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Coding Faux pas: A coding lesson for physiotherapists

According to the dictionary, the definition of faux pas is “a significant or embarrassing error, mistake or a social blunder”. Now the question is, are you guilty of a coding faux pas? A more relevant question should perhaps be, can you afford a coding faux pas in your business?

In the South African health industry, all practitioners are responsible for coding. All have to follow the RPL 2006 coding rules. This means that as a physiotherapist you must also follow the RPL 2006 coding rules.

Let’s look at a few general mistakes that can happen in coding where the physiotherapist might end up with egg on their face.

Only 3 codes can be billed for.

I often get asked – how do I bill for this if I spend all this time with the patient but I can only charge 3x codes. This is the most common blunder physiotherapist can make. The answer to this is easy. One can bill for 3x modality codes in addition to any other * or “stand alone” code if your notes can justify the use for those codes. Always bill for what you have done and don’t try and over bill the patient by adding some ghost codes that do not reflect on your notes.

Code 72303 can only be charged ONCE per treatment session.

According to the RPL 2006 coding structure the definition of code 72303 is “Myofacial release/soft tissue mobilisation, one or more body parts”. This means that even if you treat 2 or more conditions or body parts in the same treatment session that you can only charge this code ONCE. Often this is the downfall of physiotherapist when you undergo a forensic investigation, as there is no way to hide behind this definition. You have to stick to the rule or as they say – pay back the money.

What is the hospital treatment indicator - Code 72901 or modifier 0014?

Code 72901 is per definition the following: “Treatment at a nursing home: Relevant fee plus (to be charged only once per day and not with every hospital visit

Modifier 0014 is part of rule 014, which is the following per definition “Physiotherapy services rendered to an in-patient in a nursing home or hospital”

So with this in mind it should be easy not to have a social blunder as once should use rule 014 with the appropriate modifier 0014 after each code billed for the hospital patient, to indicate that the service was delivered in hospital. This modifier is almost like a key that unlocks the hospital benefit for the patient when the code arrives on the medical aid side. The code 72901 is to indicate that the service was administered at the hospital. This is more to cover for the risk than do indicate where the service took place.

What's the BIG FUSS??

Code 72501 - Rehabilitation where the pathology requires the undivided attention of the physiotherapist. Rule 008 does not apply. Duration: 30min.

When I speak to my colleagues it’s clear that this is the problem child amongst codes. Everyone is almost too scared to use this code as everyone always asks, “Won’t I get a clawback if I use this code”? The answer is easy. No you won’t get a clawback if you use code 72501 correctly.

So now, the next question is - what the correct usage is of this code? Let me try to explain it to you best I can.

Rehabilitation is a collective word for what physiotherapy is. According to what all falls under rehabilitation it can be a combination of either/ or (1)education,(2) coping strategies and (3)exercise. The definition states clearly that it must encompass the undivided attention of the physiotherapist, so it cannot be a half job where you treat 2 patients at one time.

In addition, the last bit of the definition is where the trouble comes in… you must spend 30 minutes with the patient. You cannot spend 15 minutes with the patient, doing rehabilitation with all your undivided attention and then still think you can charge this code. NO! You must spend 30 MINUTES with the patient. Only then, when you can say yes to all three these components of the code 501, can you charge the code 72501 and be sure not to get a clawback from a funder. Please just make sure your notes reflect exactly what you have done. I also suggest you make a little side note to stipulate exactly what components of rehabilitation you included in your treatment and if you can add time to your notes, then you can get a gold star perhaps.

So there you have it – NO more egg on your face, NO more social blunders and NO more faux pas!

To get personalised consultation for you practice on best practices for physiotherapy billing and coding consider becoming an iZandla member today. You can join by filling out this form here or email iZandla Consulting is a member owned physiotherapy collective for private physiotherapists in South Africa. Learn more today by clicking here.

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1 Comment

Aarifah Em
Aarifah Em
Aug 01, 2022

Informative and well written, thank you!

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