How to Create Claims
Claims are generated based on the following four criteria:
Patient Case Payment Method (Insurance or self-pay).
Payer Unit Calculation Methodology (CMS vs. AMA).
Treatments and/or Evaluations performed.
Time Spent on each treatment.
Claims are automatically created when the rendering provider signs and submits their clinical documentation.
Claim Requirements
Providers cannot submit clinical documentation if any of the following conditions are true:
Missing Patient Demographics: Gender or address is not provided.
Missing Plan of Care Details: No treatment diagnosis (DX) code is included.
Missing CPT Codes: No procedures or interventions are listed.
Time Inconsistencies: Treatment time exceeds the documented start and end times.
Missing Insurance Details: No insurance on file for patients using insurance.
Charge Creation
Treatment Charges
Charges are automatically added to claims as the provider writes their note.
When treatments/interventions are documented, the corresponding CPT codes are added.
Evaluation Charges
PatientStudio automatically includes evaluation charges if:
The note type is set to Evaluation (not daily or progress notes).
Clinical complexity is selected.
The discipline (PT, OT, SLP) is specified in the plan of care.
Other/Manual Codes
Providers can manually add evaluation or other codes as needed (e.g., 97164 for re-evaluation in a progress note).
Treatment codes must be added directly through documentation to align with charges.
Unit Calculation
Units are calculated using either the 8-Minute Rule (CMS) or the Rule of 8 (AMA), depending on the payer’s methodology.
Self-Pay (No Insurance): Uses the Rule of 8.
Defaults for Time-Based Treatments:
If no minutes are entered for any treatment, each charge defaults to 1 unit.
If minutes are entered for some treatments but omitted for others, omitted treatments default to 0 units.
Note: 0 units charge will not be transmitted to the clearinghouse or the payer.
Modifiers
Modifiers are automatically applied to charges based on criteria but can be manually added or removed by the provider before submission.
Modifier Rules:
GP Modifier: Applied if the plan of care discipline is set to PT.
GO Modifier: Applied if the plan of care discipline is set to OT.
GN Modifier: Applied if the plan of care discipline is set to SLP.
KX Modifier: Applied to all charges for notes submitted after a patient’s Medicare cap is reached (see Medicare Cap details).
CQ Modifier: Applied to charges for treatments performed by an Assistant user.