Reimbursement Seminar for Motion Analysis

Laboratories

Wayne Stuberg, PhD, PTGCMAS Reimbursement Committee

Objectives

1. Describe the differences between coding and reimbursement rules.

2. Review the Medicare Resource-Based Relative Value Scale system related to Motion Lab coding and reimbursement.

3. Describe the current Motion Lab Codes and their reimbursement value.

4. Discuss the impact of Center for Medicare & Medicaid Services (CMS) Local Medical Review Policies (LMRP) on reimbursement .

Coding vs Reimbursement

• Coding• CPT codes established

and published by the AMA CPT Editorial Panel

• Input given by professional societies

• Motion Analysis Codes• 96000-96004

• Reimbursement• Payor fee schedules

often developed from CMS RBRVS physician fee schedule

• Payor determines:• Medical necessity

(ICD-9 allowable codes)

• LMRP written by the payor

Motion Analysis CodesCode Description

96000 Comprehensive computer-based motion analysis by video-taping and 3-D kinematics

96001 96000 + dynamic pressure measurement during walking

96002 Dynamic surface EMG, during walking or other functional activity, 1-12 muscles

96003 Dynamic fine wire EMG, during walking or other functional activity, 1 muscle

96004 Physician review and interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface EMG, dynamic fine wire EMG during walking or other functional activities with written report

CPT, 2002

Description of Codes 96000-96004Codes 96000-96004 describe services

performed as part of a major therapeutic or diagnostic decision making process. Motion analysis is performed in a dedicated motion analysis lab (i.e.. facility capable of performing videotaping from the front, back and both sides, computerized 3-D kinematics, 3-D kinetics, and dynamic EMG).

CPT, 2002

Reimbursement and RBRVS(Resource-Based Relative Value Scale)

• CPT Code – description of the service• Relative Value Unit (RVU)

• value assigned to service• Geographic Practice Cost Index (GPCI)

• cost of living adjustment by geographic area• Conversion Factor

• CMS reimbursement per RVU ($36.79 in 2003)• Service Setting

• CMS facility vs non-facility (Motion lab CPT codes are same for facility & non-facility)

Relative Value Unit (RVU)

• Total RVU includes 3 components:• Work Expense• Practice Expense• Malpractice Expense

• Example for CPT Code 96000• Work = 1.8• Practice = 0.72• Malpractice = 0.02• Total = 2.54

Reimbursement for CPT Code 96000

RVU(CMS Base)

GPCI (Delaware)

Adj. RVU(RVU*GPCI)

Work 1.8 1.019 1.83

Practice 0.72 1.035 0.75

Malpractice 0.02 0.712 0.01

TOTALS 2.54 2.59

RVU Adj. Reimbursement = [(work RVU*GCPI)+(practice RVU*GCPI)+(malpractice RVU*GCPI)] * CMS Conversion Factor

CMS Base Reimb. = $93.45 Delaware = $95.29

Motion Analysis RVUs

CPTCode

Description RVU CMSFee

FacilityFee

Totals

96000 Motion Analysis with 3-D Kinematics

2.54 $93.46 $150 $243.46

96001 96000 + dynamic pressure analysis of walking

3.03 $111.47 $150 $261.47

96002 Surface EMG1-12 muscles

0.59 $21.07 $150 $171.07

96003 Fine-wire EMG1 muscle

0.55 $20.23 $150 $170.23

96004 Physician review and interp with report

2.60 $95.65 $95.66

Facility vs Non-Facility Reimbursement

• Facility = CMS approved facility• Hospital• Comprehensive OP Rehab. Facility (CORF)• OP Rehab. Facility (ORF)

• Facility allowed to bill APC (ambulatory payment classification) fee• 96000-96003 = APC 0708 (New Technology Level III)

= $150• 96004 does not include APC fee as it is a professional

service

LMRP & ICD-9 Codes

• CMS’s New York regional office has developed a local medical review policy for Motion Analysis Codes.

• Lists ICD-9 codes that support medical necessity, e.g. CP, spina bifida codes.

• States that any codes not listed as supporting medical necessity will be denied payment.

Case Scenario 1

Child with spina bifida seen for assessment in Lab including videotaping, 3-D kinematics & kinetics, surface EMG (8 muscles), fine wire EMG (2 muscles) & physician review & interp. with written report:

CPT Codes:

96000, 96002, 96003 (X2) & 96004

Case Scenario 2

Child with CP seen for assessment in Lab including videotaping & 3-D computer-based kinematics, dynamic plantar pressure measures during walking, surface EMG (8 muscles), & physician review & interp. with written report:

CPT Codes:

96001, 96002, & 96004

Common Questions

Should I bill code 96000 X2 if we do barefoot & walking with orthoses?

Should I bill code 97001 with Motion Lab codes if PT performs physical exam with gait study?

No, code is inclusive for the session regardless of number of conditions

No, both are diagnostic codes & would be considered redundant

Common Questions

Should I bill code 96000 & 96001 in the same session?

Should I bill code 96004 if a physical therapist reviews and interprets the gait study?

No, 96001 is an extension of code 96000

No, code 97004 can only be used for physician review & interpretation

Common Questions

Should a Lab bill codes 96000-96003 if a physician is not involved in the gait study?

Likelihood a Lab will be reimbursed for billing motion analysis codes for diagnoses not identified as a medical necessity?

Yes, 96000 – 96003 are Medicine CPT codes to be used for gait studies.

Good Question! let me know (;-)

The Future & Reimbursement

Input to local providers regarding LMRP and Motion Analysis codes.

Input to CMS regarding RVU valuations of the codes as set in 2003.

Input to Advisory Panel on Ambulatory Payment Classifications (APC) to justify increasing level of APC coding.

Other ideas?

References

1) www.cms.gov2) http://cms.hhs.gov/about/regions/

professionals.asp (regional CMS office listing)

3) CPT 2002, AMA, 20024) CPT Coding for the Gait Lab,

seminar notes, GCMAS, Nov. 2002