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Billing & Credentialing Cranberry Twp. (Pittsburgh)

Billing and coding for Occupational Therapy practices is evolving every year. Even with the new 3-level evaluation codes put into place this year, CMS is still collecting data throughout 2017 to see if there need to be more changes made to how Occupational Therapists are reimbursed. There are multiple rules and regulations for occupational therapy billing and coding. Every insurance company is different, which is why checking eligibility, submitting authorizations and documentation and adhering the correct modifiers to your patient’s claims can be a daily task that many offices struggle to learn and understand. Medwave and its professionally trained staff are here to help you and your office succeed in submitting your claims correctly and affordably.

Keeping Compliant

The first step to ensuring that you and your occupational therapy practice are on the right track is to make sure that you are documenting your patient’s visits correctly. Correctly documenting your patient’s notes can be the difference between getting paid and acquiring authorizations and losing thousands of dollars in income a year.

What should you be including in your documentation?

Most current ICD-10 codes

Updated CPT Evaluation codes

Patient Specific Functional Scale (PSFS)

G- Codes upon Evaluation and Re-evaluation and at least every 10th

New Occupational Therapy Evaluation Codes

As of January 1st, 2017, the CPT code 97003 for an Occupational therapy evaluation and 97004 for Occupational therapy re-evaluation will be replaced by 4 [http://www.trendmx.com/faq14/?qa=user/c0lwxtg967 behavioral health electronic health records] new CPT codes. The new codes will allow therapists to make a more specific evaluation based on the complexity of the patient’s diagnosis and performance.

New CPT Codes for Occupational Therapy

97165 - Occupational Therapy Evaluation- Low Complexity

97166 - Occupational Therapy Evaluation- Moderate Complexity

97167 - Occupational Therapy Evaluation- High Complexity

97168 - Occupational Therapy Re-evaluation

Patient Specific Functional Scale

The patient-specific functional scale score is being used by multiple insurance companies as a way to properly measure a patient’s functional condition. Before being evaluated, the patient is asked to list as many as three activities they are having trouble performing based upon their diagnosis. Once identified, they will point to a number scale from 0-10, 10 being fully functional, and score how they deem themselves able to perform that activity. This will be completed before the initial evaluation and upon every re-evaluation after.

Patient-specific activity scoring scheme (Point to one number):

0 1 2 3 4 5 6 7 8 9 10

Unable to perform Able to perform

Functional Reporting using G-codes

As of January 1st, 2013, it is required to append “G” codes to the initial visit, at least every 10th and upon the discharge of treating a patient under Part B Medicare. Highmark BCBS has now initiated the same policies for tracking the functional limitations of a patient. As of July 2017, all claims will be denied if G-codes and their modifiers are not used.

How do I know which G-code to use?

Based on the patients DX codes, you would choose the corresponding G-codes that best explain the patient’s functional limitations. You will always need to include 2 of the 3 codes in a set. You will either use the current status code with the goal status code or the current status code and discharge code. These codes will also need to be included in the patient’s documentation for every date of service:

Mobility G-code set:

G8978 Current Mobility status

G8979 Mobility goal status

G8980 Mobility D/C status

Changing & Maintaining Body Position G-code set:

G8981 Body position current status

G8982 Body pos goal status

G8983 Body pos D/C status

Carrying, Moving & Handling Objects G-code set:

G8984 Carry current status

G8985 Carry goal status

G8986 Carry D/C status

Self-Care G-code Set:

G8987 Self-care current status

G8988 Self-care goal status

G8989 Self-care D/C status

Severity Modifiers

Modifiers are needed to more accurately show the level of functional status the patient currently has and the goal being reached. There are a total of seven modifiers to choose from:

Modifier Impairment Limitation Restriction

CH - 0 percent impaired, limited or restricted

CI - At least 1 percent but less than 20 percent impaired, limited or restricted

CJ - At least 20 percent but less than 40 percent impaired, limited or restricted

CK - At least 40 percent but less than 60 percent impaired, limited or restricted

CL - At least 60 percent but less than 80 percent impaired, limited or restricted

CM - At least 80 percent but less than 100 percent impaired, limited or restricted

CN - 100 percent impaired, limited or restricted

When submitting claims for Medicare it is still necessary to append the GO modifier to show the service is being performed as outpatient occupational therapy.

Medwave Billing & Credentialing has a dedicated team of medical billing and credentialing experts to help you maximize your office’s reimbursement and keep you up-to-date with today’s ever-changing medical billing and coding regulations. Our team is experienced and well educated in the medical billing and coding guidelines of Occupational Therapy and has firsthand experience working with commercial, government, auto and workman’s compensation companies to get your claims paid fast and efficiently.

Our sole objective is to move your office to a more efficient and effective work process so that your claims reimbursement is at its maximum. Utilizing the most current ICD-10 and CPT coding ensures that your office’s claims are clean and paid the first time. Our staff is here to help you and your office succeed in preparing claims and getting reimbursed. Contact us today to see how we can be the best asset to your office by helping you get paid fast and efficiently.