Eli's Rehab Report

Published on Mon Sep 05, 2011 PDF

The following Q&A's have been provided by Rick Gawenda, PT, founder and president of Gawenda Seminars & Consulting Inc.

Question: For commercial insurances that do not adhere to Medicare's billing requirements (i.e. "8-minute rule"), how much time must you provide of a time-based CPT® code in order to bill it to an insurance carrier?

Answer: Many people believe that the Medicare program develops CPT® codes and that we must apply them to all insurance companies. They do not. CPT® codes are developed by the American Medical Association (AMA) and are used by all insurance companies that must comply with HIPAA. In the December 2003 edition of CPT Assistant, the AMA provides the following example: During a treatment session, a therapist or assistant provides 25 minutes of manual therapy and 10 minutes of self care/home management. AMA's intent is that you look at each code individually towards the "each 15-minutes" when determining the billing. AMA goes on to say that since a substantial portion of the 30 minutes was provided of the manual therapy, it is their intent that you would bill 2 units of manual therapy. They add that since a substantial portion of the 15 minutes of self care was provided, it is their intent that you bill 1 unit of self care/home management. So in this example, you would bill 3 units.The AMA further states that's their intent; however, if an insurance carrier is more or less restrictive, follow that insurance carrier's policy. In the above example, the Medicare program would be considered more restrictive as 35 minutes of time-based minutes only allows 2 units to be billed where you could bill 3 units to an insurance carrier that follows AMA's intent.If you were to contact the AMA and ask then how much time must you provide of a time-based CPT® code in order to bill for it, they will tell you that you must provide at least half of the minutes of the CPT® code.

Keep in mind, some payors could require you provide the entire 15-minutes in order to bill for it. It's always best to check if unsure.

Question: Does the Medicare program reimburse for treatment on the same day as an evaluation? How about other insurance carriers?

Answer: The Medicare program does reimburse for treatment provided on the same day as an initial evaluation for all three disciplines and my hope is that we are doing treatment on the day of the evaluation.

At minimum, are you implementing the home exercise program? Might you actually get in and begin treatment and do ultrasound, mechanical traction, unattended electrical stimulation, manual therapy, therapeutic activities, treatment of speech, etc.? For other insurance carriers, you will need to check. It is my experience that the majority do reimburse for treatment on the same

day as an initial evaluation, but I also know there are some that do not, especially those that require prior authorization to continue with therapy once the evaluation has been completed.

Source: Rick Gawenda, PT (www.gawendaseminars.com). Gawenda is consulting editor for Rehab Report.