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Multiple Diagnoses, documentation
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Multiple Diagnoses, documentation - April 7, 2008 10:04:31 PM
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kiwi PT
Posts: 75
Joined: December 2, 2007
From: MI, USA (dreaming of New Zealand)
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From a documentation standpoint how do you handle treating pts with more than one diagnosis at the same time or on the same script. My boss is telling me that there needs to be a chart and eval for each diagnosis, a separate in out time documented in each chart and the pt to pay a copay for each body part treated on the same day (so much for treating patients and not body parts). This seems crazy to me. We just had a script faxed over for a pt in which listed 1)BKA s/p 8 months, 2)LBP, 3)Rhomboid strain, 4)Upper trap strain. My boss said we would need at least 3 and possibly 4 charts for this pt. Does this depend on which insurance you are dealing with? Where can I look up information this to better inform myself and others.
Kyle PT
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"I have never let my schooling interfere with my education."
Mark Twain
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RE: Multiple Diagnoses, documentation - April 7, 2008 10:11:06 PM
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jma
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From: NY
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From a multiple diagnosis perspective, I have only heard of patients with at least two different diagnosis' being treated on different days and on the same day by two different therapists, with medicare. Not aware of the logistics when it comes to billing but it was allowed, at least in a hospital setting.
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RE: Multiple Diagnoses, documentation - April 7, 2008 10:14:03 PM
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TexasOrtho
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Kyle. That example sounds a bit extreme, but we have had patients with two completely different conditions from two completely different doctors have two charts. I can't imagine having three, but you never know. It could work, but wouldn't you then have to charge the patient 3-4 copays?
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Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Multiple Diagnoses, documentation - April 7, 2008 10:14:04 PM
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jlharris
Posts: 476
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From: Nebraska
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Man Kyle, where the hell do you work? It always seems the "manager" is pushing some weird agenda. Multiple copays? I've used seperate charts in the past (different referral doctor for different Dx), but if same doc, same insurance, would seen like you use one chart and just be sure to attach charges to the specific diagnosis (eg, 2 units ther ex to BKA and 1 unit MT to Upper back pain).
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Jason L. Harris, PT, DPT
My PT Blog
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RE: Multiple Diagnoses, documentation - April 8, 2008 7:35:19 AM
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SJBird55
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From: Michigan
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Yeah, Kyle, where do you work? ;) Jason, he's in MI! LOL
Kyle... first off - the patient's perspective needs to be brought into the picture. What the physician faxed on a referral can be very different than what is really relevant to the patient. Plus, I've had cases where a physician wrote LBP and the pain was actually thoracic pain. There may really only be 2 conditions to be treated.
Life will be much easier from a billing perspective AND getting paid if you evaluate on different days. Generally speaking, if you evaluate everything on the same day, your claim WILL get booted from the payor's computerized system because the computer will determine "duplicate claim." EVEN with separate account numbers AND both evaluations done on the same day - one wasn't initially paid because of "duplicate claim." I went round and round with one particular payor and trust me, it's not worth the time, the person at the other end of the phone doesn't "think." I'm not sure if a -59 modifier would help, but from a getting paid perspective, it would be much less of a headache doing the evaluations on separate days. For example in this case, evaluate whatever is the most important problem from the patient's perspective on the first day. Also, on the first day, have enough of a conversation to learn how many truly different problems there are.
I personally create as many charts as there are problems. The reason that I do this is from the perspective that I'd have X number of evaluations, X number of plans of care to maintain and procedures for each separate diagnosis. IF I were ever to be audited and let's say it is 2 years later.. I may not remember if everything is all in one chart. IF everything is separated, everything is as clear as mud to me. Also, from a legal perspective, if something were ever to go wrong, again, clear as mud what was what. AND, from a legal perspective, IF my records were requested, I'd make a boat load of cash. LMAO My policy for record retrieval is per account, not per patient. LMAO That's the least of my reasons, but hey.. My biller believes as Jason... same referral source, one chart. The thing is that I'm the one that has to be held accountable for everything that I do, so even though multiple accounts is a pain, and it will be a HUGE pain if the person has a per day copay because which claim will the money get tagged? LOL But, if there were any "problems" or issues down the road, I know I feel 100% confident that I could easily and more readily at a glance know what occurred with that patient compared to everything all in one chart.
When it comes to copays, generally is is a straight copay per day, like say $15/visit OR it is a percentage of the CPT code charges. If the person has some type of definitive dollar amount for a co-pay, someone in your office just needs to contact the insurance company and ask if the copay is per visit or per diagnosis. I do know that years back, when I was capped per day with BCBSM payments, I had a lady at the time that was being seen for 2 different problems on the same day - different diagnoses, different physician - I was paid the capped amount for EACH account on her visits. If I would have lumped them all in under one chart, I would not have maximized my potential to earn what was truly due to me. It all depends on the language of the contract. If she would have had a $15/visit kind of a thing, she would have racked $30/day to me because of the language of that contract. (Things have changed in MI though, Kyle, so BCBSM doesn't have the maximum amount you can be paid in a day - they now operate on a fee schedule.)
Jason, from a billing perspective, if you only have one chart and you have a couple of ICD-9 codes tagged to that account, when your claim goes out say on a 1500 form, the CPT codes aren't tagged to any specific diagnosis. The 1500 isn't designed that way. The only way to truly indicate on a claim what CPT code goes to what ICD-9 code is to have 2 separate accounts. I'm not a biller, but looking at the 1500 form, that's what it appears to me. That would mean that if you wanted to be clear what was what, you'd need to do that in your own documentation within the chart.
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RE: Multiple Diagnoses, documentation - April 8, 2008 4:36:12 PM
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jlharris
Posts: 476
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From: Nebraska
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quote:
Jason, from a billing perspective, if you only have one chart and you have a couple of ICD-9 codes tagged to that account, when your claim goes out say on a 1500 form, the CPT codes aren't tagged to any specific diagnosis. The 1500 isn't designed that way. The only way to truly indicate on a claim what CPT code goes to what ICD-9 code is to have 2 separate accounts. I'm not a biller, but looking at the 1500 form, that's what it appears to me. That would mean that if you wanted to be clear what was what, you'd need to do that in your own documentation within the chart.
I'm not a biller either, and don't own my own clinic. I know we use PTOS and in the past with a situation where there were multiple Dx were were told to attach charges to the specific Dx and I know in PTOS that the charge is then attributed to that Dx. Now, what happens when the bill is sent, I don't know. I'm completely ignorant there.
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Jason L. Harris, PT, DPT
My PT Blog
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RE: Multiple Diagnoses, documentation - April 8, 2008 5:11:08 PM
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kiwi PT
Posts: 75
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From: MI, USA (dreaming of New Zealand)
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Thanks guys,
We didn't end taking the BKA pt because we didn't accept her insurance, too bad sounded like an interesting case. However yesterday I evaled a pt 3 months s/p tibial plateau fx who also had a shoulder strain from using the walker. Both from the same script/physician, so as SJ said I just did the eval and treatment on the knee yesterday, and will do eval and treat on shoulder, and treatment on the knee tomorrow. So the pt will have two $20 co-pays tomorrow, yikes! In some ways it makes sense from a billing perspective since BC only pays so much a visit and treating both does require more time/skill. I just find it annoying to sign 2 treatments logs and two daily notes, and keep track of the in/out time for both charts, instead of going back and forth between knee and shoulder. It makes me feel like I'm cutting the pt in half.
Kyle PT
_____________________________
"I have never let my schooling interfere with my education."
Mark Twain
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RE: Multiple Diagnoses, documentation - April 9, 2008 5:33:27 PM
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SJBird55
Posts: 2430
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From: Michigan
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Kyle, you might want to contact the third party payor to ensure the patient does have two $20 copays. The language of the benefits contract is what determines this particular case. You'll need to have your biller probably use -59 modifiers so that "duplicate claim" doesn't occur as a denial - or at least discuss the billing with someone (and you'll learn from talking to someone in billing too). Meaning the one account may have to have every line item tagged with a -59 modifier. It all depends on how you are submitting claims though - most places are doing it electronically and for some reason the darn computers at the third party payor end don't always "get" that two separate accounts have been created for a single subscriber with a single provider for physical therapy services. It must do with the rules written within the computer program to reduce erroneous billing.
Having 2 accounts for her with separate documentation could be helpful down the road. You're only separating her via the documentation. You have to remember, you never know if you'll be audited and you never know the educational level of the person doing the audit. I'd think it would be a lot easier for someone to just go through a single chart for a single diagnosis versus having both in the chart and someone (you or someone else) having to try to figure out what is what. A single chart for each entity is also much easier to see the definite plan of care for that problem and to track how you progressed to reach the goals in that plan. As I said though, my biller takes the opposite opinion - single chart and a single evaluation covering both diagnoses. Since I own my own business and I disagree with him, that's okay. LOL I do what I believe is correct.
Time in and time out... well, I have every patient sign in and sign out. When a person has 2 accounts, I don't have them do that process twice. I just document total treatment time for the timed codes in each chart and then the total time in the clinic. Each account would have the full amount of time in the clinic because the person was in the clinic that whole chunk of time. That's just the way I do it though.
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RE: Multiple Diagnoses, documentation - April 9, 2008 9:49:29 PM
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kiwi PT
Posts: 75
Joined: December 2, 2007
From: MI, USA (dreaming of New Zealand)
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I will try to look into it some more as far as the co-pays, I'm not the one that called to verify benefits, it (2 co-pays) seems strange to me, but that is what I was told.
As far as sign in/out we don't make them sign out but for pts like this we have them sign in twice, yes that IS ridiculus.
_____________________________
"I have never let my schooling interfere with my education."
Mark Twain
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RE: Multiple Diagnoses, documentation - April 10, 2008 6:06:15 AM
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SJBird55
Posts: 2430
Joined: May 10, 2004
From: Michigan
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Since you normally don't call on benefits, if you did take the time to call versus asking someone in your clinic - you can call the number on the back of the patient's insurance card. The number is for customer service. The best tactic to use is playing dumb. Providers have a different number they are supposed to use and you won't have that number because you aren't in the billing department. You'll need to have the subscriber's name, contract number and date of birth. (Subscriber will be the name on the card.) Then, you'll need to also know the patient's name and date of birth. You will also be asked the date of service (just use the first date of service). Shoot... you will need your clinic tax ID or NPI. Hmmm... I've sweet talked my way around that one... you may need to do some thinking on your feet. Anyways, another idea if the person on the other end bulks... ask if instead if they could give out the benefit information for the group number. That number will be on the card also. You can play the game that you don't want to do anything fraudulent by overcharging the patient and you have no other direction to turn and could use the help because you're just the PT. LOL That line helps too. If you get nowhere... then, write down exactly what you want to know.... then, when the patient comes in, have the patient call customer service, have the patient initiate the conversation and then hand the phone to you (that trick works also). Especially if the patient states the situation isn't common and clarification is needed. THAT tactic WILL eat up time, so then you'll be behind with the rest of your patients. But, you went the extra mile and that particular patient will highly appreciate your attempt to clarify. You'll be given a gold star that day by that patient.
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RE: Multiple Diagnoses, documentation - April 10, 2008 9:10:46 AM
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jma
Posts: 2405
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From: NY
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Thats a good idea. Seen the people at billing try talking to benefits and it does take a while to get through and going through each of the phone prompts.
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RE: Multiple Diagnoses, documentation - April 10, 2008 1:52:59 PM
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buckeye
Posts: 170
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I think the second chart for a second physician is a must - unless it is the same 'diagnosis' without any intervening procedure such as surgery. Example: John Doe is referred by PCP for right shoulder pain to get PT started. Two weeks later John Doe has an appointment with the orthopedic surgeon who sends the patient to PT with a referral for right shoulder tendinitis. I think this type of situation just takes good documentation and discussion with the patient regarding the second referral is just a continuation of the current therapy.
One patient, one physician, multiple diagnoses - more than one chart makes sense to keep the billing and treatment clean. Time in and time out can be recorded in each chart.
sjbird has a great point to bring in the patient's perspective. Are they capable of handling long treatments from a physiologic standpoint? Can they absorb the needed education for all body parts involved?
You also should take into account the resources of the clinic. Is it practical to treat one patient for two hours or more?
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RE: Multiple Diagnoses, documentation - April 10, 2008 7:29:01 PM
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SJBird55
Posts: 2430
Joined: May 10, 2004
From: Michigan
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I currently have a patient with 2 Dx with one physician. I did each evaluation on 2 separate days. I created 2 separate accounts. My biller is wanting me to now combine the charges under one account. Well, that won't be happening. All he needs to do is tag a -59 modifier to one account and we should be good to go. The situation doesn't happen very often, so I think he forgets that he and I have gone round and round on this issue. The other times it occurred and I did it my way and I checked the ledger - I was paid going that route on every single situation it occurred. (That's the bottom line - getting paid.) Below is the info that I sent him (Kyle this info would be helpful for you IF you are in a private practice setting billing under Medicare B) - my biller backed down on evaluating both body parts on one day and charging one evaluation. Evaluations are time intensive - it makes no sense to provide a free evaluation for some third party payor. They already pay crappy.
From page 4 http://www.wpsic.com/medicare/part_b/education/ptot_qa.pdf
5. A patient presents with bilateral TKA's (Total Knee Arthroplasty) for outpatient
physical therapy. An evaluation on both knees is done. Can we bill one PT evaluation
for the right knee and a second PT evaluation for the left knee? If yes, what, if any,
modifier would be used?
Since both knees are known to need therapy and have an order for therapy, the evaluation of
both knees of a patient, rendered on the same date of service would be billed as one evaluation.
The appropriate modifier to distinguish the type of provider who performed the outpatient
rehabilitation service should be used, GN (Services delivered under an outpatient speechlanguage
pathology plan of care), GO (Services delivered under an outpatient occupational
therapy (OT) plan of care), or GP (Service delivered under an outpatient physical therapy (PT)
plan of care).
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RE: Multiple Diagnoses, documentation - April 10, 2008 9:09:08 PM
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Sebastian Asselbergs
Posts: 1191
Joined: September 29, 1999
From: Barrie, Canada
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Just a brief comment from up here in Ontario. Wow.
Am I glad I am practicing here.
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