Reimbursement Seminar for Motion Analysis Laboratories Wayne Stuberg, PhD, PT GCMAS Reimbursement Committee
Objectives 1.Describe the differences between coding and reimbursement rules. 2.Review the Medicare Resource-Based Relative Value Scale system related to Motion Lab coding and reimbursement. 3.Describe the current Motion Lab Codes and their reimbursement value. 4.Discuss the impact of Center for Medicare & Medicaid Services (CMS) Local Medical Review Policies (LMRP) on reimbursement.
Coding vs Reimbursement Coding CPT codes established and published by the AMA CPT Editorial Panel Input given by professional societies Motion Analysis Codes 96000-96004 Reimbursement Payor fee schedules often developed from CMS RBRVS physician fee schedule Payor determines: Medical necessity (ICD-9 allowable codes) LMRP written by the payor
Motion Analysis Codes CodeDescription 96000Comprehensive computer-based motion analysis by video-taping and 3-D kinematics 9600196000 + dynamic pressure measurement during walking 96002Dynamic surface EMG, during walking or other functional activity, 1-12 muscles 96003Dynamic fine wire EMG, during walking or other functional activity, 1 muscle 96004Physician review and interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface EMG, dynamic fine wire EMG during walking or other functional activities with written report CPT, 2002
Description of Codes 96000-96004 Codes 96000-96004 describe services performed as part of a major therapeutic or diagnostic decision making process. Motion analysis is performed in a dedicated motion analysis lab (i.e.. facility capable of performing videotaping from the front, back and both sides, computerized 3-D kinematics, 3-D kinetics, and dynamic EMG). CPT, 2002
Reimbursement and RBRVS (Resource-Based Relative Value Scale) CPT Code – description of the service Relative Value Unit (RVU) value assigned to service Geographic Practice Cost Index (GPCI) cost of living adjustment by geographic area Conversion Factor CMS reimbursement per RVU ($36.79 in 2003) Service Setting CMS facility vs non-facility (Motion lab CPT codes are same for facility & non-facility)
Relative Value Unit (RVU) Total RVU includes 3 components: Work Expense Practice Expense Malpractice Expense Example for CPT Code 96000 Work = 1.8 Practice = 0.72 Malpractice = 0.02 Total = 2.54
Facility vs Non-Facility Reimbursement Facility = CMS approved facility Hospital Comprehensive OP Rehab. Facility (CORF) OP Rehab. Facility (ORF) Facility allowed to bill APC (ambulatory payment classification) fee 96000-96003 = APC 0708 (New Technology Level III) = $150 96004 does not include APC fee as it is a professional service
LMRP & ICD-9 Codes CMS’s New York regional office has developed a local medical review policy for Motion Analysis Codes. Lists ICD-9 codes that support medical necessity, e.g. CP, spina bifida codes. States that any codes not listed as supporting medical necessity will be denied payment.
Case Scenario 1 Child with spina bifida seen for assessment in Lab including videotaping, 3-D kinematics & kinetics, surface EMG (8 muscles), fine wire EMG (2 muscles) & physician review & interp. with written report: CPT Codes: 96000, 96002, 96003 (X2) & 96004
Case Scenario 2 Child with CP seen for assessment in Lab including videotaping & 3-D computer- based kinematics, dynamic plantar pressure measures during walking, surface EMG (8 muscles), & physician review & interp. with written report: CPT Codes: 96001, 96002, & 96004
Common Questions Should I bill code 96000 X2 if we do barefoot & walking with orthoses? Should I bill code 97001 with Motion Lab codes if PT performs physical exam with gait study? No, code is inclusive for the session regardless of number of conditions No, both are diagnostic codes & would be considered redundant
Common Questions Should I bill code 96000 & 96001 in the same session? Should I bill code 96004 if a physical therapist reviews and interprets the gait study? No, 96001 is an extension of code 96000 No, code 97004 can only be used for physician review & interpretation
Common Questions Should a Lab bill codes 96000-96003 if a physician is not involved in the gait study? Likelihood a Lab will be reimbursed for billing motion analysis codes for diagnoses not identified as a medical necessity? Yes, 96000 – 96003 are Medicine CPT codes to be used for gait studies. Good Question! let me know (;-)
The Future & Reimbursement Input to local providers regarding LMRP and Motion Analysis codes. Input to CMS regarding RVU valuations of the codes as set in 2003. Input to Advisory Panel on Ambulatory Payment Classifications (APC) to justify increasing level of APC coding. Other ideas?