97110 – CMS Audit Probe

Posted on October 31, 2018April 24, 2020 by kellyausiello

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 !

Therapy Claims for 2018 and beyond for Medicare.

Posted on April 20, 2018 by kellyausiello

After decades of monitoring the annual Medicare therapy caps and temporary exceptions fiascos, I got an early morning call from a Washington DC friend contact that Congress had finally “repealed” the cap on therapy services.

It was well into the early morning hours when the Senate finally voted 71-28 to pass a budget bill known as the Bipartisan Budget Act of 2018 .

I knew word would spread fast and my phone would soon start ringing so I quickly reviewed the bill’s language and found we still had a cap at $2010 but it had been changed back to a “soft” cap and the exception process missing from the previous legislation in January, had now been provided.

Section 50202 – Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy – The new law requires for services after December 31, 2017:
* Medicare claims are no longer subject to the therapy caps (one for occupational therapy services and another for physical therapy and speech-language pathology combined);
* Claims for therapy services above $2010, the same amount as the previous therapy caps, must include the KX modifier indicating that such services are medically necessary as justified by appropriate medical record documentation; and
* Claims for therapy services above $3,000 of incurred expenses may be subject to targeted medical review.

So, the threat of a hard cap is gone and Medicare beneficiaries can still obtain necessary therapy services beyond the $2,010 limit as long as you affix the KX modifier to the claim.

Discipline Modifiers:
CMS also implemented a requirement for billing therapy services by ANY PROVIDER. (MM101076) effective 1/1/2018 set an additional billing requirement for any “always therapy” service provided by any provider specialty type. The instruction informed all providers that each code designated as “always therapy” must always be submitted with one of the therapy discipline modifiers GN, GO or GP in addition to any other relevant payment modifier like the KX modifier.

Based on this policy change, even a chiropractor providing an always therapy service must append the appropriate therapy modifier (normally GP) for the service being billed IN ADDITION TO modifier GY to indicate the service is non-covered by Medicare for their provider type.

Many Chiropractic offices are having claims “rejected” by CMS rather than being “denied and forwarded” to the secondary insurance just because they did not append the default GP discipline modifier to the therapy line items.

A rejected claim does NOT PROCESS through the system at all and therefore does not generate a valid denial for purposes of collection from the patient or their secondary coverage carrier. Offices that are not following the new reporting requirements have found themselves in a revolving door of re-submissions.

If, on any claim from any provider, one of the therapy modifiers, GN, GO or GP, is not appended then the claim will reject and not process through the Medicare processing system for denial.

You will need to refile the claim with the appropriate modifiers for it to process for denial.

The last battle: To offset future costs associated with eliminating the hard cap, Congress also enacted a payment differential for PTAs and COTAs like that used for Physician Assistants and Nurse Practitioners, which means therapist assistants will be reimbursed 85% of the amount PTs and OTs receive for the same services.

This reduction is set to go into effect on January 1, 2022 and will have more impact on “facilities and rehab agencies” than the Part “B” office setting where direct supervision of an enrolled PT or OT is required.

Baring any legislative actions to the contrary, we should be firmly set on the issues of caps and exceptions until the end of 2027.

Therapy Claims Must Be Coded With Modifiers

Posted on April 18, 2018July 6, 2018 by kellyausiello

There have been several “issues” caused by the changes in billing Medicare for 2018. Many practices, including Chiropractic offices are now having claims “rejected” by CMS rather than being “denied and forwarded” to the secondary insurance.

A rejected claim does NOT PROCESS through the system at all and therefore is NOT a valid denial for purposes of collection from the patient or their secondary coverage carrier. Offices that are not following the new reporting requirements have found themselves in a revolving door of re-submissions.

Chiropractic Office Issues: You all know that Medicare policy states a chiropractor should bill any service they provide that is not covered by Medicare for their specialty with modifier GY to receive a formal denial of the service and, when possible, have the denial forwarded to the patient’s secondary carrier for payment. This was proper UNTIL 2018 when there was a change to this process FOR ALL PROVIDER TYPES that may have been overlooked.

CMS implemented a change (MM101076) effective 1/1/2018 for always therapy services that contained an additional billing requirement for any always therapy service provided by any provider specialty type.

All providers were informed that each code designated as “always therapy” must always be accompanied by one of the therapy modifiers GN, GO or GP in addition to any other relevant payment modifier.

What you need to do:
Based on this policy change, all providers, including a chiropractor providing an always therapy service must append the appropriate therapy modifier (normally GP) for the service being billed IN ADDITION TO modifier GY to indicate the service is non-covered by Medicare for their provider type.

If one of the therapy modifiers, GP,GO or GN, is not appended then the claim will reject and not process through the Medicare processing system AT ALL.

Chiropractors will need to refile the claim with the appropriate modifiers for it to process for denial.

Medical offices will encounter a CO 4 denial ” The procedure code is inconsistent with the modifier used or a required modifier is missing” with a MA130 remark “Your claim contains incomplete and/or invalid information and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the correct information”

Again, the ruling applies to ALL PROVIDERS who bill therapy services to Medicare.

Clinician MIPS Participation Status Letters Coming

Posted on May 1, 2017 by kellyausiello

CMS is now reviewing claims and will be notifying practices which clinicians will need to take part in the Merit-based Incentive Payment System (MIPS), under the new Quality Payment Program (QPP).

In late April through May, you will get a letter from your Medicare Administrative Contractor (MAC) providing the participation status for each MIPS clinician associated with your Taxpayer Identification Number (TIN). Clinicians are included in MIPS if they bill Medicare Part B more than $30,000 a year in allowable charges and provide care for more than 100 Medicare patients a year, and you are a:

Physician
Physician assistant
Nurse practitioner
Clinical nurse specialist
Certified registered nurse anesthetist
For those of you with multiple TINs or with clinicians who practice under multiple TINs, eligibility notifications will be at the TIN level of their eligibility and therefore may have different eligibilities for each of the TIN/practice combinations.

Also note that if your group chooses to report as a group, MIPS assessment will be based on all individuals in the group including those clinicians who do not exceed the low-volume threshold as individuals.

The Quality Payment Program (QPP) is designed to shift reimbursement from the volume of services provided towards payment that rewards clinicians for their overall work in delivering the best care for patients. QPP replaces the Sustainable Growth Rate (SGR) formula and streamlines the “Legacy Programs” – Physician Quality Reporting System,(PQRS) the Value- based Payment Modifier, and the Medicare Electronic Health Records Incentive Program, also known as “meaningful use”.

During the first performance period that began January 1, 2017, CMS will allow you to pick your pace of participation. If you are participating in MIPS you will have three flexible options to submit data to MIPS and a fourth option to join an Advanced APM in order to potentially become a Qualifying APM Participant.

The first performance period of MIPS is 2017, and the first payment year is 2019. This means that your submitted data in calendar year 2017 will be used to determine your MIPS adjustment to Part B payments for items and services provided in 2019.

We recommend you participate, if for no other reason than to avoid the 4% payment reduction that will be assessed in 2019 if you don’t send in any 2017 data. You can avoid the downward payment adjustment by just submitting a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017)

This will ensure that you do not receive a negative payment adjustment in 2019.

If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment and if you submit a full year of 2017 data to Medicare, you could earn a positive payment adjustment for 2019. To potentially earn a positive payment adjustment in 2019, you should send in your data to Medicare no later than March 31, 2018.

There are several ways to report;

Report as an individual.

If you report as an individual, your payment adjustment will be based on your performance.

An individual is defined as a single clinician, identified by a single National Provider Identifier (NPI) number tied to a single Tax Identification Number (TIN).

You will need to send your individual data for each of the MIPS categories through an electronic health record or a registry or include quality data through your routine Medicare claims process.

Report as a group.

Each Clinician participating in MIPS via a group will receive a payment adjustment based on the group’s performance.

Under MIPS, a group is defined as a single Taxpayer Identification Number (TIN) with 2 or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their National Provider Identifiers (NPI), who have reassigned their Medicare billing rights to the TIN.

If your group would like to participate in MIPS via the CMS Web Interface and/or elect to administer the CAHPS for MIPS survey, you should register between April 1 and June 30, 2017.

Only these two options require registration.

If your group registered for the GPRO Web Interface in 2016 to report for The Physician Quality Reporting System (PQRS), CMS automatically registered your group to use the CMS Web Interface in 2017 for MIPS. If you want to report under another method, you need to cancel the GPRO election during the registration period (4/1 to 6/30/2017)

If you registered for the Web Interface in 2016 and wish to continue in 2017, you should review and update your information, between April 1-June 30, 2017, if:

The number of eligible clinicians in your group has changed since 2016
Your group wants to enroll in the Consumer Assessment of Health Providers and Systems (CAHPS) for MIPS survey
https://qpp.cms.gov/learn/about-group-registration

What should you do “NOW”.

We strongly suggest you complete the following action items to insure you are ready for MIPS.

Make sure your electronic health record is certified by the Office of the National Coordinator (ONC) for Health Information.

Check if you want to use a qualified clinical data registry or other registry to submit your quality data.

See what MIPS data your practice can choose to send in. Figure out which measures and activities best fit your practice.

Go to: Explore the MIPS Measures

Decide whether you should report as an individual or with a group.

CMS has provided quite a few educational resources to help you. Please visit their site https://qpp.cms.gov/resources/education

PAINT IS NOT THE ONLY LEAD HAZZARD

Posted on January 28, 2016January 28, 2016 by kellyausiello

President Obama has been crowned the greatest gun salesman in America. People are flocking to the gun ranges to shoot their newest protection piece and concealed weapons permits are up significantly.

One “medical concern” you should be looking for is “lead contamination”.

You and/or your patients are exposed to lead every time they shoot. Lead is typically contained in the primer of each bullet or shell, so when you fire your gun all of the residue and powder from the explosion lands on your hands, face and shirt and you’re essentially covered in lead particles. In the crime shows they call the GSR (gun shot residue) This vaporized lead obviously can be inhaled, but the particles of lead sheared off as an unjacketed bullet travels down the barrel are small enough to be easily inhaled as well. Once inhaled the lead readily crosses to the bloodstream and is distributed throughout the body. It is absorbed like calcium and interferes with iron absorption and can be deposited in bone and fat and other soft tissue.

In addition, if you clean your firearm when you get home, that firearm is covered in lead dust. When you’re shoving the cleaning rod down the barrel that dust is shooting out of the barrel into your house.
If you happen to walk around and pick up your brass or shell cases after you shoot, those are covered in lead. And if you put that in your pocket or scoop it up in a hat, then you have a pocket or hat covered in lead dust as well.

Symptoms of lead poisoning are varied and may affect many parts of the body. Most of the time, lead poisoning builds up slowly following repeated exposures to small quantities of lead and is difficult to detect until symptoms progress. Most doctors do not inquire about recreational gun use and when symptoms present, lead poisoning is way down the list of differential diagnoses. Typically it is diagnosed by a blood lead levels test. CDC recognizes blood lead levels (BLLs) of >25 µg/dL in adults and >10 µg/dL in children as levels of concern.

Signs and symptoms in adults may include:
• High blood pressure
• Abdominal pain
• Constipation
• Joint pains
• Muscle pain
• Declines in mental functioning
• Pain, numbness or tingling of the extremities
• Headache
• Memory loss
• Mood disorders
• Reduced sperm count, abnormal sperm
• Miscarriage or premature birth in pregnant women

HIPAA and Firearms Background Check System.

Posted on January 6, 2016 by kellyausiello

The following notice was released by OCR today. We are distributing it so our members are aware of their professional responsibility under the revisions to HIPAA.

OCR HIPAA Privacy Rule information
The following notice was released by OCR today. We are distributing it so our members are aware of their professional responsibility under the revisions to HIPAA.
Obama administration modifies HIPAA to strengthen the firearm background check system

On January 4, 2016, the Department of Health and Human Services (HHS) moved forward on the Administration’s commitment to modify the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to expressly permit certain covered entities to disclose to the National Instant Criminal Background Check System (NICS) the identities of those individuals who, for mental health reasons, already are prohibited by Federal law from having a firearm.

This modification better enables the reporting of the identities of prohibited individuals to the background check system and is an important step toward improving the public’s safety while continuing to strongly protect individuals’ privacy interests.

The final rule gives States improved flexibility to ensure accurate but limited information is reported to the NICS. This rulemaking makes clear that, under the Privacy Rule, certain covered entities are permitted to disclose limited information to the NICS. The information that can be disclosed is the limited identifying information about individuals who have been involuntarily committed to a mental institution or otherwise have been determined by a lawful authority to be a danger to themselves or others or to lack the mental capacity to manage their own affairs – that is, only about those who are covered under the pre-existing mental health prohibitor.

The new modification is carefully and narrowly tailored to preserve the patient-provider relationship and ensure that individuals are not discouraged from seeking voluntary treatment.

This rule applies only to a small subset of HIPAA covered entities that either make the mental health determinations that disqualify individuals from having a firearm or are designated by their States to report this information to NICS.

The rule does not apply to most treating providers.

It is important to note that the vast majority of Americans with mental health conditions are not violent and that those with mental illness are in fact more likely to be victims than perpetrators. An individual who seeks help for mental health problems or receives mental health treatment is not automatically legally prohibited from having a firearm; nothing in this final rule changes that. HHS continues to support efforts by the Administration to dispel negative attitudes and misconceptions relating to mental illness and to encourage individuals to seek voluntary mental health treatment. And the Department remains committed to robust enforcement of the civil rights laws that bar discrimination based on disability by entities that receive funding from the Department.

Summary:
This rule applies only to providers who either make the mental health determinations that disqualify individuals from having a firearm or are designated by their States to report this information to NICS.

The rule does not apply to most treating providers.

Drug Testing – Watch your coding

Posted on January 6, 2016January 6, 2016 by kellyausiello

Your HCPCS level II code books are incomplete.
The Centers for Medicare and Medicaid Services released 49 corrections to the 2016 HCPCS Level II code set December 2, too late to be included in any of the hard copy code-books. You will also be hard pressed to find many of these corrections in the Medicare guidelines even though the codes became effective on January 1, 2016.

DRUG TESTING Codes: 2016 Replacement Codes for G0431 and G0434

Effective for the dates of services from January 01, 2016 CMS implemented the following changes for drug testing;

1. Deleted the HCPCS codes G0431, G0434 and G6030 through G6058

2. Continue to not recognize the AMA CPT codes 80300 – 80377

3. For presumptive testing, created three G codes:

G0477 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service

G0478 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service

G0479 – Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service

4. For definitive drug testing, created four tiered G codes:

G0480 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed

G0481 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed

G0482 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed

G0483 – Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed

Guidelines to report Presumptive Testing;

Presumptive codes G0477 – G0479 is eligible for reimbursement when testing is performed in an office, laboratory or facility setting. These codes are not eligible for reimbursement for chemical dependency facilities. Reimbursement for procedure codes G0477 – G0479 is limited to one unit per day. Only one of the three codes may be billed per day.

Guidelines to report Definitive Testing;

The definitive tests must be both more sensitive and specific than the initial screen. Reimbursement for procedure codes G0480 – G0483 is limited to one unit per day. The unit used to determine the appropriate code to bill is “drug class.” The number of drug classes tested determines the appropriate code to use. Each drug class may only be used once per day. Only one of the four codes may be billed per day.