Correct coding on the medical/client record is required for all reimbursement. Current Procedural Terminology (CPT) codes, developed and owned by the American Medical Association (AMA), are numeric codes for medical procedures. They are required for billing of all medical services including physical therapy. As of 2010, the most recent CPT-4 edition contains over 10,000 codes. The Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS), Levels I and II, identify specific codes that may be used for billing services delivered to Medicare beneficiaries. Level I codes are most similar to the CPT codes; Level II codes are not found in the CPT codes. As reimbursement is integrally linked to documentation, the knowledge and inclusion of CPT code verbiage when entering into the medical record is key to third party payers, internal organization billing and coding personnel for correct coding and billing for services.
Also required for documentation are International Classification of Disease codes (ICD-CM, which will be referred to as ICD in this text), which are numeric codes for diseases and pathologies, medical procedures including surgeries, and functionally oriented deficits or conditions. As of fall 2002, ICD-9 (9th revision, Clinical Modifications, 1993, with annual updates in the fall of each calendar year) code versions are in use for physical medicine and physical therapy procedures. Although the ICD-10 was published in 2001, there is now an ICD-11 version. As of the middle of 2010 the transition to ICD-10 use has not been made in the United States. CMS is replacing ICD-9 with ICD-10 for diagnosis and procedural coding by 2013. The ICD codes were developed by the World Health Organization (WHO) as a way to standardize classification of diseases worldwide (see a sample of ICD-9 codes in Appendix D).1
As the CPT codes that describe physical therapy–related procedures have historically been categorized as physical medicine codes, it has been difficult for physical therapists to distinguish themselves from others licensed to administer some of the same procedures. Although recent changes have resulted in evaluation and reevaluation codes unique to physical therapy, it remains incumbent on the physical therapist to prove medical necessity of the service based on consistent matching of CPT codes, ICD-9 codes, and appropriate documentation of what classifies the intervention as skilled.
Another category of code the physical therapist must be familiar with is the Relative Value Resource Based Systems (RVRBS). The RVRBS is a standard system developed by the federal government that assigns a dollar value to medical treatments in order to standardize reimbursement to physicians, with slight adjustments for geographic area. The values are derived from the time and skill (work) required for administration, the related practice cost, and professional liability costs. RVRBS values have been established for reimbursement by the federal government for physical therapy (PT) services rendered by physical therapists in private practice (PTPP, formerly referred to as physical therapists in independent practice, PTIPs) for outpatients that are ...