Eli's Rehab Report

Published on Sat Apr 01, 2000 PDF

For many coders, the March Physical Medicine & Coding Alert article which gives billing advice to non-physician providers, Correctly Bill for Incident to and Optimize Pay Up on page 19, may have only scratched the surface of this complex subject. To help ease any further confusion, we have outlined some additional topics that the previous article didnt elaborated upon.

In particular, the article quoted a physical medicine and rehab (PM&R) practice that employed a physical therapist who plans to bill incident to for evaluation and management (E/M) codes. Ron Nelson, PA-C, president of Health Services Associates, a healthcare consulting firm in Fremont, Mich., points out, however, a physical therapist (PT) often would be reimbursed at a higher rate by billing 97001 (physical therapy evaluation) and using the PTs own billing number, rather than billing an established patient E/M code and using the physicians billing number. In most states, the 97001 pays between $60 and $70, whereas a CPT 99213 (office or other outpatient visit for the evaluation and management of an established patient; physicians typically spend 15 minutes face-to-face with the patient and/or family) normally pays between $40 and $50.

In this situation, says Nelson, billing under the doctors number would actually cost your practice money. In addition, to bill the 99213, the healthcare provider performing the E/M must do current history decision-making and complexity to meet those requirements. Often, a physical therapist would be reviewing the area where the patient needs physical therapy but might not necessarily be performing a full review of systems.

Nelson also points out that physical therapy procedures such as therapeutic exercises (97110) and gait training (97116) have their own CPT codes and should not be billed using E/M codes.

Coders should note that all caregivers, not just physical therapists, should bill only for services within their own scope of practice so the CPT codes assigned will stand up to the test of an audit, if one occurs.

And to reiterate the most important points of billing incident to, caregivers billing under this designation must be employed by the practice, and authorized and licensed by the state to provide the services that they are rendering. Additionally, the physician must have made the patients initial diagnosis, must be on-site at the time of the incident to exam, and must see the patient for any new medical problems. Billers are urged to contact their insurance