2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and Abuseas the time of the general session. Documentationof the total therapy time, including untimed codes,is required in accordance with CMS guidelines, theAmerican Medical Association (AMA) CPT Manual,and Presbyterian’s provider manual. Counselingservices and behavioral health services must alsoprovide documentation for the face-to-face timespent with the patient.The CMS Medicare Benefit Policy Manual providesguidelines for physical therapy, occupationaltherapy, acupuncture service, and chiropracticservices (see the CMS Medicare ClaimsProcessing Manual, Chapter 5, Section 20.3,Determining What Time Counts Towards 15-MinuteTimed Codes All Claims). Providers report the codefor the time actually spent in the delivery of themodality requiring constant attendance and therapyservices. Pre- and post-delivery services are not tobe counted in determining the treatment servicetime. In other words, the time counted as “intraservicecare” begins when the therapist orphysician (or an assistant under the supervision ofa physician or therapist) is directly working with thepatient to deliver treatment services. The patientshould already be in the treatment area (such as onthe treatment table or mat or in the gym) andprepared to begin treatment.The time counted is the time the patient is treated.For example, if gait training in a patient with arecent stroke requires both a therapist and anassistant, or even two therapists, to manage in theparallel bars, each 15 minutes the patient is beingtreated can count as only one unit of code 97116.The time the patient spends not being treatedbecause of the need for toileting or resting shouldnot be billed. In addition, the time spent waiting touse a piece of equipment or for other treatment tobegin is not considered treatment time. (See theAmerican Medical Association CPT Manual,Physical Medicine and Rehabilitation, TherapeuticProcedures: Physician or therapist [is] required tohave direct (one-to-one) patient contact.)These services are generally timed. Here is anexample of a CPT code with its guidelines: 97110Therapeutic procedures, 1 or more areas, each 15minutes; therapeutic exercises to develop strengthand endurance, range of motion and flexibility.Claims Validation AuditsUnder your existing contract, Presbyterian reservesthe right to audit our members’ records forpurposes that may include but are not limited toAccuracy of claimsCoverage of servicesAppropriateness of servicesAppropriateness of billingPresbyterian routinely conducts claims validationaudits. To ensure accurate payment, please ensurethat complete and accurate supportingdocumentation exists in the patient’s medicalrecord that includes the following requiredelements:Date of treatment.Identification of each specificintervention/modality provided and billed for,both timed and untimed codes in languagethat can be compared with the billing on the15-32014 Practitioner and Provider Manual - Ver. 3