Medicare Billing Risks and
How To Avoid Them
December 11, 2012
•
This session will be recorded
–
Link to the recording and
resources will be emailed to all
registrants
•
Questions can be asked in the
“Question panel”
–
We’ll leave 15 minutes at the end
to answer questions
Welcome
Jim Plymale
CEO Clinicient•
Stop the Therapy Cap: Now is the time to take action
•
Three webinars
– How to Survive the Therapy Caps & Manual Medical Review (MMR) Process – Documentation According to the World of MMR – MMR: What We Know Now and Can Expect in 2013•
Coming Next: Jan. 10
th – G‐codes, Functional Limitation Reporting and PQRS – Things to Know for 2013•
Resource Page:
www.clinicient.com/mmr‐resources/
How We Got Here….
Welcome Nancy
• Compliance expert in the Rehab industry; certified in healthcare compliance • Specializes in providing compliance program development for outpatient therapy and DME providers • Popular industry speaker and author on compliance topics related to outpatient therapy • Serves as a Compliance columnist for IMPACT ‐ the magazine of the APTA Private Practice SectionNancy Beckley
President•
The risk of therapist's documentation not matching the claims
•The hidden danger and common practice of inadvertently
submitting false claims
•The importance of appropriately accounting for therapist's time,
properly applying CCI edits and aggregating units correctly
•What you need to know about RAC audits in 2013
Today’s Objectives
Fourth in a series of Compliance WebinarsThe Elephant Again….
•
Functional Reporting
–
42 New Therapy only codes
–
G codes, modifiers
•
Transmittals, MLN Article
–
Transmittal R163B
–
Transmittal R2603CP
–
MM #8005
•
CMS mandated to collect information on function and condition
•
Non‐payable G codes and modifiers will now be included on claims
– Onset of every therapy episode – Every 10th visit at a minimum (new progress reporting period beginning 1/1/13) – Discharge•
Therapist’s projected goal for discharge
– 1st claim for services, and at the end of the episode•
January 1
ststart date, July 1
stmandatory report
– Grace period to “test”
WHAT IS RISK?
The OIG recognizes that many….practices may not have in place
standards and procedures to prevent erroneous or fraudulent
conduct in their practices.
In order to develop standards and procedures, the …. practice may
consider what types of fraud and abuse related topics need to be
addressed based on its specific needs.
One of the most important things in making that determination is a
listing of risk areas
where the practice may be vulnerable.
OIG – Risk Assessment
OIG: Four Areas of Practice Risk
Coding & Billing Reasonable & Necessary Documentation Improper Inducements•
The OIG will review outpatient physical therapy services provided
by independent therapists to determine whether they were in
compliance with Medicare reimbursement regulations.
•
In the past, the OIG has identified claims for therapy services
provided by independent physical therapists that were not,
medically reasonable and necessary, or properly documented.
•
They will focus on independent therapists who have a high
utilization rate for outpatient physical therapy services because of
their concern that they may not be medically reasonable and
necessary.
OIG Work Plan ‐ 2013
Do You Know Where Your Risks Are?
Regulatory
• Credentials
• Medical
necessity
• Supervision
• Documentation
• Therapy Cap
• Students
• Credentials
• Medical
necessity
• Supervision
• Documentation
• Therapy Cap
• Students
MAC
• MR Program
• KX Modifier
Profiling
• CERT Errors
• LCD
• ICD‐9 Map
• MR Program
• KX Modifier
Profiling
• CERT Errors
• LCD
• ICD‐9 Map
Internal
• Monitoring
findings
• Audit findings
• EMR issues
• HR issues
• Billing issues
• Monitoring
findings
• Audit findings
• EMR issues
• HR issues
• Billing issues
The OIG recommends that a …. practice focus
first on those risk areas most likely to arise in its
particular practice.
HealthSouth – “The Wagon to Disaster”
What is right is right, even if
no one is doing it.
What is wrong is wrong, even
if everyone is doing it.
14CAPTURED:
Jose Diego Calero
• In August 2009, Jose Diego Calero was indicted on charges of Health Care Fraud, Money Laundering, and Forfeiture. Calero allegedly submitted more than $4.8 million in claims to Medicare for physical and occupational therapy services that either were not prescribed by doctors or were not provided as claimed. • Calero was the Director of Premier Quality Physical Therapy, Inc., a Florida‐ based company that purportedly provided physical therapy and occupational therapy services to Medicare beneficiaries. • Investigators believe that from approximately Sept 2008 to Feb 2009, Calero caused Premier to submit more than $4.8 million in false claims to Medicare, for which he received more than $2.7 million in payments. 15Calculated Risk?
•
TACOMA PHYSICAL THERAPY firm required to pay more than
$655,559 for healthcare fraud
– STAR Physical Therapy billed state and private health plans for bogus private therapy sessions – ….instructed employees to fill out the billing code for private aquatic therapy sessions when patients had actually been treated in a group session – 1 group session billed as if “9 hours of therapy” – During the period of the fraudulent billing, NANCY WONG served on the Washington State Board of Physical Therapy – $50,000 fine and double damages Source: US Attorney’s Office: 11/18/2005Calculated Risk?
•
CARLSON THERAPY NETWORK has entered into a civil
settlement agreement with the Government in which it has
paid $1,886,834.00 to resolve allegations that it violated the
False Claims Act by submitting false claims to various
Government health care programs.
– The Government alleged that, on numerous occasions, CTN billed for direct, one‐on‐one care when such services were not provided. – CTN therapists would routinely provide therapy services to multiple patients at the same time, but would bill Government health care programs, such as Medicare and Tricare, as if the therapist was providing direct, one‐on‐one care.Calculated Risk?
•
BENCHMARK PHYSICAL THERAPY
, has entered into a settlement
with the United States and the State of Tennessee to pay over $1.8
million resolving allegations that it improperly billed the Medicare
and TennCare/Medicaid programs for physical therapy services in
violation of federal and state laws and regulations
– Benchmark submitted claims representing…provided therapeutic exercise for TennCare patients when medical records indicated that the patients had instead received aquatic therapy, a service subject to reimbursement restrictions – The United States also alleged that Benchmark submitted claims through the Medicare program for physical therapy services which did not qualify for payment or were not medically necessary Source: USDOJ, 6/30/2010•
After it
self‐disclosed
conduct to the OIG, HealthWorks
Rehab & Fitness, (HealthWorks), West Virginia, agreed
to pay
$8,132.16
for allegedly violating the Civil
Monetary Penalties Law.
•
The OIG alleged that HealthWorks inappropriately
billed Medicare for the performance of iontophoresis
services, which is not a covered service under
Medicare because it is deemed experimental.
•
Ionto not covered by Local Coverage Determination
Self Disclosure
•
HealthSouth
–
Group and concurrent therapy
•
Physiotherapy Associates
–
Group issues
•
Advanced Physical Therapy
–
Not enough “group”
•
Carlson Therapy Network
–
1:1 vs. Group
Qui Tam Relators
Risks: Hand Therapy
•
Hand therapy performed by either PT or OT
•
Certification level of CHT: either PT or OT
•
While treatment may seem to be interchangeable,
practice, documentation, coding & billing is not
interchangeable
•
Commercial plans may not recognize OT, regardless of
CHT certification
–
Case Study
•
Medicare requirements and Practice Act requirements do not
allow PT working on OT plan of care and vice‐versa
Risks: Coding for Same Day Services
•
Multiple body parts, same treatment session
– Typical in general outpatient therapy – Same treatment plan, multiple treatment plan approaches – Single referring MD, multiple referring MDs – Documentation approach:•
Timed vs. Untimed codes
– Timed codes based on minutes (8 minute rule) – Untimed codes based on 1x per session regardless of time • Exception: Morning session and afternoon session, untimed codes may be billed again in second session with ‐76 modifier – Documentation approach…NGS: Documentation: 97150
• The purpose of the group and the number of participants in the group
• Description of the skilled activity provided
in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual. • What is not covered: – Supervision of a previously taught exercise program or supervising patients who are exercising independently is not a skilled service and is not covered as group therapy or as any other therapeutic procedure. – Supervision of patients exercising on machines or exercise equipment, in the absence of the delivery of skilled care, is not a skilled service and is not covered as group therapy or as any other therapeutic procedure. Medicare Benefit Policy Manual Chapter 15, Section 230 A. Group Therapy Services. Contractors pay for outpatient physical therapy services (which includes outpatient speech‐ language pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy services (97150). B. The individuals can be, but need not be performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one‐ on‐one patient contact is not required.
Risks: Group Therapy
Risk: NCCI Edits
• The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. • The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have been combined into one table and include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual. • Therapy code pairs apply across disciplines on same day • In certain circumstances pairs can be bypassed with ‐59 modifier • Separate and distinct time, medically necessary • Most often modified – 97530 – 97140 • Updated quarterly, 1st of month • Physician edits (private practice) • Hospital edits (Part A) • http://www.cms.hhs.gov/NationalCor rectCodingInitEd/59
Risks: New Technologies
•
I have a bridge in Brooklyn…….
–
Vendor promises of payment, “if you bill this way…”
•
May be paid for a period of time pending review by
payors and/or regulators, or may have a T code while
pending CPT
review
–
Anodyne
– NCD (no longer covered by Medicare)
–
Mist Therapy
– LCD (covered only per local coverage
determination)
•
Purchase and clinical strategies
•
Use of automatic exceptions process through KX
modifier and attestation
•
PTPP Comparative Billing Reports by SGS
–
2010, 2011, 2012
•
Comparative Billing Reports
–
SNF (by SGS)
–
Individual providers
–
Profiling utilization
Risks: Excessive Therapy
•
Total timed minutes recorded in record
•
Appropriate number of units billed based on time
•
Recoupment request:
–
“total time not noted in the daily record”
Recording Minutes – New Twist
Total time (in timed codes) Total treatment time (incudes untimed codes) Time‐in/Time out X total treatment timeThe Risk in CERT ‐ WPS
Billed CPT 97110(2 units) ‐ The time spent rendering therapeutic occupational exercises on billed date of service is not recorded, therefore two units can not be verified. Total time is not recorded on the billing sheet or on the flow sheets. The flow sheets are unsigned. The letter sent additional documentation request is an addendum/late entry and cannot be used. Also received physician's order and plan of care, initial evaluation and progress note.100%
•
Noridian Service Specific Probe – Physical Therapy
– TOB 74X (Rehab Agency) Code: 97110•
Noridian Widespread Service Specific – Aquatic Therapy
– TOB 131‐135 (Hospital Outpatient) Code: 97113•
PalmettoGBA J‐11 Part B MAC – Medical Review Probe
– Private Practice claims – 12 codes listed (just about everything!) – 100 claims per state: Virginia, West Virginia, North Carolina, South CarolinaProbe Examples
Recovery Auditors (RAC)
The “RAC” Process
•
Automated Reviews
– Data review, no record requests•
Complex Reviews
– Request medical records•
Semi‐automated Reviews
– Data review suggests aberrancy – Records requested to support recoupment•
Likely Issues for Therapy…
RAC Response
•
Understand RAC process
•
Register at your RA’s
website to ensure delivery
•
Have RAC team ready to go
•
Understand your LCD –
– Pay attention to suggested documentation per code – Utilization parameters per code•
Previous medical history including diagnosis, premorbid conditions,
and recent hospitalizations impacting functional abilities
•
Patient’s prior level of functional abilities, i.e. able to ambulate
functional distance in recent past
•
Timely physician certification/involvement with clear
frequency/duration and certification date range parameters on plan
of care
•
Medical necessity supported ‐ patient would benefit from the
development of an effective home strengthening program to:
– Regain ability to safely ambulate to/from bathroom to ensure appropriate pericare, etc. – Facilitate the patient’s ability to maintain strength and prevent further functional decline with other functional skills, i.e. transfers/bed mobility.CMS – Documentation Needed
Reasonable and Necessary
Treatment should be consistent with the nature/ severity of illness / injury•
Is this a new or acute
problem?
– May need intensive focused care – E.g. reduce pain and/or work on a specific impairment or functional loss•
Is this an old or chronic
condition that needs
retraining, or has had a change
in condition?
– May need to update or modify program•
Is this an exacerbation of a
condition?
– May have to modify treatment, change assistive devices as the condition deteriorates – Are there other conditions (e.g. medical diagnosis) that are the underlying problem?•
Cognitive performance can
impact care
– What is the beneficiary’s ability to retain newly learned information (cognitive function)? – What is the beneficiary's ability to participate and benefit from rehabilitative services? Source: CMS Open Door Forum Slide Show 9/5/12•
Assessing Objective Measurable Gains for
Rehabilitation Therapy
•
Look at:
–
Changes in the level of assistance required to perform
functional tasks
–
Changes in the types of functional activities/ tasks
–
Changes in the types of assistive devices
–
Improvement in rating of reported pain levels and
changes in the ability to perform tasks given the
reduction of pain
• (E.g. ‐ Ability to sit for a duration of time as a result of pain reduction)Reasonable & Necessary
Considerations:
•
Did the therapist consider the beneficiary’s goals?
•
Were the therapist’s and beneficiary’s goals realistic based on
the beneficiaries condition and,
•
For rehabilitation therapy did the therapist change goals/
treatment plan in response to improvement or lack of
improvement in the beneficiary’s condition?
•
Were there objective, measurable changes using standard
scales and assessment tools?
•
What was the beneficiary’s response to treatment?
–
Did this change over time?
–
Was it sustained?
Reasonable & Necessary
Source: CMS Open Door Forum Slide Show 9/5/12“Top 5” Best Practices
For Demonstrating Medical Necessity and Skilled Care
Best Practice:
Monitoring & Auditing Topics:
1
Initial Evaluation:Test, measure and document functional scores, performancetests and clinical findings
1. Relate functional scores to norms
2. Identify complexities and comorbidities and impact on therapy progression
3. Provide contralateral measurements and significance
2
Initial Evaluation and Plan of Care:Relate clinical findings and short term goals to functionaldeficits and long term goals 1. Prior level of function identified for each identified ADL item 2. Current level of function contrasted to prior level of function for each item 3. Relate pain scores to inability to perform functional activities
3
Daily Notes: Demonstrate skilled intervention through ongoing patient assessment, exercise, functional progression, and techniques and parameters utilized 1. Identify patient compliance with HEP 2. State exercise progressions and introduction of new exercises 3. Relate functional activities to ADL deficits and patient progression4
Progress Evaluation:Serially track and update important clinical and functional findings related to goals 1. Compare initial objective tests & measures to current, comment on status 2. State % goal achievement and status 3. Update patient functional ADL status“Top 6” Best Practices
For Reducing Medicare Billing Risks
Best Practice:
1
Always make sure your documentation supports the claim2
Document total treatment minutes and timed treatment minutes in each daily note3
Convert minutes to units appropriately4
Apply CCI edits properly, and by a therapist or certified coder5
Use PTAs and Extenders appropriately, and document correctly6
Appropriate use of KX modifier for attestationRisks & Interdependencies
•
Medical Necessity
–
Treatment
–
Documentation
–
Coding
–
Billing
–
KX Modifier
Therapy Evaluation Plan of Care Coding ‐ ICD Daily Treatment Document Coding ProceduresHow an EMR and
Practice Management System
Can
Minimize Your Risks
Critical Actions
Requirements:
How Clinicient Helps:
1
Always make sure your documentation supports the claim Charges created directly from signed therapist encounter with change notification2
Document total treatment minutes and timed treatment minutes in each daily note Automatically totals timed minutes and total treatment minutes in daily note3
Convert minutes to units appropriately Automatic conversion of timed minutesaccording to Medicare guidelines
