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Coding to Purpose

Mary R. Daulong, PT, CHC, CHP

January 12, 2016

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Question

Can you discuss what it means to "code to purpose" when billing a patient after treatment?  

Answer

Demonstrating progression in a session should be easily see in how we code a claim.  If we are looking at therapeutic exercise; I call it SERF (strength, endurance, range of motion, and flexibility); we want to see that as a foundation.  It is a foundation of what we do, because you will not be able to walk, you are not going to be able to do dynamic activities if you have poor strength, poor endurance, etc.  You obviously start in that arena.  You may be combining other procedures during that time, but what happens when we continue to use therapeutic exercise throughout the episode of care without demonstrating a progression of the exercise difficulty or a change?  As an auditor, it is difficult to swallow when I see the same exercises that were taught for a home exercise program being performed in the clinic and being included in the one-on-one billing time.  It is something that can be looked at just from the claims level.  You want to make sure that you are demonstrating progression of the exercise during the course of the episode. 

For an example with a patient with patellofemoral pain, you can begin with exercises to develop strength, endurance, and ROM   Later on, in a few visits or whatever the patient tolerates, you progress to one foot standing, maybe using the Air-X and/ormedicine ball for balance.  That is taking more effort on the patient’s part.  It is engaging different systems and it is showing the continuum of the episode, not just focusing purely on strengthening or increasing range of motion.  We may then move to dynamic activities such as stair-climbing where the purpose is to engage the entire body when you are going up and down the stairs and it is a also a functional activity.  You are not teaching them merely to put foot over foot as you go up the stairs with a strong quad set or something of that nature.  You want to think of moving the patient through the continuum and demonstrating that through your choice of codes, again documenting and coding to purpose. 

The claim does tell part of the story.  If you use the same codes all the time for all of your patients whatever the diagnosis is, then you are not showing a whole lot of skill and there is always a possibility of it looking like a false claim.  When you have progressive coding, it does demonstrate clinical decision-making and it is showing that you are reacting to the patient’s ability.  You may start with exercises, get them to a certain point where you are working with balance, doing some manual work, dynamic activities, and maybe they flare up.  You may go back to some lower grade exercises just to calm the condition down.  Again, that shows clinical decision-making.  When a patient walks in the clinic and says they were really sore after their therapy, could not do their home exercise program, and is hurting right now they may not want to come back to therapy, then we see these same procedures performed that were performed before.  Not only does that not demonstrate skillful clinical decision-making, but it also could be a liability problem.  You are ignoring what the patient says, and you would be surprised how many times those types of things are documented and we do not see the proper course of action taken by the therapist. 

Finally, think purpose, not equipment.  An example is we performing core stabilization on a ball.  That is therapeutic exercise, but if we are sitting on the same therapy physio ball and we are doing balancing, then that is going to be neuromuscular reeducation.  Again, with the same ball and we are perform lunging activities, pivoting, etc., it becomes dynamic and it is under 97530, therapeutic activities.  Code to purpose; code to show progress, and move from basics to advanced activities.  


mary r daulong

Mary R. Daulong, PT, CHC, CHP

Mary Daulong, PT, CHC, CHP is a physical therapist and is also certified in Healthcare Compliance by the Health Care Compliance Certification Board and the HIPAA Academy. Her consulting company, Business & Clinical Management Services, Inc. was established in 1985 and has been, for the past dozen years, 100% dedicated to working with rehab professionals in the areas of federal and state compliance, provider enrollment, practice and business office audits/surveys, payment policy: billing, coding, documentation and compliance policy and procedure manual production.

Mary is chair of the TPTA’s Payment Policy Committee, is a member of the Private Practice Payment Policy Committee and is the representative for PT & OT for Jurisdiction JH. She is also on Novitas Solutions’ Provider Outreach Education Advisory Board and has been recently served on Novitas Solutions’ JH Transition Consulting Team.

Mary has been a featured speaker at National, State and Section Annual Conferences and is one of the contributing authors to “Compliance Corner” for the Private Practice Section’s Impact Magazine. 

 


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