Auditors have identified frequent compliance issues with providers of all disciplines reporting of CPT code 97110; Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

The new audit probe will focus on; medical necessity, correct billing of timed codes and relationship to other therapy codes provided under same POC.

We offer the following Documentation Guidance to help you receive a Successful Review for your Outpatient therapy CPT Code(s) 97110

  • Physical and/or occupational therapy initial evaluation
    • Diagnosis and description of problem being evaluated
    • Objective, measurable current functional status
    • Subjective patient self-report of status
    • Clinician’s clinical judgments that describes the patient’s status
    • Determination of the need for treatment
    • Documentation to support the services require the skills of a therapist
  • Advance Beneficiary Notice of Non-Coverage (ABN), if applicable
  • Physician certification and recertification of the therapy plan of care
  • Physical and/or occupational therapy plan of care
    • Diagnoses
    • Long term measurable treatment goals
    • Type, amount, duration and frequency of therapy services
  • Physical and/or occupational therapy progress reports
    • Written by a clinician – not an assistant.
    • Minimum progress reports are every 10 treatment days
    • Assessment of patient progress towards goals
    • Plans for continuing treatment
    • Changes to goals
  • Physical and/or occupational daily treatment notes
  • Physical and/or occupational therapy treatment log
    • Total time spent for each modality billed
  • Physical and/or occupational therapy re-evaluation(s) as necessary
  • Physical and/or occupational therapy discharge note
  • Any additional documentation needed to support Medicare guidelines

We remind you that your total units of therapy being billed are constrained by your total therapy time and subject to the “8 minute” rules on individual therapy line items.

Under typical interpretation of time standards, you should not bill for any daily therapy (one unit total for the day) if it is less than 8 minutes however some carriers “may permit” billing of one unit for “modalities” greater than 5 minutes. Most however, will consider the service to be “incidental” to some other primary procedure for that day and not pay separately for the additional service.

For any single code, reported without any additional therapy services, providers should bill a single 15 minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes.

If the duration of the single modality or procedure is greater than or equal to 23 minutes and less than 38 minutes, then two (2) units are billed.

Time intervals for larger numbers of units are as follows:

3 units > 38 minutes to < 53 minutes
4 units > 53 minutes to < 68 minutes
5 units > 68 to < 83 minutes
6 units > 83 minutes to < 98 minutes

The schedule shown above is intended to assist you in rounding time into 15 minute increments. It does not imply that any minute until the 8th should be excluded from the total count as the timing of active treatment counted includes all active therapy time.

It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were also performed for more than 15 minutes. Regardless of what some consultants may recommend, if you perform therapeutic exercises (97110) for 15 minutes and massage (97124) for 15 minutes you should report one unit of each service and not combine the times to two units under either code especially to receive a higher reimbursement OR to hide it where NCCI or non-coverage edits would preclude payment.

If however, any 15 minute timed service is performed for 7 minutes or less on the same day as another 15 minute timed service that was also performed for 7 minutes or less, the total time of the two combined is 8 minutes or greater. In this case you would legitimately bill “one unit for the service performed for the most minutes”. Your documentation will show the actual services in support of the billing.

Good Luck !

Effective January 1, 2018, CPT modifiers 96 “habilitative services” and 97 “rehabilitative services” will be in effect for use.  CMS deleted modifier SZ as of December 31, 2017 and added modifiers 96 and 97 to their edits.

  • (MLN Matters MM10385). 1/1/2018 — Add the following new modifiers to the valid modifier list;
    – FY: Computed radiography x-ray
    – JG: 340B Acquired Drug
    – TB: Tracking 340b acquired drug
    – X1: Continuous/broad services
    – X2: Continuous/focused services
    – X3: Episodic/broad services
    – X4: Episodic/focused services
    – X5: Svc req by another clinician
    – 96: Habilitative services
    – 97: Rehabilitative services

Private payers will probably adjust their policies to use the 96 and 97 modifiers as well, but you should confirm that with a benefits representative. The addition of a valid CPT modifier should NOT cause a reject and the new modifiers DO clarify your claim for the carrier.

The two new modifiers were created to identify services as habilitative or rehabilitative and made their appearance in the 2018 CPT™;

Modifier 96 Habilitative Services: When a service or procedure that may either be habilitative in nature or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified healthcare professional may add modifier 96- to the service or procedure code to indicate that the service or procedure provided was habilitative. Such services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.

Modifier 97 Rehabilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97- to the service or procedure code to indicate that the service or procedure provided was rehabilitative. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.

Simply put, rehabilitative services help patients restore functions or skills that have been lost, while habilitative services develop skills and functions that had not been developed previously.

Now that CMS has deleted modifier SZ in favor of the AMA’s 96 and 97, and naturally expect these modifiers to be reported with services such as physical medicine and rehabilitation codes allowing the payer the ability to differentiate habilitative from rehabilitative services.

This differentiation is required by the Patient Protection and Affordable Care Act.

Physical medicine and rehabilitative services are designed to improve, restore, or compensate for loss of physical functioning following disease, injury or loss of a body part which makes them an ideal ancillary inclusion for pain management and rehabilitation practices. Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to determine the impairments, functional limitations, and disabilities of the individual patient and then address them through design and implementation of a plan of care tailored to the specific needs of the individual patient. The services are not only beneficial for the patient but are a good source of revenue for the practice. Therapy service income often out performs other clinical services on a consistent basis.

Unfortunately, many multidisciplinary consultants are apparently uninformed on Medicare “requirements” on who can actually “perform” the therapy services and often misrepresent permissible delegation and the actual supervision requirements over unlicensed individuals in the physician’s office setting.

As a result, practitioners are learning the rules the hard way as a whistle blower, disgruntled employees or competitor reports prompt on site audits and recoveries in the hundreds of thousands of dollars.

The premise for therapy is based on patients who must have a potential for restoration or improvement of lost functions and require the services of a skilled therapist. Rehabilitation services are typically short term, intensive and have clear goals for services employed to restore and maintain a level of function. Naturally Medicare patients are often subjected to illnesses and conditions effectively treated with physical therapy rehabilitation efforts.
Under Medicare policies, intervention with PM&R modalities and procedures is indicated when:

• an assessment by a physician, NPP or therapist supports utilization of the intervention,
• there is documentation of objective physical and functional limitations (signs and symptoms), and
• the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time.

Skilled therapist; for Medicare reimbursement means that the covered therapy services were “personally performed by one of the following individuals;

• Licensed therapy professionals: licensed physical therapists and occupational therapists
• Licensed PTA with appropriate supervision by a licensed physical therapist.
• Licensed occupational therapy assistants (OTA) with appropriate supervision by a licensed occupational therapist.
• Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
• Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
• Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
• “Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met.
o Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed. (Otherwise called an “unlicensed graduate PT/OT”).

There always seems to be some “consultants” who spend more time advising their clients on possible ways to “beat the system” than educating them on how to do things properly and avoid potential conflicts with regulations. Knowledgeable consultants know  that reimbursement for skilled services have an included calculated component based on the amount of “professional” time required to render the service to the patient. You may have noticed this “little requirement” in the description of various “time based” therapy codes where the language clearly states “one-on-one patient contact by provider”.

In my opinion, it is completely illogical for any provider to expect a carrier to pay for professional time when the services were provided by “trained aides” who lack the comprehensive training necessary to exercise professional judgment over the therapy or procedure.

The Federal programs for example, draw fairly clear lines on who is and who is not qualified to receive reimbursement for “professional time” by reviewing Medicare regulations 230.1(C) and 230.2(C) which clearly state;

Services provided by aides, even if under the supervision of a therapist, are NOT therapy services in the outpatient setting and are NOT covered by Medicare.

  • Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Services of athletic trainers, massage therapists, recreation therapists, kinesio-therapists, low vision specialists or any other profession may not be billed as therapy services.
• This includes service performed by Chiropractors since Medicare will not pay for any service performed, ordered or supervised by a Chiropractor.

In short, Medicare will not pay for the services of a “qualified provider” unless the services are performed by a “qualified provider”. Learn the difference and apply the principles.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.

  • Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law.
  • Assistants may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of licensure. Qualified personnel have been educated and trained as therapists and qualify to furnish therapy services under direct supervision and incident to a physician or NPP.

So next time, your so-called consultant wants you to bill the services of a med tech under your provider number, remember;

Fraud, as defined by Federal Regulation (42CFR455.2) , is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.

Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary. (under the carrier’s published policy).

The primary difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime?
In either case, the key component is that the perpetrator knew or should have known that the act was improper and under the revised false claims act you could face the possibility of treble damages and civil penalties of up to $11,000 for each improper claim and full membership in the exclusive OIG’s excluded individuals club !

References: CR10001 – Medicare Claims Processing Manual – Pub 100-04 Chapter 12, Sections 50 and 140.   https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Effective May 15, 2017 CMS revises their manual to bring it in line with current payment policy for moderate sedation and other anesthesia services in light of the CPT changes for January 1, 2017.

Anesthesia services range in complexity from least to the most complex as follows:

  • local or topical anesthesia,
  • moderate (conscious) sedation,
  • regional anesthesia and
  • general anesthesia.

General Payment Rule:

The fee schedule amount for physician anesthesia services furnished is typically based on the allowable base and time units multiplied by an anesthesia conversion factor specific to the geographic locality and communicated to the MACs by means of the annual updates to the Healthcare Common Procedure Coding System (HCPCS) file. The base units and conversion factor are available at https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html

Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation but does not include minimal sedation, deep sedation or monitored anesthesia care.  Practitioners are instructed to report the appropriate CPT and/or HCPCS code that accurately describes the moderate sedation services performed during a patient encounter, which are performed in conjunction with and in support of a procedural service, consistent with CPT™[1] guidance.

CPT codes 99143-99150 previously used for reporting moderate sedation were deleted from CPT 2017™ and replaced with;

NEW

99151

 

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age

99152     initial 15 minutes of intraservice time, patient age 5 years or older
 

 

99153

 

each additional 15 minutes intraservice time (List separately in addition to    code for primary service)   [Regardless of age of patient.]

99155 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
99156     initial 15 minutes of intraservice time, patient age 5 years or older
99157     each additional 15 minutes intraservice time (List separately in addition to code for primary service)

 

According to the AMA guidelines,

Preservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

Intraservice time:

  • is used to determine the appropriate CPT code to report moderate sedation services:
  • Begins at the administration of the sedating agent(s);
  • Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified healthcare professional providing the sedation and personal continuous face-to-face time with the patient;
  • Includes ordering and/or administering the initial and subsequent doses of sedating agents;
  • Requires continuous face-to-face attendance of the physician or other qualified healthcare professional;
  • Requires monitoring patient response to the sedating agents, including:
    • Periodic assessment of the patient;
    • Further administration of agent(s) as needed to maintain sedation; and
    • Monitoring of oxygen saturation, heart rate, and blood pressure

Intraservice time of less than 10 minutes should NOT be reported.

If the physician or other qualified healthcare professional who provides the sedation services also performs the procedure supported by sedation (99151, 99152, 99153), the physician or other qualified healthcare professional will supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.

An independent trained observer is defined as an individual who is qualified to monitor the patient during the procedure and who has no other duties during the procedure.

Postservice Work

The postservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, such as a local or topical anesthesia, then the conscious sedation code should not be reported and no payment should be allowed by the A/B MAC (B). There is no CPT code for the performance of local anesthesia and as payment for this service is considered in the payment for the underlying medical or surgical service.

[1] CPT is a registered trademark of the American Medical Association, used with permission.

Combo-Logo-21-150x150

By R.L. Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.  Executive Director. 

Physical medicine and rehabilitative services are designed to improve, restore, or compensate for loss of physical functioning following disease, injury or loss of a body part which makes them an ideal ancillary inclusion for pain management and rehabilitation practices.  Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to determine the impairments, functional limitations, and disabilities of the individual patient and then address them through design and implementation of a plan of care tailored to the specific needs of the individual patient.  The services are not only beneficial for the patient but are a good source of revenue for the practice.  Therapy service income often out performs other clinical services on a consistent basis.

Unfortunately many multidisciplinary consultants are apparently uninformed on Medicare “requirements” on who can actually “perform” the therapy services and often misrepresent permissible delegation and the actual supervision requirements over unlicensed individuals in the non-facility (Doctor’s office) setting.

Practitioners are learning the rules the hard way as whistle blower, disgruntled employees and competitor reports prompt on site audits and recoveries in the hundreds of thousands of dollars.

The premise for therapy is based on patients who must have a potential for restoration or improvement of lost functions and require the services of a skilled therapist.  Rehabilitation services are typically short term, intensive and have clear goals for services employed to restore and maintain a level of function. Naturally Medicare patients are often subjected to illnesses and conditions effectively treated with physical therapy rehabilitation efforts.

Under Medicare policies, intervention with PM&R modalities and procedures is indicated when:

  • an assessment by a physician, NPP or therapist supports utilization of the intervention,
    there is documentation of objective physical and functional limitations (signs and symptoms), and
  • the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time.

Skilled therapist, for Medicare reimbursement privileges means that the covered therapy services are “personally performed ONLY by one of the following;

  • Licensed therapy professionals: licensed physical therapists and occupational therapists
  • Licensed PTA with appropriate supervision by a licensed physical therapist.
  • Licensed occupational therapy assistants (OTA) with appropriate supervision by a licensed occupational therapist.
  • Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
  • Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
  • Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
  • “Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met.Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed.

There always seems to be some “consultants” who spend more time advising their clients on possible ways to “beat the system” than educating them on how to do things properly and avoid potential conflicts with regulations.

The basic facts are that reimbursement for services performed have a calculated component based on the amount of “professional” time required to render the service to the patient.  You may have noticed this “little requirement” in the description of various “time based” therapy codes where the language clearly states “one-on-one patient contact by provider”.

In my opinion, it is completely illogical for any provider to expect a carrier to pay for professional time when the services were provided by “trained aides” who lack the comprehensive training necessary to exercise professional judgment over the therapy or procedure.  The Federal programs for example, draw fairly clear lines on who is and who is not qualified to receive reimbursement for “professional time” by reviewing Medicare regulations 230.1(C) and 230.2(C) which clearly state;

Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Services of athletic trainers, massage therapists, recreation therapists, kinesio-therapists, low vision specialists or any other profession may not be billed as therapy services.      (This includes services performed by Chiropractors since they are statutorily excluded  for payment for any service performed other than spinal manipulation by CMT.- DrR)

In short, Medicare will not pay for the services of a “qualified provider” unless the services are performed by a “qualified provider”.  Learn the difference and apply the principles.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.

  • Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law……..o    Assistants may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of a license. Qualified personnel must have been educated and trained as therapists to qualify for furnishing therapy services under direct supervision and incident to a physician or NPP.

PTAs, even if licensed, may NOT perform “incident to” a physician or NPP, since they do not meet the definition of a therapist.

Aides are “everyone other” than those described above.  Med Techs, Chiropractic Assistants, Exercise Physiologists, Athletic trainers, massage therapists, LVNs, LPNs or any individual with a certificate of anything are NOT eligible to perform PT/OT for Medicare reimbursement.

So next time, your so called consultant wants you to bill the services of a med tech under your provider number, remember;

Fraud, as defined by Federal Regulation (42CFR455.2) , is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.
Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary. (under the carrier’s published policy).

The only difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime?

In either case, the key component is that the perpetrator knew or should have known that the act was improper.  

There are many “restrictions” providing PT / OT –  Don’t hesitate to contact us with questions.

U.S. Department of Health and Human Services Office of the Inspector General  : WORK PLAN Fiscal Year 2015

????????????????????????????????????????????????????????????????????????The office of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) was created to protect the integrity of HHS programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse; identifying opportunities to improve program economy, efficiency, and effectiveness; and holding accountable those who do not meet program requirements or who violate Federal health care laws.

OIG staff members serve in the Washington DC headquarters but also deployed throughout the Nation in regional and field offices to conduct audits, evaluations, and investigations; provide guidance to industry. The collaborate with HHS and its operating and staff divisions, the Department of Justice (DOJ) and other executive branch agencies, Congress, and States to bring about systemic changes, successful prosecutions, negotiated settlements, and recovery of funds.

Each year, the OIG prepares and issues a “Work Plan”[1] for the fiscal year that summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond.

It is important for providers and suppliers to be aware of the current plan since it is developed to assess relative risks in the programs for which they have oversight authority; identify and set priorities for those areas of concern most in need of attention

So who and what’s on this years “list[2]. Continue reading “Chiropractors, Ophthalmologists, sleep disorder testing and Physical Therapists all make the OIG “Hit List” for 2015”

CMS lookNational CERT data showed projected rises in improper payments for outpatient E&M services for 2013 with CPT codes 99205 and 99215 being in the top 15 codes identified for improper payment. Previous review of high level outpatient E&M services resulted in high error rates because services were frequently billed at a higher level than could be supported for medical necessity by the medical record.

Audit Results: The overall percentage of services recoded or denied for CPT 99205 was 78.66%. The overall percentage of services recoded or denied for CPT 99215 was 78.50%. The key reasons services were denied are as follows:

  • Failure to respond to the request for documentation
  • Documentation was missing a provider signature
  • Insufficient or missing documentation
  • The medical record did not support the coverage requirements forservices of nonphysician personnel furnished incident to physician’s services billing
  • Documentation did not support a separately identifiable E&M service performed in addition to procedure billed for the same date of service (inappropriate use of modifier 25)

The key reasons services were recoded to a lower level E&M service are as follows:

  • The medical record failed to support the medical necessity of the highest level of outpatient E&M service
  • For new patient E&M service CPT 99205, all 3 key components (comprehensive history, comprehensive examination, and high complexity medical decision making) were not supported at the level billed
  • The provider selected the level of E&M using time as the controlling factor, but the medical record failed to differentiate physician time devoted to face-to-face counseling with the beneficiary from the time dedicated to history and physical examination; or the record failed to provide sufficient detail about the coordination of care or counseling provided to justify the level of E&M billed

The majority of the services billed as CPT 99205 were recoded one or two levels, and the majority of the services for CPT 99215 were recoded one level. Based on the results of this widespread audit, prepayment review of CPT 99205 and CPT 99215 will resume for Part B claims in Illinois, Minnesota and Wisconsin beginning June 2014.