Neurology & Pain Management Coding Alert

Having a physical therapist as part of your neurology practice is a great convenience to patients, allows the physician to exercise more control over a treatment plan and affords the opportunity to bill at higher incident to rates.

Incident to rates allow the practice to bill as if the physician performed the service, although it was actually performed by another clinician in the physicians employ, in this case, a physical therapist.

But those higher billing codes for physical therapy services can also attract the attention of auditors, so its important to be sure that your neurologist/physical therapist relationship meets Medicare and provider requirements.

There are five basic areas that deserve special attention if your practice employs a physical therapist.

1. The physical therapist must be an employee. The most basic requirement is the employer-employee relationship. First of all, under Medicare rules you need to bring the physical therapist up under his or her own provider number to be part of the practice, says Mary Jean Sage, CMA, senior consultant with the Sage Consultants in San Ramon, CA, who often lends advice to specialty practices, such as neurology, that want to maximize profits while being careful to adhere to compliance standards. She adds that the physician must provide Medicare and other payers with the physical therapists provider number in order to make them part of the neurology practice. They then have the same eligibility for reimbursement as any other practitioner employed by the practice.

The test is whether or not the practice issues the physical therapist a W-2 and pays payroll taxes. If that requirement is met, the practice can be creative in how the work is structured. For example, the physical therapist might be part time, sharing his or her time with other practices, or even on call.

While a subcontractor relationship might be economically efficient, Sage strictly advises against it. If a physical therapist absorbs any part of their overheadfor facilities, medical supplies, marketing or anything elsethe relationship could be defined as a subcontract. To meet the employer-employee test, the physical therapist should work for the physician practice under the same basic employment terms as a nurse, office manager or office administrator. Again, the best test is whether or not the physician files a W-2 and pays payroll taxes for the physical therapist.

Jim Nugent, director of reimbursement for the American Physical Therapy Association, warns that physicians who employ physical therapists should be wary of violating federal rules against self-referrals for profit. If the doctor refers to his own PT to make a lot of money, we frown on that type of relationship, he says.

But I can understand that an on-site PT is going to be more convenient for the patient and allow the doctor more control over treatment. But the doctor should ask: Is this arrangement for the benefit of the patient or the doctor?

The association doesnt compile data on the number of physical therapists who are employed by physician practices. But, Nugent suspects that there may be more physical therapists looking for employment by doctors because the impact of the Balanced Budget Act has changed the marketplace. As some skilled nursing facilities close, more physical therapists are going to be looking for jobs.

2. The physician must sign off on the physical therapy treatment plan. A critical part of the neurologist-physical therapist relationship is the treatment plan. There must be a treatment plan on record and signed by the physician. Every 30 days, the plan must be reviewed and signed again by the neurologist. That treatment plan has to be part of your practice protocol, because its the first thing theyll look for in an audit, Sage warns.

As a first step in getting the treatment plan, the neurologist should make an order asking for the physical therapist to evaluate the patient, says Paula Smith, RN, CMA, a management consultant with Seim, Johnson, Sestak & Quist LLP, an accounting and healthcare consulting firm in Omaha, NE, that helps medical practices deal with compliance issues. The physical therapist will make a plan, then go back and get the neurologist to sign off on it, she says. They should agree on the goals and treatment for the patient.

Physical therapy is one area where Medicare can
differ significantly from some managed care plans in what is medically necessary and is reimbursed. Medicare is fickle in physical therapy reimbursement, sometimes paying for a service in one circumstance, but denying payment in another.

For instance, hot and cold packs (97010) are a common physical therapy service, but Medicare will not necessarily pay for a physical therapist to administer these treatments. In general, Medicare doesnt believe this treatment requires the skills of a qualified physical therapist. But if the patients condition is complicated by open wounds, circulatory deficiency, areas of desensitization or other conditions, it will be paid as a physical therapy service.

Most practices learn of these limitations, Sage says, when they do the service and it comes back from the carrier with a big zero in the payment column.

3. The physician must remain on the premises. Another absolute requirement: In order to bill incident to, the referring physician must be physically present in the office at all times when the patient is receiving physical therapy. The doctor doesnt have to see the patient, but must be physically accessible if needed.

The doctor does not actually have to be in the room when the physical therapist is performing those services, says Cynthia Swanson, RN, CMA, a management consultant with Seim, Johnson, Sestak & Quist LLP. Youre billing under incident to as if the physician actually did those services, adds Swanson, so its very important for the doctor to be on the premises because under Medicare rules the doctor is overseeing the treatment.

4. Be diligent in establishing medical necessity. Another big issue, says Smith, is establishing medical necessity. If youre doing more maintenance workfor example an MS patient might be seen but were doing strengthening-type things rather than rehabilitative or restorativeMedicare wont reimburse without medical necessity. Other carriers, she says, may be more lenient on medical necessity because the normal $1,500 maximum yearly benefit allowed by Medicare will be reached quickly. This $1,500 cap is for physical therapy and occupational therapy combined.

One red flag for auditors, Swanson says, is when they see too many services rendered in one physical therapy session. For example, the application of hot and cold packs (97010), massage (97124), and ultrasound (97035) might all be indicated medically, but theyll also attract the attention of auditors. Generally, auditors believe that only one or two physical therapy services are medically necessary or effective on the same day. Too many services rendered together leads auditors to suspect a doctor is trying to quickly exhaust the patients coverage. Physicians who insist on rendering a group of services on the same day should be prepared to justify their medical necessity. To be safe, schedule these services on different days to avoid reimbursement problems.

You dont want to be doing five or six services in one day. Make sure theyre all medically necessary, says Swanson.

5. Documentation: Note who, what and when. Documentation should be very clear in noting the time devoted to physical therapy treatment, who rendered the care and each modality. It should include a copy of the current treatment plan with signatures of the supervising physician and physical therapist. Documentation also must note the date the patient was last seen by the physician.

Although its convenient to have the neurologist and physical therapist on the same premises, Sage cautions not to make it too convenient. Medicare will not pay for an office visit and physical therapist visit on the same day if both stem from the same diagnosis, which is usually the case. Medicare allows payment for both visits on the same day only if each has a separate diagnosis. However, these claims are likely to be rejected and treated as if they were filed under one diagnosis. If you decide to file for payment of both on the same day, attach a letter that emphasizes the separate diagnoses.

Normally, it would be the neurologists office visit (which pays more) that would be denied. So a patient cant come in and see the doctor, and then go off to another room to have their physical therapy, Sage says. Youll have to schedule the follow-up physical therapist visit on a different day.