March 22, 2017 Webinar Attendee Questions and Answers

April 10, 2017
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Should we avoid using medical terminology abbreviations?

The use of abbreviations is certainly acceptable and a practice that we use to save time because our brains work faster than our hands. A “best practice” recommendation is for each clinic to compile a list of “approved” abbreviations that the therapists can use freely. If charts are requested for audit, a copy of the “approved” abbreviation list can be sent to the auditor. If you use abbreviations that are not widely known and accepted without an “approved” abbreviation list, you run the risk of someone not understanding your documentation.

Are we scared of over coding and getting an ADR? Is that why we are choosing low complexity evals? Or are we just not worried about it business-wise until 2018?

Most of our data regarding coding since the beginning of the year is for post-op orthopaedic patients, so a substantial portion of the evals are low complexity. Nevertheless, we believe that taking a little time now to develop new habits like learning the evaluation components and the requirements, making sure that your documentation succinctly ties comorbidities to the POC, including a statement about the clinical presentation, and summarizing your clinical decision making, will lead to choosing the correct eval code for all types of patients.

What would you choose if you have some components in the low category and some in the moderate?

To bill for a higher complexity, ALL components must meet the criteria for that higher code. So, if some components are in the low category and some are in the moderate category, you would be required to choose the low complexity.

Can you give examples of what is considered stable, evolving and changing, and unpredictable? Is this literal… meaning, if pain range is 2/10 am and 4/10 pm, that is evolving and changing?

There is room for interpretation regarding the clinical presentation descriptors based on each patient and how the measurements may be affecting the patient’s activity limitations and participation restrictions. However, a guideline that you should look for is if the patient’s condition is changing at a normal/expected rate of healing, then that is “stable”. Evolving relates to something that is not expected and is changing in a way that is not easily explained by normal healing expectations. So, as to your scenario, if a patient is progressing with healing and pain is fluctuating between 2/10 in the morning and to 4/10 in the afternoon and they have worked all day, you might expect this variation and feel like this is a stable recovery. But, if this patient is not doing any activity, the pain levels are fluctuating and there is swelling or other symptoms that you are concerned about, you might define this case as “evolving”. There is no list of examples that would support all patients. You are best off understanding the concepts of “stable,” “evolving” and “unpredictable” so that you can make the right choices for all patients.

Can you define “unstable”? For example, if a patient desaturates with gait to 80% on 3 liters, when 02 is increased to 6 liters, 02 sats return to 90%, patient has pulmonary fibrosis and acute CHF, is this unstable?

Yes, this would be an example of a condition that is unstable. A good description of the word “unstable” is that “things could change without warning”. So, in your example, the patient desaturates and requires more oxygen. Depending on the activity level and a variety of other conditions, the patient’s oxygen saturation could change without warning and therefore is unstable. A good question to ask yourself is if a patient has diabetes, is it unstable? If patient must carry sugar tablets, perhaps. If they have angina, is it unstable? Do you have to be concerned about that during your treatment? That is the question you should ask yourself when considering the comorbidities and the primary diagnosis to choose the correct clinical presentation.

The time assigned to each category does not seem to be relevant. For example, being able to spend 1hr with an uncomplicated joint replacement who can complete ADLs & do therex during eval is a low compared to an acute CVA who is not able to tolerate 20 mins due to poor activity tolerance & is total assist for bed mobs & unable to progress beyond sitting during eval is a medium or high. Is this correct?

You are correct. Time is really not a significant factor considered in choosing the correct code. But keep in mind that the time estimates for initial evals are based on the time to complete the evaluation, not the entire first therapy session which may involve evaluation as well as treatment. Therefore, you could have an unstable patient with 3-4 comorbidities and bill a HIGH eval code in only twenty minutes, but the evaluation documentation would need to demonstrate an examination that included 4 or more elements of body structures and functions, activity limitations and/or participation restrictions. On the other hand, that uncomplicated joint replacement might have some comorbidities or concerns that could be presented as a higher-level code if you consider all of the personal factors.
In your audits, do you consider using a standardized test/measure v counting objective measures (assist levels, MMT, etc.)?

The definitions in the examination portion of the new eval codes include use of standardized tests and measures. This is an expectation that every patient evaluation includes standardized tests to support the examination findings. One could argue that ROM measurements taken with a goniometer are “standardized measures” for a patient with limitation in ROM and a MMT is a “standardized measure” of strength. If the tests and measures support the patient and the POC, that is what would be required. To use the moderate or high complexity codes, you would be required to add more standardized tests to meet the requirement for the number of components. This would also demonstrate a higher level of clinical decision making by the therapist which is required for the higher-level codes.

Are the codes only for Medicare B evals?

No, these new evaluation and re-evaluation codes are for ALL PT and OT evaluations that are billed using CPT codes on the claim form for DOS on and after January 1, 2017. They are to be used for virtually all payer types and all clinical service settings. The components are the same whether the patient is being seen in an outpatient clinic, skilled nursing facility, inpatient rehab hospital, acute care hospital or home care. The only payers that were not required to change to the new codes are work comp and auto. But, it appears that these payers are following the Medicare guidelines and accepting the new codes as well.

You should not that Part A SNF, IRF, HH and IP acute are not paid based on CPT codes, so they do not need to use the new evaluation codes. However, the software many therapists use report services delivered using CPT codes, so if that is the case (as with most SNF Part A stays), the therapists need to choose the correct code that matches the CPT code on the claim. In home health, CPT codes are NOT used on the claim, so the only time these codes would need to be used is if the provider is billing Part B therapy outside the home health episode of care.

Are you stating that for each eval level, we must have the minimum number of criteria for each component? For example, for a complex eval, we must document 3-4 personal factors and/or comorbidities that impact care, 4+ tests and/or elements for the examination component, document unstable and unpredictable characteristics for the clinical presentation AND document high complexity using standardized assessments?
Yes, this is what the definitions require. If you use a template to help guide you while you learn the requirements, you will see the number of components in each category that are required to bill the specific level of complexity. Remember, if you do not have the number of requirements for every category, the correct code will default to the next lower code that is met.

Would hospital inpatients be considered evolving because they are in the hospital?

As discussed above, there are no set clinical presentations based on setting. Whether a condition is evolving relates to whether the course of healing is atypical. If someone is still in an acute stage, but they are progressing with care as expected for their acuity level, then they are stable. If, however, they are demonstrating signs and symptoms that are not typical, their condition could be evolving.

Is this going to impact outpatient payments more than acute payments?

There is no way to answer this question at this time. It depends on how CMS sets the payment for each eval level which will depend on 2017 utilization and possibly other factors.

Is there any breakdown of codes by type of facility (HH, SNF, IRF, O/P)?

The only data we have is for orthopaedic outpatient settings. This data, which is for a relatively short period, shows 2% high, 28% moderate and 70% low. We do not have data for other settings.

The example phrasing you gave us to support our evaluation level was excellent. Do you have anything specific for acute care settings? I feel that the comorbidities and # of elements sections are relatable, but it would be great to have example phrasing for acute care patients regarding clinical presentation and clinical decision making levels.

The following are the examples converted for the acute care patient. You will see that the components stay the same.
A low complexity evaluation of this 66 y/o male 1 day s/p L TKR. Pt presents with well controlled pain levels, minimal post op edema, clean incision site, decreased knee ROM & strength, walking short distances with walker; condition is stable. Pt is otherwise in good health, PMH is unremarkable and good social support from spouse in place. Pt will benefit from PT intervention to address the impairments identified above, as per protocol, to allow patient to return home with home health.
A moderate complexity evaluation was performed of this 66 y/o male 1 day s/p L TKR. Pt presents with high degree of pain at rest, significant post op edema confirmed by girth measurement and limited knee ROM & strength, and an antalgic gait pattern with dependence on walker at this time. PMH includes L4/5 decompressive surgery 2015 and personal factors such as recent loss of his wife and lack of social support that are expected to impact the POC and complexity of this case. Patient’s condition is evolving due to the complexity of multiple factors affecting recovery. Pt will benefit from PT intervention to address the impairments identified above, as per protocol, to allow patient to transition to home or SNF for continued rehab as quickly as possible.
A high complexity initial evaluation was performed of this 66 y/o male 1 day s/p L TKR. Pt presents with high degree of knee and low back pain at rest, significant post op edema confirmed by girth measurement and limited knee ROM & strength, and an antalgic gait pattern with dependence on walker at this time. PMH includes Parkinson’s Disease and hearing impairment, L4/5 decompressive surgery 2015 with ongoing recurrent LBP, and post-traumatic stress disorder (blast injury sustained in the military) that are expected to impact the POC and complexity of this case. At this time, patient demonstrates unstable recovery due to changing pain levels. This patient will need written instructions and a more private environment of care to improve his attention and anxiety levels. Pt will benefit from PT intervention to address the impairments identified above, as per protocol, to allow patient to transition to SNF for continued rehab as quickly as possible.

Are the following notes adequate to “defend” a moderate complexity level?


Pt is s/p fall two months ago, and demonstrates symptoms consistent with tendonitis at R peroneal and anterior tibialis muscles as she has tenderness at these muscles and reproduces this pain with resisted DF. She also reports symptoms of motion sensitivity, as opposed to vertigo, as she has “dizziness” and nausea feelings when driving in the car and going around turns. She is most limited in walking, sit<>stand, going up an incline, and stairs due to her R leg pain. She is most limited in driving due to her motion sensitivity. Pt would benefit from skilled physical therapy to address the above impairments and functional limitations.
Evaluation complexity

1. Number of persona factors/comorbidities indentified:3-4
2. Number of body structures/activity limitations/participation restrictions identified: 4+ elements
3. Clinical presentation: Evolving
4. Complexity level: Moderate

This type of template would be adequate if the information in the narrative assessment clearly supports the criteria in the bulleted list. In this case, the bulleted list has 3-4 personal factors/comorbidities; this # is not identified by the auditor. However, documentation does support 1-2 for moderate.

Though not specifically required, it makes for stronger documentation if there is a narrative summary assessment/statement that pulls the information together instead of a bulleted list that leaves it up to the auditor to figure out what are the things that the therapist considered to be supporting each requirement. For example: instead of the list of 1. Number of personal factors/co-morbidities identified: 3-4, the therapist could state: The patient’s reports of motion sensitivity is a comorbidity that may affect the plan of care.
Yes, a reviewer can assume and find the complexities, etc., but then you are leaving it up to their judgement instead of clearly documenting what factors the evaluating therapist considered in choosing the complexity level.

Are there CCI Edits for the new eval codes?

Yes, the CCI edits are as follows: