![\"\"](\"https:\/\/medfitnetwork.org\/public\/wp-content\/uploads\/2018\/10\/medical-billing.jpg\")
<\/p>\nIt has been over 24 years since I wrote my first book on Medical Insurance Billing for the Health and Fitness Profession.\u00a0\u00a0The book was based on my years as an exercise therapist who used CPT coding for sessions with diabetic patients.\u00a0\u00a0Our use of proper billing, follow up letters, and reasonable pricing allowed our physician practice to bill out for some exercise sessions for over two years.<\/p>\n
<\/p>\n
I have been asked recently to discuss the issue of reimbursement in our current system.\u00a0\u00a0Over the past 50 years the system has worked for physicians, and some allied health professionals, who have developed procedures that they will get paid for \u2013 and they usually perform specific types of services within their practice that allow them maximum reimbursement.<\/p>\n
The times are changing, though.\u00a0\u00a0As they have since the mid 1990s when managed care tried to curb the amount of fee for service payments for specific services.\u00a0\u00a0If you talk with physical therapists, you would see that they have been concerned over a decade that they are unable to bill for the same amounts per service that they once did.\u00a0\u00a0A sign of the times?\u00a0\u00a0Perhaps \u2013 but in the wellness profession we need to dig a bit deeper to see how the system (that is not built for us) can work for us.<\/p>\n
All healthcare agencies that use CPT coding to some degree.\u00a0\u00a0How they use them is a different situation.\u00a0\u00a0Some medical practices will submit bills to CMS or health plans and wait for payment.\u00a0\u00a0It is based on where they live, and what these agencies pay on an average for the particular service.\u00a0\u00a0Medical professionals will \u201cbundle\u201d a number of different procedures together for each payment in hopes of getting a higher payout.\u00a0However \u2013 using CPT codes are also valuable for health promotion professionals to understand the \u201clanguage\u201d of health care.\u00a0\u00a0Let\u2019s look at some examples of how these codes may work well for wellness programs.<\/p>\n
Perhaps one of the biggest success stories of working with healthcare is the Silver Sneakers program.\u00a0\u00a0They don\u2019t bill directly for FFS \u2013 they have used specific CPT codes to negotiate for contracts for their wellness programs.\u00a0\u00a0Another example is Wellquest \u2013 the east coast company that competed in the senior wellness space with Silver Sneakers.\u00a0\u00a0They were also successful in negotiating contracts with regional health plan.\u00a0\u00a0They didn\u2019t use CPT codes \u2013 but specific types of programming to convince health plans to buy into their model.\u00a0\u00a0There are a few companies that use versions of coding to help injured athletes come back to work.\u00a0\u00a0One is the Industrial Athlete in Detroit, MI.\u00a0\u00a0This company has been delivering preventive and therapy services to companies since 1989.\u00a0\u00a0Companies look to specific CPT codes to detail the particular type of program they are delivering.\u00a0\u00a0Of course \u2013 they may want to know what type of reimbursement is being delivered in their area, but many in the health club setting look to costs of personal training, which may range from $30-150 per session depending on the location.\u00a0\u00a0Let\u2019s look at the types of codes that have been historically been used for exercise-related services.\u00a0\u00a0There are other worker\u2019s compensation programs that are billing directly for personal training with staff that have been to the Occupational Medicine doctors, and now want to get back to work.\u00a0\u00a0With chronic exercise, many of them reduce their risk for future back injuries by almost 100%.<\/p>\n
When I started investigating CPT billing codes, I uncovered what I thought was the Holy Grail for many allied healthcare personnel.\u00a0\u00a0They thought that because they studied an allied healthcare curriculum in school, and passed a state board licensure exam \u2013 they were entitled to receive reimbursement based on these skills.\u00a0\u00a0However \u2013 when I spoke with the American Medical Association (the national body that owns the \u00a9 the CPT codes used by all healthcare professionals), I received a different story.\u00a0\u00a0The codes are merely descriptors of services. They are copyright of the AMA, and they are licensed to others to use them directly. For our purposes, we will be discussing CPT codes that have to do with exercise therapy, and some health education procedures.<\/p>\n
![\"\"](\"https:\/\/medfitnetwork.org\/public\/wp-content\/uploads\/2018\/10\/trainer-senior-male-client.jpg\")
<\/p>\n
Exercise therapy falls under the physical medicine section of the CPT coding book. They may be used for exercise prescription if an MD or other licensed professional wishes to incorporate these services in their practice. Specific codes for these services are as follows:<\/p>\n
*Physician or therapist is required to have direct patient contact.<\/p>\n
97110\u00a0–\u00a0Therapeutic procedure, one or more areas<\/strong>, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility.\u00a0\u00a0This code is used for limited visits, such as exercise training for rotator cuff therapy, or general use of aerobic machines.\u00a0\u00a0This type of training may encompass a one or two-week period, and be billed out \u2248 3-5 times.<\/p>\n 97112\u00a0–\u00a0Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, & proprioception<\/strong>.\u00a0\u00a0This code is used primarily by Physical Therapists and Massage Therapists for patients with neuromuscular deficits that require movement along with physical manipulation of body parts (along with pressure point work, etc.).\u00a0\u00a0This code would not be used for therapeutic exercise procedures, but specific movement programs such as shoulder or hip movement post stroke, or shoulder movements post breast cancer surgery.<\/p>\n 97113\u00a0–\u00a0Aquatic therapy with therapeutic exercises is used for any therapeutic activity involving water<\/strong>.\u00a0\u00a0Aquatic therapist and inventor of the Hydro-Tone equipment Dan Solloway of Oklahoma used this code for all of his work with patients referred to him for aquatic exercise therapy for over two decades.<\/p>\n 97116\u00a0–\u00a0Gait training is again used for persons who have orthopedic limitations with movement<\/strong>.\u00a0\u00a0It is used infrequently (or not at all) by most exercise therapists, but could be used in the expanding market of senior gait and balance prevention exercises.<\/p>\n 97150\u00a0–\u00a0Therapeutic procedure(s), group (2 or more individuals).<\/strong>\u00a0This code is used for classroom programs, such as T\u2019ai Chi, yoga, chair aerobics, therapeutic step classes, etc.\u00a0\u00a0This is designed for practitioners who teach in the group setting \u2013 especially with special population classes.\u00a0\u00a0One of the top codes that could be used in wellness.<\/p>\n 97530\u00a0–\u00a0Therapeutic activities, direct (1 on 1) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes.<\/strong>\u00a0\u00a0\u00a0It replaces the old Kinetic Activities code that was used primarily for exercise therapy procedures.\u00a0\u00a0This code should still be used most by exercise therapists for 2-4 segments of 15 minutes each<\/p>\n 97535\u00a0–\u00a0Self care\/home management training (e.g., activities for daily living [ADL] and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct 1 on 1 contact by provider, each 15 minutes<\/strong>.\u00a0\u00a0This code is used primarily in the PT\/OT settings, where patients need to regain day-to-day skills, as opposed to general strength and aerobic capabilities.\u00a0Community Training (97537) is an extension of the self-care coding used primarily by PT and OT.\u00a0\u00a0However \u2013 now that more trainers and coaches are training in the home, this code may have a benefit relating to home care fitness and wellness programs.<\/p>\n 97537\u00a0–\u00a0Community\/work reintegration training<\/strong>\u00a0(i.e.: shopping, transportation, money management, vocational activities and\/or work environment\/modification analysis, work task analysis), direct 1 on 1 contact by provider, each 15 minutes.<\/p>\n 97545\u00a0–\u00a0Work hardening\/conditioning; initial 2 hours<\/strong>.\u00a0\u00a0It is used for applying exercise to rehabilitate a person after an injury or accident, allowing return to competitive employment.\u00a0\u00a0The role of the exercise specialist would be to provide specific work-related exercises, and education principles to patients in these rehab settings (low back, carpel tunnel syndrome, lifting techniques, etc.).<\/p>\n 97546\u00a0–\u00a0Work hardening\/conditioning; each additional 1-hour<\/strong><\/p>\n 97750\u00a0–\u00a0Physical performance test or measurement<\/strong>\u00a0(e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.\u00a0\u00a0It is used to measure strength and aerobic performance, and should be used for all testing procedures that do not require physician supervision or monitoring equipment (such as ECG).\u00a0\u00a0This is a good code to use for pre and post testing.<\/p>\n 90900\u00a0–\u00a0Biofeedback training; by electromyogram application<\/strong>\u00a0(e.g., in tension headache, muscle spasm) is used by persons applying low intensity exercise and breathing techniques (Ayurvedic medicine, Hatha yoga, etc.) using EMG applications in the clinical setting.\u00a0\u00a0It is used by some exercise physiologists who perform relaxation exercises with patients.<\/p>\n 90904\u00a0–\u00a0Blood pressure regulation<\/strong>\u00a0(e.g., essential hypertension) may be used for programs that offer stress reduction for hypertensive patients.\u00a0\u00a0Does not have to include monitoring equipment, but would necessitate improvements in BP control over time independent of pharmacological agents.<\/p>\n 93015\u00a0–\u00a0Cardiovascular stress test using maximal or sub-maximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and\/or pharmacological stress; with physician supervision, with interpretation and report.<\/strong>\u00a0\u00a0It is used for cardiac and pulmonary testing, using ECG and monitoring equipment, physician supervised.\u00a0\u00a0This code should be used in the clinical exercise setting when performing testing services on patients who are involved in cardiopulmonary rehab services.<\/p>\n 96150 –\u00a0Health\u00a0behavior assessment<\/strong>\u00a0(e.g. – health focused clinical interview, behavioral observations, health-orientated questionnaires), each 15 minutes, face-to-face \u2013 initial assessment.\u00a0\u00a0Mostly for counselors, but could be used with health coaching programs.<\/p>\n Since reimbursement is harder to obtain for most licensed health care practitioners \u2013 it certainly won\u2019t be something that anyone in the exercise community will be able to obtain simply by becoming licensed or accredited.\u00a0\u00a0\u00a0The system is in a transformation mode.\u00a0\u00a0Most of the methods for obtaining reimbursement or contracting dollars will come from outcomes-based programming.\u00a0\u00a0Companies such as Optum are moving into this realm by their executive summaries relating to data analytics, outcomes, and ROI.\u00a0\u00a0Health and fitness professionals should do well to read the recent report by Marshall et. al. on outcomes in the health club setting.\u00a0\u00a0It has set the stage relating to the opportunities to work with clinical populations, and sets the stage for developing relationships with third party payors through a contract mechanism that will satisfy the needs of both parties.<\/p>\n CPT codes are the language of health care procedures, and they were made for physicians.\u00a0\u00a0However \u2013 that language can help health and wellness professionals to negotiate contracts that will help pay for memberships, personal or group training, nutrition, and mind\/body health programs through the health club industry.\u00a0\u00a0After 25 years \u2013 I think that the disruption in the health care industry is big enough that smart health club companies and training programs will be able to offer comprehensive wellness services that will be reimbursed at some level.\u00a0\u00a0We see it as the next logical step in the progression of the industry.<\/p>\n Reprinted with permission from Eric Durak.<\/em><\/p>\nWhere is the Future?<\/strong><\/h4>\n
\n