Knowledge Base Article

“The ABC’s of …” refers to the basic facts of a topic. This article looks at the basic facts of the rehabilitative therapy updates for 2015, which involve C’s (caps and codes), D’s (documentation), E’s (exceptions and extensions), and F’s (functional reporting). So the ABC’s of the CDEF’s of therapy are…

There are not a lot of changes for rehabilitative therapy for 2015 like there have been the past few years. But all of the changes from previous years remain in place, at least for now. So let’s look at what is new and review some of the ongoing requirements for therapy services.

Therapy Caps

• The 2015 therapy cap for physical therapy and speech-language pathology combined is $1,940
• The cap for occupational therapy is $1,940 for 2015
• There is an exception process for therapy services beyond the cap limit if services are reasonable and necessary
• Use KX modifier on therapy services to request exception to therapy caps
• KX modifier - therapist is attesting that the services above the therapy caps are reasonable and necessary and that there is documentation of medical necessity for the services in the beneficiary’s medical record
• See MLN Matters Article MM8970

Therapy Code List

• Two new codes created to describe negative pressure wound therapy with the use of a disposable system
• CPT Code 97607 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are less than or equal to 50 square cm
• CPT Code 97608 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are greater than 50 square cm
• CPT codes 97607 and 97608 designated as “Sometimes Therapy”
• Negative pressure wound therapy CPT codes 97605 and 97606 revised to specify the use of durable medical equipment
• G-codes (G0456 and G0457) that described negative pressure wound therapy using disposable device are being deleted
• See MLN Matters Article MM8985

Extension of Therapy Provisions

The Protecting Access to Medicare Act of 2014 (PAMA) extended the following provisions through March 31, 2015:

• The exceptions process for outpatient therapy caps
• The manual medical review process for therapy services exceeding threshold of $3,700 (one threshold for PT/SLP combined; one for OT)
• The application of the therapy caps and related provisions to services furnished in hospital outpatient departments
• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.

Functional Limitation Reporting

Reporting of the functional limitation G-codes and severity modifiers is now a requirement for rehabilitative therapy claims to allow Medicare to gather data on therapy usage and outcomes to assist in reforming the Medicare payment system for outpatient therapy services. From therapy reviews performed by Medical Management Plus, it appears providers are generally reporting these correctly. The one issue that needs improvement is the documentation of the rationale for selection of the severity modifiers. The Medicare manual states – “Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.”

Documentation should clearly indicate the measures and reasons the therapist selected a particular degree of impairment. Some examples of documentation that meets these requirements are:

• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.
  (Paraphrased from APTA Functional Limitation Reporting Toolkit at the following link: http://www.apta.org/Payment/Medicare/CodingBilling/FunctionalLimitation/)

• Patient’s goal for PT is to be able to walk in her house and around the community (G8978) with minimal to no assist. Her current impairment is 80% (CM) based on her OPITMAL, Berg Balance, and 10 meter walk scores. She is expected to be able to walk with minimal assistance with around 30% (G8979 CJ) impairment after 6 weeks of therapy.

Therapists definitely need to know their alphabet for billing, coding and documentation.