Introduction
Access to physiotherapy in a hospital, unlike medical and nursing services, is not always available throughout the whole day or on all days in a week. Twenty-four-hour availability of physiotherapy is however advocated in some areas of the hospital, such as the specialised care units.
It is not uncommon for Physiotherapists to see patients outside their normal working hours or to be called out to see a patient.
Specific codes were developed for these situations and this blog will discuss them in detail.
Modifier 0006
The descriptor of Rule 006 in the RPL is as follows:
“Where emergency treatment is provided:
a. during working hours, and the provision of such treatment requires the practitioner to leave her or his practice to attend to the patient in hospital; or
b. after working hours the fee for such visits shall be the total fee plus 50%.
For purposes of this rule:
a. "emergency treatment" means a bona fide, justifiable emergency physiotherapy procedure, where failure to provide the procedure immediately would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy; and
b. "working hours" means 8h00 to 17h00, Monday to Friday.
Modifier 0006 must be quoted after the appropriate code number(s) to indicate that this rule is applicable.”
To qualify as an emergency:
You have to do the treatment immediately. Definition of immediately is: at once; instantly, straight away, promptly, etc.
Therefore it cannot be a scheduled treatment that fits into your normal practice / hospital routine even when it is afterhours.
It must be a situation that if the treatment is not done immediately that the patient’s life is placed in serious jeopardy or serious impairment to bodily functions or a bodily organ is at risk.
Remember that ALL treatments for patients with PMB’s or ICU patients therefore does not necessarily warrant a 0006.
The only other codes that may be charged for treatment done outside normal conditions are codes 72720 & 72721 of the SASP coding structure, which is not accepted by many medical funders and would therefore not be paid.
Code 72720
The description of code 72720 is:
“Essential continuation of physiotherapy care, in an after-hours situation”
This code may be used under the following circumstances where failure to provide the Physiotherapy intervention might result in any or all of:
Serious impairment to bodily functions
Serious dysfunction of a bodily organ or part,
Reduced functional ability due to severe pain
Would place the patient's life in serious jeopardy
Increase of length of hospital stay
Prolongation of expected recovery time
Explanation and use of "after- hour situation"
"After- hour situation" shall mean all physiotherapy interventions, where essential continuation of care is required in excess of ordinary working hours in the following circumstances:
Weekdays before 07:00h and after 17:00h Saturdays, Sundays and Public holidays.
Always make sure that the normal hours of operation of your practice is clearly stipulated to support the use of this code in an after-hours situation.
Code 72721
The description of code 72721 is:
Emergency Physiotherapy intervention
Code 72721 may only be used where an emergency Physiotherapy intervention is provided. Emergency is defined as a sudden, and at the time, unexpected onset of a health condition or an unplanned event that requires immediate unscheduled Physiotherapy intervention. Failure to provide the Physiotherapy intervention immediately might result in any or all of the following:
Serious impairment to bodily functions
Serious dysfunction of a bodily organ or part,
Reduced functional ability due to severe pain
Would place the patient's life in serious jeopardy
In circumstances where the above criteria are not met the use of code 72721 is not applicable.
Codes 72720 and 72721:
cannot be modified with modifier 0008 as rule 008 does not apply
can only be charged once per intervention
may not be charged together at the same single intervention
Only a few medical aids have accepted codes 72720 and 72721 and will reimburse them. Should you decide to use these codes with any other funder they will not be reimbursed and the patient will be liable for payment. It is important that applicable co-payments must be stipulated in your consent forms.
Codes 72720 and 72721 cannot be charged where a contract is in place with a funder with a payment agreement to only bill codes accepted by the funder. Charging these codes in a situation like this will be seen as a breach of contract and will bear the necessary consequences.
Conclusion
If you are a Physiotherapist regularly seeing patients in after-hours and/or emergency situations, you should familiarise yourself with the descriptions of the above mentioned codes. Modifier 0006 and code 72721 are emergency codes and code 72720 is the only after-hours code. Make sure that when you use emergency codes that the treatment falls within an emergency criteria as mentioned before.
Also make sure that you understand all of the rules and regulations applicable to the use of these codes to avoid any non-payments, funder queries or worse, possible clawbacks.
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