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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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Site Updates

  • Medicare Advanced Notification of Noncoverage (ABN) Updated

    24 Jun 2021 2:02 PM | Zachary Edgar (Administrator)

    An Advanced Beneficiary Notice of Noncoverage (ABN) is a form given to the Medicare patient before performing healthcare services that the provider knows are not covered or that the provider thinks may not be covered by the Medicare program.   The form is used to serve as notice to the patient that 1) the service is not covered and 2) that they will be liable to pay for the service. 

    When it is Mandatory to Issue an ABN?

    When it is Voluntary to Issue an ABN?

    Triggering Events (When to give the patient the ABN)

    • Initiations
    • Reductions
    • Terminations
    Issuing the ABN

    ABN Form and Instructions

    • Header
    • Body
    • Options
    • Additional Information
    • Signature Box

    ABN Preparation Requirements

    • Language Choice
    • Effective Versions
    • Number of Copies
    • Reproduction
    • Length and Size of Page
    • Contrast of Paper and Print
    • Font
    • Customization
    • Modification
    • Retention Requirements

    ABN Notice and Delivery

    • Proper Notice Requirements
    • Readability Requirements
    • Specificity, Delivery, and Receipt
    • Defective Notice
    • Timeliness
    • Effective Delivery
    • Telephone Notice
    • Capable Recipient
    • Authorized Representatives

    Routine Notice Prohibitions and Exceptions

    • Generic ABNs
    • Blanket ABNs
    • Signed Blank ABNs
    • Exceptions
    ABN Modifiers


  • Florida Occupational Therapy Additions

    21 Jun 2021 4:38 PM | Zachary Edgar (Administrator)

    Florida Occupational Therapy

    Continuing Education

    • How many continuing education hours are required during a reporting period?
    • How is credit hour defined?
    • How long is the reporting period?
    • Can CE credits be carried over into the next reporting period?
    • Are there any specific requirements for continuing education?
    • What types of activities can be used for the continuing education requirements?
    • What type of approval is needed for the courses?
    • How long must continuing education records be retained?

    Scope of Practice

    • How is occupational therapy defined in Florida?
    • What is included in the practice of occupational therapy?
    • What is specifically excluded from the practice?
    • Are there any special trainings or requirements?

    Electrical Stimulation Devices

    • Required Training
    • Supervised Treatment Sessions
    • Minimum Competency Levels

    Ultrasound Devices

    • Required Training
    • Supervised Treatment Sessions
    • Minimum Competency Levels

    Neurofeedback Devices

    • Required Training
    • Supervised Treatment Sessions
    • Minimum Competency Levels

    Assistants

    • What type of supervision is required?
    • Does the supervising OT need to be present?
    • Does the supervising occupational therapist need to co-sign documentation created by the OTA?
    • What is the ratio between supervising OTs and OTAs?

    Aides

    • How is an aide defined?
    • What can an aide do?
    • What is an aide expressly prohibited from doing?
    • What are the responsibilities of the OT when delegating to an aide?
    • What type of supervision is required?
    • What is the ratio between supervising OTs and aides?
    • Required designation for aides

    Students 

    • Can students practice in a clinical setting?
    • How must students identify themselves?

    Unprofessional Conduct 

    • Reporting Obligations
    • Prohibitions
    • Fee Splitting


  • Maryland Occupational Therapy Additions

    20 Jun 2021 3:31 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 Occupational Therapy defined in Maryland?
    • What services are included in the scope of practice?
    • Services specifically excluded from the scope of practice
    • Are there any specific procedures or modalities regulated by the board?

    Physical Agent Modalities

    • Definitions
    • Standards of Competence for Electrical Modalities
    • Didactic Education
    • Clinical Requirements
    • Documentation of Education
    • Treatment Plan Guidelines for Physical Agent Modalities
    • Superficial Physical Agent Modalities

  • HIPAA Updates and Page Cleanup

    10 Jun 2021 2:49 PM | Zachary Edgar (Administrator)

    HIPAA Guides and FAQs

    HIPAA Basics

    The Security Rule

    Breach Notifications

    The Privacy Rule

    Business Associates 

    Sample Forms and Agreements - A collection of notices, forms, policies and procedures that can be used by small and medium healthcare providers to supplement their existing material.

  • June 2021 NCCI Updated Have Been Added

    7 Jun 2021 1:37 PM | Zachary Edgar (Administrator)

    See our NCCI page for more information. 

  • 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

     

About Me

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

Learn More 

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