Procedural coding, or billing, translates what was done clinically to an account, so that one can be remunerated for the treatment rendered.
Currently most medical aids or funders use the outdated 2006 NHRPL as baseline for reimbursement of physiotherapy services, with some variances.
There are currently 5 different coding structures in use (RPL, SASP structure, COID structure, RAF, and private structures)
Physiotherapists have a professional obligation to know the codes, the rules and how to use them correctly.
The currently used system uses mostly billing per modality (fee-for -service), and there are rules for each different coding structure that govern how many codes can be charged, what modifiers to apply etc. Make sure you know the rules. Ignorance is not an excuse!
In this article we will take a closer look at the evaluation codes 72701, 72702 and 72703 as defined in the “RPL 2006 “and SASP 2019 coding structures.
The evaluation codes in these structures are similar but slight changes differentiate between them.
In the NHRPL 2006, the descriptor has a “/” between evaluation and counselling. This refers to either / or. In the SASP 2019 structure evaluation and counselling are split in different codes so there is clarity in which is used where.
In this article we will only discuss the interpretation of the “NRPL 2006” structure:
NRPL 2006 Structure:
Evaluation/counselling at the first visit only (to be fully documented)
Note the / in this descriptor
Complex evaluation/counselling at the first visit only (to be fully documented)
Note the / in this descriptor
One complete re-assessment of a patient's condition during the course of treatment
To be used only once per episode of care
The initial evaluation codes 72701 and 72702 can only be used at the first visit of the patient, to the practice, for a specific condition/s.
The re-evaluation code, 72703, can only be used once per episode of care of the patient, to the practice, for a specific condition/s. This code can be charged on any follow up visit during the course of the treatments.
As illustrated previously there are a couple of Funders that have accepted the SASP Coding structure. In the SASP structure 72703 can be charged daily. Note that in this structure it has a lesser RVU, so a lesser rand value.
Refer to list of funders who accept SASP 2019 structure as basis for reimbursement.
The charging of assessment codes per condition is done per billing entity:
A specific practice via a practice number (PR) for a specific patient for a specific condition (ICD10 code) at the first visit of that patient with that condition to the practice.
It cannot be used when the same patient is seen by a different physiotherapist in the same practice, for the same condition, in the same treatment series, billed under the same PR number e.g.
For a second opinion or advice within the same practice or
When another physiotherapist in the practice or a locum takes over the treatment of the patient or
When the same patient is seen as an outpatient when previously being treated for the same condition in hospital by the same practice. If a reassessment was done, the correct code to use would be 72703
As a registered professional each physiotherapist has the responsibility to be up to date with any coding and billing requirements, rules, and regulations.
As practice owner, you remain responsible to ensure your staff are trained and up to date and ensure regular audits to see that the coding is compliant with requirements.
Ignorance is not an excuse!
Comprehensive clinical notes must be able to verify any evaluations done.
What is the difference between a simple and complex evaluation?
This is determined by the physiotherapist, and not the condition
In general terms, a simple assessment is when the problem literally presents itself.
The physiotherapist does not have to use a complex process of deductive and clinical reasoning to reach the diagnosis.
The complex evaluation refers to when clinical reasoning must be used to get to the diagnosis of the patient or if the patient presents with multiple complex diagnoses.
Clinical reasoning refers to clinical deductions made to eliminate hypotheses to get to the definitive answer of what to treat the patient for. This is not time dependent, so just because an evaluation takes time, does not imply that it is a complex evaluation.
Note that in the 2006 NRPL structure the descriptor of the evaluation codes have the “/ “so it is used for either evaluation or counselling.
Can code 72701 and 72702 be used together in the same session?
Yes, if the notes can justify that either a complex or simple clinical evaluation was done together with counselling at the “first visit only.” Thereafter it cannot be used again. Ensure that your clinical notes at all times reflect accurately what was done.
Need more clarity? or have any questions?
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