Urology Coding Alert

7 choices help you pinpoint the patient’s status

When you’re coding for a physiotherapy case that involves “C” modifiers, it’s important to know how those modifiers are assigned. These five guidelines will help you stay on the right track:

• In clinical cases, the therapist will use multiple measurement tools during the evaluative process to form clinical decision making and use clinical judgment to combine these results to determine a functional limitation percentage.
• Therapists can use their clinical judgment in the assignment of the appropriate modifier. Therapists will need to document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.
• Use the CH modifier (0 percent impaired, limited or restricted) to reflect a zero percent impairment when the therapy services being furnished are not intended to treat a functional limitation.
• In some cases for beneficiaries where improvement is expected to be limited, you can use the same severity modifier in reporting the current and goal status.
• In cases where the therapist does not expect improvement, such as for those individuals receiving maintenance therapy, the modifier for projected goal status will be the same as the one for current status.