Eli's Rehab Report

As an integral part of most patients rehabilitation, occupational therapy is a way to help them regain independence while suffering from impairments, such as those resulting from a stroke (436) or multiple sclerosis (340). Because occupational therapy services are not restricted to the obvious occupational therapy codes, such as the evaluation and reevaluation codes (97003-97004), training in activities of daily living (97535) and community/work reintegration training (97537), its important to learn the full range of an occupational therapists (OT) services so billers can code these therapy claims more accurately.

OTs May Bill Most PM&R Codes

With the exception of the physical therapy evaluation codes (97001-97002), there are no national limitations to physical medicine and rehabilitation (PM&R) 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 restrictions on some codes, Thomas says, OTs can bill for most codes from the PM&R section of CPT. There are no designations in CPT Codes regarding which codes should be billed by physiatrists, physical therapists, occupational therapists or speech therapists.

Its a misconception that any one procedure or code, other than the physical therapy evaluation and re-evaluation codes, should be designated physical therapy, Thomas says. 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 the PM&R section of CPT. For example, an occupational therapists evaluation of a patient recovering from a stroke may involve range of motion measurements (95851-95852) and muscle testing (95831-95834) to help appraise the patients condition and establish a plan of care.

The stroke patients treatment plan may require therapeutic procedures (97110), manual therapy techniques (97140), therapeutic activities (CPT 97530 ), neuromuscular re-education of movement (97112), gait training (97116) and instruction on how to prepare meals, bathe and perform other activities of daily living while recovering from the stroke (97535). The occupational therapist could perform and bill for these services at various times throughout the patients rehabilitation.

Employing an Occupational Therapist

Physiatrists who have OTs on staff must make sure the therapist is an employee of the practice. Under Medicare rules, you need to bring in the therapist under his or her own provider number to be part of the practice, says Mary Jean Sage, CMA-AC, president of Sage Associates, a practice management consulting firm in San Ramon, Calif. The practice must issue a W-2 and pay payroll taxes to establish the OTs proof of employment. If you meet the employment requirements, says Sage, the practice can structure the therapists work. For example, the OT may be full-time, part-time or share work with other practices.

Billing for Concurrent Care

Thomas says that most insurers will pay for a physiatrists evaluation and management (E/M) and an OTs evaluation or procedure for the same patient on the same day, assuming the diagnosis code is sufficient for the insurer to see the medical necessity for both services. If a physiatrist saw an established carpal tunnel syndrome (354.0) female patient for a level three E/M visit (99213), the patient then could go to the OT for therapeutic procedures (97110) such as hand and wrist exercises, and activities of daily living (ADL) training (97535). The OT may show the patient ergonomic products that can help her use her wrist more comfortably or demonstrate 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 physiatrist must review and sign the treatment plan of record every 30 days. The treatment plan has to be part of your practice protocol because its the first thing asked for in an audit, says Sage.

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

Documenting for Therapy

All documentation for therapy should note precisely the time devoted to each therapeutic treatment, the person who provided the care and each modality. In addition, the patients chart should include a copy of the current treatment plan with signatures of the supervising physiatrist and occupational therapist. Documentation also must include the date that the physiatrist 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;
patients diagnoses that require therapy;
related physician orders;
therapy goals and potential for achievement;
any contraindications;
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, Health Care Financing Administration (HCFA) rules dont necessarily apply to all insurers, and practices should check their payers documentation and billing guidelines before submitting occupational therapy claims. Medicare is just one payer, although a major one, says Thomas. She notes that OTs perform their services in healthcare settings other than outpatient practices, and PM&R 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.

Note: This article is the second in our series examining how to organize the billing process when a practice employs or outsources practitioners other than medical doctors and doctors of osteopathy, such as chiropractors, physical therapists and occupational therapists.