Coding Efficiency

Practice Intel:

Coding Efficiency

At PredictionHealth, understanding the challenges that physical therapists encounter when accurately coding visits is central to our mission, particularly regarding coding rules such as the Total Minute Rule (used by federal payers) and the AMA Rule (utilized by most commercial insurances). To address this, PredictionHealth has created a module explicitly designed to optimize coding practices, ensuring the most suitable allocation of minutes. This feature helps identify therapists who may benefit from assistance in maximizing the total number of units through efficient minute allocation.

To provide the most transparent view of coding efficiency, PredictionHealth conducted an in-depth analysis for each specific note type, factoring in unique codes selected during each visit. Aspects such as timed/untimed or direct/indirect codes were considered to offer comprehensive insights into coding practices. For more specific information on code types, users are advised to refer to the Coding Rule Definitions and Examples.

The specific note types analyzed are as follows:

• Initial Evaluation: 
  • This includes an eval CPT code which is untimed.
• Re-Evaluation: 
  • This involves a re-eval CPT code which is untimed.
• Progress Visit, Follow Up, Discharge:
  • These visit types are identified by how they are mapped in the EMR. The visit types will mirror the same visit types in the "Visit Type (General)" Filter. 

The "Unit Pickup Opportunity" is calculated through a specific approach based on the note type:

• For Initial Evaluations/Re-Evaluations:
  • During the development of this feature, PredictionHealth established an expected minute range for each type of evaluation code considering complexity. These minutes are listed in the table below. For any minutes in an evaluation exceeding the expected evaluation minutes, the opportunity for additional units is calculated based on the Total Minute Rule and AMA Rule.

• For Follow-up Visits/Progress Visits/Discharge:
  • The expected units for the Total Minute Rule and AMA Rule are applied to the minutes recorded in each visit. Additionally, a cap for potential units in the AMA calculations has been set at 5 direct codes in a visit. This ensures that the calculated opportunity does not suggest billing more than 5 separate timed codes within one patient encounter.

Note: Some EMRs may not list all minutes in the visit. In these cases, PredictionHealth won't be able to evaluate the coding efficiency of those visits.

PredictionHealth is devoted to empowering physical therapists with the tools and insights needed to optimize their coding practices. By leveraging this feature, users can effortlessly enhance coding accuracy, improve operational efficiency, and ensure optimal reimbursement.

For further queries or additional support, users are welcome to contact the support team at ptsupport@predictionhealth.com . The PredictionHealth team is ready to help users succeed!

Specific Examples:

Example 1:

During an Evaluation, a therapist saw a patient for a total of 55 minutes with 3 total units broken into the following CPT codes and minutes:

• 97162 - Pt eval mod complex - 1 unit - 30 mins
• 97140 - Manual therapy - 2 units - 25 mins

When applying our calculations for the Total Minute Rule analysis, we would show a zero unit pick up opportunity based on the below calculations: 

55 - 20 (pre-set minute expectation for moderate complexity evaluation)  = 35 minutes for Total Minute Rule analysis = 2 units for 35 mins + 1 eval unit → 3 total units for this visit.

When applying the calculations for the AMA Rule analysis, we would show a 2 unit pick up opportunity based on the below calculations:

55 - 20 (pre-set minute expectation for moderate complexity evaluation) = 35 minutes (35/ 8) = 4 units + 1 eval unit → 5 units.  Since the therapist billed 3 units, there is a 2 unit pick up opportunity.

Example 2:

During a Follow up Visit a therapists saw a patient for a total of 53 minutes and 3 units broken into the following CPT codes and minutes: 

• 97530 - Therapeutic activities - 2 units - 35 mins
• 97110 - Therapeutic exercises - 1 unit - 18 mins

When applying our calculations for the Total Minute Rule analysis, we would show a one unit pick up opportunity based on the below calculations: 

53 minutes = 4 units and since the therapists only billed 3, this is 1 unit pick up opportunity.

When applying the calculations for the AMA Rule analysis, we would show a 2 unit pick up opportunity based on the below calculations:

53 minutes (53 / 8) = 6 unique individual units allowed → 5 units expected with our 5 unit cap.  Since the therapist billed 3 units, this is a 2 unit pick up opportunity

Example 3:

During a Follow up Visit a therapists saw a patient for a total of 40 minutes and 3 units broken into the following CPT codes and minutes:

• 97116 - Gait training therapy - 1 unit
• 97110 - Therapeutic exercises - 1 unit
• 97530 - Therapeutic activities - 1 unit - 10 mins
• 40 total treatment minutes

In a note like this, we will not be able to provide an analysis of coding efficiency due to the lack of minutes documented in the note.