Keeping track of the latest regulatory issues in post-acute care can be a challenge. Understanding what they all mean to you, your business and your patients can be even harder. Casamba is here to help.

With “Ask The Regulatory Expert,” you can ask specific questions of Holly Hester, Casamba’s SVP of Compliance and Quality. We’ll get you your answers quickly, so you can focus on patient care.

Check back often for topical questions and answers.

Ask Holly

In reviewing the CMS PDPM ICD-10 Mappings for SLP comorbidities, I saw that the only ICD-10 codes for dysphagia, “other speech and language deficits,” and apraxia in the mapping tool are codes from the I69 series, representing sequelae or deficits following a cerebrovascular incident (or stroke). If the patient has dysphagia due to something other than a stroke, should I use the “unspecified cerebrovascular disease” code to be able to capture dysphagia as a comorbidity for SLP classification under PDPM?

An ICD-10 code describes a specific medical condition, illness, injury, or symptom and cannot be used to describe or represent any other condition or illness.  Therefore, the codes in the I69 series can only be used to describe patients who have suffered a cerebrovascular incident such as an infarct, hemorrhage, or subdural hematoma as specifically outlined in the description of each individual ICD-10 code. The “unspecified cerebrovascular disease” codes would only be used if specific information about the type and laterality of the deficit is unknown. For dysphagia, the symptom or deficit-based ICD-10 codes representing the phase of dysphagia (i.e., those in the R13 series) should be used to indicate the specific phase of impairment (oral, pharyngeal, etc.) in addition to the code describing the reason for dysphagia.

If the cause of the patient’s dysphagia is a condition other than a stroke (or cerebrovascular incident), then the medical diagnosis code representing that condition should be utilized.  Remember, a medical diagnosis code can only be documented and chosen by a physician or non-physician practitioner.

With respect to PDPM classification, the ICD-10 codes CMS lists in their mappings tools are the codes they identified in their data analysis to be ones that impact the amount of resources or cost of providing care. Diagnosis codes or conditions that are not found in the mapping tool will not trigger as a comorbidity for SLP.

Do all of the ICD-10 needs to map to PDPM or just the primary medical diagnosis?

Come October 1, 2019, the ICD-10 code in MDS item I0020B must map to a PDPM clinical category for the purposes of PT, OT, and SLP case-mix group (CMG) classification. This code is to represent the primary reason for admission to the SNF.  And, if the patient is evaluated for PT, OT or ST, this diagnosis code will likely also represent the primary medical diagnosis on the therapy plan of care. Therefore, within Casamba Skilled, the primary medical diagnosis should map to a PDPM clinical category. The therapy treatment diagnoses should represent the conditions, deficits, or impairments being addressed in the therapy plan of care, and most likely will not correlate to a PDPM clinical category.

In PDPM, does a diagnosis of depression or major depression disorder factor in to nursing or NTA classification?

Depression, as coded via the PHQ-9 in Section D of the MDS, is a factor in nursing case-mix group classification in PDPM in the same way as it is today under RUG-IV.  Signs and symptoms of depression are used as a third-level split for Special Care High, Special Care Low, and Clinically Complex categories. Depression does not factor in to non-therapy ancillary, or NTA, classification. Refer to CMS’s PDPM Classification Walkthrough document for details.

Can CPT code 97760 be billed more than once during a therapy episode of care?

CPT codes 97760 (orthotics management and training) and 97761 (prosthetics training) were modified effective 1/1/2018 to include the description “initial encounter.” Both of these codes are to be billed only for the first, initial visit (the initial encounter) during an episode of care. All subsequent visits for either orthotics or prosthetics training are to be billed using the new “subsequent encounter” code, CPT 97763.

Can a therapist assistant complete a weekly progress note for a Medicare Part A patient in a skilled nursing facility (SNF)?

The only specific CMS reference for content and timing of therapy progress notes refers to the Medicare Part B 10th Visit Progress Report. The Medicare Benefit Policy Manual (Chapter 15, Section 220.3.D) outlines this requirement and clarifies what an assistant can and cannot document. There is no specific requirement for a weekly progress note in Medicare Part A – this has simply been an industry standard for many years. Chapter 8 of the Medicare Benefit Policy Manual, Section addresses coverage and documentation requirements for SNF Part A, but simply states that the medical record must demonstrate that services are skilled and medically necessary. If the content of a weekly progress note for a Medicare Part A patient includes an assessment of the patient’s progress/status and modifications to the goals or treatment plan, then Medicare is clear in Chapter 15 that this falls outside the scope of what an assistant can do and document.

Which CPT code should I bill for dry needling services?

Currently, there is no CPT code for dry needling. The APTA has instructed the use of 97799, unlisted procedure, absent a specific payer policy to use a different code, and the AMA CPT manual suggests 20999, unlisted procedure, musculoskeletal system, a code not to be used by therapists but potentially by MDs/chiropractors. Neither of these codes are reimbursed under Medicare or other commercial payers. In September 2018, the APTA and American Chiropractic Association submitted an application to the AMA CPT Panel for the addition of two CPT codes for dry needling/trigger point acupuncture. This application was accepted, and the industry anticipates the addition of two new codes for this service to be effective January 1, 2020.  Whether or not these new codes will be reimbursed by Medicare or other insurances carriers remains to be seen.

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Can PTAs and OTAs treat TRICARE patients?

Currently, PTAs and OTAs are not authorized providers for TRICARE in any venue. The National Defense Authorization Act passed into law in December 2017 added assistants as eligible providers of therapy services, but this change cannot be implemented until the rule-making process is completed and the regulations are finalized and published by the Department of Defense (DoD).

On December 20, 2018, the DoD published a Proposed Rule in the Federal Register to add PTAs and OTAs as authorized providers of therapy services under TRICARE.  If finalized, this Rule will align TRICARE with Medicare policy. The earliest the rule-making process could be completed and implemented is fall of 2019, but it could be as late as early 2020. Until this happens, PTAs and OTAs remain unable to treat TRICARE beneficiaries.

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Are all PTs, OTs and SLPs providing outpatient therapy services to Medicare Part B beneficiaries eligible to participate in MIPS?

No. Only therapists who bill for Medicare Part B services on professional claims (i.e., the CMS 1500 or 837p) can participate in the Merit-based Incentive Payment System, or MIPS. Therapists working for institutional providers, such as hospitals and skilled nursing facilities, or rehab agencies (i.e., those billing on the UB-04) are not eligible to participate.

Who should complete Section GG of the MDS – nursing or therapy?

Since Section GG is coded based on the patient’s “usual performance,” the information should be completed with input from both nursing and therapy. Section GG assessment is to be based on direct observation, patient self-report and the report of direct care staff.

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