Common Mistakes with OWCP Billing
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Are you overutilizing ultrasound applications? Are you certain your billing accurately reflects the important distinctions between codes 99214 and 99215? Are you billing the Department of Labor physical therapy services through a massage therapist, chiropractor, or physical therapist? Is electric stimulation part of your continued treatment for existing patients? Are you aware that most PT codes conflict with other modalities? Do you know what supervision is required when it comes to code 97110? Do you have precise documentation to differentiate between codes 97161, 97162, 97163, and 97164? How do your notes justify high-complexity evaluations? Are you integrating psychological counseling, DME, or acupuncture in your treatment?
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Oberheiden P.C. is a team of former Justice Department healthcare fraud prosecutors and experienced federal lawyers with substantial knowledge and familiarity with OWCP billing and OWCP regulatory compliance. Our attorneys and consultants have avoided federal criminal charges for countless healthcare clinics across the United States. Call attorney Dr. Nick Oberheiden and his team of former federal healthcare fraud prosecutors, former Special Agents, and certified coders and billing experts today—to end your Department of Labor billing worries.
Medical CPT Codes
New patients are billed differently than existing and returning patients. However, just because a patient is new does not mean that the billing should become a routine billing of Code 99204. In fact, billing should never be routine. Level 4 can flag your practice, in particular if, as it is quite common, this higher reimbursement form is overutilized or used as a standard level of care. Talk to our Department of Labor billing team to find the right and defendable balance. Form CA-17 is needed to document “Modifier 25.”
99203 OFFICE OUTPATIENT NEW 30 MINUTES. Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient.
99204 OFFICE OUTPATIENT NEW 45 MINUTES. Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to severe, severity. Physicians typically spend 45 minutes face-to-face with the patient
99080-25 Special review code for reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form (DOL CA forms). The modifier 25 is significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
Re-Evaluation Codes for Physician Visits
Most mistakes occur in the context of returning patients. The rules are stricter, and time with the patient is typically less generous and more restricted. Before you bill codes 99211, 99212, 99213, 99214, 99215 you should speak to our attorneys to avoid common pitfalls. Once you use one of these codes, you may fall into what we call the “Department of Labor Coding Trap” because several other modalities and treatment options become no longer available. Also, the following codes require a profound understanding of the OWCP supervision requirements. Special attention is also required to carefully distinguish between code 99214 and 99215. The important differences between these two codes—detailed versus comprehensive—are almost always misunderstood and applied incorrectly. Finally, it is in this section of re-evaluations where the aspect of medical necessity is heavily scrutinized and becomes a key in a DOL clinic’s billing fraud defense case.
99211 59 E/M Evaluation and Management code for return visits. Office or other outpatient services; established patient. MINIMAL PROBLEM FOCUSED NONE-MINIMAL STRAIGHTFORWARD 5MIN Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
97112 – Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
99213 E/M evaluation and management code for return visits. LOW TO MODERATE EXP. PROB. FOCUSED EXP. PROB. FOCUSED LOW to Moderate COMPLEXITY 15MIN
99214 E/M Evaluation and Management code for return visits. MOD-HIGH SEVERITY DETAILED MODERATE COMPLEXITY 25MIN
99215 E/M Evaluation and Management Code for return visits. MOD-HIGH SEVERITY COMPREHENSIVE COMPREHENSIV E HIGH COMPLEXITY 40MIN Office or another outpatient visit for an established patient
Physical Therapy CPT Codes
Most PT CPT Codes contain dual or triple requirements. Take for example code 97530. In order for therapeutic activities to be covered, the following requirements must be met: (1) The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning; (2) The patient’s condition being such that he/she is unable to perform therapeutic activities except under the supervision of a physical/occupational therapist; (3) There being a clear correlation between the type of exercise performed and the patient’s underlying medical condition for which the therapeutic activities were prescribed. In many charts reviewed by Oberheiden PC, we found sufficient documentation for the first two prongs, but not always for the third prong. Documentation is key! With PT codes, be extra careful when it comes to appropriate supervision. Are you letting a massage therapist provide treatment and services under code 97110? What about code 97112? Are you over-utilizing code 97035? Talk to our attorneys and expert consultants today to identify potential billing errors.
97140 – Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
97760 – Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes
97530 – Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
97110 – Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises require one-on-one assistance, therapeutic exercises to develop strength and endurance, range of motion and flexibility.
97112 – Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
97035 Ultrasound, each 15 minutes. Timed code with area, type of ultrasound and body area needed.
97113 – Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
97116 – Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)
97124 – Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
A4595 Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes).
99070-5 Prior to June 1, 2019 referred to supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided).
E0217 DME CODE E0217 is a valid 2019 HCPCS code for water circulating heat pad with pump or just “Water circ heat pad w pump” for short
97022 Application of a modality to 1 or more areas; whirlpool”. Whirlpool (to one or more areas)
Whirlpool bath treatments typically do not require the unique skills of a therapist. However, therapist supervision of the whirlpool modality may be medically necessary for the following indications: a condition complicated by a circulatory deficiency or areas of desensitization;an open wound which is draining, has a foul odor, or necrotic tissue; exfoliative skin impairments. If greater than 8 visits are needed for whirlpools that require the skills of a physical therapist, the documentation should support the medical necessity of the continued treatment.
G0283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE
97016 Vasopneumatic Compression device. Application of a modality to one or more areas; vasopneumatic devices, captures devices that provide and external pumping force to the soft tissues of the lower or upper extremities. A sleeve containing separate chambers is applied to the extremity and can be progressively inflated, thereby providing a pumping action required to facilitate removal of edema.
97161 Physical therapy evaluation: low complexity
97162 Physical therapy evaluation: moderate complexity
97163 Physical therapy evaluation: high complexity
97164 Re-evaluation of physical therapy established plan of care requiring:
97163-27 GP Physical Therapy Re-Evaluations.
Acupuncture is allowable under the Department of Labor billing regulations. However, there are not just important exceptions (which are not covered under OWCP guidelines), but also a number of mutually exclusive codes that conflict with traditional workers compensation treatment codes. Be particular careful with coding for acupuncture as manual therapy, trigger point injections, as well as with billing acupuncture assessments at E/M codes Level 4. The following is a list of what is considered acupuncture codes.
97780 – Acupuncture, one or more needles; without electrical stimulation;
97781 – Acupuncture, one or more needles, with electrical stimulation.
97800 – Acupuncture, one or more needles; without electrical stimulation;
97801 – Acupuncture, one or more needles, with electrical stimulation;
97802 – Cupping;
97803 – Moxa.
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