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Am I Medicare Part A or Part B?
Medicare Part A administers payment for hospital outpatient, skilled nursing facilities, CORF, and rehabilitation facilities. In these settings an individual Medicare provider number is not required for an OT or PT to work in this setting. Billing is performed on the (CMS-1450) UB-92 form.
Medicare Part B administers payment for private practice therapist offices or clinics. The therapist would be required to have his or her own Medicare number. A group number can also be applied for and if the therapist has several office locations then location group numbers will need to be established. Billing is performed using the CMS-1500 form and Part B coding rules apply.
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What is the difference between Medicare and Medicaid?
Medicare is an insurance program that is a federal program. The medical bills are paid from a trust which those covered have paid into. It primarily covers people over 65 and younger disabled people and dialysis patients. Patients are responsible for their deductibles and other hospital cost. Small monthly payments are required for non-hospital coverage. The program is run by the Centers for Medicare and Medicaid Services (CMS), a government agency, and is basically the same everywhere in the US. The CMS web site is www.cms.gov.
Medicaid is an assistance program and is a federal-state program. Medical bills are paid from federal, state, and local tax funds. This serves low-income people of all ages and patients usually pay no part of cost (or a small co-pay) for covered expenses. The program varies from state to state and is run by state and local governments within federal guidelines.
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How do I bill for splints?
For patients that receive splints from hospital outpatient, SNF part B, CORF, and rehabilitation facilities, bills should be billed on the CMS 1450 forms to the providers intermediary using the Medicare alpha-numeric Level II HCPCS codes. Most of these codes are found in the L and A sections and the charge for the splint should include the fabrication time. When applying the splint to the patient, the orthotics fitting and training code 97504 can be used in addition to the Level II HCPCS code. If adjustments or modifications are performed the checkout for orthotic/prosthetic use 97703 can be used.
In place of the above, some intermediaries are also recognizing the CPT codes 29000 through 29750 for OT’s and PT’s. These are strapping and casting codes in the surgery section of the CPT. These codes are CCI edited with 97504. You can use a –59 modifier, but it means that you have to justify why these codes are used together every time you use them. Check with your intermediary carrier to determine which way they prefer you to submit for fabricated splints.
If you are in private practice or physician office, Medicare Part B, you must obtain a DME supplier number to bill for splints billed to Medicare. They may also bill the orthotic fitting code 97504 to their local carrier and the L code to the DMERC on the same date of service but a medical necessity form will need to be completed.
The Medicare Level II HCPCS code book is available through the AMA (800-621-8335) or other publishing companies. These are updated yearly and the revised publication available.
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Many of the Level II HCPCS codes (L codes) do not describe the splints that I am fabricating. How do I choose the proper code?
When choosing the L code, the body part splinted is considered and the therapist are advised to choose the most appropriate code that describes the splint. The splinting nomenclature manual (Splint Classification System) published by ASHT may help clarify this process.
ASHT and AOTA are working toward new HCPCS Level II codes that better describe the fabricated splints.
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How do I bill for fabricated dynamic splints?
A medical analyst for SAMERC, the national HCPCS coding unit, clarified that even though the dynamic addition codes L3810-L3860 are listed to be used with the base splint short or long opponens, L3805 and L3800, they can also be used with the wrist gauntlet code L3906. This wrist splint can be dorsal or volar.
These are only to be used for custom fabricated splints.
If the dynamic splint is prefabricated, then the prefabricated codes that best describe the splint are to be used.
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How do I charge for supplies that are not covered by Medicare or other insurance companies?
If you are a DME provider a few supplies can be billed to the supplier. However, for non-DME providers and non reimbursable items from Medicare and other insurance companies the patient can purchase the supplies from the clinic and the patient must sign an agreement that they are aware that the supplies provided are not covered by their policy and they agree to pay for the supplies. The cost of the supplies can be marked up to cover the cost of shipping and handling. To determine the amount of mark up allowed, the clinic should follow fair trade practice laws in their states. The agreement should then be kept in the patient’s chart.
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hat are CPT codes and how are they used?
Current Procedural Terminology or CPT codes are developed and published by the AMA and revised yearly to provide descriptive terms that are uniform to allow for better communication. Centers for Medicare and Medicaid Services, (CMS), formerly known as HCFA, adopted this system and now requires these to be used for hospital out-patient services, skilled nursing homes, rehabilitation facilities, and private practice practitioners. The codes are used by physicians and other medical providers to describe the services that were provided when processing claims to all healthcare insurance programs.
The codes used by OT’s and PT’s are found in the Physical Medicine and Rehabilitation PM&R section of the CPT code book.
An updated CPT book can be purchased from several medical publishers. Therapist can also contact the AMA Department of Coding and Nomenclature (800) 621-8335 to order publications.
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How are the CPT codes given values for reimbursement?
Each CPT code is given a value based on time, one-to-one supervised or unsupervised modalities, technical skill and judgment to perform the code, and risk to the patient. A committee including OT and PT representatives helps to establish these values. They are evaluated and adjusted yearly and reflected in the fee Medicare fee schedule.
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What are CCI edits and how do I know which CPT codes cannot be used with other CPT codes?
The Correct Coding Initiative was developed by the CMS to promote national correct coding methodologies to control improper coding that leads to inappropriate payment for Medicare Part B carriers. The coding policies developed are based on the AMA’s CPT codes, coding guidelines developed by national societies through analysis of standard medical coding practice. The CCI identifies edits that are "Mutually Exclusive Procedures". These are codes that cannot be performed on the same date of service. Other edits are "Comprehensive and Component Procedures" or code combinations that will not be reimbursed on the same date of service unless a modifier is used. The AOTA states that these "edits raise a red flag for carriers when determining reimbursement". Therapist should use the –59(distinct procedural services) modifier on one of the edited pair. The note should provide an explanation of why both procedures were medically necessary with either different goals or treatment to a different body area. The coding edits can be found in the publication The National Correct Coding Initiative at (703)605-6000 and request chapter 11 for the Medical, Evaluation, and Management Services. This will be revised every quarter.
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What are ICD9 codes and how should they be properly reported on claims?
International Classification of Diseases, 9th edition codes make up a classification system for diseases that are medically based and not functionally based. These codes are revised yearly and are used to identify the treatment diagnosis. In coding for treatment the therapist primary diagnosis should match the physician diagnosis. The secondary diagnosis should then reflect why the therapist is treating the patient. Several ICD9 codes can be used to describe treatment.
Examples: 1) osteoarthritis of the CMC joint of the thumb- localized osteoarthritis is the physician diagnosis and pain in joint is the treating diagnosis and/or joint stiffness. 2) Crush injury is the physician diagnosis. The treating diagnosis may also include joint stiffness, localized edema, pain in hand, and/or tendon adhesions.
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