September 3, 2009

Department Of Medical Assistance Services (DMAS)
600 East Broad Street

Richmond, VA 23219

Dear Sir or Madame:

The Virginia Physical Therapy Association (VPTA) respectfully requests a reconsideration of the Department of Medical Assistance Services’ determination limiting the CPT codes available to physical therapists for claims submission. This policy is problematic as it creates additional financial and administrative burdens for physical therapists. In addition, it does not adequately reflect the scope of practice of physical therapists and the services they deliver. It violates the standards of practice physical therapists utilize to ensure that the services billed are supported by the documentation in the patient’s medical record. Finally, it is inconsistent with the billing practices of other insurers, including Medicare.

As the policy stands, physical therapists would be required to bill the Department for all physical therapy services provided to the state’s Medicaid beneficiaries using a small subset of CPT codes. Specifically these codes are 97001 (PT evaluation), 97110 (therapeutic exercises), and 97150 (therapeutic procedures, group). Physical therapists typically bill for their services utilizing codes in the 97000 series as well as select other codes outside this series as provided by the American Medical Association in the CPT 2009 coding manual[1].

For example, CPT code 97110, therapeutic exercise is defined in the CPT Manual as “Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.” Compare this to another intervention, wound care, within the scope of practice of physical therapists. CPT code 97597 is described in the CPT manual as “Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters.”

CPT code 97110 does not at all describe or could not be considered applicable to a CPT code used to describe services associated with wound care. To expect that physical therapists would be able to adequately capture the services they provide and appropriately document the medical necessity of those services by using only three codes is unreasonable and does not comport to professional standards of practice. In fact, to report one service as another, in this scenario wound care as therapeutic exercise, would be considered fraudulent under all other insurer policies.

The professional standards of practice developed by APTA dictate that at each visit or encounter the following pieces of information are included in the medical record:

·  Documentation of each visit/encounter shall include the following elements:

o Patient/client self-report (as appropriate).

o   Identification of specific interventions provided, including frequency, intensity, and duration as appropriate. Examples include:

·          Knee extension, three sets, ten repetitions, 10# weight

·         Transfer training bed to chair with sliding board

·          Equipment provided

oChanges in patient/client impairment, functional limitation, and disability status as they relate to the plan of care.

o   Response to interventions, including adverse reactions, if any.

o     Factors that modify frequency or intensity of intervention and progression goals, including patient/client adherence to patient/client-related instructions.

o  Communication/consultation with providers/patient/client/family/ significant other.

o  Documentation to plan for ongoing provision of services for the next visit(s), which is suggested to include, but not be limited to:

·  The interventions with objectives

·  Progression parameters

·   Precautions, if indicated

Physical therapists document the specific interventions they provide at a given encounter for several important reasons. It is important that the therapist has a record of services provided to ensure that the most appropriate services are being rendered to a patient. If all services were recorded as therapeutic exercise, it would not give an accurate picture of the patient’s condition and needs or the interventions provided.  

In 2000, the Department of Health and Human Services (HHS) designated the CPT codes as the national coding standard for physician and other health care professional services and procedures under the Health Insurance Portability and Accountability Act (HIPAA). This means that for all financial and administrative health care transactions sent electronically, the CPT code set will need to be used. In fact, payers including Medicare and private insurers have adopted the 97000 series codes as those appropriate to bill for reimbursement of physical therapy services. By limiting physical therapists to three codes, DMAS is establishing a payment system in direct contradiction with Medicare and other federal healthcare programs.

Therefore, we strongly urge DMAS to retract its policy which limits physical therapists to documenting for services using only the three delineated CPTs codes, as mentioned above, and to mandate a new policy which clearly states that physical therapists are permitted to use the full scope of the CPT 97000 series and other CPT codes as needed per their clinical judgment to adequately and appropriately document medical necessity of physical therapy services delivered to patients under the Virginia Medicaid program.

We thank you for your time and consideration and would be more than happy to lend our expertise in this area, if further information is needed.

Sincerely,