Cashing in on a new set of patients

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1 Vol. 11 No. 8 August 2006 INSIDE No more billing blunders Learn what changes Medicare made to its billing system on p. 5. Take the coding test Test yourself and your staff by taking our coding and billing quiz on p. 6. Attempt to code the five scenarios and then discover how accurate you were with the answers and rationale on p. 9. NPI update Are you on top of your NPI number and incorporating it into your systems? Learn whether you are and what you need to do if you re not on p. 7. Also find out how to apply for an NPI if you haven t already done so on p. 8. BRRR coding corner Can an SLP charge for CPT codes and on the same day? Can a PT bill for codes and on the same day? Rick Gawenda, PT, lets you know on p. 10. BRRR Q&A Turn to p. 11 to get insight from columnist Nancy J. Beckley on documenting for automatic exceptions to the therapy caps and how the CERT affects rehab providers. FOR PERMISSION TO REPRODUCE PART OR ALL OF THIS NEWSLETTER FOR EXTERNAL DISTRIBUTION OR USE IN EDUCATIONAL PACKETS, PLEASE CONTACT THE COPYRIGHT CLEARANCE CENTER AT OR 978/ Cashing in on a new set of patients The world of reimbursement is changing. If your facility wants to succeed, you need to change with it, according to Jim Nugent, director of reimbursement for the American Physical Therapy Association (APTA) in Alexandria, VA. Nugent spoke during APTA s annual conference on June 23 in Orlando, FL. Insurance companies are paying lower reimbursement rates these days, while at the same time, fewer patients have insurance, he said. The combination of lower reimbursement rates and fewer people with insurance means that it is crucial to find other methods of payment (e.g., cash-paying patients), he said. We are too comfortable with insurance, even though it s not automatically a good deal. Taking on more cash patients is vital, and not too difficult, although it does take preparation. In this age of higher deductibles and copays, patients are growing more accustomed to paying for their medical services, which can help you make the transition to more cash-based business. Many consumers have no problem dishing out monthly fees to gyms and personal trainers (who are usually not as qualified as a PT or OT to get consumers into good physical shape). Encourage potential cashpaying patients to use their money on your services instead. Dealing with dollars Prior to taking on more cashpaying customers, you will have to educate the following people, Nugent said: Improving your facility s atmosphere Tips on how to make patients enjoy going to therapy Finding ways to save money in your rehab facility can be important to the bottom line. But cutting costs should not come at the expense of making your facility a less enjoyable place to work and seek treatment, says Dick Hillyer, PT, MBA, MSM, a rehab consultant at Hillyer Associates in Cape Coral, FL. The customer has a choice of therapists, but not all rehab providers realize that, says Hillyer. Excellent > p. 2 treatment only gets you so far if your facility is depressing to go to. Keeping the facility well-lit is the simplest way to keep morale up, Hillyer says. I ve been in clinics where morale was down, and a big part of it was the company was trying to save money by keeping the lights off or dim as much as possible. That just makes for an oppressive environment for everyone. > p. 4

2 Cashing in < p. 1 Insurers They may offer better contracts if they learn that you are getting better reimbursement elsewhere. Referral sources If you re trying to limit insurance customers, you ll want to let your primary referring physicians know so they can send you patients who are willing to pay cash. If certain referral sources routinely send you patients that have insurers with low fee schedules, consider getting new referral sources if possible. Staff You ll have to undergo changes to your intake, bookkeeping, and banking when you start receiving more payments up front from patients, and not insurers. Yourself and other management personnel A cash-based customer plan will require more marketing efforts directed at patients rather than physicians and insurance companies. Remember: When we say cash, we are talking about any form of payment from the customer directly. This includes check, credit card, debit, and actual cash. Excluding any form of payment will make it difficult to increase your cash-paying customers. Pulling in the patients You are likely to see three types of patients willing to pay cash for your services, including patients with no insurance at all insurance that doesn t cover a particular service insurance that you do not accept (these patients will still typically file claims with their insurers) In all three cases, the most important thing to remember is to either obtain the payment at the time of service or have the patient sign an agreement on when he or she will pay, Nugent said. In instances in which the patient has insurance but you don t accept it, or the insurance won t pay for a particular service, you must sit down with the patient and explain why the therapy will still be beneficial and how you can work with him or her on payment options. Keep in mind that many patients do not really know what therapy is all about. These patients may be willing to pay for routine massages and chiropractic treatments yet doubt the need for PT or OT services. Let s say a patient wants to strengthen his shoulder to improve his tennis game. Insurance wouldn t cover that, and the person might be willing to pay a personal trainer. PTs and OTs have to look at that person as a potential client, Nugent said. It may seem strange to have to sell your facility or specialty to a patient, but if the services will truly help the patient, you aren t doing anything unethical, Nugent said. Regarding concerns over the cost of therapy, there are several options that could reduce patient costs while still being beneficial to your facility, including fewer visits weekly, but over a longer time period more intense but less regular visits increased, but appropriate, use of group sessions more frequent use of PT assistants The price is right One of the key aspects of asking patients to pay cash for your services is setting the right price. This is why it s important to know all of your other payer contracts thoroughly. Some contracts may specifically state that you cannot offer your services for less than you are receiving from the payer or may include other similar language. When setting up your cash-based fee schedule, consider charging per service visit episode Each option has pros and cons for you to think about, so weigh them before deciding. If you are thinking about setting a fee schedule based on each service, remember that although this helps patients who will also be filing with insurance, it increases the likelihood of patient insurance fraud and the chance that other insurers will learn what you are charging. Page HCPro, Inc.

3 However, this option best corresponds to your actual efforts: The more services you do, the more you bill. If you charge on a per-visit basis, you might lose money on timely procedures that use expensive equipment. However, this method is patient-friendly because it allows patients to know exactly what they ll pay for each visit. When charging on a per-visit basis, you should use general descriptions to describe the services you performed, such as 45 minutes of exercise, said Nugent. In this case, you don t have to worry about CPT codes because patients will not understand them anyway. The final option is episode pricing, in which you set up a price for the entire treatment course. This is an option primarily in cases for noncovered benefits in which you are providing services similar to those of a trainer or wellness coach, according to Nugent. You can set up a payment plan, making things easier on the patient. However, a payment plan may make it harder for patients to file claims. Also, you may have to adjust the fee for every patient because it s rare that any episode will be the same. You also run the risk of losing money if the treatment takes longer than expected. One last option to consider is to simply take your normal fee schedule and offer an automatic cash discount. Again, this could get you into trouble with other payers if you aren t careful with your contracts. It also might not be necessary because it s likely that some patients will pay your full fee. However, it is a good incentive to get people thinking about paying cash in the first place. Final tips When deciding whether or not to add more cash business to your facility, take into account that the best reason to do so is the potential for additional business. You ll probably always have to take insured payers, but if you can add patients who are willing to pay cash to improve athletic performance or their overall health, you will be adding an additional income base without having to deal with the hassles of insurance companies trying to cut the services they cover and the amount they reimburse for services. You ll most likely run into some issues when you begin trying to increase your cash business (e.g., your bookkeeper may not like the change, and you may have to spend more on your legal team to ensure you adhere to already-signed contracts), but it may be necessary to survive in the long run, said Nugent. However, whatever you do and however you charge, be sure to maintain high-quality documentation and high standards of care, Nugent said. BRRR Subscriber Services Coupon Start my subscription to BRRR immediately. Options: No. of issues Cost Shipping Total Print 12 issues $249 (BRRRP) $24.00 Electronic 12 issues $249 (BRRRE) N/A Print & Electronic 12 issues of each $299 (BRRRPE) $24.00 Order online at Be sure to enter source code N0001 at checkout! Sales tax (see tax information below)* Grand total For discount bulk rates, call toll-free at 888/ *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CT, FL, GA, IL, IN, KY, MA, MD, MI, NC, NJ, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone address (Required for electronic subscriptions) Fax Payment enclosed. Please bill me. Please bill my organization using PO # Charge my: AmEx MasterCard VISA Signature (Required for authorization) Card # (Your credit card bill will reflect a charge to HCPro, the publisher of BRRR.) Expires Mail to: HCPro, P.O. Box 1168, Marblehead, MA Tel: 800/ Fax: 800/ customerservice@hcpro.com Web: HCPro, Inc. Page 3

4 Atmosphere < p. 1 It may seem as though you re wasting electricity by leaving lights on in rooms where no one is working, but by turning the lights off, it gives the impression that you re closing or lacking in patients. It may also keep patients in the dark about the services you offer. Keeping the lights on in a treatment room might allow a patient to see a piece of equipment that prompts him or her to start asking questions about therapy in general. And the more the public knows about therapy, the better it is for business. The four Cs Making your facility brighter isn t the only way to improve the atmosphere, however. Creating an environment that is conducive to healing is an ongoing process, but one way to start is by using the four Cs, according to James E. Glinn, DPT, OCS, president of San Luis Sports Therapy & Orthopedic Rehabilitation in San Luis Obispo, CA. Glinn says the four Cs include the following: Conversation Cleanliness Catering Creativity Incorporating the four Cs into your facility will take time, but Glinn has seen it work in the practices he runs. Atmosphere requires creativity and innovation, and so often these are the areas [in which] individuals with a clinical background falter, Glinn adds. You can provide great clinical care, but if your facility is dull and dirty, in the end it will not matter. Something to talk about Good conversation leads to many positive effects on a facility, says Glinn. It allows therapists and patients to interact, leading patients to feel as though they are a part of the facility. Therapists should try to learn something personal about their patients during conversation, while avoiding controversial subjects (e.g., religion and politics), Glinn says. If patients feel as though their therapist cares about them, they are more likely to keep appointments and be on time. This requires therapists to be thoughtful and truly listen to their patients. It s important to follow up and build on patient/therapist conversations. It will strike a false note if on the patient s next visit, the therapist doesn t remember anything about the last session other than the treatment in his or her notes. For example, if the therapist asks in one visit whether a patient has children, and in the next visit asks the same question, the patient could easily be put off. Creating an ambience Perhaps the most important aspect of your facility s overall atmosphere is how it looks. Keeping the lights on is part of that, but so is cleanliness. It s unprofessional to have equipment strewn all over the floor or have a patient enter a room that hasn t been picked up yet from the last patient. This is where having a trusted technician or therapy aide is invaluable. It s inefficient for therapists to pick up after every patient, so the extra cost of an aide is well worth it, Hillyer says. Your facility should appear clean from the moment a patient pulls into the parking lot, says Hillyer. Trash in front of your entrance is almost as bad as a mess inside. The same goes for your facility s restrooms and waiting room. Keeping your office clean is only part of the overall ambience. Although it may seem unimportant in the overall treatment of your patients, making the facility look good aesthetically plays a large part in a patient s view of your practice, says Hillyer. Consider hiring an interior decorator, Hillyer adds. They re experts at figuring out what color schemes work for what you want. Certain colors will have a calming effect on patients, whereas others may make them feel energized. Page HCPro, Inc.

5 Factor in the purpose of individual rooms when selecting colors for the rooms. A decorator can also help you choose the furniture and layout for the waiting room, as well as artwork and other details that may seem inconsequential to therapy but are key for customer relations, Hillyer explains. The fastest way to a patient s heart An important aspect of any therapy treatment is keeping the patient focused. That can be hard to do if the patient has an empty stomach and is thinking about what s for lunch. It won t cost you too much money to have some type of refreshment table in your facility where patients can grab a snack or beverage, says Glinn. Most facilities offer water, but it doesn t take much more effort to provide coffee and some type of juice. Rehabbing an injury can take a lot of work and energy. Providing a few baked goods or pieces of fruit to patients might be just what patients need to keep up their energy for those last exercises. Keep the snacks and beverages healthy and don t go crazy paying for fancy pastries. A little bit of food is a nice gesture to your patients. Put the right side of your brain to work The final C in Glinn s model will vary according to the image that you want your facility to portray, but he says to maximize your success, you must use your creativity to keep patients interested in attending therapy. One way to mix things up is to host facility events in which patients and staff get together for some fun, whether at a cookout or bake-off, Glinn suggests. It all goes back to making your patients feel like a part of your facility s family. You could also offer contests (e.g., raffles or games) that patients can participate in during appointments. Other ways to get creative include the following: Hold therapy sessions outside on nice weather days; this even has clinical benefits for some patients, such as those relearning to walk on different surfaces Installing televisions in exercise areas to give your facility more of a gym feel Have a flat-screen television or Internet-ready computers in the waiting room Install stereos in each room so patients can listen to music Make sporting activities (e.g., playing catch or swinging a golf club) part of the treatment. The most important thing you can do is to give your patients a good experience from start to finish of every appointment, says Hillyer. That begins with the facility s appearance and covers everything from frontline staff s attitude, the chemistry of the entire staff, and making each patient s experience customized to the individual. Medicare fixes two billing problems CMS recently took steps to resolve two billing problems that were causing confusion for rehab providers, according to PT Bulletin Online. The agency instructed fiscal intermediaries and home health intermediaries to begin reprocessing claims for electrical stimulation (HCPCS code G0283) when billed with treatment for swallowing dysfunction or oral function for feeding (CPT code 92526). Prior to the change, an erroneous Correct Coding Initiative edit caused claims with both codes to be denied after January 1, reported PT Bulletin Online. CMS also corrected an inconsistency between the Medicare benefits manual and the manuals for claims processing and national coverage determination that caused many carriers and intermediaries to require the date a patient was last seen by a referring physician on the claim form, even though the benefit manual no longer requires a physician visit before treatment begins. The correction does not apply to therapy services provided incident to, which still require a prior physician visit HCPro, Inc. Page 5

6 Put your coding skills to the test How well do you know your coding and billing? Rick Gawenda, PT, director of rehabilitation services for Detroit Receiving Hospital and owner of Gawenda Seminars ( in Ypsilanti, MI, created the following billing scenarios to test your reimbursement knowledge. Use this test to determine how much you and your staff know about correct coding and billing. Assume that all of the patients in the examples are Medicare beneficiaries. Based on the treatment provided in the examples, determine which CPT codes you would bill and how many units to bill for each CPT code. Answers are on p You are treating a 63-year-old female following a left cerebral vascular accident three weeks ago. Treatment today consisted of 15 minutes of transfer training in preparation for gait 10 minutes of pregait activities on the parallel bars 25 minutes of range of motion (ROM) and strengthening exercises on a mat table 10 minutes of postural and balance exercises while sitting 2. You evaluate and treat an 82-year-old male with an open wound on his left calf due to arterial insufficiency. Treatment today consisted of 25 minutes on a PT evaluation 10 minutes of sharp debridement (total wound surface of 15 sq cm) 20 minutes of whirlpool to same wound that was debrided 15 minutes of gait training with a walker 3. You are treating a 79-year-old female following a left total knee replacement 12 days ago. Treatment today consisted of 15 minutes on a treadmill for warm-up 35 minutes of left extremity strengthening and ROM exercises 20 minutes of balance exercises using the Baps Board and trampoline 4. You are treating a 54-year-old female with an acute exacerbation of multiple sclerosis. Treatment today consisted of 15 minutes of activities for daily living (ADL) for dressing 10 minutes of ADL for feeding 25 minutes of bed mobility and transfer training to and from wheelchair and bed 15 minutes of training the caregiver in dressing techniques 10 minutes of OT reevaluation 5. You are treating a 65-year-old male following a cerebral vascular accident three weeks ago. Treatment today consisted of 40 minutes of speech evaluation 20 minutes of speech treatment focusing on voice and communication 10 minutes of instruction to the patient in a home exercise program Editor s note: The preceding coding and billing scenarios come from HCPro s new book Coding and Billing for Outpatient Rehab Made Easy: CPT Codes, Modifiers, and ICD-9 Codes by Rick Gawenda, PT. For more information or to order your copy, call our Customer Service Department at 800/ , or visit our online store at Page HCPro, Inc.

7 Start your transition to NPIs now May 23, 2007, is the date that rehab providers must begin using their national provider identifiers (NPI) to identify themselves in standard transactions. It may seem like a long way off, but there s a lot of work to do. And applying for an NPI is only one step. Without the proper preparation, your organization will not only be out of compliance, but it won t get paid either, says Susan Miller, JD, independent consultant and chief operations officer at HealthTransactions.com in Concord, MA. Your implementation plan should involve many different members of your facility, which in a hospital includes your director of rehabilitation, health information management director, credentialing/contracts staff, chief information officer, chief financial officer, privacy official, and information security officer (ISO), says Miller. And it should include the following steps: Get buy-in from management Look at your organization s governance Determine need for NPI subparts Apply for NPI Look at all contracts Cross-map old identification numbers to NPIs Determine systems impact Test with payers Designate an NPI project manager and ask the main person or people who deal with health plans and processing claims to participate in the project, says Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, OR. The ISO and compliance officer should also get involved when there are changes to applications, he says. That way, they can make sure the organization maintains sufficient security. One of the biggest barriers to NPI implementation is that it covers all transactions, so you have to test NPIs with all of the health plans that you work with, Apgar says. You have to make sure your numbers work with your software and then coordinate with payers. You may have applications that aren t compatible they won t accommodate or communicate your NPI so you may have to change vendors or applications. Talk to payers to learn what information you will need to include in transactions to get the same payment you re getting now, says Apgar. This is especially critical with Medicare and Medicaid because there are so many legacy numbers. It s not that transactions are going to be totally different, but the NPIs will not contain some of the information contained in legacy numbers, such as location, contract information, and fee schedule, he says. Providers should already have an inventory of all their applications and their ability to handle NPIs, says Apgar. They should now be contacting and negotiating with payers to address their internal and external concerns and to set a timeline for testing. Bulk enumeration Larger organizations have been reluctant to apply for NPIs because they re waiting for bulk enumeration, says Apgar. Bulk enumeration, also referred to as electronic file interchange, is a process by which a healthcare provider or group of providers can have an organization apply for NPIs on their behalf. A file can contain thousands of providers applications, so the administrative burden on providers and CMS is greatly reduced with this process. CMS expects it to be ready by late spring. Some have estimated that, overall, enumeration is going so slowly that it won t be finished until 2013, says Miller. But just because CMS is behind, don t expect a delay on the May 2007 compliance date, says Miller. Apgar agrees. Ultimately, it will depend on Medicare s and Medicaid s ability to accept NPIs, he adds. The end of a legacy Payers want the transition to NPIs to be successful. If a provider uses an NPI incorrectly or does not include all of the information needed to process the claim without the legacy number, the payer may have to process the claim manually because it is missing information, says Apgar. And having to spend staff time doing such extra work can get expensive. > p HCPro, Inc. Page 7

8 NPIs < p. 7 To prevent errors, develop a database of legacy numbers as they relate to the NPIs, he says. Eventually, you ll transition from the legacy numbers to the NPIs, but you may need to use your database to identify missing information when you first begin testing and after going live with NPI numbers. Testing Testing with payers is an important step in the transition process. And if you work with clearinghouses, billing services, or third-party administrators, you will need to involve them. For larger organizations, this can be a long process. But regardless of your organization s size, you need to make sure that you re communicating information in claims and transactions accurately, says Suzanne Stewart, electronic data interchange coordinator at Aurora Health Care in Milwaukee. Stewart is currently working on the enumeration phase of the organization s implementation plan and has also been working with health plans to determine what identifiers they currently use. Many times, what you have in your system as active identifiers is not what the health plans have as identifiers in theirs, or vice versa, she says. And building that list of current legacy identifiers and crosswalking those to the NPIs are important steps in the testing process. Then, full testing is critical. Not only should you be concerned with how the health plans are processing the NPIs you re sending, you also need to make sure health plans are sending back the correct NPIs on remittances. If they re not, it s a good indication they re not processing claims correctly, Stewart says. A lot of providers don t understand the process of NPI implementation, she says. Many believe the project is simple you get an NPI, plug it in, and you re done. There will be a period during which many providers go into panic mode, she says. Don t let that happen to you organization. Create a checklist of the transactions that you need to test and with whom. And leave time to address changes. NPIs have even more of an impact on providers than HIPAA s transactions and code sets rule because if providers aren t ready, they won t get paid correctly, says Stewart. That s why you need to communicate with health plans and trading partners early. How long it takes to complete testing will depend on what transactions you re doing, the number of health plans you re testing with, and whether you need updates from software vendors. Applying for your NPI The National Provider Identifier (NPI) is a 10-digit numeric identifier that will be used as the standard identifier on all claim forms once it is fully implemented by CMS and the National Provider System. It is required for all individual rehab providers beginning May 23, The application process began in May 2005 and can be done either online or on paper. Currently, an electronic application process is underway. To complete the application online, go to NPPES.cms.hhs.gov. To request a paper application, call There are two categories of NPIs: Entity type code 1 for individual therapists and SLPs Entity type code 2 for healthcare provider organizations All HIPAA-covered healthcare providers must obtain NPIs. All individual therapists must have their own NPIs even though the organization they work for will have one as well. Until NPIs are fully implemented, providers who already have an NPI should continue using their regular identifier numbers in conjunction with the NPI. Page HCPro, Inc.

9 Coding and billing test solutions Here are the answers to the test on p Answer: You could bill for this scenario in one of three ways: Two units of (therapeutic exercise), one unit of (neuromuscular reeducation), and one unit of (gait training) Two units of and two units of One unit of 97110, one unit of 97112, and two units of Rationale: The total treatment of timed CPT codes is 60 minutes. Using Medicare s eight-minute rule, you can bill four units. You spent 15 minutes on transfer training in preparation for gait, plus 10 minutes working on pre-gait activities on the parallel bars, for a total of 25 minutes of treatment focused on gait. You also spent 25 minutes on range of motion (ROM) and strengthening exercises and 10 minutes working on sitting balance. 2. Answer: The correct answer is one unit of (PT evaluation), one unit of (wound care selective; removal of devitalized tissue from wounds less than or equal to 20 sq cm), and one unit of (gait training). Rationale: The total treatment time of timed CPT codes is 15 minutes. Using Medicare s eight-minute rule, you may bill one unit of timed CPT codes. Because the only timed service provided was gait training, CPT code would be the timed CPT code billed. You would bill codes and one unit each because they are both untimed. Bill one unit of code since the total wound surface area is less than 20 sq cm. You would not bill code because the whirlpool charges are included in the reimbursement for Answer: In this example, you could either bill three units of and one unit of or two units of and two units of Rationale: The total treatment of timed CPT codes is 55 minutes, so you may bill four units of timed CPT codes. Do not include the 15 minutes of treadmill for warming up in the sum of timed CPT codes, as this time is nonskilled therapy, and Medicare will not reimburse for it. Because you spent at least 30 minutes on strengthening exercises and 15 minutes on balance exercises, bill at least two units of and one unit of This leaves five minutes left over of both and Determine which is the most appropriate code to bill, based on the treatment provided and document to support the charges. 4. Answer: Your two options in this example are either three units of (self care/activities of daily living training), which requires modifier -59 for one unit of (therapeutic activities), and one unit of (OT reevaluation), which also requires modifier -59; or two units of 97535, which requires modifier - 59, two units of 97530, and one unit of 97004, which also requires modifier -59. Rationale: The total treatment of timed CPT codes is 65 minutes, so you may bill four units of timed CPT codes. The time spent performing the OT reevaluation is not counted in the total because it is an untimed CPT code. You spent a total time of 40 minutes on dressing and feeding, so you would bill at least two units of You also spent 25 minutes of transfer training, which is considered a functional activity, so you would bill at least one unit of That leaves one more unit to be billed. You have 10 minutes of dressing and feeding time left and 10 minutes of transfer training time. Determine which is the most appropriate code to bill, based on the treatment provided. The documentation must indicate that the services were performed at separate and distinct times from the other services billed on that date to append modifier Answer: You would bill for one unit of (speech therapy evaluation) and one unit of (speech therapy treatment) in this instance. Rationale: Speech evaluation and speech treatment are both untimed CPT codes, so regardless of the amount of time spent providing each service, you may only bill one unit of each HCPro, Inc. Page 9

10 BRRR coding corner Editor s note: This column appears monthly in BRRR to help answer subscribers coding questions. Rick Gawenda, PT, director of rehabilitation services for Detroit Receiving Hospital and owner of Gawenda Seminars ( in Ypsilanti, MI, answered the coding questions below. Submit questions to Associate Editor Kevin Moschella at kmoschella@hcpro.com or fax questions to 781/ Q: Can an SLP charge for cognitive skills (CPT code 97532) performed on the same day as CPT code 92507? A: Under the current version of the Correct Coding Initiative (CCI) edits (Version 12.3), development of cognitive skills (CPT code 97532) is considered a component of the more comprehensive code, speech treatment (CPT code 92507). The CCI edits do allow the use of modifier -59 when these two procedures are provided on the same day to the same Medicare patient by the same provider. The provider would have to append modifier -59 to on the claim form in order to receive reimbursement for both procedures. Documentation would need to support that both procedures were medically necessary and provided at separate and distinct times. In addition, the documentation would need to clearly support versus and/or To view the most current version of the CCI edits on the CMS Web site, go to NationalCorrectCodInitEd. Private practices and physician-owned clinics should click on NCCI Edits Physicians, whereas all other settings should click on NCCI Edits Hospital. You also want to check with your Medicare contractor to see if it allows SLPs to bill and be reimbursed for You can find this information in your specific Medicare contractor s local coverage determination for speech therapy. Q: Do the CCI edits state that you can t bill therapeutic activity (CPT code 97530) and manual therapy (CPT code 97140) together on the same day if performed by the same provider? A: Under the current version of the CCI edits (Version 12.3), therapeutic activity is considered mutually exclusive of manual therapy. This means that therapeutic activity and manual therapy cannot be reasonably provided to the same Medicare patient by the same provider on the same day of service. The CCI edits do allow the use of modifier -59 when these two procedures are provided on the same day to the same Medicare patient by the same provider. The provider would have to append modifier -59 to on the claim form in order to receive reimbursement for both procedures. Documentation would need to support that both procedures were medically necessary and provided at separate and distinct times. Q: Is there a specific CMS reference regarding the ability to accept stamped dates/dated fax receipts for certification dates? A: As of July 2006, there is no specific reference from CMS. Individual Medicare contractors may or may not have a specific reference regarding the use of a stamped date or dated fax receipt for certification dates. Page HCPro, Inc.

11 BRRR Q&A Editor s note: Nancy J. Beckley, MS, MBA, president of Bloomingdale Consulting Group in Brandon, FL, answered the questions below. Please submit questions to Associate Editor Kevin Moschella at kmoschella@ hcpro.com. Q Do we need to send our Medicare payer documentation for Medicare s therapy caps automatic exceptions process? Or do we just send the documentation for the manual exceptions that we are requesting? A Your Medicare payer (either the fiscal intermediary [FI] or the carrier) should provide specific instructions on the exceptions process. As a general rule, therapy clinics do not have to send the documentation on the automatic exceptions process to the payer. However, the documentation must be available in the chart for review if requested. With requests for the manual exceptions process, it is important to follow the specific instructions that your payer provides. For example, First Coast Service Options in Florida (both the carrier and the FI) provides a form on its Web site for providers to use as the cover page for faxed documentation. First Coast is offers several different fax numbers to send requested manual exceptions. The cover page details the items that must be included in the fax in order for a manual exception to be considered. On the other hand, Mutual of Omaha does not accept faxed requests and strongly discourages requests that are sent by overnight and express delivery services. It has provided three different cover pages (i.e., physical therapy, occupational therapy, and speech therapy) to be included with the requested documentation. Instead, Mutual of Omaha accepts requests via its post office box. With First Coast in Florida, it will probably take a day or two to hear back on your request from the time you fax it in; however if you are covered by Mutual of Omaha, plan on at least a week to process something sent by mail. If you cannot find the process specific to your payer, try using the search engine on the payer s Web site and look for therapy caps exception. Q A What is CERT, and how does it involve rehab providers? The Comprehensive Error Rate Testing program (CERT) calculates the paid claims error rate for Medicare claims submitted to Medicare contractors. CERT randomly selects a statistical sample of Medicare annual claims for review to determine whether the claims were paid properly. The CERT program uses two contractors to accomplish this task: the CERT Review Contractor and the CERT Docu-mentation Contractor. The CERT Review Contractor is responsible for reviewing the selected claims and associated medical record documentation. The CERT Documentation Contractor is responsible for requesting and receiving the medical record documentation from providers. The CERT Documentation Contractor call center operation attempts to make an initial telephone contact with the provider to explain the program and then follows up with a faxed or mailed medical record request letter. In regard to rehab providers, if you receive a call from the CERT documentation center, it will ask you to send medical records for review under the CERT program. It is your responsibility to comply with the request and provide the documentation for the CERT Review Contractor. The most important thing that rehab providers can do in anticipation of a review request is to ensure that the address and phone number for their clinic or administrative office is correct. This does not have to be the location where therapy is performed. You can do this by visiting the CERT provider portal Web site at You will have to enter your provider number, and then you can verify that the correct contact information is listed in the event that the CERT program request documents from your facility HCPro, Inc. Page 11

12 News briefs Professional organizations form coalition The American Physical Therapy Association, American Occupational Therapy Association, and American Speech-Language-Hearing Association partnered with more than 40 other organizations to form a coalition urging Congress to extend the Medicare therapy cap exceptions process two tiers beyond Without action, the exceptions process will expire on December 31. MedPAC calls for pilot studies to improve therapy data The Medicare Payment Advisory Commission (MedPAC) suggested that CMS conduct pilot studies to evaluate methods for improving collection of data before the agency attempts to revise Medicare s system of paying for outpatient therapy services. The suggestion is based on findings that show that Medicare spending on outpatient therapy services has doubled since MedPAC found that about 12% of Medicare beneficiaries use outpatient therapy. Private practices treated the largest number of beneficiaries, seeing 24% of the population receiving therapy, followed closely by nursing homes (23%) and hospital outpatient departments (19%). Physician sentenced for defrauding CMS A Texas physician was sentenced to 11 years and three months in prison for his participation in a scheme to defraud Medicare and Medicaid, according to a U.S. Department of Justice (DOJ) report. Anant Mauskar is in part responsible for more than $15 million in losses to the two healthcare benefit programs. Mauskar signed forms stating that he personally evaluated and supervised physical therapy services that either never took place or were performed by unqualified people. Mauskar received payments of $500 per month for his signature, which allowed owners of the physical therapy clinics to bring in more than $1 million, reported the DOJ. CPT codes, descriptions, and material only are Copyright 2001 American Medical Association (AMA). All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. BRRR Editorial Advisory Board Contributing Editor: Nancy J. Beckley, MS, MBA Bloomingdale Consulting Group Brandon, FL Kate Brewer, PT, MBA, GCS Director of Clinical Serves and Program Development Greenfield Rehabilitation Agency Greenfield, WI Tessa Chenaille, CHC President and CEO Chenaille Compliance Consulting, LLC Medford, MA Peter Clendenin Executive Vice President National Association for the Support of Long Term Care Alexandria, VA Rick Gawenda, PT Director of Rehabilitation Services Detroit Receiving Hospital Detroit, MI Peter R. Kovacek, MSA, PT President Kovacek Management Services, Inc. Harper Woods, MI David O. Lane, PT, MHS Manager of Compliance Chart Links, LLC New Haven, CT Ken Mailly, PT Mailly & Inglett Consulting, LLC Wayne, NJ Christina Metzler Chief of Public Affairs American Occupational Therapy Association Bethesda, MD Angie Phillips, PT President and CEO, Images and Associates Amarillo, TX Lynn Steffes, PT President, Steffes & Associates New Berlin, WI We want to hear from you... For news and story ideas: Contact Associate Editor Kevin Moschella Phone: 781/ , Ext Mail: 200 Hoods Lane, Marblehead, MA kmoschella@hcpro.com Fax: 781/ Group Publisher: Paul Amos Online resources: RehabRegs (free weekly e-zines): Rehab Talk (online talk group): kmoschella@hcpro.com Access to past issues: Subscriber services and back issues: For new subscriptions, renewals, changes of address, back issues, billing questions, or permission to reproduce any part of BRRR, please call customer service at 800/ Briefings on Outpatient Rehab Reimbursement & Regulations (ISSN ) (USPS ) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA Subscription rate: $249 per year. Periodicals postage paid at Marblehead, MA and other mailing offices. Postmaster: Send address changes to Briefings on Outpatient Rehab Reimbursement & Regulations, P.O. Box 1168, Marblehead, MA Copyright 2006 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com. Visit our Web site at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. Opinions expressed are not necessarily those of BRRR. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Page HCPro, Inc.