What did they do to me in Physical Therapy?

Did they actually perform the therapy that that was billed?  A lot of names for physical therapy are tossed around.  Many have more than one definition within the main category.  To add to the confusion there are often just letters that represent the service.  I have assembled a few of the most common ones that are found in occupational therapy, physical therapy and chiropractic therapy notes. 

 Manual Therapy: 

• Hands on movement of joints and surrounding tissues by therapist to enhance the healing process by decreasing pain and increasing motion
• Joint Mobilization (JM):  Techniques to increase joint range of motion.  Restores normal joint movement and circulation to the joint.
• Myofascial release (MFR):  A “hands-on” treatment used to simultaneously assess and relax restricted soft tissues.
• Soft-Tissue Massage (STM):  Directed at trigger points, scars and muscle adhesions.  To improve blood flow, mobility and length of tissue.

 Exercise: 

• Passive Range of Motion (PROM):  A “hands-on” technique by a therapist to help increase a joint’s range of motion.
• Flexibility Exercises:  Exercise used to decease muscle tightness, improve soft-tissue and muscle length and increase range of motion
• Strengthening Exercises:  Use of resistance to increase muscle strength, tone and bulk.  Free weights or weight machines may be used.
• Manual Resistive Exercises:  Therapist applies resistance against patient’s effort through the range of motion to increase strength.
• Isokinetic Exercises:  A form of strengthening exercises using variable resistance at a fixed speed of movement.  Can also be used as a testing procedure.  Various brands of equipment include Cybex, Kin-Com, Biodex and Lido.
• Home Exercise Program (HEP):  Instruction in specific individualized exercise or functional activities to enhance improvements made in therapy.  Revised on an on-going basis as the patient progresses.
• Therapeutic Activities:  Activities or exercises designed to improve functional performance through simulation of functional movements, i.e. stair climbing.
• Neuromuscular Re-Education:  Exercises to improve balance, coordination, stabilization, posture and proprioception to correct movement patterns.
• Gait Training:  Instruction in use of devices such as crutches or cane, or correction of gait pattern.  Selection and fitting of assistive device may be included.

 Modalities: 

• Physical agents used to reduce swelling, pain and to prepare tissues for therapeutic exercises
• Biofeedback (EMG, BFB):  A device used to identify muscular activity and assess muscle imbalances.  Treatment may be designed to enhance or relax specific muscle groups. Often used for pain control.
• Cold Pack and Ice Massage (CP):  Also referred to as “Cryotherapy”.  Used to decrease pain, spasm, and swelling.
• Hot Packs or Moist Heat (HP or MH):  Packs of moist heat used to promote healing and relaxation and decrease pain.
• Electric Stimulation:  Electrical Muscle Stimulation (EMS):  An electrical device, which uses different frequencies of electronic current to treat a variety of conditions.  Indicated for swelling, pain, muscle spasms, nerve injury and re-educating weak muscles.
• Transcutaneous Electrical Nerve Stimulation (TENS):  Nerve stimulation device that helps to relieve acute or chronic pain. 
• Microcurrent Electrical Nerve Simulation (MENS):  Technique which uses very low levels of current to stimulate cellular growth and repair at the injury site.
• Interferential (IFC):  Another form of electrical stimulation used to decrease pain or swelling.
• Ultrasound (US):  Deep penetrating heat generated by sound waves.  Used to decrease swelling and muscle spasm.  Usually feel a minimal warmth since ultrasound reaches up to two inches below the skins surface.
• Phonophoresis:  Medicine, in a paste or gel, transferred by low levels of electrical current into tissue surrounding an injury site.
• Traction:  Often used for disorders of the neck and back.  A mechanical pull of soft tissue and joints to decrease pressure, relieve pain and guard muscles. 

 

Orthopedic Diagnostic Testing

When reviewing medical records, I like to have a handy sheet remind me of the reason for the orthopedic tests that that are not intuitive as they often are named after a person.  Below are some of the common ones that I see in records for musculoskeletal examinations: 

 

Neck:

Adson Test	The arm being tested is held in a dependent position while the head is rotated from side to side. The test is positive for thoracic outlet syndrome if there is an obliteration of the radial pulse.
Allen's Test	While the patient raises one arm and makes a fist the examiner compresses the radial and ulnar arteries. Once the arm is lowered and the hand opened, the examiner releases one of the arteries then repeated releasing the other artery. If there is no flushing of the hand upon release of one of the arteries, the test is positive indicating a vascular occlusion of the released artery.
Compression Test	The examiner places their hands on the top of the patient's head and presses down causing a narrowing of the neural foramen. The test is positive if increased pain is noted and indicates nerve root irritation.
Spurling Test	Patient is asked to look up, turn the neck to one side while gentle downward pressure is applied to the head. The test is positive indicating a pinched cervical nerve when the patient reports pain and tingling.

 

Back:

Bragard Sign	The lower extremity is flexed at the hip with the knee stiff until the patient experiences pain then the foot is dorsiflexed. Increased pain is a positive sign indicating nerve involvement.
Heel and Toe Walk Test	The patient walks on their heels indicating L4-L5 nerve root irritation if they are unable to perform this activity. If unable to walk on their toes this indicates lumbar nerve root irritation.
Lasegue Sign	The patient is able to flex the hip with the knee bent without experiencing pain. The examiner then raises the straightened leg by the heel. The test is positive if there is pain indicating nerve root irritation.
Patrick Test	A test to distinguish sciatica from lumbosacral or hip pain. With the patient lying supine, the examiner places the ankle of the affected side over the patella of the opposite leg and pressure is placed on the flexed knee. Patients with sciatica will not experience pain while those with lumbosacral or hip disorders will.
Straight Leg Raising Test	Patient lifts leg with the knee remaining straight, a positive test will result in pain along the sciatic nerve suggesting nerve root irritation.
Waddell Test	Five or more tests for malingering in patients complaining of back pain. The tests include tenderness, simulation (axial loading and rotation), straight leg raising, regional disturbances (weakness or sensory disturbances) and overreaction. The Waddell test is positive if the patient has positive results and complains of pain in three or more of the five tests, suggesting the complaints are non-organic.

 

Shoulders:

Apprehension Test	The patient's arm is extended, held abducted and externally rotated. The patient will be apprehensive in a positive exam, motion will be painful to patients with anterior subluxing or dislocating shoulder.
Drop Arm Test	The arm is lifted to a fully abducted position then lowers the arm slowly towards their side. The test is indicative of a rotor cuff tear if the patient cannot actively control lowering the arm past 90 degrees.
Impingement Test	The examiner forcefully abducts and internally rotates the shoulder causing the greater tuberosity of the humerus to impinge the undersurface of the acromion. A positive test could indicate an impingement syndrome or rotator cuff tendonitis.

 Hands:

Finkelstein Sign	The thumb is folded into the palm of the hand and fingers are closed around it while the wrist is gently pushed down. The test is positive when there is pain in the thumb side of the wrist. Pain indicates synovitis of the abductor pollicis longus tendon to the wrist also known as DeQuervain's Tenosynovitis.
Phalen's Test	The wrist is flexed as far as it will go and held for one minute which compresses the median nerve that runs through the carpal tunnel at the wrist. The test is positive for carpal tunnel syndrome if the patient experiences paresthesia or pain.
Tinel's Sign	The test suggests positive findings for carpal tunnel syndrome when the patient reports tingling sensation when the examiner taps the area over the median nerve.

 Hips:

Ely Test	With the patient lying prone, the examiner flexes the leg on the thigh, bringing the heel towards the buttocks. The test is positive if the pelvis is arched away from the table, indicating tightness of the rectus femoris, contracture of the lateral fascia of the thigh, or femoral nerve irritation.
Thomas Sign	With the patient supine and flexing the opposite hip, the affected hip will rise from the table. If this occurs, the test is positive indicating hip joint flexion contracture.
Trendelenburg Test	The examiner stands behind the patient while they lift one leg then the other. If the pelvis drops downward on the non-weight bearing side the test is positive suggesting muscle weakness of the weight-bearing hip.

 

 

Knees:

 

Apley Test	While prone the patient compresses their knee at 90 degrees, the examiner rotates the tibia in both directions. The test is repeated with the knee joint under distraction (pulling the patient's foot upward). If the patient experiences pain on compression, the test indicates a meniscal injury; pain upon distraction suggests a ligamentous injury.
Drawer Sign	With the patient supine and knee flexed 90 degrees, the proximal tibia is pulled anteriorly and then pushed posteriorly. Excessive movement while being pulled suggests a torn anterior cruciate ligament. Excessive movement while being pushed suggests a torn posterior cruciate ligament.
Lachman Test	This test is performed with the patient supine and the knee flexed to 20 degrees. The examiner pulls the tibia anteriorly. A torn anterior cruciate ligament is indicated by a "give" reaction.
McMurray's Test	The patient is supine. The examiner rotates the foot outward and slowly extends the knee from a fully flexed position. The test is repeated but with the foot rotated inward. The test is positive if a "clicking" is noted while extending the knee. A "click" with the foot rotated outward indicates a tear of the medial meniscus, while a "click" with the foot rotated inward indicates a lateral meniscus tear.
Pivot Shift Test	This test is for a torn anterior cruciate ligament. The examiner internally rotates the leg with the knee fully extended. With valgus stress, the knee is gradually flexed. The test is positive if the knee shifts at 30 to 40 degrees.
Slocum Test	This test is for rotatory instability of the knee. The patient is supine with the knee flexed 90 degrees, and the foot internally rotated. The examiner sits on the patient's foot and pulls the proximal tibia anteriorly. This test is repeated with the foot externally rotated. Excessive motion of the joint indicates a rotatory instability of the knee.

The Appropriate Modifier for an Assistant in Surgery

In the event that an operative report indicates an assistant at surgery and the physician documents the purpose of the assistant appropriately, the next consideration is determining what modifier is appropriate for the surgical codes.  There are a number of options to choose from and each has its documentation requirements.

The modifier 80 identifies a surgical assistant.  Assisting surgeons usually charge between 20 to 25 percent of their normal fee for performing the surgery alone.  This reviewer has noted that often the charge is the full surgery fee normally charged by the surgeon.  This occurs most often due to the coding software that produces a fee for the main code and does not take into consideration the modifier.

Modifier 81 is appended when there is a minimum assistant at surgery.  This modifier is used when the surgeon plans to perform the procedure on his own, but due to circumstances in the surgical suite requires the assistance of another surgeon for a short period of time

Modifier 82 indicates that the procedure was performed requiring the presence of an assistant surgeon when a qualified resident surgeon was not available. In teaching hospitals, special requirements must be met to allow billing for an assistant surgeon, and modifier 82 is typically used in those instances. Check with your Medicare carrier for details.

Modifier AS is added to the primary surgical code when the assistant at surgery is a physician assistant, nurse practitioner, or clinical nurse specialist.  This modifier again requires specific documentation.  The operative report should note that no qualified resident was available, the reason for the assistant’s services, and a statement indicating that the primary surgeon has a policy of never involving residents in the preoperative, operative, or postoperative care of his/her patients.

As with medical coding in general, all surgical modifiers must provide documentation as to the reason for the modifier and appending the code to an appropriate root surgical code.

Assistant at Surgery Billing

The first consideration in billing for an assistant surgeon is to be knowledgeable of the surgeries that require assistant surgeons.  The source that I use for this important consideration is the American College of Surgeon’s “Assistant Surgeon Study”.  It should be noted that this is a guideline and ultimately the surgeon and assistant surgeon’s documentation in the operative report will determine if an assistant surgeon will be allowed.  

To bill for an assistant at surgery, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant.

Once an operative report has been signed by the surgeon, it becomes a legal document and cannot be altered or redone. For claims denied for lack of documentation for assistant at surgery claims, the surgeon can dictate an addendum to the operative report and the claim can be resubmitted.

ICD 10 Compentency!

Barb King and Cortney Hubbard have successfully passed the course and testing to ensure ICD 10 proficiency! Just another milestone to keep up with the medical coding changes!

 

2016 Illinois Workers Compensatioon Fee Schedule

The 2016 Illinois Workers Compensation Fee schedule is available at https://iwcc.ingenix.com/download.asp