Eli's Rehab Report

Published on Mon Dec 24, 2012 PDF

AMA expands and clarifies its definition of qualified providers.

The good news is that CPT® code updates for the rehab specialty were fairly slim for 2013. The American Medical Association did not assign new codes in the Evaluative and Therapeutic Services and the Therapeutic Procedures sections of CPT®.

"There were significant changes to the EMG (electromyography) codes, but they affect only a small number of therapists across the country who actually bill them," says Gayle Lee, JD, senior director of health finance and quality for the American Physical Therapy Association.

Bigger news: In an attempt to establish provider neutrality, the American Medical Association made tweaks in code descriptors across all healthcare specialties, including rehab.

According to CPT® instructions, "any procedure or service in any section of the CPT® codes set may be used to designate the services rendered by any qualified physician or other qualified health care professional or entity," points out Carmen Elliott, director of payment and practice management for the American Physical Therapy Association. "To provide consistency, CPT® guidelines and parenthetical instructions throughout the manual were revised to reflect physician or other qualified health care professionals," she explains.

Clarification Only, No Scope of Practice Changes

Specific to rehab, under the Physical Medicine & Rehabilitation section headline, the word "physician" was added in the coding instructions.

"In 2012 the wording read ‘work of the qualified healthcare professional’ with no reference to a physician," points out Joanne Byron, LPN, BSNH, CCA, CHA, CHCO, CIBS, CMC, CMCO, COBS, PCS, CPC, CPC-I, ICDCT-CM, ICDCT-PCS,CEO of the American Institute of Healthcare Compliance in Medina, OH. "This revision brings clarification that a physician is included as a provider to render therapeutic services and report codes within the Physical Medicine and Rehabilitation section of CPT®."

The AMA made a similar change to the Therapeutic Procedures subcategory. "In 2013 we find another guideline wording change which removes the word ‘therapist’ from 2012 and replaces it with ‘other qualified health care professional’, expanding the definition of the types of providers approved to use codes in this section of CPT®," Byron says.

Plus: In the 2013 CPT® book, you’ll also see a blue triangle next to five of the codes under Therapeutic Procedures. "When conducting a side-by-side comparison of wording between 2013 and 2012, we find the AMA has omitted the word "by provider" in each code description," Byron observes. "Direct, one-on-one contact is still required to report any of the therapeutic procedures within this code range (97530, 97532, 97533, 97535 or 97537); however, specific provider reference is no longer evident."

Implications: "We do not anticipate the CPT® language change will have an impact on the PT profession," Elliot says. The revised language simply allows for broader use of all CPT® codes by qualified individuals, she explains. "This includes physical therapists."

"According the 2013 CPT® Changes: An Insider’s View, these distinctions were created to better align CPT® codes with the reporting and payment policies of the Centers of Medicare and Medicaid Services (CMS) and/or private payers," Elliot reports.

Tread Carefully With Broader Definitions

A more open door to qualified providers in CPT® terminology doesn’t mean a free-for-all when it comes to billing services.

"Just because the AMA and CPT® recognizes the procedure, does not mean that a payer will reimburse for it," says Ken Mailly, PT, MPA, with Mailly & Inglett Consulting in Wayne, NJ. "That disconnect is always present, always has been, and always will be."

Key: State practice acts, payer policies, professional scope of practice, and credentialing, to name a few, must be in line first.

Mailly believes the interest in acknowledging other qualified professionals in CPT® is part of a broader effort to expand the medical profession’s ability to delegate to other practitioners. "There certainly is an interest among athletic trainers, for example, to be able to bill for various CPT® codes beyond athletic training codes," Mailly observes. "And I do have doubt that there’s an interest in a number of physicians to delegate to athletic trainers."