Part B Insider (Multispecialty) Coding Alert

Published on Sun May 28, 2006 PDF

You are allowed to report 97001-97546

You can receive payment when you perform physical therapy (PT) modalities, and if you learn the rules--and follow them--you can cut out shaky claims.

Many podiatrists shy away from reporting therapy modalities and procedures (97001-97546) because they ascribe to the myth that only physical or occupational therapists are allowed to report these particular codes.

Reality: Under Medicare rules, podiatrists are given full rein to report 97001-97546. "Each state is a little bit different, but with podiatrists seeing on average 50 percent Medicare patients, Medicare does cover the physical therapy codes," says Paul Fehring, owner of Drs. Central Billing Inc., a Fairfield, OH-based podiatry-specific billing service.

Beware: Most areas require that the physical therapy be done specifically by the doctor, certified tech or physical therapist ...quot; and the doctors' notes have to reflect who performed the service. This may determine whether the insurance company will pay for the service or not, says Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC of Hampton, VA.

The passing of the Deficit Reduction Act carried with it a rein statement of therapy caps for Medicare beneficiaries. As of Jan. 1, physical therapy coverage (combined with speech language pathology services) maxes out at $1,740 per year. Medicare instituted an exception process to this cap on March 13, retroactive to Jan. 1.

Good news: A diabetes mellitus (250.xx) diagnosis will qualify for an automatic exception to this cap if the following conditions are met:

•  A beneficiary is now being treated for this condition; and

•  The severity of the condition or related therapy disorder for which that patient is treated is such that the skills of a therapist are required for services to address the medical needs above therapy caps that meet the qualifications for reasonable and necessary services.

Modifiers make the difference: To take advantage of this exception in appropriate circumstances, you only need to attach modifier KX (Specific required documentation on file) to the physical therapy code. This modifier is in addition to modifier GP (Services delivered under an outpatient physical therapy plan of care), which you must now attach to all physical therapy codes.