evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Progress note elements include(CMS required elements are italicized): ? Date of the beginning and end of the reporting period that this report refers to;Date that the report was written by the clinician, or if dictated, the date on which it was dictated;Objective reports of the patients subjective statements, if they are relevant;Objective measurements (impairment/function testing) to quantify progress and support justification for continued treatment;Description of changes in status relative to each goal currently being addressed in treatment. Descriptions shall make identifiable reference to the goals in the current plan of care;Assessment of improvement, extent of progress (or lack thereof) toward each goal;Plans for continuing treatment, including documentation of treatment plan revisions as appropriate;Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment;Signature with credentials of the clinician who wrote the report.No specific format is required to demonstrate patient progress as long as all information noted in the bullets above are included at least once in the medical record for each progress report period (10 treatment days or 30 calendar days, whichever is less). Progress report information may be included in the treatment notes, progress reports and/or formal re-evaluations (when re-evaluation guidelines are met).During each progress report period, the clinician must personally furnish in its entirety at least one billable service on at least one day of treatment. Verification of the clinicians treatment shall be documented by the clinicians signature on the treatment note and/or progress report.Treatment NotesMedical record documentation is required for every treatment day, and every therapy service to justify the use of codes and units on the claim.The treatment note must include the following required information:date of treatment;identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;record of the total time spent in services represented by timed codes under timed code treatment minutes;record of the total treatment time in minutes, which is a sum of the timed and untimed services;signature and credentials of each individual(s) that provided skilled interventions.In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:patient comments regarding pain, function, completion of self management/home exercise program (HEP), etc;significant improvement or adverse reaction to treatment;significant, unusual or unexpected changes in clinical status;parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;description of the skilled components of the specific exercises, training, or activities;instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);communication with patient, family, caregiver;equipment providedany additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.If grid or checklist forms are used for daily notes or exercise/activity logs, include the signature and credentials of the qualified professional/auxiliary personnel providing the service each day. Listing of exercise names (e.g., pulleys, UBE, TKE, SLR) does not alone imply that skilled treatment has been provided, especially if the exercises have been performed over multiple sessions. Be sure to occasionally document the skilled components of the exercises so they do not appear repetitive and therefore, unskilled. Documenting functional activities performed (e.g., ambulated 35 feet with min assist, upper body dressing with set up and supervision) also does not alone imply that skilled treatment was provided. The skilled components/techniques of the qualified professional/auxiliary personnel used to improve the functional activity should be occasionally documented to support medical necessity.When documenting treatment time, consistently use the CMS language of total Timed Code Treatment Minutes and Total Treatment Time. Do not use other language or abbreviations when referring to treatment minutes as it may be difficult for medical review to determine the type of minutes documented. The amount of time for each specific intervention/modality provided may also be recorded voluntarily.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Do not record treatment time as Time in / Time out for the entire session as this does not accurately reflect the actual treatment time. Do not round all treatments to 15-minute increments, but rather record the actual treatment time. Also do not record as units of treatment, instead of minutes.Only intra-service care of skilled therapy services should be reflected in the time documentation. Do not include unbillable time, such as time for:changing;waiting for treatment to begin;waiting for equipment;resting;toileting; orperforming unskilled or independent exercises or activities.Discharge NotesA discharge note is required for each episode of treatment and must be written by the clinician. The discharge note is a progress report covering the time from the last progress report up to the date of discharge, and includes all required components of a progress report. The discharge note may be considered the last opportunity to justify the medical necessity of the entire treatment episode. Therefore, if a discharge summary has been completed, it may be prudent to submit it with any request of records for medical review, even if the claim under review is for a treatment period prior to the date of discharge.In the case of an unanticipated discharge, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified auxiliary personnel. In the case of a discharge anticipated within 3 treatment days of the progress report, the clinician may provide objective goals which, when met, will authorize the assistant or qualified auxiliary personnel to discharge the patient. In that case, the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist. There must be indication that the clinician has reviewed the treatment notes and agrees to the discharge.Certifications and RecertificationsMedicare beneficiaries receiving outpatient therapy services must be under the care of a physician/NPP. Orders (sometimes called referrals) and certifications are common means of demonstrating such evidence of physician involvement.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Certification, which is a coverage condition for therapy payment, requires a dated physician/NPP signature on the therapy plan of care or some other document that indicates approval of the plan of care. A certification often differs from an order or referral in that it must contain all required elements of a plan of care. To assist medical review in determining that the certification requirements are met, certifications/recertifications should include the following elements(CMS required elements are italicized):The date from which the plan of care being sent for certification becomes effective (for initial certifications, the initial evaluation date will be assumed to be the start date of the certified plan of care);Diagnoses;Long term treatment goals;Type, amount, duration and frequency of therapy services;Signature, date and professional identity of the therapist who established the plan; andDated physician/NPP signature indicating that the therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan. (Note: The CORF benefit does not recognize an NPP for certification.)Effective January 1, 2008, the interval length shall be determined by the patients needs, not to exceed 90 days. Certifications which include all the required plan of care elements will be considered valid for the longest duration in the plan (such as 3x/wk for 6 weeks which will be considered as a total of 18 treatments). If treatment continues past the longest duration specified, a recertification will be required.Documentation Requirements for Unlisted Procedure CodesUnlisted modality- In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxilliary personnel, the time spent by the qualified professional/auxilliary personnel, one-on-one with the beneficiary.Unlisted therapeutic procedure- Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Unlisted physical medicine/rehabilitation service or procedure- Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.Unlisted procedure, casting or strapping- Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.Untimed CPT CodesWhen a therapy treatment modality or procedure is not defined in the AMA CPT Manual by a specific time frame (such as each 15 minutes), the modality or procedure is considered an untimed service. Untimed services are billed based on the number of times the procedure is performed, often once per day. Untimed services billed as more than 1 unit will require significant documentation to justify treatment greater than one session per day per therapy discipline. The minutes spent providing untimed services are reflected in the documentation under Total Treatment Time(and are not included in the minutes for timed CPT codes when determining the number of timed-based units that may be billed).Time Based Codes (if applicable)When billing time-based codes the CPT time rule appliesExact times MUST be documented in the medical recordThe code reported should be selected based on the time closest to that indicated in the code descriptor
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
When billing time-based codes the CPT time rule appliesExact times MUST be documented in the medical recordThe code reported should be selected based on the time closest to that indicated in the code descriptorMany CPT codes for therapy modalities and procedures specify that direct (one-on-one) time spent in patient contact is 15 minutes. The time counted is the time the patient is treated using skilled therapy modalities and procedures, and is recorded in the documentation as Timed Code Treatment Minutes. Pre- and post-delivery services are not to be counted when recording the treatment time. The time counted is the intra-service care that begins when the qualified professional/auxiliary personnel is directly working with the patient to deliver the service. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment. The intra-service care includes assessment. The time the patient spends not being treated because of a need for toileting or resting should not be counted. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. Time spent supervising a patient performing an activity that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the Timed Code Treatment Minutes. Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.When determining the allocation of units, it is easiest to separate out each service first into 15-minute time blocks. For example:24 minutes 97112 = one 15-minute block + 9 remaining minutes23 minutes 97110 = one 15-minute block + 8 remaining minutesEach code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most remaining minutes (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is 2 units 97112 + 1 unit 97110.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
The first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise and 20 minutes self-care/home management training. The total Timed Code Treatment Minutes documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in Timed Code Treatment Minutes will determine the number of units billed.Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.Do not bill for documentation time separately(except for standardized cognitive performance testing). This is incorporated in the HCPCS/CPT fee reimbursed for each individual service provided.Do not code higher than what the procedure requires. Coding in this manner may allow the provider to collect inappropriate revenues without incurring additional costs.Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.Do not unbundle services/procedures. Unbundling refers to the practice of splitting a single payment code into two or more codes. This may lead to inappropriate multiple payments.Do not bill separately for supplies used to provide therapy services, such as electrodes, theraband, theraputty, etc.Therapists, or therapy assistants, working together as a team to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient. For example, if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.Examples of treatment time documentation
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Examples of treatment time documentationA treatment session includes 20 minutes therapeutic exercise (97110), 15 minutes therapeutic activities (97530) and 20 minutes unattended electrical stimulation (G0283).Time documentation in the treatment noteTimed Code Treatment Minutes: 35 minutesTotal Treatment Time: 55 minutesA 30 minute OT initial evaluation is completed (97162), followed by 20 minutes fluidotherapy (97022).Time documentation in the treatment noteTimed Code Treatment Minutes: 0 minutesTotal Treatment Time: 50 minutesThe first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise (CPT 97110) and 20 minutes self-care/home management training (CPT 97535). The total Timed Code Treatment Minutes documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in Timed Code Treatment Minutes will determine the number of units billed.Once the minutes have been summed, use the chart below to determine the total allowable units, based on the total Timed Code Treatment minutes.1 unit>8 minutes through 22 minutes2 units>23 minutes through 37 minutes3 units>38 minutes through 52 minutes4 units>53 minutes through 67 minutes5 units>68 minutes through 82 minutes6 units>83 minutes through 97 minutes7 units>98 minutes through 112 minutes8 units>113 minutes through 127 minutesWhen the total Timed Code Treatment minutes for the day is less than 8 minutes, the service(s) should not be billed.It is important to allocate the total billable units for timed services to the appropriate CPT codes based upon the number of minutes spent providing each individual service. Any timed service provided for at least 15 minutes, must be billed one unit. Any timed service provided for at least 30 minutes, must be billed two units, and so on. When determining the allocation of units, it is easiest to separate out each service first into 15-minute time blocks. For example:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
20 minutes of Therapeutic Exercise (CPT 97110) = one 15-minute block + 5 remaining minutesAt least 1 unit must be allocated to this code38 minutes of Self-care/Home Management Training (97535) = two 15-minute blocks + 8 remaining minutesAt least 2 units must be allocated to this codeIf 38 minutes of CPT 97535 is the only treatment provided, then 3 units would be billed. However, as demonstrated in the examples below, there may be treatment sessions in which the correct billing would only allow 2 units, based on the remaining minutes.The remaining minutes (those minutes remaining after the 15-minute blocks have been allocated) are considered when the total billable units for the day allow for an additional unit to be billed. See the following examples:24 minutes of neuromuscular reeducation (CPT 97112)23 minutes of therapeutic exercise (CPT 97110)____________________________________________47 total Timed Code Treatment minutesUtilizing the chart above, 47 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first24 minutes 97112 = one 15-minute block + 9 remaining minutes23 minutes 97110 = one 15-minute block + 8 remaining minutesEach code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most remaining minutes (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is2 units 97112 + 1 unit 9711020 minutes of neuromuscular reeducation (CPT 97112)20 minutes therapeutic exercise (CPT 97110)________________________________________40 total Timed Code Treatment minutesUtilizing the chart above, 40 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Utilizing the chart above, 40 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first20 minutes 97112 = one 15-minute block + 5 remaining minutes20 minutes 97110 = one 15-minute block + 5 remaining minutesEach code contains one 15-minute block, therefore, each code shall be billed for at least 1 one unit. As 3 units is allowed, a review of the remaining minutes is required to determine which code should be billed the additional unit. Since the remaining minutes for each service are the same in this example, either of the codes may be billed for the additional unit. The correct coding is either one of the following2 units 97112 + 1 unit 97110OR1 unit 97112 + 2 units 971104 minutes assessing shoulder strength prior to initiating and progressing therapeutic exercise (CPT 97110)32 minutes therapeutic exercise (CPT 97110)7 minutes manual therapy (CPT 97140)_______________________________________43 total Timed Code Treatment minutesUtilizing the chart above, 43 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first36 minutes 97110 = two 15-minute blocks + 6 remaining minutes7 minutes 97140 = zero 15-minute blocks + 7 remaining minutesCode 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the remaining minutes, and apply the additional unit to the service with the most remaining minutes. The correct coding is2 units 97110 + 1 unit 9714018 minutes of therapeutic exercise (CPT 97110)13 minutes of manual therapy (CPT 97140)10 minutes of gait training (CPT 97116)8 minutes of ultrasound (CPT 97035)_______________________________________49 total Timed Code Treatment minutesAppropriate billing for a total of 49 minutes is 3 units. To allocate those 3 units, determine the 15-minute blocks first