Neurology & Pain Management Coding Alert

Neurology practices that erroneously classify all therapy services as physical therapy may be shortchanging their patients by assuming that occupational therapists are able to bill only a few CPT Codes . In reality, occupational therapists can perform and bill a wide range of codes, and some neurology practices can benefit by employing occupational therapists on staff.

As an integral part of most patients rehabilitative treatment, occupational therapy (OT) is recognized as a way to help patients regain independence after suffering from an impairment, such as a spinal cord injury or a stroke (436), or while learning to adjust to a disease, such as multiple sclerosis (340). The American Academy of Neurology recently recommended OT evaluations and early treatment for many children suffering from autism (299.0x).

Few Limits to OT Coding

Because OT services are not restricted to what some billers view as OT codes, such as the codes 97003 (OT evaluation) and 97004 (OT reevaluation), CPT 97535 (self care/home management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment] direct one on one contact by provider, each 15 minutes) and 97537 (community/work reintegration training [e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis], direct one-on-one contact by provider, each 15 minutes), neurology practices employing occupational therapists should learn the full range of their services so billers can more accurately code these therapy claims.

With the exception of the 97001 (physical therapy evaluation) and 97002 (physical therapy reevaluation) codes, there are no national limitations to rehabilitation codes that occupational therapists can use, says Judy Thomas, director of the reimbursement and regulatory policy department of the American Occupational Therapy Association in Bethesda, Md. Although there may be state practice act restrictions on some codes, she says, occupational therapists can bill for most codes from the physical medicine and rehabilitation section of CPT, and there are no designations in the CPT regarding which codes should be billed by physicians, physical therapists, occupational therapists or speech therapists.

Procedures Beyond Physical Therapy

It is a misconception that any one procedure or code, other than the physical therapy evaluation and reevaluation codes, should be designated physical therapy, Thomas explains. She notes that payers and clinicians sometimes refer to physical therapy as a generic expression for rehabilitation services, but a clearly written plan of treatment usually can justify any therapists billing for these services.

In fact, says Thomas, occupational therapists often bill codes outside of the physical medicine and rehabilitation section of CPT. For example, an occupational therapists evaluation of a patient recovering from a stroke might involve performing codes 95851-95852 (range of motion measurements) and 95831-95834 (muscle testing) to help appraise the patients condition and establish the plan of care.

The stroke patients treatment plan might require 97110 (therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility), 97140 (manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes), 97530 (therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes), 97112 (therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception), 97116 (therapeutic procedure, one or more areas, each 15 minutes; gait training [including stair climbing]), and instruction on how to prepare meals, bathe, and perform other activities of daily living while recovering from the stroke (97535). And the occupational therapist normally could perform and bill for these services at various times throughout the patients rehabilitation.

Employing an Occupational Therapist

Neurologists who hire occupational therapists on staff must be sure to make the therapist an employee of the practice. Under Medicare rules, you need to bring the therapist under his or her own provider number to be part of the practice, says Mary Jean Sage, CMA-AC, senior consultant with the Sage Consultants in San Ramon, Calif., a practice management and consulting firm doing business throughout the United States. The practice must issue the occupational therapist a W-2 and pay payroll taxes to ensure that the proof of employment is established. If that requirement is met, says Sage, the practice can structure the therapists work in its own way. For example, the occupational therapist might be full-time, part-time or share work with other practices.

Concurrent Care

Thomas says that most insurers will pay for a neurologists evaluation and management (E/M) code and an occupational therapists evaluation or procedure for the same patient on the same day, assuming that the diagnosis code is sufficient for the insurer to recognize medical necessity for both of the services. For example, if a neurologist sees an established carpal tunnel syndrome (354.0) patient for a level-three E/M visit (99213), the patient could then go to the occupational therapist for therapeutic procedures (97110), such as hand and wrist exercises, and/or activities of daily living training (97535). The ADL training might involve the OT providing advice on ergonomic products that can help the patient use his or her wrist without pain, or showing the patient how to brush her hair and button her clothes without exacerbating the carpal tunnel pain.

Another critical issue when billing for occupational therapy is that the neurologist must sign off on the therapy treatment plan. The treatment plan on record must be signed by the neurologist and reviewed and signed again every 30 days. The treatment plan has to be part of your practice protocol because its the first thing auditors will look for, says Sage.

As a first step in creating the treatment plan, the neurologist should request that the occupational therapist evaluate the patient, says Paula Smith, RN, CMA, a management consultant with Seim, Johnson, Sestak & Quist LLP, an accounting and healthcare consulting firm in Omaha, Neb. The OT normally will create the plan, then get the neurologist to review it and sign off on it. They should agree on the goals and treatment for the patient, says Smith.

Document Thoroughly

All documentation for therapy clearly should note the time devoted to each therapeutic treatment, who rendered the care and each modality. In addition, the patients chart should include a copy of the current treatment plan, with signatures of the supervising physician and occupational therapist. Documentation also must include the date that the neurologist last saw the patient.

Section 2218 of the Medicare Carriers Manual (MCM) states that the following information must be included in the patients plan of care: the patients significant past history; the patients diagnoses that require therapy; related physician orders; therapy goals and potential for achievement; any contraindications; the patients awareness and understanding of diagnoses, prognosis and treatment goals; and when appropriate, the summary of treatment provided and results achieved during previous periods of therapy services.

Of course, the Health Care Financing Administrations (HCFA) rules dont necessarily apply to all insurers, and practices should be sure to check their payers documentation and billing guidelines before submitting occupational therapy claims. Medicare is just one payer, albeit a major one, says Thomas. She notes that occupational therapists perform their services in other types of healthcare settings besides outpatient practices, and occupational therapy providers in pediatric or community rehabilitation facilities may not abide by Medicares rules. In addition, state-to-state differences exist in licensing and billing mandates for therapists, and these also should be investigated before billing occupational therapy claims.