90 minutes with about an hour to an hour and 15 minutes of presentation followed by QA if you have a question during the webinar go ahead and ask it in the side panel we'll do our best to answer as many questions as possible at the end of the presentation we're recording this webinar and we're going to send the entire recording and the slide deck as well as an FAQ to everyone by early next week with that I'll hand it over to Heidi thanks char welcome everyone I'm Heidi Heidi janiga I'm a physical therapist with more than 15 years of experience practicing and sports medicine and orthopedic private practice now I'm also the founder and president of web PT which is the web-based electronic medical record solution specifically designed for physical therapists occupational therapists and speech-language pathologists I started this company in 2008 with my husband Brad who is a seasoned technologist because there wasn't a documentation solution available at the time that truly suited my needs as a physical therapist in clinic director since then we've grown to more than 60,000 members and and servicing over 9,000 clinics across the country we here at web PT hosts these free webinars every single month because one of our goals as a company is to help rehab therapists achieve greatness and practice and I truly believe that that starts with education today I am thrilled to be joined by Rick Gwenda president and CEO of going to seminars he's the founder and president of going to seminars and consulting incorporated he also graduated in 1991 with a bachelor's degree in physical therapy from Wayne State University in Detroit Michigan Rick also serves as the director of finance for apt private practice with multiple offices in Southern California from 2003 to 2009 he was the director of physical medicine in rehab at Detroit receiving hospital where he was responsible for inpatient and outpatient physical therapy occupational therapy and speech-language pathology services he has provided valuable education and consulting to hospitals private practices and rehab agencies in the areas of CPT and ICD 9/10 coding billing documentation compliance revenue enhancement and denial management Rick is also the past president of both the American Physical Therapy Association section on health policy and administration and the Michigan Association of medical program rehabilitation administrators he serves on the editorial advisory board for Advance for directors and rehabilitation and acts as a liaison between the Michigan physical therapy association and the national government services Rick is the author of the how-to manual how to manual for rehab documentation a complete guide to increasing reimbursement and re reducing denials and coding and billing for outpatient rehab made easy proper use of CPT codes icd-9 codes and modifiers and I don't know when you sleep Rick but I am so thrilled to have you join us today Thank You Heidi and also to Charlotte for inviting me to do this presentation with you today nice to see we have a few people interested in the new eval eval codes here so looking forward to it and I have a feeling we're gonna use the whole the whole hour and a half today perfect well I know everybody all 11,000 people who have registered for this webinar are really excited to dig into the material this webinar is going to be entirely educational and you probably know that if you've attended one of our webinars before we appreciate having all of you on all right let's jump in we've got a lot to cover today so let's get right to it so starting off let's run through a few highlights from the 2017 Medicare final rule we'll go through this really quickly so we can actually get to the meat of the presentation but you can check out an in-depth summary of the final rule on the weblog if you just search final rule so okay here we go the therapy cap was bumped from nine 60 which is where it was at this year 20 more dollars have been added so it's now at nineteen eighty which is the therapy cap for the entire year there's still one cap for PT and SLP combined and one cap for ot that means that PT and SLP if you're being treated by multiple providers you have nineteen eighty to spend for the year and then ot also has that same amount the cap includes all diagnosis and care episodes over the course of the calendar year that's January 1 through December 31 of 2017 the Medicare access and chip reauthorization program also known as Macra extended the therapy cap process through 2017 and modified the manual medical review process so now previously the manual medical review process applied to all claims that went over $3,700 threshold in 2017 it's slightly different so MMR no longer applies to all claims exceeding 3,700 instead there will be a targeted review process based on specific criteria recovery auditors will not no longer be used in fact Macra actually prohibits the use of the racks the conversion factor increased from thirty five point eight eight seven to a slight increase but every little bit helps when we're talking about reimbursement or payment and as you know and we will discuss in a bit the new CPT codes for PT and ot evaluations and re-evaluations will go into effect January 1 of 2017 however the proposed changes to current CMS guidelines for documentation and evaluations were delayed okay now for another change that has really sent shockwaves through the rehab industry the demise of PQRS beginning in on January 1 of 2017 PQRS is going away yes you heard me right I know there's a lot of people who haven't actually heard this but PK russ is going away instead it's being replaced by the merit-based incentive payment system better known as MIPS again you can read more about MIPS on the web PT blog but the gist of it is is that it combines parts of PQRS the value-based modifier program and the EHR Incentive program all into one and as of right now we're talking 2019 before therapists are really going to be eligible and because HSS can't add eligible professionals to the program until 2019 pts OTS and SOPs which are not included on the initial list won't have the opportunity to report any MIPS data for at least two years now while many of you are probably out there celebrating this reprieve from data collection I personally just want to make sure that we understand well that because of this exclusion it doesn't mean that it's always going to be a positive thing it actually could have a negative impact on the future of rehab profession now if you've subscribed to our newsletter or our blog you may have seen my recent founder letter urging therapists not to abandon their data analysis efforts in the new year and beyond now CMS has indicated that therapists may have the opportunity to participate in MIPS on a voluntary basis though we haven't really seen any details yet around that about how we can actually go about doing this but if and when those details come down the pike I would strongly urge you to consider collecting data on a voluntary basis not only because it'll keep you in the habit of collecting data but also because that data could prove incredibly valuable down the road especially as we continue to move forward towards a value-based payment environment as well as just being able to be represented representative our selves as rehab therapists now next thing we haven't really talked about in a while is functional limitation reporting with the elimination of pqrs we've had a lot of people asking whether functional limitation or flr is going away too the answer is no therapists still must fulfill FLL requirements for Medicare patients otherwise they risk automatic claim denials so as a reminder you must submit FL FL our data that is the G codes and severity modifiers at the outset of the therapy episode so on your initial visit so initial exam every tenth visit at a minimum and then at discharge of the patient now when a eval or real Valentine's Day and at nine seven zero zero four it will apply to CPT codes nine seven one six one through nine seven one six eight and 2017 which we'll talk about more later to end reporting of one functional limitation and to begin reporting of a different functional notation that needs to be done at the evils when the evals are built Rick okay you talked about what's new for 2017 thank you and why we think a lot of you are listening today is because there are some major changes coming here in just over two weeks so hopefully we all know that effective January 1 of 2017 the current PT eval CPT code nine seven zero zero one is going to be deleted in replaced with three new CPT codes that you see here on slide 11 nine seven one six one Pte valve low-complexity nine seven one six 2 PT eval moderate complexity nine seven one six three PT eval high complexity in addition the current re-evolve a PT 9700 to is also being deleted replaced with a new cpt code nine seven one six four but we did that one ot to feel left out so ot your current eval code nine seven zero zero three is also being deleted at the end of this year replace with three new eval codes nine seven one six five o te valve low-complexity nine seven one six six ot eval a moderate complexity in nine seven one six seven ot eval high complexity in addition your current ot eval code nine seven zero zero four is also being deleted place with nine seven one six eight something I want to stress now and I'll do again later in today's webinar is all eight of the new CPT codes all on the time service based there's not a time component to them it's going to be other components the OT and the PT will be evaluating and determining that will then determine the level of complexity of the evaluation also for the new we eval codes you know for PT 9 7 1 6 4 is the Revo code ot 9 7 1 6 8 is the revile code the reason to charge a re-evaluation skum Pannu including the Medicare program does not change with the new codes so again we evals are not the norm they don't happen that often top 3 reasons why you may do a read eval number one there's been a significant change in the patient's function a change in their status that you were not anticipated to see today in that patient when they came in to see you based on how they left you after their last visit that is probably the number one reason why we do a we eval second reason maybe there's new clinical findings there's new things that are present today that weren't present at the industry eval that may impact the plan of care and the third reason why you may do a read eval is perhaps you've seen the patient 4 7 9 10 11 12 visits you know you're trying different interventions you're changing things up nothing's working might you do a leave out to find out why the patient's not responding to the current treatment plan are there new cloaca findings going on did you miss something the first time around now I'll probably the biggest myth I hear out there is people think that these new eval codes only apply to the Medicare program no they don't these new eval and rebound will apply to all insurance carriers not just Medicare and that's because of HIPAA HIPPA states that all HIPAA covered entities must use the current years CPT codes well I think we all would agree Medicare is a hipaa-covered entity but also your Medicare Advantage plans are HIPAA covered entities insurance carriers such as Aetna Cigna Blue Cross Blue Shield Humana United Healthcare Priority Health federal blue class TRICARE those are HIPAA covered entities which means they must adopt and use the current years CPT codes I'm not saying they have to pay for them they have to use them as we go to the next slide you may have noticed I did not mention workers compensation and auto no-fault carriers and that's because workers compensation and auto no-fault are not insurance carriers which means HIPAA does not apply to them which means they are not mandated to use the current years CPT codes it's gonna be their option so might some state workers comp might some auto no-fault carriers transition to the new eval andreeva codes in January 1 2017 yes might some not transition to the new eval codes the new revile codes and continue to use 9700 1 through 9700 for absolutely you're gonna have to go find out and you might think well who would do that well I can tell you we have a couple practices in Southern California and up through 2013 California work comp was used in the old cpt goes back from the early 90s that were tanked in 30 minute increments they were using different eval codes and we're using today California work command just transition to the current CPT codes that we are familiar with back in 2014 so that's gonna be a tough one for many of us around the country is contacting your work comp carriers contacting you auto no are they going through transition to the new eval eval codes and you may call people and talk to people and they may have no clue what you're talking about because they don't even know these new codes are coming January 1 of 2017 now as we get into the eval components for PT and ot I cannot stress enough you cannot look at the PT eval codes and figure well how is this applied to the OT val codes you can't look at the oat eval codes and say well how is that compared to the Pete eval codes you have to look at them completely separately think of the Pete eval code as a reason think of the oat eval code as the biggest pumpkin you've ever seen okay you can't look completely different so you have to look at them differently so here on slide 17 we look at the PT evaluation components so physical therapists are going to use four components to assist them in selecting the appropriate evaluation CPT code and you see it says patient history in comorbidities we're going to talk about coma biddies when we go through a couple case scenarios and a little bit examination in the use of standardized tests and measures and there is that word standardized and people always get a heart attack when they see that word because people think standardized tests and measures means I must do an outcome two I must do an outcome questionnaire like the - the quick - the upper extremity functional index the lower extremity functional scale the Purdue pegboard tests the 1080 the time get-up-and-go etc that's not what it means because isn't taking range-of-motion measurements for the goniometer a standardized test and measure isn't taking girth measurements with a tape measure a standardized test and measure isn't doing me and your muscle testing a standardized test in measure so these new eval codes do not mean D you used and help come to an outcome questionnaire you can just use your normal standardized tests and measures now in my opinion do I think outcome tools outcome questionnaires are good in addition to standardized test measures absolutely and then you see number three and number four clinical decision making development of plan of care now as we go to slide 18 and we look at the OT about components the top two are different so T's also going to use four components to us to help them select the appropriate eval code so you see occupational profile and client history 15 is a subjective intake assessments of occupational performance and with that one people think or that's that's work that's their job and it could be but occupational performance can also be bathing dressing toileting eating drinking cooking you know meal prep using household appliances perhaps assisting others with their mobility needs their bathing needs their dressing needs so just don't think of occupation performance as work and then you see number three and number four or the same as PT cloaca decision making development of the plan of care now this kind I want to go through some definitions here because it's always tough to decide do we give you the CPT codes and the criteria first and then the definitions or vice versa and I like to do the definitions first and then we'll kind of bring those back as we walk you through the CPT codes so a couple I do want to highlight is body systems this kind of remember must feel skeletal neuro must or you know think of cardiovascular pulmonary in the skin so keep those in mind body structures structural or anatomical parts of a body such as organs and here's the key limbs and their components so kind of put your right arm out in front of you that's that's a limb okay that's the upper story that is a limb components of that limb would include bones joints muscles tendons ligaments fascia those be considered components of the limb components of the upper extremity we're going to spend some time talking about personal factors today and again personal factors some examples could be the age of the patient the sex of the patient could be their social background education level past in current experience and we don't mean just past and current experience with their injury or the illness just past and current experience in life you know I have seen motivation their coping styles overall behavior patterns and they think of an autistic child think of a patient with a stroke or traumatic brain injury you know how do they interact socially at home in a family unit how do they interact out in the community at church at a restaurant at a shopping center so we're going to talk about that during some of our examples here today now on slide 20 I want to stress the top these definitions relate only to the OT evaluations so performance deficits in ability to complete activities due to lack of physical skills conscious skills and/or psychosocial skills so what they mean by inability to complete activities this would be your self-care you're a needy house could be bad mobility transfers me oh crap household chores things like that you have a deficit doing those activities due to lack of phys coal skills so other impairments with the patient's balance mobility range of motion strength dexterity sensation etc do they have an inability to complete activities due to deficits related to cognition so do they have deficits relate to the ability to attend perceive think Tom Saab how about mentally sequence you know how many times do patients need to do as a task and lost multiple staffs that need to be done in a logical sequence let me talk about psychosocial skills so again skills related to interpersonal interactions habits routines behaviors now active use of coping strategies so we're gonna talk about that in the scenarios as well slide 21 now as I go through the next two slides I know you're gonna see time but I know you heard me say that these codes are untied again before I do sides 21 and 22 all the new evalue revile codes are under timed service-based okay time will not determine which CPT code you pick but for those of you that are familiar with the physician e and M codes the evaluation and management codes physicians have five levels of E&M codes for a new patient five levels of E&M codes for an established patient and they are also under timed but there's kind of a quote a hidden time component to them so AMA wanted to keep the kind of nomenclature the same so I show you these times we go over them I do want to stress time or not determine which CPT code you pick so for nine seven one six one four low-complexity for the PT valve typically the PT spends 20 minutes face to face with the patient and/or family for moderate the key word typically the PT spends 30 minutes face to face with the patient and/or for high complexity 45 minutes in for the P Tyr eval 20 minutes so keep that in mind for PT 20 30 40 5 20 because as we go to the OT eval Coast look at the time component you will see 30 45 60 30 she get this one or two ways P keys are quicker than ot saw rotis are just more detailed than Petey's but again all in these codes are untimed service-based and before I turn this back over to Heidi a question I get asked a lot you know we know these codes apply to outpatient therapy but I always get questions about what about inpatient acute care what about inpatient rehab what about skilled nursing facility part a we're we're we're billing under you know red levels do these codes apply and in the inpatient acute setting in the inpatient rehab site in part a standard MDS red levels you are not paid via CPT codes you know in the inpatient acute care setting for example you're paid under DRGs you know sniff part a you're paid under your rug levels you're not building via CPT codes now with that said do I do I think that inpatient therapist and sip party therapists occupational therapists need to be familiar with these codes absolutely because I know many of you you know still do the billing the same way for productivity purposes so I think that would be good to do also keep in mind especially in the inpatient acute setting you know might you have a patient admitted into the acute care setting that doesn't have any part a benefits they've exhausted all their part a benefits which means the therapy you're doing is being charged up under their Part B benefits which means you would have to use these new eval and we've al Cowen's you know also it's possible what happens the most in the hospital as the patient does have Part II benefits they already admitted you may see them for two three four days as an imp a but after they get discharged home your utilization review people switch them from inpatient status to outpatient status because they did not qualify for a house for inpatient admission which means those visits you did have not being charged out under their Part B benefits which means you need to use these Louisville and revile codes also in the inpatient rehab setting is possible that a patient is in the inpatient rehab facility setting and doesn't have Part A benefits which means the therapy you are doing is being challenged under their Part D benefits so do I think inpatient therapist need to know these cones yes do I think the poor nativity purpose isn't on that you should use in these codes yes knowing that in the vast majority of the cases you're not going to be paid separately for these hosts but that patient did transition from Part A Part B then you're already going to be covered because it you're gonna be done correctly the documentation will be done correctly in the medical record so hopefully that helps clear up some of the inpatient questions people may have and will turn this Thank You Brad - Heidi yeah thank you Rick that's a valuable information because we do get those questions all the time even though we're we're very focused on outpatient this is a general profession change so we all need to be aware of the and how it's applicable to us so from aside from time let's let's talk about complexity levels and there are a few other factors that go into determining the appropriate level of complexity and let's go over some of those factors for each code first the low complexity physical therapy evaluations here are the defining characteristics first the patient has a history of the present problem without any personal factors and/or comorbidities that impact the plan of care the PT completes an examination of body systems using standardized tests and measures addressing one to two elements from any of the following body structures and functions activity limitations and or participating restrictions now it's going to be key for you to go back and review the definition that Rick just went over to really get ahold and understand understanding of each one of these complexity levels the clinical presentation of the patient is stable and or uncomplicated and the PT exercises clinical decision-making of a low complexity using a standardized patient assessment instrument and or measurable assessment of a function of the functional outcome now on to low complexity ot evaluations here are the defining characteristics first the patient's occupational profile in medical and therapy history includes a brief history with review of medical and or therapy records related to the presenting problem the OT completes an assessment and assessment identifying one to three performance deficits relating to physical cognitive or psychosocial skills that results in activity limitations and/or participation restrictions and finally the OT exercises clinical decision-making of a low complexity which includes an analysis of the occupational profile analysis of data from problem focused assessments and consideration of a limited number of treatment options the patient presents with no comorbidities that effect occupational performance modification of tasks or assistance either physical or verbal with assessments with assessments is not necessary to enable completion of about this evaluation component now let's move on to moderate complexity PT evaluations here are the defining characteristics first the patient has a history of the present problem with a history of one to two personal factors and/or comorbidities that impact the plan the PT completes an examination of body systems using standardized tests and measures addressing a total of three or more elements from any of the following body structures and functions activity limitations and or participation restrict the clinical presentation is evolving with changing characteristics and this is kind of a key piece from moving from low to moderate the PT exercises clinical decision making of a moderate complexity level using a standardized patient assessment instrument and or measurable assessment of functional outcome here are the characteristics of a moderate complexity ot evaluation the P the patient's occupational profile and medical and therapy history includes an expanded review of medical and or therapy records and an additional review of physical cognitive and psychosocial history related to current functional performance the OT performs an assessment under identifying three to five performance deficits relating to physical cognitive or psychosocial skills that result in activity and limitations and/or participation restrictions the OT exercises clinical decision-making of a moderate and analytical complexity which includes an analysis of the occupational profile analysis of data from detailed assessments and consideration of several treatment options the patient may present with comorbidities that affect occupational performance minimal to moderate modification of tasks or assistance whether it be physical or verbal with assessment is necessary to enable completion of the evaluation component now last but not least let's talk about the high complexity evaluations and here are the defining characteristics for pts first the patient has a history of the present problem with three or more personal factors and/or comorbidities that impact the plan of care to the patient completes an examination of body systems using standardized tests and measures addressing a total of four or more elements from any of the following body structures and functions activity limitations and/or participation restrictions three the clinical presentation of the patient is unstable with unpredictable characteristics and finally the PT exercises clinical making with a high level of complexity using standardized patient assessment instruments and or measurable assessment of functional outcome and finally the characteristics of a high complexity ot evaluation the patient's occupational profile in medical and therapy history includes a review of medical and therapy records in an extensive additional review of physical cognitive or psychosocial history related to current functional performance the OT completes an assessment identifying five or more performance deficits relating to physical cognitive or psychosocial skills that result in activity limitations and/or participation restrictions and with respect to decision-making it should be of high analytical complexity which includes an analysis of patient profile analysis of data from comprehensive assessments and consideration of multiple treatment options the patient presents with comorbidities that affect occupational performance and significant modification of tasks or assistance whether it be physical or verbal with assessment is necessary to enable completion of the evaluation component now I think it's it should be clear from those definitions but I want to just emphasize that we when were picking these codes that we are actually picking them for complexity of the evaluation not necessarily complexity of the patient and I know we'll talk about that more later now I want to emphasize also that there's no simple formula for selecting the correct level of complexity a lot depends on your clinical judgment and reasoning as a health care expert on that note there are additional factors that also may influence your decision and things you should be thinking about as you're assessing the patient and going through the evaluation and beyond especially beyond the ones that we've already discussed that are formally addressed in the code definitions so some of these complicating factors may include patients age times since onset of injury or illness or since the actual injury was exacerbated the mechanism of injury illness or exacerbation definitely want to take into account their past medical history surgical history comorbidities that are currently impacting them and their ability to continue with progress or improve prior level of function current level of function status of their current function patients cognitive status and safety concerns and then the patient's overall level of motivation of motivation this is where the psychosocial components come into play and finally the patient's home situation whether their environment they have the environment proper environment to progress and or family the support that they need you want to keep they also think about as you're moving through your examination you want to also take into account your objective examination findings and as you continue to assess the patient the goals and goal agreement with the patient the rehab potential or your prognosis and and probable outcome and then the expected progression of the patient essentially you're going to take into account everything that you do during your evaluation to assess the complexity of the evaluation what I just went through was you know the list that you should be thinking about especially high on the subjective section of taking this current information which as you know we collect very well in web PT especially the prior and current levels of function but going through to really make sure that complexity level is assessed can be as easy as really understanding how complex your evaluation is versus just thinking about the patient as it in general okay if you wanna give us an example sure we're gonna do what we call a patient sample number one here of a low back pain and you're gonna see it done one way and then I'm gonna kind of give you some tips on how you'd be able to maybe ask the right question documented something how it may went from one level complexity to a different level of complexity so in example number one we are on slide 30 to him at 53 year-old male come in for therapy and he had low back pain begin about two weeks ago however do subjective intake of the industry the how he tells you that about two days ago he started get kind of pain and numbness into the top and Silver's right foot he subjected braces paint a six out of ten he tells you that the king in the low back is causing the wake up three to four times per night now the key here is past medical past surgical history comorbidities insignificant there's nothing there now you do man your muscle testy you see in quit dorsiflexion is good great toe dorsiflexion fair plus ankle plantar flexion good - you know as you do your pop Asian of his low back the l4 and l5 light transfers process processes are more posterior than the lab so he's kind of rotated you did sensation testing on the white foot and you note a new document decrease sensation the light touch and pinprick as you analyze his gait he has an intelligent gait paired with weight bearing on the right lower extremity so when he puts down his right foot and he lifts his left leg up to move forward he kind of moves it quicker so he's got a decreased stance time on the right lower extremity now you didn't have to but you did give him the oswestry that he completed and he scored 44 percent in a couple things off the oswestry the patient's stay in the heat can that sit or stand no more than thirty minutes he can't lift heavy weights but he can still lift and carry medium weights says we were to slide 30 to look at the history so are there any personal factors with this patient that you think are going to impact the plan of care when this in this example I did not give you any are there any comorbidities that are present that will impact the plan of care and we said insignificant there's nothing so the patient's gonna meet the low category here for history now as we go to examination you know I think it's gonna be very easy for the physical therapists to get play for more elements in the vast majority of your patients now we didn't get a chance today to go through the ICF the International classification of functioning disability and health manual and some slides and you know I'll tell you how you can get that a little bit later but when you look at this patient based on what I documented and you look under body functions we actually has a couple what we call elements here because for PT under the exam you want to try to get as many elements as you can from body structures and functions at to the limitations and or participation restrictions so here under body functions and he's got pain he's got you know that earase he's also got sensation deficits he's also got muscle weakness in the right dorsi flexors implanted flexors so here's an here's two elements right here well body structures you know it's it's the low back that we're treating so the body structure would be structure of the trunk and would be the vertebral column that actually counts as an element under active daily living he actually has three different elements here because it's gonna be one would be mobility walking that's gonna be an element he also can't carry heavy weights in the hands he can't carry heavy weights and the arms because of his back pain or carrying moving and Hamelin objects is a separate component under mobility so that would be a nother element and then sleeping that actually falls under change in maintaining body position so under mobility which is chapter 4 in the ICF manual under activities and participation under mobility you have what we call three at least three components one being carrying movement and handle objects a second one change it in maintaining body position and the third one be like walkin so walking and caring and sleeping would all be considered separate elements so in this example you actually have six elements which puts them in the high category for the PT exam now as we go to clinical presentation and I believe if I move this up to slide 35 we're gonna kind of ask I think what you think so I'm gonna turn this over to Charlotte based on this patient's details what level of clinical presentation do you believe is most appropriate for this evaluation we got a lot of people answer in okay and we still have people responding but you can see the results starting to come in it looks like the majority of people are saying moderate yes but by far I'd pie say 60% of you roughly are saying moderate with you know twenty and twenty going low and high and as you continue to know do this I will give you the answer in this example this would be considered a moderate clinical presentation because I'm gonna kind of go back to this back aside hopefully this will work and because you look at the clinical presentation is evolving with changing characteristics and the evolving changing part was you know he just had centralized low back pain for about two weeks but two days ago it started to evolve started to change we started get the numbness the burning and tingling sensation into his right foot so that'd be an example of moderate because his presentation is evolving it's changing okay because he had that centralized low back pain for two weeks but two days ago I saw the e Bob change we tried to get numbness tingling into the right foot you know people might wonder what what would an example of unstable unpredictable a bit what that patient told you that he almost passed out twice yesterday when kind of standing because of the pain becoming dizzy like heaviness you know what if he journeyed out today he became lightheaded I thought it had a drop in blood pressure you know what if there's no line or reason to when his pain occurs you know what time of the day it occurs what activities he's doing there's no kind of rhyme or reason Sunday's he has no pain other days he doesn't want to do anything and this pains like 7 8 9 out of 10 you know so again that's unstable unpredictable never know when it's going to come so that would be an example of moderate so as we go now to the decision making in this example which CPT code would you built so think about it you had for the patient history it was low for patient examination was high because there were six elements and for the clinical presentation was moderate she had low for history high for exam moderate the clinical presentation know which CPT code do you bill and you must report the lowest one so in this example you have to report CPT code nine seven one six one even though it exam was high in clinic presentation was moderate the history was low so in order to better say the moderate PT val code nine seven one six two the patient must meet the criteria for moderate for history at least moderate for exam at least moderate the clinical presentation now using that fifty three your patient what if this actually had happened what this actually did occur but you didn't document it what is 53 European one if he was five foot five 210 pounds if you do the BMI calculation he would have come out morally obese even overweight and you were to put that you know maybe there's a comorbidity now just because he's obese does not mean it's gonna always impact the plan of care but what if in this example you said because he's five foot five too many ten pounds morbidly obese what if you said this was going to impact terrible could that have been that one comorbidity under patient history that were to got you into the moderate level of complexity for history would have been high for exam model for clinical presentation which now means you have been able to go the moderate complexity PT bal code nine seven one six two you know what if I told you some sweet insulin-dependent diabetic along with a BMI of you know thirty seven point two do you think because of the instant defend diabetic diabetes that's going to give that the planet care and again it's not always yes it's not always know it's going to be just based on that patient how they present and what your professional assessment is so that's why I think extremely important to document personal factors past medical pass surgery history you know also what if I've told me that 53-year patient we just did what about though he had compression fractures of the lumbar spine okay he's five foot five to ten he's an incident dependent diabetic okay there's we're gonna say those are two personal factors but what if the cause of the compression fractures of lumbar vertebra were due to a car accident in which he was the driver he was the cause of the accident and his wife was killed in the accident and that to me gruesome but I'm trying to get you to think of the patient's personal factors of maybe motivation his coping styles how is he handling knowing the fact he was the cause of the accident that killed his wife might that have an impact on the plan of care he doesn't care about himself he wasn't care about his back you know he's caught up in other issues going on in his life so could the BMI the insulin dependent diabetes and the way the accident happened his personal factor could that have been you know three or more personal factors comedies that we gotta hi for history still hi for exam and then moderate in this example for clinical presentation what has to have been nine seven one six two but I'm just trying to give you a couple you know using that same example based on how you document what's going on with a patient how a simple document a simple word you may document a simple career you may document may take you from a nine seven one six one two maybe at nine seven one six two we're gonna go through a patient example to and I think that's really important stuff that you just talked about there Rick it goes back to the the comprehensiveness of documentation and you're taking of your past medical history and all of the the comorbidities and diagnosis codes that are applicable to that particular patient that may have some impact on the on the plan of care that you're actually creating so it's really trying to put the clinical reasoning and determination from a therapist brain basically now into some sort of documentation and in the best way possible so that you can support which code you're selecting so let's take a look at another patient this patient is eighty is an 82 year old female she has a non traumatic brain stem infarction nine nine weeks ago so she had one she spent twelve days in an IRF and five weeks in a skilled nursing facility and she now presents two outpatient therapy therapists did a review of the hospital IRF records as well as this the sniff physician her therapy psychologist and social worker records and documentation to those you were lucky to get all of that information that she brought with her to the outpatient visit she's got some personal factors including she's five foot three and 183 pounds her husband passed away five months ago she's living a lot she was living alone prior to having the CVA now staying with her 53 year old daughter who provides assistance she's also having difficult difficulty with coping after her husband's death and was going to a support group but now is unable to attend due to her current status past medical history or surgical history includes type 1 insulin dependent diabetes she's legally blind and she had a left knee replacement one year ago to further on the this patient example to give you more info she also presents with short-term memory deficits as well as difficulty giving sustained attention to tasks this patient presents with muscle weakness in her right upper extremity and right lower extremity she has hemiplegic gait and proprioceptive deficits on the right side this patient also requires minimal assistance with bed mobility and transfers and ambulance with a rolling walker 35 to 50 feet with minimal assistance and verbal guidance for sequencing and finally to just give you the full comprehensive review of the patient she requires minimal assistance for upper extremity dressing moderate assistance for lower extremity dressing and minimal assistance with bathing and toileting and due to her cognitive and physical deficits this patient is unable to perform domestic activities or household chores including vacuuming dusting and laundry due to the cognitive and physical deficits ot has to provide moderate modification to some evaluative components and assistance to the patient in order for her to be able to complete some tasks so hopefully you have this picture of someone like your grandma going through this and Rick you want to take us through how we would determine the appropriate code for this particular patient be happy to so on to slide 42 you look at the history for the OT so in this example obviously the occupational therapist did do a subjective intake you know of the patient probably had assistance of of the family member to you know get the information right now but the OT also did pretty in a pretty extensive review of past medical records man access to the inpatient rehab facility therapy records so they looked at that there were the skilled nursing facility therapy medical records but they also reviewed the psychologist and social worker medical records from the nursing home as well so when you look at the criteria over here and you look at say moderate you see an expanded review of medical and or therapy records and an additional review of physical cognitive or psychosocial history you look at hi you see again review of medical and or therapy records and an extensive additional review of physical cognitive or psychosocial history and again it's that definition where you going to try to figure out extensive additional versus just additional so without that you definitely need some out of it I think you can actually make an argument for hi here when you look at not only to do subjective intake of the patient but you also did a pretty extensive review of the inpatient rehab facility records the skilled nursing facility therapy records the psychologists a social worker therapy records from say the nursing home so try that you can make an argument argument for hi for history royalty absolutely we then get into the examination and again due to the deficits in physical skills whether it be related to mobility proprioceptive deficits balanced emphasis strength deficits due to performance deficits as result as deficits in cognitive skills you know attention memory sequencing things like that you know you see at we just came up with seven performance deficits here which would put you into the high category for ot examination this ot completes the assessment identifying five or more performance deficits as a result of death as impairments in physical content or psychosocial skills so I think you can have pretty good argument here high for history high for exam we now go over to decision making and I know we were gonna plan on doing a poll question think for sake of time and the way things been going I think what I'll just kind of go and do this one for us you know decision making what do you think well I think we all would agree it's definitely not gonna be low when we look at moderate you see for decision maker Proteus as the patient may present with comedies that affect occupational performance when you look at high says the patient presents with comorbidities that affect occupational performance if you kind of go back and look at that patients you know past medical history shared her quote good like her good me replaced one year ago she's also legally blind and I think I gave her insulin dependent diabetes so you know being that the left knee was replaced a year ago being that she is legally blind do maybe the instant the pen diabetes do I think you know we can make an argument that she's got at least one committee that's going to impact the plan of care that will affect occupation performance absolutely the key is how you decide between moderate or high and that's why I had to tell you in that example that the OT provided moderate modification moderate assistance to the patient during the eval in order for them to complete some of the eval components and when you look at moderate here it says minimal to moderate modification of tasks for assistance with assessments is necessary to enable completion of eval component where for high its I can't modification and then week I given that definition of well what is minimum what is moderate and typically when you look that up if you do it like a google search you know minimal tends to be like 1 to 25% assistance you know moderate is that bigger range typically you know 26% to maybe 74 percent and then significant might be you know 75 percent or greater would be significant modifications that we get assistance to the patient so because I told you the OT had to provide moderate magnification matter assistance that would make you pick decision making moderate for ot so this example we're gonna see you have high for the history high for the exam moderate for the decision maker which means ot would have to build nine seven one six six the OT about moderate complexity because in order to very high complexity ot now they must meet the criteria for high for all three categories history exam decision-making and they don't they only meet high for history and exam they only met moderate for decision-making and that's why this would be ninety seven one six six I'll turn this and before I turn the staff - hi do you know something I do want to say is you know in the first year 2017 the Medicare program is gonna pay off through the PT balco's the exact same dollar amount all through the OT Valco is the exact same dollar amount because CMS is concerned about people like myself and web PT and ot and APTA be able try to find you know three four or five hundred thousand pts and OTS and get you educated on all this and ready to go you know the first day of business which would probably be January the third for outpatient of therapy so they're concerned about the therapists not knowing which CPT code to pick and always choose me how you're one that would pay more money so that's why they're gonna for the first year CMS will pay all three codes same for PT all three the same for ot now I know what you thinking well then it doesn't really matter which code i bill you know I'm just gonna do high for everybody or matter for everybody it's gonna matter because during the first five months of 2017 seeing us would be collecting the data these eval codes in seeing the quotes coming in and the percentages codes it was estimated that PT would be low-complexity 25% of the time moderate 50% of the time high 25% of the time ot was estimated that they would know the low-complexity I believe it was 50% of the time moderate 40% of the time high 10% of the time so again gonna be very important to make sure you do know the applicable eval CPT code based on your documentation regarding all the other payers there are payers that do pay a percent of what Medicare pays so because Medicare is gonna pay all the codes the same dollar amount for PT and then the same for ot those payers that pay a percent of what Medicare pays were also most likely pay all three PT velkoz the same all three OT val codes the same but those payers that don't pay a percent about Medicare pays and might need determine and come up with different places for high versus moderate versus low absolutely we're just gonna have to wait and see what happens so I'll turn the step over to Heidi now yeah I can't emphasize that information any more strongly I think that it's important for us to understand this first year that they have maintained the payment levels even across the board is to our benefit but also as have to emphasize that the importance of actually making a good-faith effort to code for each patient evaluation accurately even though you will only receive and you won't receive higher payments for higher complexity evaluations and I have to congratulate all of you on this webinar for taking the time to want to learn more it is the 11th hour but you know it's better late than never to really understand starting January 1 that you will need to reach fully understand these personal factors the complicating factors the past medical history all of the things that we talked about today that go into being able to understand the complexity level and understand that your documentation is going to have to support the level that you're actually choosing it is good to note that you know they did kind of greatest on a bell curve of the 25 50 and 25 based on you know information that they've seen in the past on claims but also just with the American Physical Therapy Association helping to drive you know the this first year of what we're trying to look at and the percentages and at the end of the day CMS needs more data that's why they're doing this but they need good data and it's really important for all of us to help provide that data otherwise CMS won't be able to come up with the right pricing structure that is really fair and that means that we may never see reimbursements that align with our true value that we are providing so it's incumbent on us seize this opportunity make sure you're educated on how you're doing this and obviously you've all taken the first step by attending this webinar and I know it's probably there's a lot of thoughtful questions that we want to ask so we're gonna move right into special offers in QA so that you'll have an opportunity to ask some of the questions that might be burning after going through this complicated CPT code discussion thanks Heidi okay so for those of you who aren't web PT members special offer for you if you sign up with us by December 31st you'll receive $100 off your initial signup cost for those of you who are already by PT members and I know there are a lot of you attending today if you refer a colleague and he or she signs up you'll receive a free month of web PT service or an Amazon gift card you can go to web PT comm slash referral to learn more with that I'm gonna hand it on over to Rick who can talk about his special offers okay guys okay in here on slide 49 or my offers you know obviously I know a lot of you already are a gold member to our website if not it's 159 per year you joined today it's good for one year get you complete access to all the content on the website so obviously I've written a lot of news articles and news stories and the new eval eval codes they are available to you as a gold member you know also I just did about a two hour and ten minute webinar yesterday on the new e bow we bow codes in which I actually went through ten case scenarios so you know we did backs and a knee replacement and carpal tunnel and we did a CP child for PT of CP child for ot but I also went through the ICF manual and kind of broke down body structures body functions and TV purchase activity notations participation restrictions and show you how to find them in the ICF manual how to count the elements and all that so if you go to our website which is go under seminars dot-com and there'll be a thing that's as webinars under that you can click on past webinars and a couple hours from now we are gonna have yesterday's webinar up there where you can purchase it and then a discount code box we're gonna purchase it just type in web PT all lowercase so w eb PT web PT all lowercase and that will give you $20 off that webinar it's the playback link that's like a DVR you can watch it here well I'll really break it down and get in a lot more examples in all that it does also contain about a 25 minute live Q&A portion that was recorded so I think the gold membership is great that's something that goes on and you know for a whole year because obviously CC adits and these modifier-59 will change drastically here on January 1 and we'll get that new cheat sheet up there for people you know in early January and that would be available to you as a global number webinars are separate priced but I do encourage you the webinar we did yesterday is a great resource has ten case scenarios so I want to thank Charlotte for letting me spend a minute on there yeah absolutely alright so we're gonna jump into the queue a really quickly so many people asking questions if we don't get to your question during today's webinar our team is compiling all the most common questions and we're gonna publish a blog post on Monday about those questions alright so Rick I'm going to pepper us with a few questions here are the most common questions is around we'll start with some complexity questions so can you give an example of when the complexity of the evaluation and the complexity of the patient do not necessarily correlate and how would you how would you choose your proper CPT code yeah that's a great question you know obviously we are determining the level of complexity of that patient based on that you know the one visit that would do an eval plus whatever the patient and/or their family may be telling us so when I say family that could be a spouse it could be the mother of a child could be a son daughter of a patient and we're basing it on all of that so based on the day you do the vow how the patient presents that day to you both what you see what they're telling you what's going on all that that's gonna be all use to determine the level of complexity of the PT Val or the OT though obviously that includes that the patient history the objective exam the president clinical presentation of the patient and then again of course for you know ot do they need to provide any assistance or modification to the patient or to complete some component or some components of that initial eval so let's just say I'll just use pts you know say PT charges nine seven one six one pt about low complexity and now two three four business late or whatever it may be patient now comes into therapy and now there's been ascend again change in their functions of again change in their status you know people are asking well do I go back and do I now change the valve code from nine seven one six one two nine seven one six two for example and the answer is no you know that would be an example there may be to do a really bad cause for PT and ot they're not based on complexity levels it's just going to be a readout regardless of how complex the patient may present to you the day you do the Reve out so again like it or not this is what we have to work with for both PT and ot so based on how the patient presents to you today for the eval based on the history that they give you and all that and looking at the you know the court the four components for PT the four components for ot making sure you document thoroughly that would then determine the level of complexity that we value bill for that data service knowing that perhaps down the road if there's been a change in function something new going on but you have to do a rebound a small percentage of your patients and that could be yes okay I have a feeling that this is the first time that many of you are really digging into the CPT code issue I'm going to repeat a few things that we talked about in the webinar during this so codes will start on January 1 of 2017 regardless of complexity selected it in your evaluation you will be reimbursed the same for all the CPT codes there is no higher pay for higher complexity during first year it's really about a data collection and trying to make sure that we're matching up with what we thought or what CMS thought in the apt a thought we would be billing so it's really a data collection time in which we can kind of see where it are the levels of complexity across the board with patients that are being seen for physical therapy also this is not just a medicare issue this is a you will see these CPT codes across the board regardless of insurance with the exception of motor-vehicle and workman's comp and so again starting January 1 these CPT codes will be used universally outside of workman's comp and motor vehicle accident insurance because of the HIPAA compliance rules those two insurances don't fall under HIPPA and so they will not necessarily be included it's not that they can't they just don't have to starting on January 1 and then in line with that there were some questions around the fact that they haven't seen these codes on their fee schedules yet well it's not starting till January 1 that is the bar so as of January 1 you will definitely see these fee schedules what PT will definitely be updated with everything you will need to go in and potentially change some of your your fee schedules that are within web PT to reflect the payment for these particular fee schedules unless it is Medicare in which we automatically upload those for you all right Rick I've got another one for you if you could clarify and not that there's been conflicting information I think this is again a first time people are hearing this do you always have to code down when a patient doesn't meet the moderate or high complexity criteria in all areas yes so for example I'll give a PT and an OT example you know if for a PT you look at the the components of history exam and clinical presentation so let's say under history they have one to two personal factors called coal areas that impact the plan of care that would be modern history for PT let's say under objective exam they may have five or six elements under that that'd be high come at me high complexity for the objective exam but let's say under clinical presentation you know they're stable they're predictable that would be low for clinical presentation so you have moderate for history high for exam low for clinical presentation you must then report the low complexity PT val code nine seven 161 same logic which you with the OT Vout you know you might have a patient that meets say low for the occupational profile of the client history you know they might have maybe say four elements under exam which we meet the moderate complexity and then maybe they actually met say moderate for the decision-making and all that because maybe the OT had to provide minimal assistance or minimal modification to some to a component of some components of the eval so now you got low for client profile client history moderate for exam you know moderate on decision-making you'd have to report the low complexity OT val code nine seven one six five so they must meet the criteria for all the components to build that level if not you must report the lowest one perfect okay next question just I'm gonna go back real quick to what I said earlier with regard to HIPAA and motor vehicle accident and workman's comp not being required to use the updated CPT codes the question was around well what do we use then do we just keep using the old ones and the answer is yes so the old CPT codes will continue to stand for workman's comp and motor vehicle accidents so again based on your insurance type within web PT the proper CPT code we'll be available to you to to select and then with respect there's a couple of other questions around guidance on what you should be documenting to support your code selection and I'll just start Rick and then you can definitely add more color