Reimbursement Guidelines for the Multidisciplinary Wound Care Team: Focus on Therapy Services

WATCH: Author Pamela G. Unger, PT, CWS, FCCWS, discusses the article. 

The expectation in today’s wound care environment is that clinicians use evidence-based medicine to guide clinical algorithms to promote wound closure and improved recidivism of the nonhealing wound. All healthcare providers strive to provide services that are effective as well as billable in order to sustain the wound care clinic business. Practically, this can be accomplished very effectively by utilizing a multidisciplinary team that includes rehabilitation professionals such as physical and occupational therapists (PTs and OTs). Physical and occupational therapists are dynamic professions with established theoretical and scientific-based methodologies that include widespread clinical applications for the restoration, maintenance, and promotion of optimal physical function that’s vital to improving wound healing and recidivism of wounds. 

This article will discuss the roles of both PTs and OTs as well as proper coding and reimbursement procedures.

PT & OT Scope

The therapist examines skin integrity to assess the effects of a variety of disorders that result in skin and subcutaneous changes including pressure, vascular (eg, venous and arterial), and neuropathic (eg, diabetic) ulcers; burns and other traumas; and a number of diseases (eg, soft-tissue disorders).^1,2 After evaluation and examination, the therapist is qualified to develop a prognosis and therapy plan of care. Mobility is a primary component of wound healing, particularly the effect on increased circulation and perfusion. Therapists also possess a firm understanding of the utilization of therapeutic interventions (ie, electrical stimulation, ultrasound).

The therapist who performs wound care services as part of a therapy plan of care is reimbursed by the Medicare Physician Fee Schedule, whether he/she is working within a hospital-based outpatient department (HOPD), private practice, or skilled nursing facility. While most Current Procedural Terminology (CPT^®) codes used by therapists are in the 97000 series (Table 1), a therapist can report any CPT code as long as the provider is qualified to perform the service represented by the specific code.³

When a therapist is practicing in an HOPD, it's necessary to utilize the appropriate revenue code (PT = 042X; OT = 043X). Likewise, the Centers for Medicare and Medicaid Services (CMS) has classified a number of 97000 series CPT codes as “sometimes therapy” codes defined as services not required to be performed by a therapist. Hence, if the therapist is performing a service defined by one of these codes it is necessary to use the appropriate therapy modifier (GP = physical therapy; GO = occupational therapy). In order to be an effective member of the multidisciplinary team, therapists must navigate unique payment rules as well as rules considered to be routine. For instance, therapists are required to utilize functional limitation reporting (FLR) “G” codes. “G” codes are based on quality data that therapists and providers include on Medicare claims forms to fulfill the requirements of the Physician Quality Reporting System and functional limitation reporting. CMS utilizes these codes to track information about Medicare beneficiary function and condition. PTs and OTs must also be conscious of Medicare’s “therapy cap” process, which has recently been extended through December 2017, and know how to navigate the “exception process” as well as use appropriate therapy modifiers. The current cap, with exceptions, is $1,940 combined for physical and speech therapies as well as $1,940 for occupational therapy. The cap, with exceptions, impacts private practice, physicians’ offices, skilled nursing facilities, HOPDs, critical access hospitals, and certified rehabilitation facilities. The exception process is automatic based on patient diagnoses that indicate continued “skilled therapy” and is coded with the “KX” modifier. Claims that are part of the exception process and exceed $3,700 are subject to post-payment review.

Coding & Medicare Payment Parameters

Unlike nurses, PTs and OTs in the HOPD environment do not have direct-supervision requirements through CMS or any other payer entity. Whereas nurses must ensure they are performing clinical services with the required direct supervision of a physician, which is defined by CMS as “immediately available to furnish assistance and direction throughout the performance of procedures” and not through physicians available by telephone,⁴ PTs and OTs must only ensure that the established therapy plan of care gets the required attending physician’s approval.

Therapists are strongly encouraged to obtain National Provider Identification (NPI) numbers that can be used on all reimbursement claim forms, unless the therapist is part of a larger entity. The NPI will also be utilized for quality measure reporting under the Medicare program. 

Therapists are currently the only healthcare providers that have specifically determined dollar reimbursement limits via the therapy cap. Beginning in July, a new manual review process will be implemented by CMS based on: 1) patterns of abhorrent billing compared to other providers in one’s region, 2) high claims denials, 3) newly enrolled providers, 4) certain medical conditions (not yet identified), and 5) part of a group that includes other providers. The impact on therapists will be to remain diligent with documentation and recognize whether or not their practice/clinic falls within one of these categories. This should not change practice.  

To remain FLR-compliant, therapists must report “G” codes along with their severity modifiers at the initial examination, then minimally during every 10th visit as well as at discharge. A reference chart of short and long descriptions provided by CMS is below. For a primer, see Table 2.

The therapist will record two separate codes at each visit: 1) current functional status and 2) projected functional goal. The utilization of both codes should be consistent with the short-term goals of the PT/OT plan of care. Note the introduction of the new modifiers that will ultimately replace modifier 59 (distinct procedural service). The “XP” modifier, “separate practitioner,” is an obvious choice when therapy is part of the multidisciplinary clinic.

Note: CMS officials have said providers should not use these new modifiers until further direction is provided by CMS.

The therapist brings a wealth of knowledge and expertise to the multidisciplinary team. It is necessary to understand and live by the basic principles behind reimbursement:

1) Develop the charge master to include all the necessary CPT codes, modifiers, revenue codes, functional “G” codes, and severity indicators.

2) Know the name of the Medicare Administrative Contractor (MAC) that processes claims.

3) Research and know the MAC’s local coverage determinations that pertain to the work the therapist performs.

4) Be aware of any national coverage and noncoverage decisions.

5) Understand all National Correct Coding Initiative edits.

References

1. Guide to Physical Therapy Practice 3.0. American Physical Therapy Association; Alexandria, VA. 2014.

2. Scope of Occupational Therapy Practice. American Occupational Therapy Association; Bethesda, MD. 2004.

3. American Medical Association. A Comparative Look at the Physical Medicine and Rehabilitation CPT Codes. CPT Assistant. 1998.

4. Schaum, K. Payment strategies. Adv Skin and Wound Care. 2015;28(5):202-204.