Question:

Do you have access to the HCPCS level II codes? I have the fee schedule from CMS but not the descriptions of each DMEPOS. I am looking for a code to bill for a warm and form lumbar corset with moulded insert. I would appreciate any help or steer me in the right direction. Thanks!

  

Response:                                                  

HCPCS codes and their fees are freely available from CMS, and more information can be accessed via the following links.

  

HCPS Level II Overview:

http://www.cms.hhs.gov/MedHCPCSGeninfo/

Alpha-Numeric HCPCS:  

http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp

 

Please note that these codes are copyrighted and we cannot advise you as to which code to use for this purpose, but you should be aware that PTs are often not reimbursed for their use on claims.

 

Question:                                                           

I want to give my staff some thoughts on how to appropriately document that the patient decided to discontinue care and we did not "stop" their care. Do you have any comments on this?

 

Response:

This issue is more important than many may recognize. You have stated a very workable response to this question in your own choice of words, however. The essential difference between discharge and discontinuation is related to achievement of treatment objectives, as outlined in the reference below. If our services are no longer needed because we met our established goals of treatment, we discharge the patient from our care. If our treatment goals have not been met, but care will not be delivered for whatever reason, treatment is discontinued.

 

As such, if a patient elects to stop receiving our services, we would document the reason for their doing so. It would likely be viewed as prudent for us to restate our justification for continued treatment along with the patients reason(s) for discontinuing, but if the patient has "decided to continue care" that is what we would want to document.

 

Reference: APTA's Defensible Documentation for Patient/Client Management.

 

Discharge

 

Discharge occurs when the anticipated goals and expected outcomes have been achieved and is based on the physical therapist's analysis of the of the patient's/client's achievement of the anticipated goals and expected outcomes. Discharge does not occur with a transfer to another site of care.

 

Discontinuation

 

Discontinuation occurs when 1) the patient/client, caregiver, or guardian declines to continue care; 2) the patient/client is unable to progress toward the expected outcomes because of medical or psychosocial complications or due to financial constraints; or 3) the physical therapist determines that the patient/client will no longer benefit from physical therapy services. When services are terminated prior to goal achievement, patient/client status and the reason for termination are documented.

 

Goals can be considered in terms of impairments, functional limitations, disability and prevention. The Guide to Physical Therapist Practice defines these terms as follows:

 

Impairments: The consequence of disease, pathological processes, or lesions.

 

Functional Limitations: When the impairments result in a restriction of the ability to perform a physical action, task, or activity in an efficient, typically expected, or competent manner.

 

Question:

Presently we are providing PT and OT services for a client with a diagnosis of ALS. As we all know, this is a degenerative disease process. Some questions have come up regarding our goals of treatment and proper billing. Since this client is quite debilitated, our treatment plan has focused on PROM to address maintenance, prevention of loss and patient's subjective comfort. We are not progressing and making positive gains. Are there any PT or OT licensure rules or regulations that might prohibit us from continuing to treat this client and or bill an Insurance company for services if we are not progressing and treating with objective and measurable goals?

 

Response:

This is yet another question that is not well-suited for a simple e-mail response, so please keep this in mind. The NJ PT regulations do not specifically prohibit PTs from rendering services that are of a "maintenance" nature, though it is highly unlikely that an insurance company would cover and reimburse for such services. What the regulations do prohibit is misrepresentation of such services as "necessary" rather than simply desired by the patient/client, including seeking payment for such unnecessary services. The regulations do acknowledge that PTS provide services other than those that are "therapeutic", but again we must not misrepresent those services. In the above scenario, it is unclear whether "treatment" is truly being provided, or whether maintenance and prevention is actually the service being rendered.

 

The specifics of any scenario like this are critical in determining the best course of action to take, and there are very few such specifics contained in the above question. This may not need to be stated, but it is ultimately up to the clinician to make clinical judgments above the necessity of their services, and whether such services may be covered by a patients' insurance plan. If a plan included coverage for maintenance and/or preventative services rendered by PTs, then the services may be reimbursable.

 

See references below, with important points highlighted, and critical points bolded.

 

References:

New Jersey Administrative Code

SUBCHAPTER 2.

PRACTICE AS A LICENSED PHYSICAL THERAPIST AND LICENSED PHYSICAL THERAPIST ASSISTANT

 

13:39A-2.1 Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

 

"Physical therapy instruction" means the act of providing consultative, educational or advisory services to one or more individuals for the purpose of preventing or reducing physical dysfunction and disability that may lead to reduced functional abilities.

 

"Physical therapy and physical therapy practice" mean the identification of physical impairment or movement-related functional limitation that occurs as a result of injury or congenital or acquired disability or other physical dysfunction through examination, evaluation and diagnosis of the physical impairment or movement-related functional limitation and the establishment of a prognosis, which includes the establishment of the plan of care and all interventions, for the resolution or  amelioration thereof and treatment of the physical impairment or movement-related functional limitation, which shall include, but is not limited to, the alleviation of pain, physical impairment and movement-related functional limitation by physical therapy intervention, including treatment by means of:

 

8. Providing training in techniques for the prevention of injury, impairment, movement-related functional limitation, or dysfunction;

9. Providing consultative, educational, other advisory services;

13:39A-3.6 Prohibition on excessive fees; overutilization

 (c) A licensed physical therapist shall not provide intervention or conduct testing which in light of the patient's history and findings are unwarranted and unnecessary.

(d) A licensed physical therapist shall not charge a fee to a patient or a third party payor for an intervention or other physical therapy which is unwarranted and unnecessary.

13:39A-3.8 Violative acts; professional misconduct

(a)    The following acts or practices shall be among those deemed to be violative of N.J.S.A. 45:9-37.11 et seq. and to constitute professional misconduct pursuant to N.J.S.A. 45 : 1 -21 (e):

 

5. Representing services as therapeutic, or permitting the representation of services as therapeutic, when, although the services are within the licensee's scope of practice, no therapeutic outcome is  expected; for example, educational activities, preventative sports conditioning, fitness/wellness programs, etc. Nothing herein shall preclude a licensed physical therapist from using or permitting the use of his or her professional education degree, title or license in connection with educational, preventative or other appropriate activities or from accepting reasonable fees or payment for such activities, provided that no claim of therapeutic outcome is made or charged for;

 

6. Rendering an intervention when, in the exercise of his or her professional judgment, the licensed physical therapist may deem such intervention to be unnecessary.

 

 

 

 

WHAT IF two individuals - college roommates - decide to open a business together? They could be licensed professionals - physical therapists, physicians, etc. - or they could be non-licensees - medical equipment supply sales representatives. They decide to start a business together. One partner brings the business acumen necessary to make the business succeed; the other partner brings a winning personality that easily builds relationships with clients. The company succeeds despite all odds against it. The partners enjoy very enriching lives - professionally, financially and family. Tragically, one of the partners falls ill and dies. The widow of the deceased partner approaches the surviving partner - catching him totally off-guard - after the funeral service and says:  "I look forward to starting work next week." "WAIT A MINUTE" thinks the surviving partner, "I didn't bust my .... for all these years only to end up being partners with my deceased partner's spouse!"  UNLESS the partners planned for this moment, the surviving partner might just have a new partner - his deceased partner's spouse.

 

Every business needs a general agreement about ownership and responsibilities. What is often overlooked either within the general agreement or outside that agreement, is a buy-sell agreement (buy - sell).  Such a buy-sell covers how and when a partner can sell his / her share of the business and at what price. Typically this type of agreement is utilized if the partners decide to split and go their own ways. Another critical purpose for such an agreement is to resolve ownership when a partner dies or is permanently disabled. I like to think of a buy-sell as dealing with the scenario outlined above - how to avoid becoming partners with your ex-partner's spouse. Nothing personal against the spouse; however, the surviving partner does not and will never want, with rare exceptions, to collaborate with the spouse about finances, marketing, client relationships, etc. Their agendas are typically different: the surviving partner is running a business with an end game in mind- usually mid - to long range thinking; the spouse typically is thinking short-term - how to maximize the money available to move forward with his / her life.

 

The absence of a buy-sell usually adds business tragedy to personal tragedy. It happens over and over again. The critical need for such agreements is exponentially increased when the spouse of your partner is not another physical therapist, as you will not be permitted to partner with the non-PT spouse.

 

The buy-sell should specifically identify that which triggers its provisions to come into action. A partner retires - perhaps he/she must divest ownership shares or at least voting rights. A partner divorces or declares bankruptcy - there's the need to consider protecting the business from a spouse or a bankruptcy trustee. A partner dies - ownership shares should be passed to the surviving partner(s) instead of a spouse or child. Life insurance is key in this latter situation.  Life insurance is purchased on the life of the partners so that when one partner dies, there is an influx of money to pay the spouse the value of the deceased partner's ownership interest (ideally a formula is set in advance by the partners in their agreement) as well as to replace the deceased partner as a contributor to the business (hire a replacement).

 

Drag-along and tag-along provisions are critical in buy-sell agreements. What are the definitions of drag-along and tag-along provisions? A drag-along provision enables a majority owner to force the sale of a minority owner's share. If the majority owner wants to sell the business to a third party a tag-along provision assures the minority owner that he/she will receive the same proportionate price as dictated by his/her ownership share.   A buy-sell must also provide a formula for valuing the ownership interest to ensure that the departing owner receives a fair price.