Palmetto Initiates PT Probe Review

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Jurisdiction 11 Part B

Medical Review Probe: Outpatient Physical Therapist in Private Practice Minor

Procedures (Other) Procedure Codes

The J11 A/B MAC Medical Review department will perform a service-specific prepay

probe review on outpatient claims in North Carolina, South Carolina, Virginia

and West Virginia. Data analysis identified 12 ‘physical therapist in private

practice outpatient services’ with significant frequency in these states.

Further analysis indicated the procedure codes listed below as most frequently

billed codes for ‘physical therapist in private practice minor procedures

(other)’ in North Carolina, South Carolina, Virginia and West Virginia. Claims

review will be performed on approximately 100 claims per state for each of the

procedure codes selected. The procedure codes identified are:

CPT code 97113 (Therapeutic procedure, one or more areas, each 15 minutes:

aquatic therapy with therapeutic exercises)

CPT code 97110 (Therapeutic procedure, one or more areas, each 15 minutes:

therapeutic exercises to develop strength and endurance, range of motion and

flexibility)

CPT code 97530 (Therapeutic activities, direct -one on one- patient contact by

the provider; use of dynamic activities to improve functional performance, each

15 minutes)

CPT code 97140 (Manual therapy techniques (e.g., mobilization/manipulation,

manual lymphatic drainage, manual traction), one or more regions, each 15

minutes)

CPT code 97112 (Therapeutic procedure, one or more areas, each 15 minutes:

neuromuscular reeducation of movement, balance, coordination, kinesthetic sense,

posture, and /or proprioception for sitting and/or standing activities)

CPT code 97116 (Therapeutic procedure, one or more areas, each 15 minutes: gait

training (includes stair climbing)

CPT code 97032 (Application of a modality to one or more areas; electrical

stimulation (manual), each 15 minutes)

CPT code 97016 (Application of a modality to one or more areas; vasopneumatic

devices)

CPT code 97150 (Therapeutic procedure(s), group (two or more individuals)

CPT code 97012 (Application of a modality to one or more areas; traction,

mechanical)

CPT code 97535 (Self-care/ home management training (e.g., activities of daily

living (ADL) and compensatory training, meal preparation, safety procedures, and

instructions in use of assistive technology devices/ adaptive equipment) direct

one on one contact by provider)

CPT code 97035 (Application of a modality to one or more areas; ultrasound each

15 minutes)

Providers who receive an Additional Documentation Request (ADR) must submit the

requested medical record information within 30 days to:

J11 Part B Medical Review

Mail Code: AG-230

P.O. Box 100238

Columbia, SC 29202-3238

Or fax it to

Providers should ensure the accuracy of their billing and send the following

documentation when responding to the ADRs:

Patient’s medical record

Plan of care

Chart notes

Diagnostic test results/reports, including imaging reports

Clinical/therapy notes

Therapy progress notes

Please submit all documentation to support the medical necessity of

services/procedure code billed

If you question the legibility of your signature, you may submit a signature log

or an attestation statement in your ADR response. Medicare requires that medical

record entries for services provided/ordered be authenticated by the author. The

method used shall be a handwritten or an electronic signature. Stamp signatures

are not acceptable. Patient identification, date of service and provider of the

service should be clearly identified on the submitted documentation.

Completed review results will be posted to the Palmetto GBA Web site. Individual

providers with significant denials will be contacted for one-on-one education.

Questions regarding this review may be directed to the Medical Review department

at .

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

www.gawendaseminars.com

Follow Gawenda Seminars & Consulting, Inc on Facebook

Register for the April 24, 2012 audio conference: " Using Risk Assessment to

Establish and Implement a Monitoring & Auditing Program " at

https://www.showmyevent.com/events/viewEventDetails.aspx?EventID=1872

Register for the PQRS webinar on May 23, 2012 at

https://www.showmyevent.com/events/viewEventDetails.aspx?EventID=1885