physical therapy billing is painless

What We Say When We Talk to Our Patients About Pain

As physical therapists we know the scenario quite well. The new patient intake forms come across our desk right before an evaluation and the body chart is completely covered in “X” marks indicating areas of pain. There is no clear nerve root pattern, no dermal pattern, no pattern at all – just X’s spanning across the body. Perhaps there was an initial trauma several years prior, though many times the onset is insidious.

Often times the medication list is extensive and includes opiates or narcotics. During the history taking portion of the evaluation the patients often recounts a long tail of failed medical remedies. Perhaps they have seen countless health care professionals of various types in various locations. Perhaps they express disdain that their physician has sent them to you because in the past physical therapy has done nothing for them. And perhaps a little voice inside our head gives a deep sigh and says “oh dear.”

There is growing concern over distribution and overuse of opioids by chronic pain patients. Medical practitioners are under pressure by third party payers and the medical boards to prescribe in a safe and conservative manner, though due to the addictive nature of the opioids and narcotics, when denied continuous access to medications some patients may seek a string of new physicians.1 While there is evidence to suggest that opioids can provide analgesic effects to a chronic pain patient for up to eight weeks, they have not been seen to provide pain relief for the same dose after 2 months. 1

Further conversation with our chronic pain patient may reveal how horrified the patient truly is at how their pain has been managed. We know that most of them are not drug seekers for the sake of drug seeking. Chronic and excruciating pain has lead them to seek whatever may get them through their day and many times the pain medications offer a window of relief.

We as physical therapists are the most equipped health care professionals to treat patients with chronic pain. So why then have we found ourselves beating our heads against our desk when we fail to make them better?

Lorimer Mosely, David Butler, Paul Hodges, and Adriaan Louw suggest that we explain pain to them to get them better. These physical therapists come from various research groups using MRI, Ultrasound imaging, mirrors, and various other techniques to develop a profound understanding of what pain is, how it behaves, and what we can do to treat patients suffering from it.

Books such as Explain Pain by Mosely and Butler (of the Neuro Orthopaedic Institute) use beautiful art and laymen’s terms to explain these concepts to patients and healthcare providers alike.2 Mosely’s book Painful Yarns uses a collection of relatable stories to explain how pain behaves (the Australian term Yarns means stories)3. The gift that Mosely gives to patients and healthcare providers alike is humor. The reader gains a sense of neuroscience through anecdotes and analogies in a empathetic and lighthearted manner.

It is the job of your brain to protect you. This is a process that has been in place since the day you were born to ensure that your needs were met. When your brain perceives a threat to you, it sends a perceivable message of pain.

The importance of this concept is that the ability to correctly and succinctly explain pain to patients is producing results. Anecdotally, it has changed the way I practice. The concept lies in explaining the concept of neuroplasticity, the brain homunculus, and physiological adaptations that take place as a result of the this process. Adriaan Louw of the Spine and Pain Institute explains that the role the sympathetic and parasympathetic nervous system in his series of books Why I Hurt.4 This series of books covers topics including general pain, back surgery, whiplash, as well as pelvic pain.

Louw demonstrates his conversations with patients in several continuing education formats. At the end of the day we as therapists are generally good at reviewing evidence based literature regarding pain, neuroscience, and therapeutic management, though conveying this subject matter to patients with a variety of educational and psychosocial backgrounds can be a challenge. The following dialogue is one that I commonly use during evaluations and treatment sessions with patients. I find that this has enhanced my ability to gain trust and build rapport with chronic pain patients.

I begin by stating that their case is one that I am familiar with. Many patients feel that their symptoms may be baffling since no single health care professional has been able to explain to them why or how their symptoms persist. Often times I hold this conversation during manual therapy when the patient is lying still and is in a relaxed and comfortable position. I assure them that their symptoms are not in their head, though the brain plays an important role in the experience of pain.

I state the following “It is the job of your brain to protect you. This is a process that has been in place since the day you were born to ensure that your needs were met. When your brain perceives a threat to you, it sends a perceivable message of pain. For example, if you fall and sprain your ankle, your brain will tell you that it hurts, so that you will stop walking on it and allow the tendons to rest.

However if you were to step off a curb and sprain your ankle, and a bus was coming at you full speed, your brain would not inform you of pain, but to get out of the way of the bus. It is in this manner that the brain decides what the greatest threat to you is.

If there was an initial injury to the patient that resulted in a chronic pain cycle I would recount the following: Your brain acts like a security system to your body, similar to how a security system would protect a house. If someone threw a brick into the front window of your home and robbed it, you would buy a very loud, noisy security system, and perhaps get a guard dog.

This security system may be so sensitive that it went off when anyone came to the door – not just a criminal. Under a high security threat some alarms go off whenever someone approaches the door. Your brain acts in the same manner to protect your body- it will become weary of normal, non-threatening movements, positions, and activities because it wants to protect you. In this way it can become so sensitive that it does not know the difference between a real threat and a perceived threat. I then explain to the patient that the goal of physical therapy is to address the true mechanical threats and to reteach them safe movements.

This dialogue has opened the doors to communication with my patients. My perception of my practice is that I am earning earlier trust and rapport which merits quicker results with evidence based physical therapy treatment of manual therapy, therapeutic activity, and exercise.

  1. Fields H. The Doctor’s Dilemma. Neuron. 2011 Feb 24; 69(4): 591–594.
  2. Butler D. Mosely L. Explain Pain 2nd Edition. Noigroup Publications; 2013.
  3. Mosely L. Painful Yarns. Dancing Giraffe Press; 2007.
  4. Louw A. Why I Hurt. International Spine and Pain Institute; 1 editiob; 2013.

physical therapy billing reimbursement

Reimbursement in Physical Therapy

On April 16, 2015 Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This act is intended to repeal the flawed sustainable growth rate (SGR) formula, and is the final and permanent piece of legislation in a long line of annual temporary adjustments since 2003 that had prevented the SGR from activating a large payment cut for physical therapists and other healthcare professionals. Most importantly, MACRA further extends the Medicare therapy cap exceptions process to December 31, 2017, and includes numerous other provisions that will impact physical therapy. With the passage of this law, Congress has laid the groundwork for significant changes to Medicare reimbursement for physical therapists and other health care professionals1.

Active immediately, physical therapists can expect to see a positive payment update of 0.5% from July of 2015-2019. Physical therapists and other health care professionals who participate in alternative payment models (APM) will receive a 5% bonus annually from 2019-2024, and the fee for service model is retained. In 2026 and beyond, physicians, physical therapists, and other health care professionals in APMs may qualify for a 0.75% annual update. PT’s participating in all other payment plans will receive a 0.25% annual update. Perhaps the most exciting upcoming advancement is the fact that technical support is provided for smaller practices, funded at $20 million per year from 2016 to 2020, to help them participate in APMs or the new fee-for-service incentive program1.

The rumblings surrounding fee for performance reimbursement will be realized in 2019. Specifically, current quality incentive and payment programs such as the Physician Quality Reporting System (PQRS) will be consolidated and streamlined into a program called the Merit-Based Incentive Payment System (MIPS) beginning in 2019. This change will be best undertaken with early implementation and use of electronic medical records to assist in tracking appropriate reporting2. A detailed list of physical therapy outcomes tools and procedures for PQRS reporting can be found at:, and

Notably, changes have also been made to the infamous Medicare Cap. MACRA provisions to the Medicare therapy cap include an annual amount of $1,940 for physical therapy and speech language pathology combined in 2015, with a separate $1,940 cap for occupational therapy.  Hospital outpatient claims for therapy services with dates of service through December 31, 2017 will continue to apply to the therapy caps. In the event that further physical therapy is deemed medically necessary, providers may obtain an exception to the therapy cap until December 31, 2017. The manual medical review process at $3,700 has been replaced with a new medical review process that becomes effective 90 days after enactment of the law, which will be right around the corner in mid-July, 2015. This new annual review process applies to exception requests for which a medical review had not been conducted by the July date.1

In the private practice domain, physical therapists can expect to continue to report in the PQRS program in 2015, however changes to to the quality reporting system will take place in 2019. Beginning in 2019, the current quality programs under Medicare part B for physicians (PQRS, Value-Based Modifier, EHR Meaningful Use) will be consolidated and replaced with a new program called the Merit-Based Incentive Payment System (MIPS)1. Performance in MIPS will be based on 4 domains: quality, resource use, meaningful use, and clinical practice improvement activities.  MIPS will implement penalties for low performing clinicians and incentives for high-performing providers and practices. Bonuses and penalties under MIPS begin at 4% in 2019 and increase to 9% in 2022.  Data-reporting under MIPS will be via electronic reporting mechanisms (such as registries). Participation in a qualified clinical data registry would also count as a clinical practice improvement activity1. It is again here where we see the value in early adoption of electronic medical record use.

All of these changes and reform should result in better and more accurate reimbursement according to the American Physical Therapy Association (APTA). “It’s an exciting time, to have this finally happening,” Helene Fearon, PT, FAPTA, said at the conclusion of the June 6, 2015 APTA session titled “Payment for Physical Therapy Care Is Changing.” The session looked at the past, present, and future of efforts to shift payment for physical therapist services under Medicare from a fee-for-service model to what another speaker, APTA Senior Director of Payment and Practice Management Carmen Elliott, called a “value mindset.”4

A look back at the Department of Health and Human Services’ mandate under the Affordable Act to meet the “triple aim” of payment reform “better quality of care, improved public health, and lower cost”and APTA’s development of the Physical Therapy Classification and Payment System (PTCPS). The PTCPS differentiates Current Procedural Terminology (CPT) evaluation codes by level of complexity for the physical therapist (PT), and further differentiates intervention codes by severity of patient condition and intensity of PT services provided. Fearon, considered one of the profession’s preeminent experts on documentation, coding, billing, and payment-related policy issues, provides greater detail on the changes for which APTA has been working, listed in full at

These revisions are intended to change the payment model from isolated visit to episodic, and considers the clinical judgment of the PT, while taking into account the severity of the condition and intensity of PT’s involvement in care. In addition to APTA’s PTCPS page, two additional documents on alternative payment methodology as particularly relevant for PT’s the Medicare Benefit Policy Manual and the ICF (International Classification of Function, Disease, and Health) “beginners guide” Toward a Common Language for Functioning, Disability, and Health.4

  1. Highlights of the Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10). American Physical Therapy Association. Available at: Accessed on June 24, 2015.
  2. Medicare Physician Quaility Reporting System. American Physical Therapy Association. Available at: . Accessed on June 24,2015.
  3. Outocmes Measurement. American Physical Therapy Association. Available at: Accessed on June 24, 2015.
  4. Reform Efforts soon will pay off-literally- experts say. American Physical Therapy Association. Available at: Accessed on June 25th, 2015. -Amanda Olson, DPT
physical therapy billing with ICD-10

Is Your Practice Ready for ICD-10?

The notion that change is inevitable is contrived but true. If at any point health care ceases to change, then we should all be worried, because if there is no change, inevitably there is no growth. The other side of this coin is the notion that change itself produces worry and confusion.

The climate of health care in the United States has been forever changed and, come what may, it will not go back to what it was. Almost in tandem we are all preparing for the global health care change from the current International Classification of Diseases (ICD)-9 to the monolithic ICD-10 coding system. There is no need to enter a sympathetic nervous system frenzy as long as you are educated on what to expect and have an electronic medical record system that will support your business and transfer to the ICD-10 system in real time.

If you visit the government site, you will be instantly greeted with a ticking countdown to the October 1, 2015 ICD-10 compliance deadline. Those who are paying attention recognize that the initial set date for implementation was October 1, 2013. As if awaiting a rapidly approaching train in a station, we scrambled in attempts to prepare staff, billing systems, patient’s, anyone involved in implementation or reception of health care.

Then we learned that the change would be delayed one year to October 1, 2014. More scrambling ensued. And then in August we were informed that yet again the change would be delayed for one year to October 1, 2015. Hopefully, this time around, the world will be prepared.

ICD-10 coding compliance pertains to any healthcare provider covered by the Health Insurance Portability Accountability Act.1 This of course includes physical therapists, many which are concerned about the cost surrounding updating their technology and training staff. The center for Medicare and Medicaid services (CMS) has created an online module titled The road to 10 available at: Within this site one may find tips for implementation for small practice. A five step plan is provided in effort to guide practitioners to preparation complete with a printable checklist.

The Road to 10 plan includes steps such as “updating your process” which pertains to analyzing company policies and procedures, and analyzing the quality of documentation supplied by staff. The next step is the elephant in the room for most clinics. This involves engaging with partners and vendors and includes recommendations for technology staff.

The CMS recommends ensuring that your electronic medical record vendor has updated their software and is compliant with all codes updated. A key question to ask is whether or not the version of EMR that you are engaging in has 5010 capability. This will indicate whether or not you are able to submit your diagnostic coding to third party payers3. This is also where grumblings from clinicians who have held out with paper charting may be heard echoing through the canyons.

At this point physical therapists have not been mandated to switch to electronic medical records (EMR), however all of our peers have, including family practice doctors, podiatrists, and chiropractors. It is speculated that this may influence referral patterns to physical therapists from referral sources who do not have the capability to send and receive paper charting from those physical therapists who have declined to engage in EMR.

This may create further barriers for these clinicians when the ICD-10 changes come about as training billing and coding staff who operate on a paper based system may take time away from current clinic tasks, and may result in human errors that can be costly. In this regard, EMR can be an enormous asset to small physical therapy practitioners, and the ability to accurately code, and bill electronically can pay for itself quickly due to expedited and improved reimbursement from payers.

With the fear of change one may seek comfort in the fact that Current Procedural Terminology (CPT) codes will not change for the outpatient realm. What we will find when we receive or implement diagnostic coding under the new system is that the terminology is much lengthier and highly specified.

For example, instead of an ICD-9 code of 724.2 Lumbago, under ICD-10 coding the diagnostic term becomes M54.5 Low back pain due to intervertebral disc displacement, or perhaps M54.5 Low back pain due to pregnancy; the diagnostic code involves mechanism of injury and highly specified features of the low back pain (with or without radiculopathy, etcetera).

The American Physical Therapy Association (APTA) has many resources available to practitioners in anticipation of this change as well. Key practice Impacts of the ICD-10 upgrade, Webinars with suggestions for planning ahead, and an upcoming release of clinical examples of phsyical therapy specific coding are all available at:

In the end, the train that is ICD 10 coding is approaching us, and we must board in order to continue practicing physical therapy. Get yourself a map: The road to 10 by the CMS is a good one, and pack your comfortable shoes. In the end we choose our attitude, we can embrace and enjoy this trip with the right amount of preparation and protection from appropriately updated EMR as our insurance. bestPT EMR is ready for ICD 10 and staff is available to guide each individual practice in their implementation of our new coding system.

  1. ICD-10. Centers for Medicare and Medicaid Services. Available at: . Accessed on June 3rd 2015.
  2. The road to 10: The small physician practice’s route to ICD 10. Centers for Medicare and Medicaid services. Available at: Accessed on June 4th 2015.
  3. ICD 10 Fact Sheet: Basics for small and rural practices. Available at: Accessed on June 4th 2015.
  4. ICD 10. American Physical Therapy Association. Available at: Accessed on: June 4th 2015.

-Amanda Olson, DPT

Outcome Measurement Tools As Evidence

Outcome Measurement Tools as Evidence

In a day of medicine in which physical therapists feel stressed by increasing demands for specified insurance guidelines, codes, and outcome measures, it serves a therapist well to have a great understanding of various outcome measurement tools.  Standardized outcome measurement tools are vital to a therapist’s ability to establish baseline performance and track change over time.  In addition, good outcome measurement tools have high inter-tester reliability, making them easily replicated by another therapist.  This means that if I do an evaluation and my colleague were to perform the reassessment, my scoring methods will remain in line with each other.

The beauty of outcome measurement tools is that they provide evidence as to what improvements my patient makes as a result of therapy.  If any of my claims go to review or I need to submit an appeal for denied coverage, using proper outcome measurement tools gives I justification for services.  Nowadays it seems like insurance representatives scour medical documents, looking for any reason they can to deny payment.  As a therapist, my job is to fill my documentation with reasons that they must pay.  They key to this evidence lies in choosing an appropriate outcome measurement tool for my patient.

Physical Therapy Outcome Measurement Tools

Click to enlarge this image.


Figure 1. Data “persists” from document-to-document and within one document. This means you can view Prior or Current Levels or Goals from any of the relevant sections

First, I determine what my primary patient population will be.  There are functional outcome measurements that are specific to predicting fall risk or rating extent of disabilities.  These types of outcome measurements are ideal for the therapist working with the geriatric population in various settings.  There are many outcome measurements tools that test specific body parts, such as functional use of an arm or a leg.  In addition, there are many pediatric specific outcome measurement tools.  Because of high interest in research, more and more outcome measurement tools are being created each year, by highly motivated and dedicated clinicians.  I find the type of outcome measurement tool I are seeking and then I become well acquainted with it.

Outcome measurement tools should not take long to administer and should be easily recreated and repeated.  If I am learning how to administer a new tool, I try practicing with an experienced clinician.  I have the clinician present as a patient might and administer the testing items.  After I perform a test a few times, I will likely master it.

Outlined are several common and highly reliable outcome measurement tools based on topic:

Geriatrics: Tinetti Outcome Measurement Tool, BERG Balance Scale, BESTest, Functional Independence Measure (FIM)

Pediatrics: Alberta Infant Motor Scale, Batelle Developmental Inventory, Peabody Developmental Motor Scale, Pediatric Evaluation of Disability Inventory

Upper Extremity: Disability of Arm and Shoulder and Hand (DASH), Penn Shoulder Score, Shoulder Pain and Disability Index (SPADI)

Lower Extremity: Lower Extremity Functional Scale (LEFS), Get Up and Go, Six Minute Walk Test, Lysholm Score

Functional Mobility: Timed Up and Go (TUG), Six Minute Walk Test, Get Up and Go

Physical Therapy Outcome Measurement Tools

Click to enlarge this image.


Figure 2. Only relevant fields appear for selected functions. No unnecessary fields get in the way.

The beauty of outcome measurement tools is that they are standardized and tested in the literature.  Once I become familiar with some of the most common outcome measurement tools used in therapy, I can more readily understand current evidence and quickly understand the functional status of my patients.  When documenting within the bestPT software, I can easily utilize outcome measurement tools.  I simply select the outcome measurement tool I would like to input in my evaluation or reassessment note.  You can easily compare my patient’s evaluation score with their (hopefully improved) score at discharge.  This evidence of improvement serves to satisfy me as a therapist, the patient, and the insurance payers.

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.


Compliance | Investing in Documentation Software


The Java Blues

Will a glowing review of bestPT amount to a hill of beans with Shannon?

Shannon parked in the only available space in the bustling parking lot, grabbed her purse, got out of the car and practically ran to the front door of the coffee shop. With things so busy in her practice and at home, she felt like she was perpetually running behind. She hoped her friend Ariana hadn’t been waiting long.

“Hey Shannon!” she heard from across the room. Shannon broke into a smile and walked toward Ariana’s table. The two had so much in common” she was looking forward to catching up with her friend.

“How have you been, Ariana?” Shannon asked. “I know it’s been a few months but things have been so busy. Sorry for losing touch!”

“No worries, Shannon,” Ariana said, giving her friend a hug. “I’ve been busy too but things have never been better!”

“Tell me all about it,” Shannon encouraged. “I could use some happy news.”

“We made some big changes in the office” we had been going around and around about whether or not to invest in that software that helps us to manage the practice but we finally dove in,” Ariana said. “It was intimidating at first but it has made a huge difference in our operations.”

Shannon sat back and stared at Ariana with renewed respect. She and her friend had talked many times about bestPT, but she never thought Ariana would be the first to go all in. “Tell me all about it,” Shannon said.

“You and I have always complained about how documentation is so tedious and takes away time from patient interactions,” said Ariana. “Plus data entry mistakes can be so costly” whether they hold up insurance reimbursements or take away from patient care because we don’t follow up on missed appointments. What put us over the edge was our poor performance on our recent audit.”

Shannon nodded, knowing what was coming, since she and Teresa had been talking about this just last week.

“We made it through our audit relatively unscathed but one area the auditors pointed out needed drastic improvement was our patient notes,” Shannon admitted. “We’d all rather just scribble notes and stuff them into files so that we can maximize our time with our patients, but that never works out well. I’m pretty good at documenting patient visits and conversations but I haven’t always documented in ways that are compliant with state, federal and insurance rules. We got ticked pretty good on that. I made a vow that we’d change things for the better and gave our bestPT coach a call the next day, after the audit was over.”

“So how are things working out with your new system?” asked Shannon.

“I couldn’t be happier” in fact, everyone seems to be enjoying things more,” Ariana said. “We have become more efficient and accurate in documenting patient notes. Not just the SOAP notes but also getting in the related images, forms, test results and verification of benefits that are required to give the proper overview of care. All of us from reception to treatment room are now able to spend more time with our patients and ensure a great experience.”

“Best of all,” Ariana continued, “I know our patients are happier too. This month we saw a 10 percent increase in referrals. Our investment in the bestPT software is going to pay off in no time.”

“That does it, you’ve talked me into it,” said Shannon. “Tomorrow I will call Tom, our bestPT coach. Today, the coffees are on me!”

Shannon is finally ready to take the plunge and start using bestPT to help with documentation. So what is the next step?

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.


Documentation | Keeping Notes Compliant

indexCooking Up a New Plan

Can Shannon make the commitment to find a better way to achieve fast and compliant patient notes?

Shannon arrived home after a busy day to find Mike surrounded by their kids. She swung Sam up in her arms and gave him a firm hug.

“How was your day, Mommy? asked Heather.

“It was so busy,” Shannon said. “I’m tired but very happy to be home!”

“Mommy, I’m hungry, announced Laurie, who was always hungry.

“Laurie, why don’t you, Heather and Sam go upstairs and finish your homework?” asked Mike. “Your mommy and I will get started on some dinner for everyone.”

Mike held Shannon’s hand as they walked toward the kitchen.

“So tell me about your busy day,” Mike said.

“Well, Teresa and I had a really good conversation this morning and I’ve been thinking about it all day,” Shannon said. “We’re both getting pretty frustrated with patient notes. I have to write everything down every single detail of each patient visit and then Teresa has to take my notes and enter them into our system, along with images, forms, test results and more.”

“That sounds like you’re doubling the work for yourselves,” mused Mike. “Plus, you know, I’ve heard Teresa give you a hard time for your handwriting.”

“Yes, that’s certainly a continuing topic of discussion in the office,” admitted Shannon. “But it’s so important to capture every detail. Therapists have it drilled into their heads that if we don’t write it down, it didn’t happen.”

“Sounds just a bit like our inventory process at the restaurant,” said Mike. “Every tidbit of food that gets pulled out of the freezer or off the shelves has to be recorded. I have to know how much we use of everything and how quickly, or else I may not reorder in time. If we don’t have the ingredients customers want, they may never return, and they certainly won’t refer us to their friends and family.”

“Teresa and I were talking about that today,” said Shannon. “The less time we spend on patient notes, the more time we can spend on patient interactions and care. Happy and healthy patients are going to be much more likely to refer us to others.”

Mike nodded. “Plus, my bookkeeper needs to track my inventory costs in exquisite detail, or else we might be in trouble if there’s ever an audit,” he continued. “So even though I grumble about what a pain it is to manage and report on our inventory, I make sure to dedicate enough time to the process to do it right.”

“You know, our bestPT coach, Tom, has warned us that every practice that has been in business for more than five years will likely be audited by a state board or insurance regulatory agency,” said Shannon. “It’s been a while since our last audit, we really need to do better with our documentation. We need to be able to have notes that are both fast and compliant with state, federal and insurance rules.”

“You know what we really need to do better with?” asked Mike. “Preparing dinner, or else Laurie might grow weak with hunger!”

Shannon laughed and opened the refrigerator to get out the salad fixings. But she knew she’d be thinking more about this issue in the coming days.

What are Shannon’s options to simplify the patient notes process while enabling her to remain in 100% compliance with state, federal and insurance rules?

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.


ICD-10: The Long and Winding Road

What a long, strange trip it’s been on the road to ICD-10. It has taken more than 30 years from inception to acceptance, with numerous detours and false starts along the way. To see where we’ve been, and where we’re headed, check out the graphic below.


What do you think about the road ICD-10 has taken.

Has ICD-10 run out of gas?

ICD-10 | 100x More Complicated | Q&A

ICD-10 Q&AAs your practice is preparing for the impending ICD-10 changes, you might have many questions concerning physical therapy billing procedures and software requirements. To help you get the answers you need, we have compiled all questions that were asked during our recent webinar ‘ICD-10 | 100 Times More Complicated,’ along with the presenter’s responses. Feel free to add any new questions in the comment section below.

watch the workflow webinar recodring now

Q: I have a question about the top 50 ICD-9 codes we use, and doing the crosswalk to ICD-10. Where is the best resource for being able to do that?

A: CMS GEMS would be one website that you can use; that’s CMS’s GEMS System, which is the General Equivalent System that they use — the General Equivalent Mapping System that they use to translate ICD-9 to ICD-10.

Another good site for you is Click on their ICD-10 link and they have a feature where you type in our ICD-9 and it returns the equivalent ICD-10 code.

GEMS prompts you to choose the lateralities and origins, whereas AAPC is more one-to-one, but GEMS is really what most systems are basing their crosswalk from, and GEMS is built and maintained by CMS, the CDC, and AMA.

watch the workflow webinar recodring now

Q: I’ve done all my conversions from ICD-9 to ICD-10 and I’ve done the left and right conversions. We’ve changed some of our documentation so it’s more specific about mechanism of injury — the when, where, the why and the how. What else is there really to do?

A: You really want to make sure that how the practice is supposed to document the guidelines for PT documentation are clearly outlined in your policies and procedures manual. And that means adding in specificity and laterality. The manual should also have references as to where you seek the information; your reference point would be to CMS.

Q: If I want to take a coding course to get certified, do I need to be certified on ICD-9 and ICD-10?

A: Right now, you have to certify for both, but after October 1, you only have to certify for ICD-10.

Q:  Are you able to come out and help us train our staff?

A: We can give you the tools that you need in order to train your practice. For PT documentation, have them listen to our webinar in March, but they can also take external classes — specifically from the AAPC, because their classes on physician documentation are extraordinary. In terms of crosswalking, we will work with you.

Click here to download an additional ICD-10 resource!

watch the workflow webinar recodring now

Is your practice ready for a Medicare Audit | Initial Eval

Physical Therapy Documentation_Audit-ChecklistIn this second in our series of Blogs asking the question “Is your practice ready for a Medicare audit?” we discuss the critical importance of the PT/OT Evaluation.

Without question, The Initial Evaluation is your first and best tool in establishing and documenting the medical necessity for skilled therapy services.  It is your opportunity to paint a picture of the patients’ medical, physical, psychological, social and living conditions and how their current functional impairment has impacted on their prior level of function in some or all of these areas.

IN LCD L26884 Medicare includes the following description of the Initial Evaluation:

“The initial evaluation establishes the baseline data necessary for assessing expected rehabilitation potential, setting realistic goals and measuring progress.
Initial evaluations need to provide objective, measurable documentation of the patient’s impairments and how any noted deficits affect ADLs/IADLs and result in functional limitations.
Functional limitations refer to the inability to perform actions, tasks and activities that constitute the “usual activities” for the patient.
Functional limitations must be meaningful to the patient and caregiver, and must have potential for improvement. 
In addition, the remediation of such limitations must be recognized as medically necessary.”

In a Review or Audit the Initial Evaluation is an auditor’s introduction to the patient.  It will generally set the tone for all the documentation of treatment that follows.  Therefore, the documentation of the Initial Evaluation should:

Paint a picture of the patient’s impairments and functional limitations requiring skilled intervention.

Describe the prior functional level to assist in establishing the patient’s potential and prognosis.

Document the medical necessity of a course of therapy through objective findings and subjective patient self-reporting.

List the conditions being treated and any complexities that make treatment more lengthy or difficult.

Identify the impact of the conditions and complexities so that it is clear to a medical reviewer that the services planned are appropriate for the individual.

Describe the needs of the patient that require the unique skills of a therapist, including the expertise, knowledge, clinical judgment, decision making and abilities of a clinician that assistants, qualified auxiliary personnel, caretakers or the patient cannot provide independently.

The initial evaluation must be performed by a clinician.  CLINICIAN refers to a physician, non-physician practitioner (physician assistant, clinical nurse specialist and nurse practitioner) or a therapist (but not to an assistant, aide or any other personnel) providing a service within their scope of practice and consistent with state and local law.

“Only a clinician may perform an initial examination, evaluation, reevaluation and assessment or establish a diagnosis or a plan of care.  The clinician may include as part of the evaluation or reevaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or reevaluation.  The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.”

In our next Blog we will explore the specific items that must be present in the documentation of an Initial Evaluation (97001 or 97003)
to support medical necessity.   

Genco Healthcare helps practices achieve and maintain a culture of compliance.  We also assist Healthcare Attorneys in defending their clients who have been audited or subject to pre payment review.  Consequently, we have our finger on the pulse of precisely what Medicare’s expectations are when it comes to medical documentation.

For more information contact David Alben at  or 914-713-3606.

Physical Therapy Compliance | Stay compliant with ICD-10

Physical Therapy Billing_ICD10TransitionTipsTools

The International Classification of Diseases, “ICD Codes” were originally developed to track how people died. In 1948, just after the creation of the World Health Organization, a committee was put together to establish one version to represent all countries. Subsequently ICD codes were used to track diseases and injuries and to find patterns that might show an epidemic could be coming, as well as to track the general health of people. Today ICD codes are not only used for this purpose, but for medical billing in the U.S.

The transition form ICD-9 to ICD–10 was agreed upon internationally to improve electronic communication by adding specificity to both diagnosis codes and Current Procedural Terminology “CPT” codes. Everyone covered by HIPAA must transition to ICD-10. The new codes are fundamentally different because they contain information that characterizes anatomic site, severity and other clinical details. The result is that diagnosis codes grow from 13,000 to 68,000, while CPT codes grow from 11,000 to 87,000. (CPT codes will only be changing for hospital inpatient billing. Outpatient providers and other clinicians will continue to use the existing CPT Procedure Codes together with the ICD -10 codes for billing.)


  • It is 30 years old.
  • Lacks details on patients’ medical conditions
  • Lacks details on procedures and services performed on hospitalized patients
  • Uses outdated and obsolete terminology
  • Uses outdated codes that produce inaccurate and limited data
  • Is inconsistent with current medical practice
  • Not able to describe diagnoses and inpatient procedures of care now delivered


  • Incorporates much greater specificity and clinical information
  • Improved ability to measure health care services.
  • Increased sensitivity when refining grouping and reimbursement methodologies.
  • Enhanced ability to conduct public health surveillance and audits.
  • Over time a decreased need to include supporting documentation with claims. (Initially more supporting documentation may actually be required.)
  • Includes updated medical terminology and classification of diseases.

ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM. These codes allow for a much greater degree of clinical detail and afford practitioners a better understanding of their patients’ medical condition. This should lead to more customized treatment plans and better tracking of outcomes.


ICD-10-CM has many new features allowing for a greater level of specificity. These include:

  • Combination codes for conditions and common symptoms or manifestations
  • Combination codes for poisonings and external causes
  • Added laterality
  • Added extensions for episode of care
  • Expanded codes (injury, diabetes, alcohol/substance abuse, postoperative
  • complications)

Practice owners are faced with many challenges right now; RAC Audits, G Codes, and PQRS to name a few. ICD – 10 is yet another potential pitfall for your practice. Being proactive in managing your business has never been more important. Here are some suggestions to ease the transition to ICD – 10.

  • Improve Documentation Now:
    • ICD – 10 Codes will have a ripple down affect throughout many areas of your practice including payment and audits. Therefore they must be as accurate as possible.
    • Accurate coding cannot be achieved without the clinicians’ effort to provide good documentation.
    • The detailed information that is required to code using ICD 10 is also needed to create Treatment Plans that comply with Medicare requirements including “G Codes”. Clinicians must ensure that sufficient information is included in the medical record to satisfy these requirements.
  • Develop the Relationship Between Coders (Billers) and Clinicians
    • Clinicians do not need to understand all of the intricacies of billing and coding, and billers / coders do not need to understand all of the clinical / medical — but they must work together to ensure optimal accuracy.
    • Clinicians must accurately, precisely, and comprehensively document the patient’s medical condition and level of functional impairment and the procedures performed.
    • Billers need to understand basic anatomy and the pathology of conditions commonly seen in a therapy practice to better understand the clinicians’ documentation.
    • Anything that practices and providers can do to improve and facilitate the working relationship between therapists and billers will contribute to a smoother transition.
    • Ultimately, practices want to encourage clear documentation by clinicians and accurate coding by billers.
  • Institute Strategies for Training
    • Practice owners need to understand the impact of ICD – 10, identify the steps necessary to implement the move to ICD – 10 and the challenges that need to be addressed including people and technology.
    • Designate a specific person responsible for moving this transition through the organization.
    • Develop a timeline for training for office staff and clinicians starting at least six months before the implantation deadline (currently October 1, 2014).
    • ICD-10 codes can not be used in actual billing until the official start date, however most payers have a process in place that allows for testing in advance. Effective testing will prevent interruptions in cash flow once the official transition is made.
  • Locate the Resources for Help
    • Official resources are available at the Centers for Medicare & Medicaid Services (CMS) ICD-10 website. The site has a number of free papers to help in implementation, and includes all the official codes and guidelines. Implementation guides for both small and large practices are available that walk the user through the process.
    • There are 2 major, well-respected, accredited societies that offer training for coders/billers: the American Association of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).
    • Genco Healthcare Management is working closely with the team at Billing Dynamix to provide training and other services to their clients. We can be reached at 914-713-3606 or by email

We are grateful to Joseph C. Nichols MD whose writing for Medscape Education in 2012, inspired some of the suggestions contained in this blog posting.