Medicare Billing Risks and How To Avoid Them. December 11, 2012 Featuring Guest Presenter: Nancy J. Beckley, MS, MBA, CHC

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1 Medicare Billing Risks and How To Avoid Them December 11, 2012 Featuring Guest Presenter: Nancy J. Beckley, MS, MBA, CHC

2 Welcome This session will be recorded Link to the recording and resources will be ed to all registrants Jim Plymale CEO Clinicient Questions can be asked in the Question panel We ll leave 15 minutes at the end to answer questions 2

3 How We Got Here. Stop the Therapy Cap: Now is the time to take action Three webinars How to Survive the Therapy Caps & Manual Medical Review (MMR) Process Documentation According to the World of MMR MMR: What We Know Now and Can Expect in 2013 Coming Next: Jan. 10 th G codes, Functional Limitation Reporting and PQRS Things to Know for 2013 Resource Page: resources/ 3

4 Welcome Nancy Compliance expert in the Rehab industry; certified in healthcare compliance Specializes in providing compliance program development for outpatient therapy and DME providers Popular industry speaker and author on compliance topics related to outpatient therapy Nancy Beckley President Nancy Beckley and Associates Serves as a Compliance columnist for IMPACT the magazine of the APTA Private Practice Section 4

5 Today s Objectives The risk of therapist's documentation not matching the claims The hidden danger and common practice of inadvertently submitting false claims The importance of appropriately accounting for therapist's time, properly applying CCI edits and aggregating units correctly What you need to know about RAC audits in 2013 Fourth in a series of Compliance Webinars 5

6 The Elephant Again. Functional Reporting 42 New Therapy only codes G codes, modifiers Transmittals, MLN Article Transmittal R163B Transmittal R2603CP MM #8005 6

7 G Codes & Severity Modifiers FINAL CMS mandated to collect information on function and condition Non payable G codes and modifiers will now be included on claims Onset of every therapy episode Every 10 th visit at a minimum (new progress reporting period beginning 1/1/13) Discharge Therapist s projected goal for discharge 1 st claim for services, and at the end of the episode January 1 st start date, July 1 st mandatory report Grace period to test 2013 MPFS Final Rule 11/1/2012 7

8 OIG Compliance Guidance WHAT IS RISK? 8

9 OIG Risk Assessment The OIG recognizes that many.practices may not have in place standards and procedures to prevent erroneous or fraudulent conduct in their practices. In order to develop standards and procedures, the. practice may consider what types of fraud and abuse related topics need to be addressed based on its specific needs. One of the most important things in making that determination is a listing of risk areas where the practice may be vulnerable. 9

10 OIG: Four Areas of Practice Risk Coding & Billing Improper Inducements Reasonable & Necessary Documentation 10

11 OIG Work Plan 2013 The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. In the past, the OIG has identified claims for therapy services provided by independent physical therapists that were not, medically reasonable and necessary, or properly documented. They will focus on independent therapists who have a high utilization rate for outpatient physical therapy services because of their concern that they may not be medically reasonable and necessary. 11

12 Do You Know Where Your Risks Are? Regulatory Credentials Medical necessity Supervision Documentation Therapy Cap Students MAC MR Program KX Modifier Profiling CERT Errors LCD ICD 9 Map Internal Monitoring findings Audit findings EMR issues HR issues Billing issues 12

13 Identifying Practice Risk The OIG recommends that a. practice focus first on those risk areas most likely to arise in its particular practice. 13

14 HealthSouth The Wagon to Disaster 14 What is right is right, even if no one is doing it. What is wrong is wrong, even if everyone is doing it. 14

15 CAPTURED: Jose Diego Calero 15 In August 2009, Jose Diego Calero was indicted on charges of Health Care Fraud, Money Laundering, and Forfeiture. Calero allegedly submitted more than $4.8 million in claims to Medicare for physical and occupational therapy services that either were not prescribed by doctors or were not provided as claimed. Calero was the Director of Premier Quality Physical Therapy, Inc., a Floridabased company that purportedly provided physical therapy and occupational therapy services to Medicare beneficiaries. Investigators believe that from approximately Sept 2008 to Feb 2009, Calero caused Premier to submit more than $4.8 million in false claims to Medicare, for which he received more than $2.7 million in payments. 15

16 Calculated Risk? TACOMA PHYSICAL THERAPY firm required to pay more than $655,559 for healthcare fraud STAR Physical Therapy billed state and private health plans for bogus private therapy sessions.instructed employees to fill out the billing code for private aquatic therapy sessions when patients had actually been treated in a group session 1 group session billed as if 9 hours of therapy During the period of the fraudulent billing, NANCY WONG served on the Washington State Board of Physical Therapy $50,000 fine and double damages Source: US Attorney s Office: 11/18/

17 Calculated Risk? CARLSON THERAPY NETWORK has entered into a civil settlement agreement with the Government in which it has paid $1,886, to resolve allegations that it violated the False Claims Act by submitting false claims to various Government health care programs. The Government alleged that, on numerous occasions, CTN billed for direct, one on one care when such services were not provided. CTN therapists would routinely provide therapy services to multiple patients at the same time, but would bill Government health care programs, such as Medicare and Tricare, as if the therapist was providing direct, one on one care. Source: US Attorney s Office, District of Connecticut 9/22/

18 Calculated Risk? BENCHMARK PHYSICAL THERAPY, has entered into a settlement with the United States and the State of Tennessee to pay over $1.8 million resolving allegations that it improperly billed the Medicare and TennCare/Medicaid programs for physical therapy services in violation of federal and state laws and regulations Benchmark submitted claims representing provided therapeutic exercise for TennCare patients when medical records indicated that the patients had instead received aquatic therapy, a service subject to reimbursement restrictions The United States also alleged that Benchmark submitted claims through the Medicare program for physical therapy services which did not qualify for payment or were not medically necessary Source: USDOJ, 6/30/

19 Self Disclosure After it self disclosed conduct to the OIG, HealthWorks Rehab & Fitness, (HealthWorks), West Virginia, agreed to pay $8, for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that HealthWorks inappropriately billed Medicare for the performance of iontophoresis services, which is not a covered service under Medicare because it is deemed experimental. Ionto not covered by Local Coverage Determination 19

20 Qui Tam Relators HealthSouth Group and concurrent therapy Physiotherapy Associates Group issues Advanced Physical Therapy Not enough group Carlson Therapy Network 1:1 vs. Group 20

21 Risks: Hand Therapy Hand therapy performed by either PT or OT Certification level of CHT: either PT or OT While treatment may seem to be interchangeable, practice, documentation, coding & billing is not interchangeable Commercial plans may not recognize OT, regardless of CHT certification Case Study Medicare requirements and Practice Act requirements do not allow PT working on OT plan of care and vice versa 21

22 Risks: Coding for Same Day Services Multiple body parts, same treatment session Typical in general outpatient therapy Same treatment plan, multiple treatment plan approaches Single referring MD, multiple referring MDs Documentation approach: Timed vs. Untimed codes Timed codes based on minutes (8 minute rule) Untimed codes based on 1x per session regardless of time Exception: Morning session and afternoon session, untimed codes may be billed again in second session with 76 modifier Documentation approach 22

23 Risks: Group Therapy Medicare Benefit Policy Manual Chapter 15, Section 230 A. Group Therapy Services. Contractors pay for outpatient physical therapy services (which includes outpatient speechlanguage pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy services (97150). B. The individuals can be, but need not be performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but oneon one patient contact is not required. NGS: Documentation: The purpose of the group and the number of participants in the group Description of the skilled activity provided in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual. What is not covered: Supervision of a previously taught exercise program or supervising patients who are exercising independently is not a skilled service and is not covered as group therapy or as any other therapeutic procedure. Supervision of patients exercising on machines or exercise equipment, in the absence of the delivery of skilled care, is not a skilled service and is not covered as group therapy or as any other therapeutic procedure. 23

24 Risk: NCCI Edits The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have been combined into one table and include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual. Therapy code pairs apply across disciplines on same day In certain circumstances pairs can be bypassed with 59 modifier Separate and distinct time, medically necessary Most often modified Updated quarterly, 1 st of month Physician edits (private practice) Hospital edits (Part A) rectcodinginited/ 24

25 Risks: New Technologies I have a bridge in Brooklyn. Vendor promises of payment, if you bill this way May be paid for a period of time pending review by payors and/or regulators, or may have a T code while pending CPT review Anodyne NCD (no longer covered by Medicare) Mist Therapy LCD (covered only per local coverage determination) Purchase and clinical strategies 25

26 Risks: Excessive Therapy Use of automatic exceptions process through KX modifier and attestation PTPP Comparative Billing Reports by SGS 2010, 2011, 2012 Comparative Billing Reports SNF (by SGS) Individual providers Profiling utilization 26

27 Comparative Billing Report Sample 1 27

28 Comparative Billing Report Sample 2 28

29 Recording Minutes New Twist Total timed minutes recorded in record Appropriate number of units billed based on time Recoupment request: total time not noted in the daily record Total time (in timed codes) Total treatment time (incudes untimed codes) Time in/time out X total treatment time 29

30 The Risk in CERT WPS Billed CPT 97110(2 units) The time spent rendering therapeutic occupational exercises on billed date of service is not recorded, therefore two units can not be verified. 100% Total time is not recorded on the billing sheet or on the flow sheets. The flow sheets are unsigned. The letter sent additional documentation request is an addendum/late entry and cannot be used. Also received physician's order and plan of care, initial evaluation and progress note. 30

31 Probe Examples Noridian Service Specific Probe Physical Therapy TOB 74X (Rehab Agency) Code: Noridian Widespread Service Specific Aquatic Therapy TOB (Hospital Outpatient) Code: PalmettoGBA J 11 Part B MAC Medical Review Probe Private Practice claims 12 codes listed (just about everything!) 100 claims per state: Virginia, West Virginia, North Carolina, South Carolina 31

32 Recovery Auditors (RAC) The RAC Process Automated Reviews Data review, no record requests Complex Reviews Request medical records Semi automated Reviews Data review suggests aberrancy Records requested to support recoupment Likely Issues for Therapy RAC Response Understand RAC process Register at your RA s website to ensure delivery Have RAC team ready to go Understand your LCD Pay attention to suggested documentation per code Utilization parameters per code 32

33 CMS Documentation Needed Previous medical history including diagnosis, premorbid conditions, and recent hospitalizations impacting functional abilities Patient s prior level of functional abilities, i.e. able to ambulate functional distance in recent past Timely physician certification/involvement with clear frequency/duration and certification date range parameters on plan of care Medical necessity supported patient would benefit from the development of an effective home strengthening program to: Regain ability to safely ambulate to/from bathroom to ensure appropriate pericare, etc. Facilitate the patient s ability to maintain strength and prevent further functional decline with other functional skills, i.e. transfers/bed mobility. Source: CMS Open Door Forum Slide Show 9/5/12 33

34 Reasonable and Necessary Treatment should be consistent with the nature/ severity of illness / injury Is this a new or acute problem? May need intensive focused care E.g. reduce pain and/or work on a specific impairment or functional loss Is this an old or chronic condition that needs retraining, or has had a change in condition? May need to update or modify program Is this an exacerbation of a condition? May have to modify treatment, change assistive devices as the condition deteriorates Are there other conditions (e.g. medical diagnosis) that are the underlying problem? Cognitive performance can impact care What is the beneficiary s ability to retain newly learned information (cognitive function)? What is the beneficiary's ability to participate and benefit from rehabilitative services? Source: CMS Open Door Forum Slide Show 9/5/12 34

35 Reasonable & Necessary Assessing Objective Measurable Gains for Rehabilitation Therapy Look at: Changes in the level of assistance required to perform functional tasks Changes in the types of functional activities/ tasks Changes in the types of assistive devices Improvement in rating of reported pain levels and changes in the ability to perform tasks given the reduction of pain (E.g. Ability to sit for a duration of time as a result of pain reduction) Source: CMS Open Door Forum Slide Show 9/5/12 35

36 Reasonable & Necessary Considerations: Did the therapist consider the beneficiary s goals? Were the therapist s and beneficiary s goals realistic based on the beneficiaries condition and, For rehabilitation therapy did the therapist change goals/ treatment plan in response to improvement or lack of improvement in the beneficiary s condition? Were there objective, measurable changes using standard scales and assessment tools? What was the beneficiary s response to treatment? Did this change over time? Was it sustained? Source: CMS Open Door Forum Slide Show 9/5/12 36

37 Top 5 Best Practices For Demonstrating Medical Necessity and Skilled Care Best Practice: Initial Evaluation: Test, measure and document functional scores, performance tests and clinical findings Initial Evaluation and Plan of Care: Relate clinical findings and short term goals to functional deficits and long term goals Daily Notes: Demonstrate skilled intervention through ongoing patient assessment, exercise, functional progression, and techniques and parameters utilized Progress Evaluation: Serially track and update important clinical and functional findings related to goals Monitoring & Auditing Topics: 1. Relate functional scores to norms 2. Identify complexities and comorbidities and impact on therapy progression 3. Provide contralateral measurements and significance 1. Prior level of function identified for each identified ADL item 2. Current level of function contrasted to prior level of function for each item 3. Relate pain scores to inability to perform functional activities 1. Identify patient compliance with HEP 2. State exercise progressions and introduction of new exercises 3. Relate functional activities to ADL deficits and patient progression 1. Compare initial objective tests & measures to current, comment on status 2. State % goal achievement and status 3. Update patient functional ADL status 5 Discharge Summary: Summarize entire episode of care to include, patient progress, goal achievement, and reason for discharge 1. Summary of entire episode. 2. Identify goals not achieved and state reason 3. Reason for discharge 37

38 Top 6 Best Practices For Reducing Medicare Billing Risks Best Practice: 1 Always make sure your documentation supports the claim 2 Document total treatment minutes and timed treatment minutes in each daily note 3 Convert minutes to units appropriately 4 Apply CCI edits properly, and by a therapist or certified coder 5 Use PTAs and Extenders appropriately, and document correctly 6 Appropriate use of KX modifier for attestation 38

39 Risks & Interdependencies Medical Necessity Treatment Documentation Coding Billing KX Modifier Plan of Care Therapy Evaluation Coding ICD Document Daily Treatment Coding Procedures 39

40 How an EMR and Practice Management System Can Minimize Your Risks 40

41 Critical Actions 1 2 Requirements: Always make sure your documentation supports the claim Document total treatment minutes and timed treatment minutes in each daily note How Clinicient Helps: Charges created directly from signed therapist encounter with change notification Automatically totals timed minutes and total treatment minutes in daily note 3 Convert minutes to units appropriately Automatic conversion of timed minutes according to Medicare guidelines 4 5 Apply CCI edits properly, and by a therapist or certified coder Use PTAs and Extenders appropriately, and document correctly Built in CCI edits presented to therapist during signoff Tracks provider credentialing, who performs procedures, and routing for co signature 6 Appropriate use of KX modifier for attestation KX modifier applied by therapist with a constant reminder to document medical necessity 41

42 Additional Documentation Resources: resources/ Samples of Good Clinical Documentation: Evals POC Certifications Progress Notes / Daily Notes Discharge Summary Top 5 Best Practices for Documentation Cheat Sheet Schedule a Demonstration 42

43 Thank You! 43

44 Resource Page: resources/ Take Action: Stop the Therapy Cap Compliance Webinar Series: Upcoming Webinars Recordings / Slide Decks Important Links: Therapy Provider Phase Tracker CMS Resources and Guidelines APTA FAQ Therapy Codes NEXT WEBINAR: 2013: G Codes, Functional Limitation Reporting and PQRS Thursday, Jan am PT / 1pm ET Keep the Conversation Going: LinkedIn Groups: NEW PT and Rehab Compliance Group Moderated by Nancy Beckley Community group for sharing discussions and questions surrounding Medicare and compliance regulations Clinicient User Group: Clinicient User Group 44

45 Contact Info Nancy J. Beckley, MS, MBA, CHC President Nancy Beckley & Associates LLC Visit our website to Learn More Schedule a Demo Get a

46 Questions? Ask a Question in the question pane 46

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