The Evolution RMT™ Coding and Reimbursement Summary and Complete Full-length Guide

Advanced Back Care, LLC
Presents
The Evolution RMT™
Coding & Reimbursement Summary

Prepared By:
DK Coding & Compliance, Inc.
1965 Byberry Road, Huntingdon Valley, PA 19006
Phone: (215) 957-1035 ● Fax: (215) 938-7097
www.dkcoding.com

The Evolution RMT™ Coding and Reimbursement Summary

Click here for a "Summary" PDF File

Disclaimer
This is a summary of a more detailed and comprehensive guide and should not be relied upon solely to determine proper coding for the Evolution RMT™. The information contained in this Coding & Reimbursement Summary is for educational purposes and is not intended to be and is not legal advice. The laws, rules and regulations regarding the establishment and operation of a healthcare facility vary greatly from state to state and are constantly changing. DK Coding & Compliance, Inc. does not engage in providing legal services. If legal services are required, the services of a health care attorney should be attained. The information in this Coding & Reimbursement Summary is for educational purposes only and should not be construed as written policy for any federal agency. No part of this Coding & Reimbursement Summary covered by the copyright herein may be reproduced, transmitted, transcribed, stored in a retrieval system or translated into any language in any form by any means (graphics, electronic, mechanical, including photocopying, recording, taping or otherwise) without the expressed written permission of DK Coding & Compliance, Inc and/or Advanced Back Care, LLC. Making copies of this Coding & Reimbursement Summary and distributing for profit or non-profit is illegal. DK Coding & Compliance, Inc. assumes no liability for data contained or not contained in this Coding & Reimbursement Summary and assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this Coding & Reimbursement Summary. CPT® is a registered trademark of the AMA. The AMA does not directly or indirectly assume any liability for data contained or not contained in this Coding & Reimbursement Summary. This Coding & Reimbursement Summary provides information in regard to the subject matter covered. DK Coding & Compliance, Inc. is not responsible for any insurance carrier laws, rules and Summary lines that may change following the purchase of this Coding & Reimbursement Summary. DK Coding & Compliance, Inc. does not guarantee that the information provided in this Coding & Reimbursement Summary will guarantee payment from any insurance carrier or patient. Every attempt has been made to make certain that the information in this Coding & Reimbursement Summary is 100% accurate, however it is not guaranteed, expressed or implied.

Information contained in this document is subject to change without notice.

Coding the Evolution RMT™
When determining how to code and bill for services, providers must assess whether the patient is presenting with actual symptoms and/or an established illness or whether the services are merely to prevent or maintain a particular level of health. Providers who bill based on coverage or payment rather than medical necessity are at significant risk of post-payment recovery to the carrier where it can be shown that the billing and the resulting separate payment, is not justified by the documentation or circumstances of treatment. We also recommend that if you have questions of a legal nature, you should contact an attorney at law.

The Evolution RMT™ is used as an adjunct to reduce muscle spasm, reduce back pain, strengthen core muscles and improve mobility of the core. The Evolution RMT™ takes the patient through repetitive end-range and passive-range-of-motion movements of flexion and/or extension via mechanical means. However typical treatment protocols for the Evolution RMT™ incorporate both one on one and supervised services. In light of this and, based on these protocols and necessity for care, it appears that there are two different ways that Providers can code for this service 1) as a supervised modality and 2) as a therapeutic procedure.

In regards to a supervised modality, unfortunately there is no CPT code that accurately identifies the Evolution RMT™. According to Current Procedural Terminology (CPT), Providers must: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.” Based on this, when using the Evolution RMT™ in a supervised capacity and, where there is no need for one on one patient contact or it is not provided, the services should be coded as CPT 97039 (unlisted modality). Unlisted procedures are described in the 2009 CPT American Medical Associations Professional Edition as "services or procedures performed by physicians that are not found in the CPT/ HCPCS book…” When an unlisted procedure or service code is used, the service or procedure should be described in detail.

In regards to therapeutic procedures, typical protocols for the Evolution RMT™ require that the Provider works with the patient through core contraction exercises while in extension. In such instances, the provider is not only using the table as a modality but first they are using the table in an effort to effect change through their clinical skills. To accomplish this, the Provider is required to instruct the patient, via timing and coaching (visual, verbal), to assist the patient into tightening and relaxing the abdominal muscles in an effort to contract the abdominal flexors and extensors with a goal to increase strength in the patient’s core. As indicated above, Modalities are coded based on the method of delivery or physical agent applied, however, Therapeutic Procedures are coded on the basis of therapeutic outcome intended. When these core contraction exercises take place (as detailed above, and as part of a treatment plan) Providers may code this service as a therapeutic procedure. Based on this, it appears that therapeutic exercise (CPT 97110) as defined by CPT [emphasis added], would be the most appropriate code, as follows:

“Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.” “Therapeutic exercise incorporates one parameter (strength, endurance, range of motion or flexibility) to one or more areas of the body. Examples include, treadmill (for endurance), isokinetic exercise (for range of motion), lumbar stabilization exercises (for flexibility), and gymnastic ball (for stretching or strengthening).”

Therapeutic exercises are performed in either an active, active-assisted or passive approach. The exercises may be reasonable and medically necessary for a loss or restriction of joint motion, strength, functional capacity or mobility that has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength or mobility (i.e., degrees of motion, strength grades, levels of assistance). As Indicated above, Therapeutic Exercises are used to increase range-of-motion, flexibility, endurance and strength.

As discussed above, when the provider is using their clinical skills, in a one on one setting in an effort to increase strength of the core abdominal muscles for the patient, therapeutic exercise (CPT 97110), each 15 minutes, appears to be the code that accurately identifies this service.

It should also be noted that most carriers feel that it is beneficial to proceed to an active phase of care as rapidly as possible, and to minimize dependency upon passive forms of treatment. Passive care for extended periods of time are often viewed as palliative and thought to foster chronicity. Therefore active forms of treatment, prescribed as part of a treatment plan, are often used in conjunction with passive care as long as the provider is clear to document the rationale and necessity of such a program.

The Evolution RMT™ Coding and Reimbursement Complete Full-length Guide

Advanced Back Care, LLC
Presents
The Evolution RMT™
Coding & Reimbursement Guide

Prepared By:
DK Coding & Compliance, Inc.
1965 Byberry Road, Huntingdon Valley, PA 19006
Phone: (215) 957-1035 ● Fax: (215) 938-7097
www.dkcoding.com

Click here for a "Complete Guide" PDF File

Information contained in this document is subject to change without notice.

Disclaimer
The information contained in this Coding & Reimbursement Guide is for educational purposes and is not intended to be and is not legal advice. The laws, rules and regulations regarding the establishment and operation of a healthcare facility vary greatly from state to state and are constantly changing. DK Coding & Compliance, Inc. does not engage in providing legal services. If legal services are required, the services of a healthcare attorney should be attained. The information in this Coding & Reimbursement Guide is for educational purposes only and should not be construed as written policy for any federal agency. No part of this Coding & Reimbursement Guide covered by the copyright herein may be reproduced, transmitted, transcribed, stored in a retrieval system or translated into any language in any form by any means (graphics, electronic, mechanical, including photocopying, recording, taping or otherwise) without the expressed written permission of DK Coding & Compliance, Inc and/or Advanced Back Care, LLC. Making copies of this Coding & Reimbursement Guide and distributing for profit or non-profit is illegal. DK Coding & Compliance, Inc. assumes no liability for data contained or not contained in this Coding & Reimbursement Guide and assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this Coding & Reimbursement Guide. CPT® is a registered trademark of the AMA. The AMA does not directly or indirectly assume any liability for data contained or not contained in this Coding & Reimbursement Guide. This Coding & Reimbursement Guide provides information in regard to the subject matter covered. DK Coding & Compliance, Inc. is not responsible for any insurance carrier laws, rules and guidelines that may change following the purchase of this Coding & Reimbursement Guide. DK Coding & Compliance, Inc. does not guarantee that the information provided in this Coding & Reimbursement Guide will guarantee payment from any insurance carrier or patient. Every attempt has been made to make certain that the information in this Coding & Reimbursement Guide is 100% accurate, however it is not guaranteed, expressed or implied.

Table of Contents

Introduction Section 1
Coding Overview Section 2
Diagnosis Coding Section 3
Procedure Coding Section 4
Reporting Units of Time Section 5
Medical Necessity Section 6
Fees Section 7

Introduction: Section One
Accurate billing and reimbursement are an important part of any practice. To help maintain a successful practice, receiving appropriate payment both from the patient and insurance carrier is critical to the survival of a practice. When it comes to reimbursement issues proper coding is just as important as thorough documentation and demonstrating the necessity of a service. Proper claims submission, including supporting documentation, will help meet the necessary requirements of the insurance carriers and produce clean claims or claims that go through the third party payer system smoothly without creating delays and creating red flags. It is the responsibility of the health-care provider to understand what is needed by the carrier in order to get paid for any type of service. Under these circumstances, coverage will be determined according to the necessity of a particular service. At a minimum, Providers should always document the patient’s condition, history and reason for service in order to provide support for the service and items furnished. Although Medicaid and private payers vary in their coverage for procedures, they will often adopt guidelines similar to those of Medicare. To obtain specific guidance, we advise that providers contact the specific insurance carrier.

This Reimbursement guide attempts – to the greatest extent possible – to address the various reimbursement issues associated with the Evolution RMT™ in a methodical, clear, direct, and unbiased fashion. When determining how to code and bill for services, providers must assess whether the patient is presenting with actual symptoms and/or an established illness or whether the services are merely to prevent or maintain a particular level of health. Providers who bill based on coverage or payment rather than medical necessity are at significant risk of post-payment recovery to the carrier where it can be shown that the billing and the resulting separate payment, is not justified by the documentation or circumstances of treatment. We also recommend that if you have questions of a legal nature, you should contact an attorney at law.

Coding Overview: Section Two
Submitting claims for payment requires, at a minimum, use of two coding systems, procedure codes and diagnosis codes. Procedure codes or Current Procedural Terminology (CPT) are required for reporting the healthcare practitioner services. Diagnosis codes or International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) are required to report the patient’s diagnosis. The world of medical billing is a very large and complex program to truly understand. Out of the several thousand CPT® codes available, only approximately 50 of them are directly related to physical medicine.

According to the manufacturer, the Evolution RMT™ is used as an adjunct to reduce muscle spasm, reduce back pain, strengthen core muscles and improve mobility of the core. The Evolution RMT™ Repetitive Motion Therapy table addresses mechanical disorders of the lower back. It is to be used in the clinical setting to enhance the effectiveness of repeated end range movement therapy for the low back. The Evolution RMT™ table enables the lumbar spine to be moved to the full degree of end-range movement in flexion and or extension a greater number of times than is physically possible by the patient alone in his or her active range of motion. In the beginning stage of rehabilitation, the patient often has a hard time getting to full end-range position due to pain and dysfunction. The Evolution RMT™ is designed to allow the patient to start rehabilitation earlier and maintain the success of their prescribed home exercise program. The purpose of the Evolution RMT™ is to take the patient through end-range passive range of motion repetitive movements and reduce the patient’s pain while increasing the patient’s active range motion, this is done in both supervised and one on one patient scenarios. Typical goals are to coordinate the patient’s exercises and Evolution RMT™ movements in the “preferred direction” that centralizes the pain. Among other things, the machine allows the Provider to passively take the patient into extension and flexion repetitively at controlled speeds and angles to increase their lumbar range of motion, lordosis and centralize the pain.

Diagnosis Coding: Section Three
When choosing the correct diagnosis for a patient that presents with symptoms and/or an established illness, the doctor needs to look at the chief complaint(s), mechanism of injury and contributing condition(s) that support the rationale behind treating the patient. ICD-9-CM codes support medical necessity for the procedure or service performed. Most third party payers employ claim “edits” or automatic denial commands within the electronic adjudication system. The procedure codes express what was done, but the diagnosis codes help to express why it was done. Diagnosis codes are generally used to determine if payment should be made for a claim and how long, not how much.

Providers should identify each service, procedure, or supply with an ICD-9-CM code to describe the diagnosis, symptom, complaint, condition or problem. Code the primary diagnosis first, followed by the secondary, tertiary and so on. Providers should always code to the highest degree of specificity and code any co-existing condition that affects the treatment of the patient for that visit or procedure as supplementary information. Providers should not code a diagnosis that is no longer applicable or that has resolved. For correct diagnosis coding, Providers should carry the numerical code to the fourth or fifth digit when available, as there are only approximately 100 valid three digit codes; all other ICD-9-CM codes require additional digits. Providers should code a chronic diagnosis when it is applicable to the patient’s treatment and distinguish between acute and chronic in the patient record.

According to the manufacturer, Evolution RMT™ patients should have been assessed to benefit from the repeated movements on pain centralization, intensity and location in flexion or extension. Common diagnoses include:

• Degenerative disc disorders
• Herniated discs
• Bulging discs
• Spinal stenosis
• Facet syndrome
• Sacroiliac syndromes (where a limitation of movement occurs in the direction of “centralization”

Contraindications include but are not limited to:
• Grade 3 and 4 Spondylolisthesis
• Tumor or Infection of the Spine: Paget's Disease etc...
• Active Inflammatory Diseases such as Rheumatoid Arthritis, Ankylosing
• Spondylitis, Osteoporosis, or Severe Osteomalacia (-2.0 or Higher on T Scale)
• Advanced Diabetes
• Fractures
• Dislocations
• Ligament Tears or Ruptures
• Lumbar Instability or has Peripheral Signs on Both Flexion and Extension
• Neurological conditions e.g. Cauda Equina Lesions, Neurological Deficits, etc.
• Surgical Fusions
• Pregnancy

It should be noted that Providers should never derive a code by only reviewing Volume II (the alphabetic index) in the ICD-9-CM manual. Volume II is a reference index to the full tabular list (Volume I) and often yields a different code, additional codes, or a more specific code – always consult Volume I when choosing a particular diagnosis.

Procedure Coding: Section Four
According to the Manufacturer, the Evolution RMT™ has many different applications however the table is most effective when used for patients with disc problems. Typically, the first step in using the Evolution RMT™ is setting up the device. Without strapping in the patient, the provider typically puts the patient through 6 – 10 repetitions of range of motion in order to determine the correct tolerances for the patient during flexion and more importantly, extension. Once the proper tolerances are determined the Provider typically works the patient through core contraction exercises while in extension. For this process, the patient is “instructed” on tightening and relaxing the abdominal muscles in an effort to co-contract the abdominal flexors and extensors to help strengthen the muscles and support disc rehabilitation and healing. This process typically takes 5 – 15 minutes of face to face time by the provider and, once completed, the patient is instructed to perform the repetitive passive assist range of motion on their own on the RMT table. After the range of motion and core strengthening process is completed (between 50 and 100 cycles) the table is typically locked into place and McKenzie exercises are performed with the patient on the locked table (the table can be locked in a flat position). Additionally, and in conjunction with McKenzie exercises, short arc extension exercises are typically performed. Treatment times for the use of the RMT table are most often (depending on patient need) three (3) times per week for up to a maximum of three (3) weeks. At this time, range of motion has typically been restored and the patient can progress to full active therapy either in the Provider’s office or at home.

There is a lot of confusion when it comes to coding Physical Medicine and Rehabilitation procedures. Most coding mistakes are due to a misunderstanding of the differences between modalities, therapeutic procedures and supervision requirements for both. Therefore, when trying to determine how a certain procedure or device can be billed, Providers need to first have a clear understanding of certain coding fundamentals.

Modalities
Modalities are defined as "Any physical agent applied to produce therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.”

Modalities are then divided into two separate categories which are: “Supervised” and “Constant Attendance.” Supervised modalities (97010-97028) are defined as the application of a modality that does not require direct (one on one) patient contact by the provider. They are coded only once per patient encounter regardless of the number of body areas treated. Constant Attendance modalities (97032-97036) are defined as the application of a modality that requires direct (one on one) patient contact by the physician or therapist. According to the AMA, “one on one” is defined as “visual, verbal and or manual contact.” These modalities are coded based on time spent face to face with the patient in 15 minute intervals. As you can see, based on the definition above, modalities are coded based on the method of delivery or “physical agent.”

Therapeutic Procedures
Therapeutic Procedures (CPT 97110-97546) are defined as: "A manner of effecting change through the application of clinical skills and/or services that attempt to improve function."

Coding the Evolution RMT™
As you can see from the descriptions above, the very nature of the Evolution RMT™ table suggests that it is a modality as it clearly is a “physical agent.” The Evolution RMT™ takes the patient through repetitive end-range and passive-range-of-motion movements of flexion and/or extension via mechanical means. However typical treatment protocols for the Evolution RMT™, as indicated above, incorporate both one on one and supervised services. In light of this and, based on these protocols and necessity for care, it appears that there are two different ways that Providers can code for this service 1) as a supervised modality and 2) as a therapeutic procedure.

In regards to a supervised modality, unfortunately there is no CPT code that accurately identifies the Evolution RMT™. According to Current Procedural Terminology (CPT), Providers must: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.” Based on this, when using the Evolution RMT™ in a supervised capacity and, where there is no need for one on one patient contact or it is not provided, the services should be coded as CPT 97039 (unlisted modality). Unlisted procedures are described in the 2009 CPT American Medical Associations Professional Edition as "services or procedures performed by physicians that are not found in the CPT/ HCPCS book…” When an unlisted procedure or service code is used, the service or procedure should be described in detail.

In regards to therapeutic procedures, typical protocols for the Evolution RMT™ require that the Provider works with the patient through core contraction exercises while in extension. In such instances, the provider is not only using the table as a modality but first they are using the table in an effort to effect change through their clinical skills. To accomplish this, the Provider is required to instruct the patient, via timing and coaching (visual, verbal), to assist the patient into tightening and relaxing the abdominal muscles in an effort to contract the abdominal flexors and extensors with a goal to increase strength in the patient’s core. As indicated above, Modalities are coded based on the method of delivery or physical agent applied, however, Therapeutic Procedures are coded on the basis of therapeutic outcome intended. When these core contraction exercises take place (as detailed above, and as part of a treatment plan) Providers may code this service as a therapeutic procedure. Based on this, it appears that therapeutic exercise (CPT 97110) as defined by CPT [emphasis added], would be the most appropriate code, as follows:

“Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.” “Therapeutic exercise incorporates one parameter (strength, endurance, range of motion or flexibility) to one or more areas of the body. Examples include, treadmill (for endurance), isokinetic exercise (for range of motion), lumbar stabilization exercises (for flexibility), and gymnastic ball (for stretching or strengthening).”

Therapeutic exercises are performed in either an active, active-assisted or passive approach. The exercises may be reasonable and medically necessary for a loss or restriction of joint motion, strength, functional capacity or mobility that has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength or mobility (i.e., degrees of motion, strength grades, levels of assistance). As Indicated above, Therapeutic Exercises are used to increase range-of-motion, flexibility, endurance and strength.

As discussed above, when the provider is using their clinical skills, in a one on one setting in an effort to increase strength of the core abdominal muscles for the patient, therapeutic exercise (CPT 97110), each 15 minutes, appears to be the code that accurately identifies this service.

It should also be noted that most carriers feel that it is beneficial to proceed to an active phase of care as rapidly as possible, and to minimize dependency upon passive forms of treatment. Passive care for extended periods of time are often viewed as palliative and thought to foster chronicity. Therefore active forms of treatment, prescribed as part of a treatment plan, are often used in conjunction with passive care as long as the provider is clear to document the rationale and necessity of such a program.

Reporting Units of Time: Section Five
As stated above, supervised modalities do not have a time component and therefore strict time reporting guidelines for these services is not critical. However, most therapeutic procedures do have a time component and the provider’s direct time requirement (one on one) is 15 minutes for each unit billed.

According to Medicare Transmittal AB-01-68; “Under Medicare, for any single CPT code, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes. If the duration of a single modality or procedure is greater than or equal to 23 minutes to less than 38 minutes, then 2 units should be billed…The pattern remains the same for treatment times in excess of 2 hours. Providers should not bill for services performed for less than 8 minutes. The expectation (based on the work values for these codes) is that a provider's direct patient contact time for each unit will average 15 minutes in length.”

Medicare provides guidance on the reporting of service units that includes documentation instructions. The Provider should record the total treatment time (or the actual beginning and ending time of treatment) for services described by timed codes. The total number of timed 15-minute units that can be billed by the provider for each patient is constrained by the total time of the skilled therapeutic one-on-one intervention by the provider. It should also be noted that for the untimed codes, including supervised modalities, group therapy, and the evaluation codes, documenting the session time can help to justify the appropriateness of the services provided.

Medical Necessity
As with all procedures, your documentation must substantiate the necessity of the services provided, be dated and signed, and support the diagnosis and services billed. A thorough and well drafted treatment plan in the patient’s record will significantly help and is required by Medicare and most, if not all,

Payers and State Boards
For most payers, Medical Necessity is defined as a need for a particular item or service required for the diagnosis or treatment of disease, injury, or defect. Typically, there must be active symptomatology or evidence of the disease, injury or defect, and the need for the services must be documented in the patient’s records. There should also be an identifiable relationship between the reported service and the diagnosis reported. Under Medicare law (often adopted by private payers) when a functional goal cannot be shown, continuing care will likely be determined to be not medically necessary. Daily progress notes and examinations need to focus on how well the patient’s condition is progressing toward planned functional goals. As stated in Medicare’s definition of necessity, where no additional functional improvement is shown or anticipated, ongoing care is considered maintenance in nature.

Fees: Section Six
The fees for The Evolution RMT™ table will vary based on the code used for the service and geographic location of the Provider. If a provider uses CPT 97110 for the applicable portion of the service, then their standard fee for that code will apply. However, as stated above, the Evolution RMT™ can be billed using different codes, namely CPT 97110 (therapeutic exercise) and CPT 97039 (Unlisted Modality). Unlisted procedure codes are miscellaneous codes used by Providers only when there are no specific Healthcare Common Procedure Coding System (HCPCS) codes that accurately identify the medical service furnished. The Social Security Act establishes the Medicare Physician Fee Schedule (MPFS) which provides a payment amount for almost all HCPCS codes. This fee schedule is used as the basis for Medicare reimbursement for physician services. However, unlisted procedure codes are not paid under this fee schedule. Therefore it is recommended that the Provider determines his or her fee based on “Fair Market Value.”

Under the HIPAA “anti-inducement” law, providers arguably have a duty when insurance is involved to determine their fees in terms of “fair market value.” A federal Medicare statute defines “fair market value” as “the value in arms length transactions, consistent with the general market value.” The definition of “fair market value” suggests that Providers can factor into their decisions what the “usual, customary, and reasonable” fee for the service may be in their region. Usually, the fair market price is the price at which bona fide sales have been consummated for assets of like type, quality, and quantity in a particular market. Based on this, it appears that the table most resembles that of a mechanical traction table and it would seem reasonable to charge a fee similar to this service.