Neurosurgery Coding Alert

CMS decisions hold promise of potential patient benefits.

The Centers for Medicare and Medicaid Services (CMS) has announced that there will be additions to the list of telehealth services eligible for Medicare reimbursement. This will encourage providers to adopt and use new technologies. Remote beneficiaries will benefit from the quality of care.

You can read more about the telehealth proposals on: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html. Comments were due on this section on Sep 6. We should now wait to hear the final decisions from CMS. You can hope to hear from CMS soon.

CMS proposed two new codes: CMS proposed to create two new codes (GTTT1 and GTTT2) that will reimburse for both initial and subsequent intensive telehealth consultation services. These critical care consultations will include telestroke and teleneurology services. Additionally, these consultations will be paid at higher rates than those paid for less complex patient consults.

Positive advance: “This is a significant advance for CMS which typically has not reimbursed for physician work that did not include direct face-to-face time with a patient,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. “Given the critical nature of rapid evaluation and triage of acute stroke victims, it is imperative that evaluation and management by a trained stroke specialist occurs quickly. Since many hospitals do not have this capability in-house, the option to have remote experienced services provided by a stroke-certified specialist will provide critically ill patients with advanced diagnosis and treatment, even in remote locations.”

What services qualify for telehealth reimbursement? For a service offered via a distant consultation, Medicare will reimburse when the following criteria are met:

1. Provided via telemedicine.
2. Provided for critically ill patients.
3. Provider should be trained in critical care services.
4. Qualified healthcare professional has in-person responsibility for the patient.
5. Patient could benefit from the distant consultation.
6. Reimbursement limited to one service, per day, per patient.

“The purpose of this service will be to provide rapid evaluation and triage to appropriate treatment protocols based on the remote evaluation of stroke-trained specialist,” Przybylski says. “One would expect the ongoing treatment will remain in the hands of the local physicians unless the patient is transported to another facility based on the nature of their condition and the treatment options available at the evaluating hospital.”

Complexity and Time Spent Are Key to OT Coding

The CMS has proposed new occupational therapy evaluation codes for 2017 as part of the Medicare Physician Fee Schedule proposed rule for 2017 (CMS-1654-P). Your provider may typically choose to use these codes for patients with stroke and spinal disorders.

Find your code: There are 3 new codes proposed based upon the complexity of occupational therapy evaluation. To pick up the right code, you need to determine the complexity of the evaluation, numbers of performance deficits assessed, and the time our provider spent with the patient and/or family. “Similar to other evaluation and management codes on the physician fee schedule, these codes have typical times associated with the three levels of complexity,” Przybylski says. “There is also an acknowledgement of the importance of time spent with the family, which is particularly relevant for the pediatric patient or adult suffering from conditions which preclude or limit their provision of history information.”

• 97165, Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.
• 97166, Occupational therapy evaluation, moderate complexity, requiring these components…..Typically, 45 minutes are spent face-to-face with the patient and/or family.
• 97167, Occupational therapy evaluation, high complexity, requiring these components……….Typically, 60 minutes are spent face-to-face with the patient and/or family.

Revaluation code: Additionally, you have a new code for revaluation of an established plan for occupational therapy, 97168 (Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal revaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family).

Example: You may read that your physician spent about an hour to examine a patient with residual aphasia after stroke and advised the family on potential changes needed in the job profile of the patient. Your physician may also prepare a rehabilitation therapy plan with the patient and his family. In this case, you submit code 97167 for the OT evaluation.

For more on the changes anticipated in 2017, check https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html.