I am an owner of a Certified Rehabilitation Agency.We have been billing Medicare and Medicaid for over 25 years. Up until now, we have been able to accurately report those services that we provide to our patients using either CPT codes (HCPCS codes) or revenue codes (which in our case are generic codes for  Physical Therapy, Speech Therapy, or Occupational Therapy Services). The new requirement that Virginia Medicaid (DMAS) has made allows us to use only 8 of the 76 appropriate and available CPT codes for therapy services. This is simply untenable. The reason we, as therapists, have been given 76 codes is because we need to be able to accurately document and bill for services rendered to our patients. The Centers for Medicare and Medicaid Services (CMS) has required all claims submitted after April 1,1998 to be reported using these 76 HCPCS/CPT codes for outpatient rehabilitation and CORF services. Virginia Medicaid is essentially asking us to fraudulently report services rendered by saying that each and every type of service (other than evaluations or group therapy) provided by Physical Therapists is therapeutic exercise (97110). It is inaccurate and inappropriate to ask us to code mechanical traction, whirlpool, ultrasound, electrical stimulation, paraffin,etc. as therapeutic exercise. That requires us to inaccurately code AND puts us out of compliance with Correct Coding Initiatives and Uniform Coding requirements. If DMAS expects to call any PT service the same as any other, DMAS needs to revert back to the revenue codes they stopped using on June 30, 2009.

I have approached  Mr. Bill Lessard about this issue several times. He stated that he was responsible for estblishing the new methodology although it required approval "up the chain". In an e-mail to me,he stated that we would be free to bill any other codes for PT we would like to besides the therapeutic exercise; however, we would not get reimbursed for them. Each of the three codes he requires to be used for each type of therapy (ie., Therapeutic exercise for Physical Therapy, Therapeutic activities for Occupational Therapy, and speech therapy for Speech Therapy) is very limiting. Speech Pathologists also work on feeding and swallowing issues which has its own code as well as sensory integration and coordination activities for oral-motor structures. To code these as speech therapy (92507) is inaccurate  and against federal regulations. Similar problems abound for Occupational Therapy.

Another MAJOR issue for us in limiting services to these few codes is the drastic problem it presents for our billing systems. Since we MUST document and charge for exactly what we do based on all our available CPT codes, for DMAS billing we will have to manually go back and modify billing to comply with Medicaid's inaccurate codes. After pressuring and much questioning on this issue, DMAS acknowledged that it would have to maintain a mechanism to accomodate automatic cross-over claims from Medicare. It appears DMAS has decided to continue paying those claims the "old way". This presents a problem for DMAS, as well as providers, because DMAS is requiring coding and billing differently for the same service depending on the primary payor source. This flies in the face of CMS as well as Virginia Medicaid's own regulations.

For DMAS to try to state, in its Background Document for this regulation, that this new reimbursement mechanism "will align the DMAS reimbursement methodology of outpatient services more closely to Medicare methodologies and other reimbursement methodologies used by commercial insurers"  is far from true. What DMAS' reimbursement  department has done is simply take the few codes DMAS allows for School Therapy billing and imposed them erroneously on outpatient services. We, as an Agency, have stated repeatedly that these codes are too limited for School Services also, but WE are not the ones who have to directly bill for those services. THAT billing is done by the Schools (not Rehab Agencies). After talking at length with Virginia Medicaid's  CMS representative, he agrees that if DMAS is going to require us to use the limited codes, then DMAS needs to figure out a way to convert our CORRECT CODES to those that DMAS requires. We should not be asked to inaccurately change our CORRECT CODES before billing them to DMAS. NOR  should we be expected to bill a primary insurance with the CORRECT CODES and then change them before billing DMAS as secondary. To simply tell us that we can bill them like that and just not get paid is very disingenuous. It is also overly burdensome administratively and costly particularly in light of the drastic cuts  DMAS has imposed on Speech Therapy reimbursement.

In the Regulatory Background Document, DMAS also states " providers would experience little to no administative costs as the claim reporting requirements are not affected". This is definitely false. Nor is it true that " providers will each save approximately $2000.00 annually since they will no longer have to do cost reports". This new system creates administrative and billing nightmares with significant increase in the cost of billing and collections while reducing payment. DMAS' Background Document also stated that  "the advantage to the Citizens of the Commonwealth is the reduction in the provider's cost." That is also simply untrue.

I, along with others, are requesting a participatory approach in developing the permanent regulations. As Mr. Lessard said to me himself, since he is not a clinician, he is not in a position to know about coding issues and requirements. These issues should have been considered before making the decision to change the reimbursement methodology.

We are not objecting to moving to CPT coding as most other insurance companies currently use. We are simply asking  to be given the opportunity to use all the codes that correctly reflect what we are doing and are mandated from us. We simply should not be asked to create a separate billing and coding system for DMAS and its MCO's.

Thank you for allowing me to comment on these issues. I would be happy to discuss any of this information or provide any clarification needed.

Jan D. Jessee, PT   President   

Professional Therapies of Roanoke, Inc.

540-982-2208

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,