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New PT CPT Codes for 2017

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CPT® 2017 has a few expanded codes for physical therapy evaluations and follow-up exams.  These codes are in effect for dates of service starting January 1, 2017.

97001 to be replaced by three codes in 2017:

These new codes will add more specificity and details regarding the scope of the evaluation and states that it involves clinical decision-making of low/moderate/high complexity. The evaluation includes history to identify any factors that impact the plan of care; using standardized tests and measures to assess body structures and functions that may limit activity or restrict participation; and evaluation of the patient’s current status on presentation. The evaluation typically includes face-to-face time with the patient and/or family.

97161 Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97162 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97163 Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.

CPT® 2017 adds 97164 to replace 97002 (Physical therapy re-evaluation).

The new code adds more specificity and details regarding the scope of the evaluation, which includes history review and standardized tests (criteria established and agreed upon by a group of experts) and measures to assess body structure and function; a revised plan of care using standardized instrument and measurable functional outcome assessment tool; and typically involves 20 minutes of face-to-face time with patient and/or family.

Consider these to be the equivalent of E&M codes (99000) for Physical Therapy.  You should now consider these elements when coding for services:

  • Patient’s history
  • Examination results
  • Clinical decision-making
  • Development of the care plan

The level of the PT evaluation performed depends on the clinical decision-making and the patient’s severity, according to CPT® instruction. For reporting, PTs must demonstrate review of these body regions and body systems:

  • Defined body regions such as the head, neck, back, lower extremities, upper extremities, and trunk
  • Musculoskeletal systems, which include gross symmetry, range of motion, strength, height, and weight
  • Neuromuscular systems, which includes gross coordinated movement and motor function
  • Cardiovascular and pulmonary systems, which include heart and respiratory rates, blood pressure, and edema
  • Integumentary system, which means assessing the pliability, scar formation, color, and integrity of the skin

One other thing-make sure to sequence these codes before your modality CPT codes (those starting at 97010).

OT and AT have similar changes.  Look for those in a future post.

References:
CPT® 2017 Professional Edition, American Medical Association, pages 664-668
Federal Register, Vol. 81, No. 136, Pat. 46162, July 15, 2016, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release: Medicare Advantage and Part D Medicare Advantage Provider Network Requirements’; Expansion of Medicare Diabetes Prevention Program Model”
AAPC Healthcare Business Monthly, November 2016

 

Advancing Care Information and Improvement Activities-Q&A

shutterstock_498951139The Merit Based Incentive Program (aka MIPS) defines four categories of eligible clinician performance, contributing to an annual MIPS final score of up to 100 points (relative weights are indicated for the CY2017 performance year and associated CY2019 payment year):

  • Quality (60% for 2017)
  • Advancing Care Information (ACI, renamed from Meaningful Use) (25% for 2017)
  • Improvement Activities (CPIA) (15% for 2017)
  • Cost (0% for 2017, but will be weighted for 2018 and beyond)

On December 13, 2016 the Centers for Medicare & Medicaid Services (CMS), briefly discussed two of the four Merit-based Incentive Payment System (MIPS) categories: Advancing Care Information (ACI) and Improvement Activities. Most of the 90-minute session was reserved for questions and answers. Here are some of the questions your colleagues asked, with answers from CMS.

Q: How is the ACI scored for hospital-based and non-facing patient clinicians who are part of a large multi-specialty reporting as a group?

A: That would depend on whether they choose to submit data, or not; they still have the option because they’re hospital-based. If they choose to participate, they will be scored as a group. The resulting update will apply to everybody in the group.

Q: When ACI is set to zero, to what category is the percentage applied?

A: The entire 25 points is moved to the Quality category, so instead of the Quality category being worth 60 points, it will be worth 85 points of the composite performance score (CPS).

Q: Will providers be submitting data through the same system for ACI and Improvement Activities as they did for the Electronic Health Record (EHR) Incentive Program?

A: No. There will be a new system for MIPS. However, if you are eligible to participate in the Medicaid EHR Incentive Program, you will need to attest through the same system as before.

Q: When reporting as a group, will nurse practitioners and physician assistants be excluded from ACI scoring if no data is submitted?

A: Yes. But if they are part of a group ,they will get the same update as everyone else in the group.

Q: Do eligible clinicians need to inform CMS in advance whether they will be attesting as an individual or a group? If so, how do they do that?

A: They don’t have to inform CMS; they just submit the data — unless they are reporting as a group through the CMS Web Interface or reporting Consumer Assessment of Healthcare Providers and Systems (CAHPS) data. Information on these protocols are forthcoming.

Q: For the test portion of Pick Your Pace, which allows for one improvement activity to receive credit, can we pick any activity or do we need to pick a high or medium activity?

A: You can pick a high or medium activity, but a medium activity will only give you have the points (7.5) toward your final score.

Q: If we do not use an EHR and cannot attest to ACI, do we have to attest or submit this fact anywhere?

A: No. Just don’t complete that part of the reporting requirements.

Q: The rule states that ACI performance for groups will be based on a group score. Does that mean the reports showing the numerator/denominator for each eligible clinician in the group have to be combined?

A: The attestation should be aggregate there is one submission — one numerator and denominator per measure — for the group. If the group is using multiple EHR technologies, you will have to sum the numerator/denominator for each measure across the different EHRs for the group.

Q: If you do group reporting, do you only need a “1” in the numerator for the entire group to get credit for the base score under ACI?

A: Yes.

Q: When will the specifics of the improvement activities be released? The working on the 90-plus activities are vague and open to interpretation.

A: We are not planning to issue more specific language around the activities for the transition year. We aren’t requiring any specific data to be submitted. What you see is on the Quality Payment Program (QPP) website is all that is required.

Q: Will the bonus payment be a one-time payment?

A: Whatever score you get in MIPS will be applied to your Physician Fee Schedule amount. The method for paying the added bonus for exceptional performers is still being worked out.

Q: What if your certified EHR technology (CEHRT) year changes mid year due to an upgrade and your submitting a full year of data?

A: You can submit a combination. Aggregate your data between the  two EHRs and submit the data for the ACI category as one submission. This is not the case for Quality reporting, however. You will need to work with a data aggression vendor to report electronic Clinical Quality Measures (eCQMs), in that case.

Q: Does MIPS reporting take the place of EHR reporting? Do we still have to use a qualified EHR or can we do claims-based reporting?

A: The data needs to come out of your EHR. For Quality measures, you’re no longer required to submit eCQMs to earn credit. In the Quality category, you could submit via claims and it wouldn’t count against you.

Q: Can you report as a group under MIPS if not all of your providers are using a CEHRT?

A: Yes.

Q: What type of documentation is required for improvement activities?

A: For improvement activities, we are not requiring documentation. But providers should retain copies of medical records, charts, reports, and any electronic records that are applicable and appropriate for up to 10 years after the conclusion of the performance period, in case of an audit.

See the whole presentation:

Last Chance to get Medisoft V21 in 2016!

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It’s the holiday season….time to spread the Flu!

santa-hat

With all the weather changes we have experienced in the south over the past few months, getting the flu has been the last thing on anyone’s mind.  80 degree temps here in Kentucky in November is unheard of!  We’ve all been taking advantage of getting out in the fresh air (flu?  what flu?).

Well, now we are experiencing our first “Arctic Blast” and my first trip to Kroger this week resulted in witnessing probably the most embarrassing thing we as parents experience….projectile vomiting from a child in the grocery store.  Okay, maybe not the most embarrassing thing in the world but one that certainly had me running for the hand sanitizer and masks (no-I didn’t stick around to help).

And yes, remembering that in fact, the flu season is upon us.

Guidelines for Billing Influenza Vaccines

Medicare pays for one seasonal influenza virus vaccination per influenza season (12 months do not have to pass). Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations. All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine.

Medicare will pay both administration fees when a beneficiary receives both the seasonal influenza virus and the pneumococcal vaccines on the same day. Report ICD-10-CM diagnosis code Z23 Encounter for immunization when an individual receives both vaccines, but report separate administration codes for the seasonal influenza virus (G0008) and pneumococcal (G0009) vaccines.

Medicare Payment Allowances for this flu season (8/1/2016-7/31/2017)

CPT® Code Payment Allowance
90630 Influenza split virus vaccine, quadrivalent (IIV4), preservative free, for intradermal use $20.343
90653 Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use $37.383
90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use Pending
90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use Pending
90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use $17.717
90657 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6–35 months of age, for intramuscular use Pending
90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use Pending
90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use $42.722
90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use $26.876
90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use $40.613
90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

*NOTE-Claims for this code must be held until 1/1/17

$22.936
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use $26.268
90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use $19.032
90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6–35 months of age, for intramuscular use $9.403
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use $17.835

 

HCPCS Level II Code Payment Allowance
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria) $16.284
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval) $16.284
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin) Pending
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Pending
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) Flu Vaccine Adult – Not Otherwise Classified: Payment allowance is to be determined by the local claims processing contractor.

The payment allowance for some codes is still pending. Check the CMS website periodically for updates.

Resources:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2016-12-08-eNews.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending#_Toc468862699