Reporting Therapy Services After Outpatient Surgeries
Q: We are struggling with how to report the functional status codes that are required when a physical therapist provides therapy services post-operatively. We have a process for doing that for our “regular” therapy patients, but are struggling with how to implement this for the outpatient surgeries.
A: The purpose of the functional status codes is to report the original clinical state and progress of a patient when they are receiving therapy services on a regular basis via the claim. Patients who have had surgery and need something like crutch training or assistance with their gait related to the surgery are not classified as “therapy patients.” Therapy services provided by physical, occupational, and speech therapists are performed under a plan of care, on a recurring basis, and under a specific therapy benefit category. Most therapy services take a period of time in order to be helpful/successful, which is another reason for the functional status reporting.
CMS noted with the initiation of the comprehensive APC (C-APC) structure that certain services would be included in the C-APC as supportive or adjunctive to the primary service (the surgery). Examples of these services included gait training or crutch walking that is provided to the patient post-operatively, due to the surgery, and not under a therapy plan of care. They refer to these as “non-therapy outpatient department services” and note that these may still be provided by physical, occupational or speech-language therapists. Section 1834(k) of the Social Security Act states that these services are not “therapy services” whether provided by therapists or non-therapist staff.
When a service such as crutch walking or gait training is performed on the same day as and because of a specific surgery (e.g., knee arthroscopy), then these are considered to be part of the C-APC and not a therapy service.
This is important because therapy services provided under a plan of care are specified under the act and subject to the annual therapy caps. To consider this a therapy service would eat into the benefit and amount of coverage for that patient, who may need a full plan of care and therapy at a later time.
Beginning with claims on or after October 1, 2016, with dates of service retroactive to January 1, 2015, CMS provides two options for reporting these “non-therapy C-APC adjunctive services:”
- Under revenue code 0940 (other therapeutic services) without using the therapy CPT code(s)
- As a therapy service with the appropriate occurrence codes, CPT codes, modifiers, revenue codes – AND the functional reporting requirements.
If you choose to report the services provided under the therapy revenue codes, with the therapy CPT codes and modifiers (-GO, -GP, -GN), then you will have to operationalize the functional reporting requirements for these services. A claim will not pass the CMS claims processing edits with therapy revenue codes but without functional reporting requirements.
For more information, see Transmittal 3602.
Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.