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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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  • New Jersey Physical Therapy FAQs

    19 Apr 2021 2:20 PM | Zachary Edgar (Administrator)

    Continuing Education

    • How many continuing education hours are required during a reporting period?
    • Can CE credits be carried over into the next reporting period?
    • Are there any specific courses that must be taken?
    • What types of activities can be used for the continuing education requirements?
    • What type of approval is needed for the courses?
    • What are the reporting requirements?
    • Waivers and audits 

    Scope of Practice

    • How is the practice of Physical Therapy defined in New Jersey?
    • What is included in the practice of physical therapy?
    • Definitions related to diagnostic testing
    • Examinations and evaluations
    • Services specifically excluded from the scope of practice
    • Are there any specific procedures or modalities regulated by the board?

    Telehealth

    • Definitions
    • License requirements
    • Standard of Care
    • PT/PTA Patient Relationship
    • Provision of Services through Telehealth
    • Records
    • Prevention of Fraud and Abuse
    • Privacy and Notice to Patient

    Orders and Referrals

    • Is a referral required to provide PT services?
    • Exceptions to the referral requirement?
    • When does a PT have to refer a patient to a physician?

    Delegation and Supervision

    • Supervision Definitions
    • What are the responsibilities of the PT when providing direct supervision?
    • What are the responsibilities of the PT when providing general supervision?

    Assistants

    • Which services are PTAs allowed to practice?
    • Are there specific services that PTAs are prohibited from practicing?
    • What type of supervision is required?
    • When the supervising physical therapist is off-site
    • What are the assistant’s documentation responsibilities?
    • Does the supervising physical therapist need to co-sign documentation created by the PTA?
    • What is the ratio between supervising PTs and PTAs?
    • What is the required designation for assistants?

    Aides

    • What can an aide do?
    • What is an aide expressly prohibited from doing?
    • What are the responsibilities of the PT when delegating to an aide?
    • What type of supervision is required?

    Documentation 

    • What must be included in the patient record?
    • What are the physical therapist’s documentation responsibilities?
    • Exception to the documentation requirements
    • How long do the records need to be retained?
    • Release of patient records
    • Charging the patient for copies
    Identification and Notification
    • PT and PTA Identification
    • Are there any specific requirements for posting notifications or licenses?
    • When does a PT have to notify the board of any information changes?

    Advertising

    • Definitions related to advertising
    • Misconduct related to advertising
    • Advertising fees
    • Advertising certification in a specialty area
    • Advertising free or discounted services
    • Testimonial advertising
    • Minimum content requires in all advertising
    • Business entities offering physical therapy services
    • Retaining advertising records

    Financial Arrangements with Patients

    • Reasonable fees
    • Required information on patient fees
    • Disallowed fees
    • Excessive fees

    Temporary License

    • Duration of the temporary license
    • Renewal
    • Responsibilities of a temporary visiting PTA

    Unprofessional Conduct 


  • NCCI PTP Practitioner Therapy Services Q2

    5 Apr 2021 5:01 PM | Zachary Edgar (Administrator)

    PTP Edits-Practitioners: These PTP code pair edits are applied to claims submitted by physicians, non-physician practitioners, and Ambulatory Surgery Center (ASCs). These edits also apply to therapists in private practice and those employed by physicians. 

    Updated: April 1, 2021

    Physical and Occupational Therapy Evals and Reevals

    • PT Eval; low complexity
    • PT Eval; med complexity
    • PT Eval; high complexity
    • PT Reevaluation
    • OT Eval; low complexity
    • OT Eval; med complexity
    • OT Eval; high complexity
    • OT Reevaluation

    Therapeutic Procedures

    • Therapeutic Exercise
    • Neuromuscular Reeducation
    • Aquatic Therapy
    • Gait Training
    • Massage Therapy
    • Therapeutic Intervention; 15 min
    • Therapeutic Intervention; add 15 min
    • Physical Medicine Procedure
    • Manual Therapy
    • Group Therapy
    • Therapeutic Activities
    • Sensory Integrative Techniques
    • Self-Care Management
    • Community/Work Integration
    • Wheelchair Management Training
    • Work Hardening

    Modalities

    • Biofeedback Modality
    • Biofeedback Training; initial 15 minutes
    • Biofeedback Training; each additional 15 minutes
    • Hot or Cold Packs
    • Mechanical Traction
    • Vasopneumatic Devices
    • Paraffin Bath
    • Whirlpool
    • Diathermy
    • Ultraviolet
    • Electrical Stimulation (manual)
    • Iontophoresis
    • Contrast Baths
    • Ultrasound
    • Hydrotherapy
    • Electrical Stimulation (unattended)
    • Electrical Stimulation (Non wound)

    Assessments and Orthotics/Prosthetics

    • Range of Motion Measurements
    • Range of Motion; hand
    • Canalith Repositioning
    • Cognitive Testing HC Pro
    • Physical Performance Test
    • Assistive Technology Assessment
    • Orthotic Management
    • Prosthetic Management
    • Orthotic/Prosthetic Management

    Wound Care

    • Removal Devitalized Tissue 20cm/<
    • Removal Devitalized Tissue addl 20 cm<
    • Wound Care (non-selective
    • Negative Press Wound tx < 50 cm
    • Negative Press Wound tx > 50 cm
    • Negative Press Wound tx </=50 sq cm
    • Negative Press Wound tx >50 cm
    • Low Frequency, Non-Contact, Ultrasound


  • NCCI PTP Hospital Edits Therapy Services Q2

    5 Apr 2021 5:00 PM | Zachary Edgar (Administrator)

    PTP Hospital edits are applied to Types of Bills (TOBs) subject to the Outpatient Code Editor (OCE) for OPPS. These edits are applied to outpatient hospital services and other facility services including, but not limited to, therapy providers (Part B Skilled Nursing Facilities (SNFs)), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and certain claims for home health agencies (HHAs) billing under TOBs 22X, 23X, 75X, 74X, 34X.

    Updated: April 1, 2021

    Physical and Occupational Therapy Evals and Reevals

    • PT eval; low complexity
    • PT eval; med complexity
    • PT eval; high complexity
    • PT Reevaluation
    • OT Evaluation; low complexity
    • OT Evaluation; med complexity
    • OT Evaluation; high complexity
    • OT Reevaluation

    Therapeutic Procedures

    • Therapeutic Exercise
    • Neuromuscular Reeducation
    • Aquatic Therapy
    • Gait Training
    • Massage Therapy
    • Therapeutic Intervention; 15 min
    • Therapeutic Intervention; add 15 min
    • Physical Medicine Procedure
    • Manual Therapy
    • Group Therapy
    • Therapeutic Activities
    • Sensory Integrative Techniques
    • Self-Care Management
    • Community/Work Integration
    • Wheelchair Management Training
    • Work Hardening

    Modalities

    • Biofeedback Modality
    • Biofeedback Training; initial 15 minutes
    • Biofeedback Training; each additional 15 minutes
    • Hot or Cold Packs
    • Mechanical Traction
    • Vasopneumatic Devices
    • Paraffin Bath
    • Whirlpool
    • Diathermy
    • Ultraviolet
    • Electrical Stimulation (manual)
    • Iontophoresis
    • Contrast Baths
    • Ultrasound
    • Hydrotherapy
    • Electrical Stimulation (unattended)
    • Electrical Stimulation (Non wound)

    Assessments and Orthotics/Prosthetics

    • Range of Motion Measurements
    • Range of Motion; hand
    • Canalith Repositioning
    • Cognitive Testing HC Pro
    • Physical Performance Test
    • Assistive Technology Assessment
    • Orthotic Management
    • Prosthetic Management
    • Orthotic/Prosthetic Management

    Wound Care

    • Removal Devitalized Tissue 20cm/<
    • Removal Devitalized Tissue addl 20 cm<
    • Wound Care (non-selective
    • Negative Press Wound tx < 50 cm
    • Negative Press Wound tx > 50 cm
    • Negative Press Wound tx </=50 sq cm
    • Negative Press Wound tx >50 cm
    • Low Frequency, Non-Contact, Ultrasound 


  • NCCI Medically Unlikely Units Updated for Q2 2021

    5 Apr 2021 3:22 PM | Zachary Edgar (Administrator)

    Practitioner Edits apply to therapists in private practice and employed by physician groups.

    Hospital Edits apply to therapists working in facilities such as outpatient hospitals, CORFs, outpatient rehabilitation, and SNFs.

    Updated: April 5, 2021

    Medically Unlikely Edits (MUE) Guide

    MUE Practitioner Edits - April 1, 2021

    MUE Practitioner Edits - January 1, 2021

    MUE Hospital Edits - April 1, 2021

    MUE Hospital Edits - January 1, 2021


  • Medicare Therapeutic Procedures

    18 Mar 2021 10:33 AM | Zachary Edgar (Administrator)
    Medicare therapeutic procedures has been updated.

    Sample: 

    Service: Therapeutic Exercise

    Code: 97110

    Description

    Therapeutic exercises are used for the purpose of restoring or maintaining strength, endurance, range of motion and flexibility where loss or restriction is a result of a specific disease or injury and has resulted in a functional limitation. Therapeutic exercises may require active, active-assisted, or passive participation by the patient (e.g., isokinetic exercise, lumbar stabilization, stretching and strengthening).

    Indications – Medical Necessity

    Therapeutic exercise is considered reasonable and necessary if at least one of the following conditions is present and documented:

    • The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint ROM, functional mobility deficits, balance and/or coordination deficits, abnormal posture, muscle imbalance; and
    • The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, ROM, or endurance as part of ADL training, or reeducation.

    Limitations

    Exercises to promote overall fitness, flexibility, endurance (in absence of a complicated patient condition), aerobic conditioning, weight reduction, and maintenance exercises to maintain range of motion and/or strength are non-covered. In addition, exercises that do not require, or no longer require, the skilled assessment and intervention of a qualified professional/auxiliary personnel are non-covered. Repetitive type exercises often can be taught to the patient or a caregiver as part of a self-management, caregiver or nursing program.

    Documentation

    Documentation for therapeutic exercise typically includes objective loss of joint motion, strength, and /or mobility (e.g., degrees of motion, strength grades, levels of assistance).

    Documentation should include not only measurable indicators such as functional loss of joint motion or muscle strength, but also information on the impact of these limitations on the patient’s life and how improvement or maintenance in one or more of these measures effects patient function.

    Documentation of progress should show the condition is responsive to the therapy chosen and that the response is (or is expected to be) clinically meaningful. Metrics of progress that are functionally meaningful (or obviously related to clinical functional improvement) should be documented wherever possible. For example, long courses of therapy resulting in small changes in range of motion might not represent meaningful clinical progress benefiting the patient’s function.

    Documentation must clearly support the need for continued therapeutic exercise greater than 12-18 visits.

    Supportive documentation for therapeutic exercises:

    • Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on function;
    • If used for pain include pain rating, location of pain, effect of pain on function Specific exercises performed, purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills of a therapist were required; and
    • When skilled cardiopulmonary monitoring is required, include documentation of pulse oximetry, heart rate, blood pressure, perceived exertion, etc.

    NCCI - PTP

    N/A

    NCCI – MUE

     Service  Max Units  Adjudication 
     Therapeutic Exercise  6  3

    Reference

    L34427 – Outpatient Occupational Therapy – Palmetto GBA

    L34049 – Outpatient Physical and Occupational Therapy Services – CGS Administrators

    L33413 – Therapy and Rehabilitation Services – First Coast Service Options

    L35036 – Therapy and Rehabilitation Services – Novitas Solutions

     

  • New NCCI Section

    8 Feb 2021 11:49 AM | Zachary Edgar (Administrator)

    Please enjoy our new NCCI section for therapy services.   Each section has been updated to the new January 2021 edits. 

    Procedure to Procedure (PTP) Edits 

    • PTP Basics
    • Using Modifier 59 and X~ Modifiers
    • PTP Hospital Edits
    • PTP Practitioner Edits 

    Policy for Physical Medicine and Rehabilitation - January 1, 2021 (updated yearly)

    • Multiple Evaluations on the Same Day
    • Evaluations and other Assessment Codes
    • Billing more than one Service in a 15 Minute Period
    • Re-evaluations
    • Re-evaluation and Orthotic/Prosthetic Management
    • Assistive Technology Assessment
    • Manual Therapy Techniques and Therapeutic Activities (Removed Jan. 1, 2021)
    • Wound Debridement and Surgical Debridement
    • Cardiac Rehabilitation and other Therapy Services
    • Ultrasound and Wound Care

    Medically Unlikely Edits - January 1, 2021

    • Physical Therapy Evaluations and Reevaluations
    • Occupational Therapy Evaluations and Reevaluations 
    • Speech Therapy 
    • Modalities 
    • Therapeutic Procedures
    • Assessments and Orthotics/Prosthetics 
    • Range of Motion and Canalith
    • ADL and Work Conditioning 
    • Wound Care
    • Biofeedback Training


  • Arizona Physical Therapy Business Entities

    26 Oct 2020 1:38 PM | Zachary Edgar (Administrator)

    Definitions

    "Business entity" means a business organization that has an ownership that includes any persons who are not licensed or certified to provide physical therapy services in this state, that offers to the public professional services regulated by the board and that is established pursuant to the laws of any state or foreign country.

    Requirement to register a business entity

    Beginning September 1, 2011, a business entity shall not offer physical therapy services unless:

    • The business entity is registered with the board; or
    • The physical therapy services are conducted by a licensed physical therapist or certificated physical therapy assistant.

    A business entity that offers physical therapy services to the public and is not exempt from registration shall separately register with the Board each location from which physical therapy services are offered in Arizona.

    Practices exempt from registration

    A sole proprietorship or partnership that consists exclusively of persons who are licensed by a health profession regulatory board.

    A facility regulated by the federal government or a state, district or territory of the United States.

    An administrator or executor of the estate of a deceased physical therapist or a person who is legally authorized to act for a physical therapist who has been adjudicated to be mentally incompetent for not more than one year from the date the board receives notice of the physical therapist's death or incapacitation.

    A health care institution that is licensed pursuant to title 36.

    A facility that offers physical therapy services to the public must be registered by the board unless the facility is any of the following:

    • Owned by a licensee.
    • Regulated by the federal government or a state, district or territory of the United States.

    What is required for the application?

    To register with the Board an Arizona location at which physical therapy services are offered, a business entity shall submit to the Board an application packet that includes the following:

    An application form, which is available from the Board and requires the following information:

    • Name, primary address, and e-mail address of the business entity;
    • Name, title, address, e-mail address, and telephone number of the manager of the location being registered;
    •  Name and business address of each officer or director of the business entity; 
    • Name and license number of each physical therapist who provides physical therapy services at the location being registered;
    • Name and certificate number of each physical therapy assistant who works at the location being registered;
    • Description of the physical therapy services offered at the location being registered;
    • For the business entity, a statement of whether any state, territory, district, or country has ever:
      • Refused to issue or renew a registration, permit, license, or other authorization;
      • Accepted surrender of a registration, permit, license, or other authorization in lieu of other disciplinary action; or
      • Suspended, revoked, cancelled, or taken other disciplinary action against a registration, permit, license, or other authorization; and
    •  Dated signature of an officer or director attesting that:
      • The business entity has a written protocol that meets the standards in A.R.S. § 32-2030(F) for the secure storage, transfer, and access of the physical therapy records of the business entity’s patients; and
      • The information provided is true and correct.

    The application fee for a business entity:

    • Application for an original registration, $50;
    • Renewal, $50;
    • Late fee, $25; and
    • Duplicate registration, $10.

    Required written protocols

    The business entity must establish and implement a written protocol for the secure storage, transfer and access of the physical therapy records of the business entity's patients. This protocol must include, at a minimum, procedures for:

    • Notifying patients of the future locations of their records if the business entity terminates or sells the practice.
    • Disposing of unclaimed physical therapy records.
    • The timely response to requests by patients for copies of their records.

    Required display of the certificate

    For each location registered, a business entity shall display, in a location accessible to public view, the:

    •  Registration certificate and current renewal verification of the business entity,
    • License and current renewal verification of every physical therapist who provides physical therapy services at the location, and
    • Certificate and current renewal verification of every physical therapy assistant who works at the location.

    Registration renewal

    The registration of a business entity expires for each location registered on August 31 of every odd-numbered year. The business entity shall separately renew the registration of each location from which the business entity offers physical therapy services in Arizona.

    To renew the registration of an Arizona location from which physical therapy services are offered, a business entity shall submit to the Board an application form, which is available from the Board and requires the following information:

    • Name, primary address, and e-mail address of the business entity;
    • Name, title, address, e-mail address, and telephone number of the manager of the location being registered;
    • Name and business address of each officer or director of the business entity;
    • Name and license number of each physical therapist who provides physical therapy services at the location being registered;
    • Name and certificate number of each physical therapy assistant who works at the location being registered;
    • Description of the physical therapy services offered at the location being registered;
    •  For the business entity, a statement of whether any state, territory, district, or country has ever:
      • Refused to issue or renew a registration, permit, license, or other authorization;
      • Accepted surrender of a registration, permit, license, or other authorization in lieu of other disciplinary action; or c. Suspended, revoked, cancelled, or taken other disciplinary action against a registration, permit, license, or other authorization;
    • Statement of whether the business entity complies with A.R.S. § 32-2030(F); and
    • Dated signature of an officer or director attesting that the information provided is true and correct

    Reference

    A.R.S. § 32-2001

    A.R.S. § 32-2030

    A.A.C. R4-24-210

    A.A.C. R4-24-107

    A.A.C. R4-24-211

  • Current Plan for the Website

    23 Oct 2020 2:18 PM | Zachary Edgar (Administrator)

    I have prepared a lot of new and updated material for the website.  The plan is to upload 3-4 states a week that will include the PT, OT, and SLP FAQs and Medicaid material.  I will also be adding new material to Medicare, Tricare, HIPAA, and compliance sections.  

    If you have any questions or suggestions, please email me at zedgar@med-comply.com


  • Ohio Physical Therapy FAQS

    5 Aug 2020 1:09 PM | Zachary Edgar (Administrator)

    FAQs

    Continuing Education

    • How many continuing education hours are required during a reporting period?
    • How long is the reporting period?
    • When are CE requirements due?
    • How is credit hour defined?
    • Can CE credits be carried over into the next reporting period?
    • Are there any specific courses that must be taken?
    • What types of activities can be used for the continuing education requirements?
    • Are there limitations on the types of courses that can be taken?
    • What type of approval is needed for the courses?
    • What type of courses or activities are not allowed?
    • What are the reporting requirements?
    • How long must continuing education records be retained?
    • Can I get a waiver for my CE requirements?
    • What happens if I am audit?

    Scope of Practice

    • How is the practice of Physical Therapy defined in Ohio?
    • What is included in the practice of PT?
    • Services specifically excluded from the scope of practice
    • Can PTs practice dry needling?
    • Can PTs administer topical drugs?
    • Can PTs practice through telehealth?

    Direct Access and Referrals 

    • Is a referral required to provide PT services?
    • Exceptions to the referral requirement?
    • Which providers can issue the referral?
    • How can PTs receive referrals?
    • When does a PT have to refer a patient to a physician?

    Supervision and Delegation

    • Definitions
    • Which services can only be performed by a licensed physical therapist?
    • What are the responsibilities of the PT when delegating?

    Assistants

    • Which services are PTAs allowed to practice?
    • Are there specific services that PTAs are prohibited from practicing?
    • What type of supervision is required?
    • Who is the supervising physical therapist?
    • What are the assistant’s documentation responsibilities?
    • Does the supervising physical therapist need to co-sign documentation created by the PTA?
    • What is the ratio between supervising PTs and PTAs?
    • Required designation for assistants

    Aides

    • What can an aide do?
    • What is an aide expressly prohibited from doing?
    • What type of supervision is required?
    • What is the ratio between supervising PTs and aides?
    • Required designation for aides

    Students 

    • Can students practice in a clinical setting?
    • What kind of supervision is required for student PTs and PTAs?
    • Documentation – Cosignatures 
    • Identification of students

    Identification and Notification

    • How can I use “Dr” in my title?
    • Are there any specific requirements for posting notifications or licenses?
    • When does a PT have to notify the board of any information changes?

    Out-of-State PT and PTAs

    • Can I practice in state if I am licensed in another state?
    • What is the process for getting reciprocity in Ohio?
    Military Service Provisions
    • Definitions
    • Eligibility for licensure
    • License Renewal
    • Continuing Education
    • Waiver of license application fee

    Forms of Business Authorized to Practice 

    • Which forms of business entities can a PT practice under?
    • Who may form the business entity?
    Unprofessional Conduct
    • When does a PT need to report to the board?
    • Conduct that may result in an offense


  • Texas Medicaid: Claims for Telehealth Service for Occupational, Physical, and Speech Therapy

    14 Apr 2020 2:09 PM | Zachary Edgar (Administrator)

    Managed Care

    Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

    Effective Dates

    Effective for dates of service March 15, 2020, through April 30 2020, authorized occupational, physical, and speech therapy for clients of all ages may be delivered as a telehealth service.

    Telehealth therapy services must be delivered within the provision of current licensure requirements found in Occupational Therapy Rules, Physical Therapy Rules, and Speech-Language Pathologists and Audiologists Administrative Rules. See Texas Medicaid for more information.

    Modifiers

    Providers should use the 95 modifier to indicate remote delivery. Providers are reminded to use the required modifiers GP, GO, and GN on all claims for physical, occupational, or speech therapy treatment.

    Prior Authorization

    There will be no changes to the prior authorization submission process. A separate prior authorization is not needed solely to allow for the remote delivery of therapy services.

    Evaluations

    Evaluation, re-evaluation, and treatment may be delivered via telehealth as determined clinically appropriate by the rendering therapist and in compliance with each discipline’s rules.

    Assistants

    Therapy assistants may provide telehealth and receive supervision within limits outlined in each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline. See Texas Physical Therapy Assistants or Texas Occupational Therapy Assistants.

    Informed Consent

    Telehealth requires consent from the client or responsible adult. Verbal consent is permissible and should be documented in the client’s medical record. Teletherapies may require participation of a parent or caregiver to assist with the treatment.

    Services that Cannot be Performed via Telehealth

    Clinical evaluations required for the provision of new complex rehabilitation technology, such as power mobility and adaptive seating systems or augmentative  communication devices, require the physical presence of the speech-language pathologist, the occupational therapist, or physical therapist and should not be delivered via telehealth unless exceptional medical circumstances exist.

    Treatment Notes

    Treatment notes should indicate that remote delivery of the service is clinically appropriate per the treating therapist’s professional judgement.

    HIPAA

    The Office of Civil Rights (OCR) has relaxed Health Insurance Portability and Accountability (HIPAA) requirements to allow for the use of additional video capabilities to deliver service via telehealth. Texas Medicaid will recognize OCR’s HIPAA enforcement discretion as it relates to telehealth platform requirements.

    Reference

    Claims for Telehealth Service for Occupational, Physical, and Speech Therapy. April 14, 2020 available at http://www.tmhp.com/News_Items/2020/04-April/04-14 20%20Claims%20for%20Telehealth%20Service%20for%20Occupational,%20Physical,%20and%20Speech%20Therapy.pdf


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