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August/September 2003


Private Practice

By Peter Guske, PT


Peter Guske, PT
It may not be fun, but understanding billing codes is key to starting a private practice.

I opened my physical therapy private practice in 1988 in a small Florida community of 8,000 people. My humble beginning was an 800-square-foot leased office space in a mixed-use commercial building. Seven years later, as I was designing the floor plan for my own 6,000-square-foot medical office building, I had the chance to sit down and reflect on some of the factors that led to my success, as well as those variables that held me back. At the top of the list of “items that held me back” was my ignorance with regard to coding and reimbursement for physical therapy services.

If there is any truth in the saying, “We teach best those tasks which were the hardest for us to learn,” then in the area of billing and coding, I should be in my prime. Although I was quite confident with my clinical skills, I had never even heard of CPT codes. When one knows so little, there is a tendency to err on the side of caution. As a result, I consistently (and often grossly) underbilled. For over a year in my small practice, I billed no more than one or two procedures (CPT codes), while treating patients one-on-one for 60-90 minutes each session.

It has been my experience in consulting with private practitioners that this same trend of coding inefficiency, although in different forms, continues, especially in many start-up PT practices. After a year of working hard and making very little money in my practice, I realized there had to be a better way. I don’t know why this is, but I think I (and many other PTs) have an aversion to learning the rules about proper billing and coding for physical therapy services. Finally, I forced myself to learn. Let me touch on a few areas.

CPT Code Edit Pairs
In 1996 the Health Care Financing Administration (HCFA, which changed its name to the Centers for Medicare & Medicaid Services, or CMS, in 2001) implemented a policy known as the Correct Coding Initiative (CCI). The CCI edit system is relatively new to the hospital setting, having been applied there only since late 2000 and early 2001. But CCI edits are something that physicians and physical therapists in private practice (PTPP) have been dealing with since their implementation by HCFA in 1996.

Medicare’s purpose with CCI is to help stop fraud and abuse in CPT coding and to develop correct coding methodologies to curtail improper unbundling of services for Medicare Part B claims. A code edit pair is a combination of two codes that cannot be billed together because either the code pair represents services that are considered by Medicare to be mutually exclusive or one code in the pair is considered a component of a more comprehensive procedure code.1 To put this in pragmatic terms, in either case, whether Medicare considers a code pair to be mutually exclusive or one code is considered to be a component of another, the result is the same: Medicare will reimburse only one of the codes. Federally funded workers’ compensation and many non-Medicare commercial carriers have also adopted the use of CCI edit pairs.

There are more than 120,000 different CCI edit pairs (pairs of CPT codes). But physical therapists need to learn only the handful of edit pairs that apply to the codes used regularly in most PT practices. One of the problems with the CCI edit system is that dealing with it can be like trying to hit a moving target. Edit pairs can and often are changed by Medicare on a quarterly basis. As a result, one of the biggest challenges facing the practice manager is constant education of staff as Medicare and other third-party payors’ policies change and evolve. Adding to the complication is that the system has a history fraught with contradictions and often inconsistencies with sound clinical practice.

The American Physical Therapy Association (APTA) reviews current and proposed CCI edit pairs that have an impact on physical therapists and makes comment to CMS when edit pairs are issued.2 The American Medical Association facilitates this comment process. To its credit, the APTA has responded promptly to Medicare concerning those edit pairs that are clinically inappropriate and inconsistent with proper use of the 97000 (physical medicine and rehabilitation) series CPT codes.

The results of the APTA’s efforts have been fruitful. Many of the code edit pairs that APTA recommended for removal were deleted from the CCI policy. However, some problematic edit pairs remain. For instance, when a physical therapist performs wrist/hand mobilizations on a patient, they would appropriately bill CPT code Manual Therapy 97140. However, in the event the therapist chose to administer a paraffin bath to the patient’s wrist/hand in preparation for the mobilization, then a problem would occur. When the PT bills both 97140 (manual therapy) and 97018 (paraffin bath) on the same day, for this same patient, then Medicare would deny reimbursement for one of these codes. The thinking on the part of Medicare is that the paraffin bath modality and manual therapy procedure are “comprehensive/components” of each other. In this case and in several other examples, it becomes apparent that, although the intentions of the CCI are good, in many cases it just does not make any sense from a clinical practice point of view.

Modifiers
Is there a way to live with the CCI system and still make sure you are reimbursed for all reasonable and legitimate services you provide? The answer in most cases is yes. This is where the -59 modifier enters the picture. The -59 modifier denotes a procedure/modality as being performed as a “distinct procedural service.”3 This modifier is used to append a CPT code indicating the procedure or service was performed as a distinct or independent service from other services performed the same day by the same provider.

I like to think of the use of the -59 modifier as a way of acknowledging to Medicare that you, as the provider, understand that Medicare does not like a particular pair of CPT codes billed together on the same day, but nevertheless you believe it is accurate and appropriate under the circumstances. In the above example, Medicare will in fact reimburse for the paraffin bath and manual therapy if the -59 modifier is used.

It seems there is always plenty of gray area with any reimbursement issue and this is no exception. The always-present uncertainty comes from the fact that some details of the use of the modifier can be carrier specific. Some carriers have differing policies concerning which code of the pair should have attached to it the -59 modifier. I have even received an email from an out-of-state provider who said the carrier told him to attach the -59 modifier to all of his codes. In the case of many carriers (governmental and a nongovernmental), it can be difficult and time-consuming to get a straight answer on specifics. But it is worth the effort to check with your carrier first.

An area of misunderstanding is the use of the -59 modifier for the untimed modality codes when separate body areas are involved. Let’s assume a PT administers a paraffin bath to the right hand and a paraffin bath to the left wrist in the same treatment session. Two separate body parts have been treated. The only basis the provider has for billing multiple units of the same procedure (same CPT code) would be the amount of time spent. This would have application only for the timed procedures and modalities. Since a paraffin bath is an untimed modality, it would not be correct or appropriate to use the -59 modifier to seek reimbursement for each paraffin bath separately. The untimed modality CPT codes (as well as some others) come with the description “application to one or more areas.”3 Regardless of how many different sites on the body the paraffin bath is administered to or the amount of time spent, you are to bill for only one unit of the paraffin bath.


Jean Minkel, PT
There are also a few edit pairs that Medicare has designated as nonmodifiable. In this case, there are no circumstances in which a modifier would be appropriate, according to CMS. The services represented by these particular code combinations will not be paid separately and no modifier can be used.

To some providers, the use of the -59 modifier may seem like one relatively easy way to “get around” the CCI edit system. But here is where caution is in order for those providers whose documentation is lax. From talking with other practice owners, it appears that the use of this modifier on more than 20% of your claims may flag the provider for audits from the carrier. On the other hand, using the -59 modifier to trigger an audit may be based more heavily on the particular billing profile of the provider. I have personally gone through three limited Medicare audits with my practice. The most recent audit was in 2001. Although I can guess, I have no certainty as to what prompted any of my audits. Whether the threshold with the use of this modifier is 20%, or any other number, the physical therapy provider is essentially faced with two choices:
  • Use the -59 modifier and receive reimbursement, but at the same time subject yourself to increased likelihood of audit. Or
  • Forgo use of the modifier, thereby reducing likelihood of an audit, but give up payment for a service that was provided.

To me, the answer is clear: Use the modifier. The modifier exists for the purpose of differentiating between services provided. I make the assumption that the modifier is being used correctly and documented accurately, and the service is being provided legitimately by qualified personnel at the highest level of quality. In this case, the specificity of the service denoted by this modifier provides the basis for which separate payment for the service is considered justified.

The Role of Fear and Confidence

The fear of an audit stops many practitioners from consistently and frequently using modifiers. But if documentation is thorough and accurate, there is no reason to fear an audit from a carrier. In my experience, a practitioner who uses the -59 modifier on a “frequent” basis is more likely to be the practitioner providing the higher quality of care and more likely to be the practitioner whose documentation is clear, accurate, and thorough. In other words, this tends to be the practice owner who has a higher level of confidence that they will go through an audit without difficulty.

As your practice grows, it is highly advantageous to have one person in charge of making sure that all the so-called “little balances” are pursued through the use of modifiers, resubmissions, coding education, and good old-fashioned tenacity. But remember; even the best administrator can only help you to bill those procedure codes that you, the clinician, have selected. If you are also the owner, as is the case in many small practices, then it is up to you to become intimately familiar with the applicable CPT codes. Too often, coding and reimbursement become a hit and miss affair and the owner has minimal involvement. The result is decreased cash flow.

When I graduated from PT school in 1986, our class was afforded no education concerning billing, coding, or administrative procedures of any kind. However, even if a student has no plans to work in the private practice setting, today’s increased pressures for productivity in all PT career settings necessitate gaining this knowledge at an early level. If nothing else, it gives physical therapists the ability to more adequately understand the administrative policies within which they have to work. But if you plan to have your own practice, take it from someone who took too long to understand that you must know the codes right from the start. It will be an essential component of your success.

References


Peter Guske, PT, sold his practice in 2001 and has transitioned his career into medical office building development. He consults and holds seminars in the area of private practice start-up and coding/reimbursement. He can reached at www.medicalarts4u.com

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