RE: Re: directions and clarity

[Guest guest]

Well said Larry. We should be striving for more autonomy as physical

therapists. We are now a doctoring profession and should be trusted to use our

professional judgment. Arbitrary rules do not help our patients whatsoever.

Dan Rootenberg, PT, DPT, CSCS

From: PTManager [mailto:PTManager ] On Behalf Of

Larry Benz

Sent: Wednesday, September 14, 2011 9:26 AM

To: PTManager

Subject: Re: directions and clarity

Damon:

While I respect Dick's thoughts on this, I don't agree with his conclusion.

I agree that there shouldn't be any difference in billing per se between

medicare and non-medicare, there is however huge differences in any rules

that they may superimpose on your practice act. Unfortunately, there are

many payors now following medicare rules and there are some payor contracts

that default to the state practice act. They key item in my opinion is to

refer to any particular contract language that you have relative to that

specific payor. Many practices simply default everything to medicare's

superimposed rules which from my perspective is very damaging to the whole

notion of an autonomous practitioner and their scope of practice.

I also agree with Dick on the use of the AMA guide. However, where we likely

disagree is on non medicare patients (where the contracts either don't

directly address the issue or they default to your practice act). Medicare

is the most restrictive. It is very explicit as to who can treat their

patients. While this is indeed unfortunate, it is reality so follow the

rules on them and don't set yourself up for potential audit problems by

grouping medicare and non-medicare patients or overlapping medicare patients

which could end up having you do manual therapy and having to bill it as

group! As to ATC's in that environment, they can't be used in any capacity

involving patient care. This actually can be extended to really any

federally funded patient.

The issue within AMA CPT code guidelines that I believe has merit is in the

definition of direct (or one on one). It is further defined as essentially

meaning visual, auditory, or manual contact. While I agree that this is

somewhat counter intuitive it is the very definition that physicians use for

allowing them to provide direct care through their support personnel (nurses

for example). I think it would be impossible for AMA to limit all codes

for physicians to explicit rules like medicare relative to one to one

because they would literally have to do every blood pressure check and HR.

Assuming that your payor isn't explicit like medicare and your practice act

allows you to use extenders (I am unfamiliar with your state's practice

act), you can use extenders for one on one codes as long as you meet the

definition within the CPT code guidelines. The larger issue really isn't

the technicality or definitions but the judgement of the physical therapist

and what should be directed and delegated. Of note, in environments in

which PT's are given the greatest autonomy (e.g. military) and least

restrictions relative to things like the medicare rules, they broadly direct

and delegate to support personnel yet still produce per capita the most

research and have the highest rate of board certification in the U.S. It is

the very model that we should strive to become which is really in part the

intention of Vision 2020.

<https://physicaltherapist.awayfind.com/larry>Larry Benz PT, DPT

PT Development LLC

CONFIDENTIALITY: This message is " Off The Record " . A lot of fancy legal

speak that none of us reads or understands is often contained here.

[Guest guest]

I agree with Larry in that the therapist should be the one to determine what

interventions the patient requires and who is best to provide those

interventions while practicing within the scope of their respective state

practice act. In the House of Delegates (HoD) this year, RC 3-11

(

 that

the American Physical Therapy Association recognizes and supports physical

therapists’ abilities to utilize the most appropriate support personnel when

directing and supervising selected aspects of physical therapy intervention,

consistent with jurisdictional law.

People think that the Medicare program develops CPT codes and that we must apply

them to all insurance companies. They do not. CPT codes are developed by the

American Medical Association (AMA) and are used by all insurance companies that

must comply with HIPAA. In the December 2003 edition of CPT Assistant, the AMA

provides the following example.

During a treatment session , a provider provides 25 minutes of manual therapy

and 10 minutes of self care/home management. AMA's intent is that you look at

each code individually towards the " each 15-minutes " when determining the

billing. AMA goes on to say that since a substantial portion of the 30 minutes

was provided of the manual therapy, it is their intent you would bill 2 units of

manual therapy. They go on to say that since a substantial portion of the 15

minutes of self care was provided, it is their intent you bill 1 unit of self

care/home management. So in this example, you would bill 3 units.

The AMA goes on to say that's their intent; however, if a payor is more or less

restrictive, follow that payor's policy. In the above example, the Medicare

program would be considered more restrictive as 35 minutes of time-based minutes

only allows 2 units to be billed where you could bill 3 units to an insurance

carrier that follows AMA's intent.

If you call AMA and ask then how much time must you provide of a time-based CPT

code in order to bill for it, they will tell you half the code. Keep in mind,

some payors could require you provide the entire 15-minutes in order to bill for

it.

Lastly, we need to stop changing our practice acts to be in alignment with

Medicare rules and regulations or other payors. Stop putting limits on how long

an order/prescription is valid for. Stop limiting our professional judgement in

who is best to provide an intervention under the supervision of the therapist.

My home state has made these changes in the last several years and in my

opinion, was wrong and all based on Medicare.

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc

Subject: Re: directions and clarity

To: PTManager

Date: Wednesday, September 14, 2011, 9:25 AM

Â

Damon:

While I respect Dick's thoughts on this, I don't agree with his conclusion.

I agree that there shouldn't be any difference in billing per se between

medicare and non-medicare, there is however huge differences in any rules

that they may superimpose on your practice act. Unfortunately, there are

many payors now following medicare rules and there are some payor contracts

that default to the state practice act. They key item in my opinion is to

refer to any particular contract language that you have relative to that

specific payor. Many practices simply default everything to medicare's

superimposed rules which from my perspective is very damaging to the whole

notion of an autonomous practitioner and their scope of practice.

I also agree with Dick on the use of the AMA guide. However, where we likely

disagree is on non medicare patients (where the contracts either don't

directly address the issue or they default to your practice act). Medicare

is the most restrictive. It is very explicit as to who can treat their

patients. While this is indeed unfortunate, it is reality so follow the

rules on them and don't set yourself up for potential audit problems by

grouping medicare and non-medicare patients or overlapping medicare patients

which could end up having you do manual therapy and having to bill it as

group! As to ATC's in that environment, they can't be used in any capacity

involving patient care. This actually can be extended to really any

federally funded patient.

The issue within AMA CPT code guidelines that I believe has merit is in the

definition of direct (or one on one). It is further defined as essentially

meaning visual, auditory, or manual contact. While I agree that this is

somewhat counter intuitive it is the very definition that physicians use for

allowing them to provide direct care through their support personnel (nurses

for example). I think it would be impossible for AMA to limit all codes

for physicians to explicit rules like medicare relative to one to one

because they would literally have to do every blood pressure check and HR.

Assuming that your payor isn't explicit like medicare and your practice act

allows you to use extenders (I am unfamiliar with your state's practice

act), you can use extenders for one on one codes as long as you meet the

definition within the CPT code guidelines. The larger issue really isn't

the technicality or definitions but the judgement of the physical therapist

and what should be directed and delegated. Of note, in environments in

which PT's are given the greatest autonomy (e.g. military) and least

restrictions relative to things like the medicare rules, they broadly direct

and delegate to support personnel yet still produce per capita the most

research and have the highest rate of board certification in the U.S. It is

the very model that we should strive to become which is really in part the

intention of Vision 2020.

<https://physicaltherapist.awayfind.com/larry>Larry Benz PT, DPT

PT Development LLC

CONFIDENTIALITY: This message is " Off The Record " . A lot of fancy legal

speak that none of us reads or understands is often contained here.