It’s a new year and this means we have some new CPT codes that are available for physical therapists (PT’s), occupational therapists (OT’s) and/or speech-language pathologists (SLP’s) to use in calendar year 2019.
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The 2019 new CPT codes applicable to PT’s, OT’s and SLP’s are:
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What are the associated CCI edits for this code? I’m assuming this cannot be billed in addition to an evaluation code, or can it with a 59 modifier? Thanks
You can access the NCCI edits at https://gawendaseminars.com/medicare-cms-cci-edits/
Do you view 96112 as a an accumulation of up to an hour even if it is over several DOS to complete?
Or 96112 always for the first DOS up to an hour then 96113 for any time beyond the first DOS?
Example: 60 minutes billed over 3 DOS. Is that billed on the last DOS as 1 unit of 96112 or 1 unit of 96112 plus 2 units of 96113?
My opinion is the therapist will spend at least 31 minutes up to the 1 hour on the first day they are administering any developmental testing. That would be the 1 unit of 96112. If the therapist does not complete the testing on day 1, then you start looking at the appropriate number of units of 96113 to complete the testing.
Thank you. Where did the 31 minute cutoff come from – based on what? (> 1/2 the code time-value?) (not a challenge, just a real question).
What if they only spend:
– 20 minutes of the first DOS on developmental testing and finish it the next DOS with 25 additional minutes?
– 20 minutes of the first DOS on developmental testing and finish it the next DOS with 45 additional minutes?
I appreciate your input since I do not find the coding descriptions give us clear guidance.
The AMA defines substantial of a time-based CPT code as once the midpoint is attained. Midpoint of a 1-hour code is technically 30 minutes and 1 second, but I always say 31 minutes. You can find that at the beginning of the CPT book under the heading of “TIME”.
Due to liability issues, I do not provide coding and billing answers and guidance in this forum.
We bought the “CPT Changes 2019: An Insider’s View” book in order to get clarification on these 2 codes. It was not at all helpful for providing further clarification on these 2 codes.
We have decided to go with the most conservative interpretation to be safe: interpret the time as cumulative.
In the example given, the cumulative time is 2 hours and 32 minutes that would still support the 1 unit of 96112 and the 3 units of 96113. I do not see OT’s and SLP’s only spending 20-30 minutes each visit to get the applicable testing completed. Not saying it can’t occur that way, but do not think will be the norm.
I am really struggling with the best way to use this code. I am a manager for an OT/PT/ST pediatric clinic. We always do standardized testing as part of the OT, PT, or ST eval. How can I maximize billing for these visits using these new codes?
You can try and do a Google Search or I do provide consulting services. If interested, please contact me via email.
What if on day 1 of your example the therapist billed one unit of 92116, day two 2 units of 96113 were billed because it was technically 50 minutes toward 96113 and since 20 minutes is more than half of the full 30 minutes it justifies the two units of 96113 and then day 3 one unit of 96113 was billed? I am wondering why we would have to wait until day 3 to bill all the units?
You would not know how much time the evaluation took until it was completed. It’s the total time that determines the correct billing and you would nt know the total time until the day the evaluation is completed.
Is time spent writing the required report billable under 96113? What if the documentation/report writing occurs on a different date than the testing?
Documentation time is not billable time.