Internal reviews can offer a revealing reflection

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1 Vol. 11 No. 3 March 2006 INSIDE Software trends New billing and documentation software can be a time and money saver. Find out how on p. 4. Better appeals If you re having trouble winning appeals, it might be because of your appeals letter. Read about the writing process on p. 6 and see a sample letter on p. 7. Coding corner Coding expert Rick Gawenda, PT, covers appending modifier -59 and using CPT code on p. 8. Get the message When leaving phone message appointment reminders, there are a few things you must keep in mind per HIPAA. Find out what they are on p. 10. BRRR Q&A Turn to p. 11 to get your questions regarding CORF regulations, billing for custom splints, and evaluation codes answered by columnist Nancy Beckley, MS, MBA. Sign up for your FREE newsletter at and visit our online store, www. hcmarketplace.com, for daily discounts and specials. 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/ Internal reviews can offer a revealing reflection Two of the biggest complaints rehab providers have are that they don t understand why a payer denied a claim or why they are losing money. Often, these financial problems stem from a lack of knowledge about the claims process. Too many providers have the approach of, Let s submit our claims and see what gets paid, says Ken Mailly, PT, of Mailly and Inglett Consulting, LLC, in Wayne, NJ. Providers need to have a strategy for coding and billing and need to know more about their practice than the outside world does. One way of discovering financial mistakes or process variances is through an internal claims review. Providers should set up a process for constantly checking their claims, either by having their therapists check each other s work or by hiring an outside consultant. If you aren t checking your claims, you re taking huge risks, Mailly says. Claiming ignorance The claims process is a culmination of caring for the patient, documenting that care, and billing for reimbursement, according to Mailly. The process also involves everything from the patient referral to the therapist s findings and interventions to patient outcomes. If you start looking at your practice solely on the basis of making more money, you might start turn- > p. 2 Therapy cap will allow for exceptions On February 13, CMS released three transmittals outlining its new Medicare Part B therapy cap exceptions process. Although nonhospital rehab providers will still fall subject to the $1,740 caps, patients will have opportunities to exceed the cap. CMS plan calls for automatic exceptions for specific beneficiaries or written requests for beneficiaries who do not fall under those conditions. You can find the transmittals as follows: Medicare benefit policy, Transmittal 46, content/55395.cfm Medicare claims processing, Transmittal 853, com/content/55397.cfm Medicare program integrity, Transmittal 139, com/content/55396.cfm Editor s note: Check out the April BRRR to get everything you need to know about complying with the exceptions process.

2 Internal reviews < p. 1 ing more of a profit, says Stuart H. Platt, PT, MSPT, a principal at Appropriate Utilization Group, LLC, in Atlanta. However, a high profit margin won t mean much to payers and patients if it isn t backed up by effective, quality care. Mailly gives the example of a rehab company and a managed care contractor attempting to negotiate a contract. The rehab provider spouts off numerous facts and figures about getting great outcomes and deserving top dollar because of the services it offers. But when the managed care representatives pull out files of cases in which the provider s treatment didn t help the patient and lacked documentation to show why, the entire sales pitch is shot. High expectations To create an evaluation tool, determine which aspects of your claims process you want to examine. What legal, ethical, and reimbursement standards must you keep in mind during the review? People associate quality with good outcomes and rightly so, Mailly says, but that s not the entire picture if you re getting those outcomes illegally or immorally. Use the following guidelines to establish your practice s expectations: State laws The guidelines of professional associations (e.g., the American Occupational Therapy Association) Medicare reimbursement regulations Other payer standards Expectations will invariably differ by state, practice size, specialties, and individual therapists, but facilities can customize their own claims checklist (see the sample checklist on p. 3). According to Platt, several types of tools exist to evaluate either an individual therapist or the facility as a whole, including chart audit. Does the technical chart contain all of the right items (e.g., referrals, signatures, dates)? peer review. This review assesses the quality of therapy provided using accepted practice standards and guidelines. For example, do you have realistic patient goals and a plan to reach those goals? utilization review. This process considers medical necessity, appropriateness, and reasonableness of services provided (e.g., the appropriate frequency and duration of care given the patient s diagnosis). Look in the mirror Once you establish ways to judge and critique your facility s claims, either self-audit your practice or hire someone to do it for you. If you opt for an internal review, you ll have to establish baseline cases and have therapists spend time reviewing cases and not treating patients. However, the review process can serve as valuable learning experience for those taking part. To establish baseline cases, Mailly recommends taking your most common treatments and collecting data about them. Determine what the typical plan of action for that treatment is and then pull out any cases that fall outside the norm. Use those cases to evaluate what went right or wrong. Review with your therapists the entire treatment to see what you can do differently. Obviously, the more detailed your baseline cases are, the better, but the most important aspect is to actually sit down and reexamine past cases. Going outside to look within Although the thought of having an external agency review internal actions be scary, hiring someone to conduct your claims review process can be beneficial. The contracted agency isn t connected with Medicare or any other regulatory commission and is under no obligation to report any wrongdoings. Instead, it can serve as a watchdog and perform the critiques that colleagues often don t want to make of each other. A contracted auditor will also have more established baselines with which to judge you and can perform Page HCPro, Inc.

3 inservice training in any area you are lacking. No matter what type of claims review process you perform, some therapists will feel as though they re being watched or singled out. Assure them that, at least in the initial phases, findings won t negatively affect them and are meant as constructive criticism. Sample claims review checklist Editor s note: The following checklist features sample questions to consider asking during an internal or peer review of claims. It is partially based on New Jersey state law, but most of the questions are applicable to, or adaptable for, all states. 1. General Did a PT/OT/SLP perform the examination? Are the findings and interventions related to a compensable event? Are interventions based on examination findings? Do interventions comply with accepted standards of practice? Is frequency and duration of interventions within accepted standards of practice? Were stated outcomes reached? 2. Referral Is a PT/OT/SLP referral present in the medical records? Did someone document follow-up of any services required in a referral? 3. Record review Did the therapist render intervention with documented progress or goal attainment? Did written reports document the results of tests performed? Did the PT/OT/SLP documentation follow association guidelines (e.g,. the American Physical Therapy Association s Guidelines for Physical Therapy Documentation) and state law? Was intervention record and documentation consistent with the billing statement? 4. Modalities Were local modalities continued unmodified for more than two weeks without evidence of improvement? Were palliative modalities limited to six to eight weeks postinjury? If so, were they provided without any other intervention? If the therapist used more than three modalities daily, did he or she include appropriate justification? Does the intervention fade (i.e., decrease in frequency over time)? If the therapist used a medical device during intervention, was it approved by the Food and Drug Administration? 5. Provider credentials Are the credentials of the provider included in the treatment record? Is the license number included as appropriate? If an assistant was involved in care, did the provider document such? Did a PT/OT/SLP cosign any documentation done by an assistant? Source: Adapted from Mailly and Inglett Consulting in Wayne, NJ, which used the APTA Guidelines for Peer Review, the Guide to Physical Therapist Practice, 2nd Edition, and New Jersey State PT regulations as guidelines HCPro, Inc. Page 3

4 Selecting the right software can be a hard choice to make Follow these tips to make updating your systems an easier, worthwhile process Of all the items you use on a regular basis to help make life easier in a rehab facility, none is used more frequently or has as many practical applications as your billing and documentation software. Selecting software that is compatible with your system and how your facility operates can save every therapist, coder, and administrator time and money. But often rehab providers stick with out-of-date software believing that the price is too high to upgrade or that they ll have to spend too much time testing the different versions. However, staying on top of the newest software trends doesn t have to be a daunting project. The right software can help you accomplish so many things, says Nancy Beckley, MS, MBA, president of Bloomingdale Consulting Group in Brandon, FL. It can improve reimbursement, compliance, and productivity. Where to start? It s possible that the software you use was there before any current employees at your facility. You probably receive the yearly updates that keep it working, but its programs might merely scratch the surface of what the latest software could do for you. So where can you find the software that is right for you? You probably receive fliers and phone calls from vendors every day touting their product, so that s a start. You can also spend a few hours of your time online searching around. However, the most practical, all-in-one shopping comes at state and national trade shows, says Beckley. Vendors often sound all of their software bells and whistles at shows such as American Physical Therapy Association s Private Practice Section. Many of the vendors will have their products on display so you can see what they actually look like and how they work as opposed to paging through samples in print. Another benefit of going to specific trade or association expositions is that you re more likely to get the software meant for rehab providers not just software for the healthcare industry in general. These conferences aren t where you should do your purchasing, but you can select a few products you like and set up appointments with vendors to perform more testing. The great divide In an ideal world, you d be able to purchase software that aids in all of your billing and documentation needs. But in reality, it s likely that you won t find one package that is best for both. That s why it s important to specify what you want each program to do for you. Billing software is often geared toward whoever will use it the most. The software you need can depend on whether your therapists do their own billing or you have centralized billing. Also factor in your software s ability to distinguish between PT, OT, and SLP bill multiple payers store easily accessible data accept updates from Medicare, Medicaid, etc. sort payer classes, procedures, etc. Although there are several tasks any billing software can help you with, technology is changing fast when it comes to documentation. Billing software should be able to get the bills out the door in a timely manner, says Dan Blaquier, LPN, RRT, administrative operations manager at the Lake Center for Rehab in Leesburg, FL. But you should make it your mission to get documentation software that puts out the best possible reports. Writing it all down When Blaquier and his facility went on a search for documentation software, he says most of the products came up short. Page HCPro, Inc.

5 The biggest problem was that the software didn t allow for a therapist s natural notetaking, says Blaquier. There wasn t anything that gave the therapists the flexibility to document their notes in their own words. Most programs allow for users to select from a set number of questions and choose a number of responses. Blaquier says that works fine for documenting most cases and establishing treatment, but it isn t as thorough as a therapist s entire handwritten chart about a patient. Unfortunately, most documentation software is still based on a therapist transferring his or her handwritten notes to a computer by clicking and pointing on the appropriate selections. When selecting documentation software such as this, make sure the selections vary enough so that you aren t settling for inadequate choices all the time. Another common program allows a therapist to type his or her notes into the forms; however this leads to duplicating a lot of work. That s why Blaquier helped design a voice-activated system he calls VARD (voice-activated rehab documentation). The product has yet to hit the consumer market on a full-scale basis, but Blaquier says similar systems will help rehab providers show payers documentation that leaves no doubt. With this program, it just takes what the therapist says and records it in [his or her] own words, says Blaquier. Your documentation should clearly describe what you ve done and how the patient is progressing. What better way to do that than to have notes in your own words. Buyer beware Knowing what you want your software to do and ensuring that it can do it are two different things. If you re not buying packaged software, verify that the billing and documentation software are compatible. Ideally, find a system that takes your documentation and transfers it to your bills. The only way you can ensure that this process works is by doing your homework. For every hour you spend doing research on the software now, you ll save tenfold that amount later, says Blaquier. There is a wide array of software available, and more expensive doesn t always mean better. A good software company will run as many demos with you as you need. It can show you demonstrations online or in person. It s a good idea to have different people in your organization participate in the demo because what works well for one group might not work well for another. Because you can t change software programs every year, it s important to choose wisely, says Beckley. 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. States that tax 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 5

6 A primer on Medicare appeals letters Between patient care and daily documentation requirements, writing appeal letters is an added stress albeit an important one on your already tight work schedule. However, appeals writing need not be a daunting process for rehab providers. In fact, you can successfully write most appeal letters by following a simple, straight-forward template (see the sample template on p. 7). Parts of the appeal letter The opening portion of your appeal letter should cover the basics of the claim and verify the beneficiary information. As indicated in the template, the following information should be inserted in the appropriate place: Denial decision date Use the date listed on the correspondence that notified your facility of the claim denial Beneficiary name The name on your appeal letter should match the name listed on the claim and all other correspondence Medicare number The Medicare number should match the beneficiary s number listed on the claim correspondence Dates of service denied The dates of service denied should mirror the information listed on the denial notification information Following is an explanation of each separate part of the letter and how to go about stating your case: State the reason the claim is being appealed and ensure that the wording is directly tied to the reason for denial. If you are unsure why the fiscal intermediary (FI) or carrier denied the claim, refer directly to the medical reason code, which you can obtain from the FI Shared System. Your letter for redetermination must address the reason the claim was denied. Begin the letter strongly by acknowledging why the FI or carrier denied the claim, then support why the agency should pay it. State prior level of function. For services denied because you didn t show that they were reasonable and necessary, it is important to paint a picture of the patient. To do so effectively, provide documentation that demonstrates what the patient was able to do before the onset of the disease, injury, or exacerbation. The documentation should support the patient s prior level of function and can most often be gleaned from the information the clinician wrote upon evaluation. If there is other supportive information in the medical record, use it as a source document if you submit copies with the packet of information. Summarize findings upon evaluation. In this section, identify your evaluation findings that established a baseline of function. This will help draw a comparison between the patient s prior level of function and the level at which the person functioned when you completed the evaluation. Refer to the evaluation directly when you reference specific information. State why therapy services were needed. Based on the information you presented to establish the baseline and patient s status upon evaluation, clearly paint a picture in this statement of why the person needed therapy services. You can often find this in a statement of medical necessity. Summarize the course of treatment and progress. To demonstrate the progress made during therapy services, reference in this section the specific dates of service in the progress notes that demonstrate the patient s progress toward goals. If the progress is limited, you have the opportunity to identify dates on which you used different techniques or interventions to address the impairments. Additional documentation to support the lack of progress (e.g., pharmacy changes) can also be referenced here. If you reference outside documentation in the letter, include copies in the packet. Page HCPro, Inc.

7 Close the letter summarizing why the services you provided should be paid as they related to the reason for denial. Use FI/carrier policy or Medicare regulations to support your argument. Perhaps the most important way to support your case in an appeal letter is to use Medicare regulations or FI/carrier policy to explain why services should be paid. If you reference specific areas of the regulations, ensure that the citation is complete and consider including a copy of the regulation to which you are referring in the submission packet. Your appeal letter can be used as a substitute for designated areas on the CMS forms that require information about why the claim should be paid. Editor s note: This article is excerpted from the book The How-To Manual for Rehab Denials and Appeals: Navigating the Medicare Process by Kate Brewer, PT, MB, GCS. Call our Customer Service Department at 800/ or go to and type the title in the search box for more information. Date letter is written Appeal letter outline Fiscal intermediary (FI)/Carrier name Address City, state, ZIP To whom it may concern: The following is a letter to support the appeal of the claim denied on [insert denial decision date] for [insert beneficiary name] with the Medicare number [insert Medicare number] for dates of services received on [insert dates of service denied]. State the reason the claim is being appealed and make sure that the wording is directly tied to the reason for denial. State prior level of function. Summarize findings upon evaluation. State why therapy services were needed. Summarize course of treatment and progress. Close the letter by summarizing how the services provided should be paid as they related to the reason they were denied. Support with FI/carrier policy or Medicare regulations. Thank you for your consideration. Sincerely, Ima Provider Very Smart Therapy Services Source: The How-To Manual for Rehab Denials and Appeals: Navigating the Medicare Process by Kate Brewer, PT, MB, GCS, published by HCPro, Inc HCPro, Inc. Page 7

8 BRRR coding corner Editor s note: This column appears monthly in BRRR to help answer subscribers coding questions. Rick Gawenda, PT, director of rehabilitation for Detroit Receiving Hospital and owner of Gawenda Seminars in Ypsilanti, MI, answered the coding questions below. Submit questions to Editorial Assistant Kevin Moschella at kmoschella@ hcpro.com or fax questions to 781/ Q Who is responsible for appending modifier -59 to the column 2 CPT code when therapy procedures provided on the same day for the same patient by the same provider are distinct and separate? Does it have to be the therapist who provides the procedure and records it on the patient treatment log? A It depends on your charge-entering and billing software. Some software allows the person who enters the charges to append modifier -59 to the appropriate CPT code or codes, while other systems do not have that capability on the front end. In those situations, it has been my experience that someone on the back end in patient accounting appends modifier -59 to the appropriate CPT code. But if it can t be done on the front end, it might not be done at all. The need for modifier -59 is provider-specific and not discipline-specific. What this means is that you must check all rehabilitation services given by the same provider on the same date of service to see whether any services require modifier -59 for them to be reimbursed. I would recommend finding two to three patients who received speech-language pathology services on the same day they received occupational/physical therapy services and for whom your Medicare contractor already reimbursed your claims. Take those patient names to your patient accounting representative and have him or her verify that all line items for all dates of service were reimbursed. If you find that Medicare did not reimburse you for one or more line items, that particular service most likely requires you to append modifier -59. As for documentation to support the use of modifier -59, when different disciplines are involved, it should be evident to the Medicare contractor. To assist the reviewer, document the time in and out of each treatment session for each discipline in the patient s medical record. In addition, the person who provides treatment must sign each discipline s notes with his or her credentials. When the need to utilize modifier -59 occurs within the same discipline, documentation must clearly demonstrate that the services occurred at separate and distinct times and were medically necessary. The following are two ways to show that you provided the services at separate and distinct times: 1. Break down the use of time for each service. For example, 9 a.m. to 9:30 a.m., aquatic therapy of (list treatment provided), 9:45 a.m. to 10:10 a.m., land-based therapeutic exercise of (list treatment provided). 2. Record aquatic therapy of (list treatment provided) followed by land-based therapeutic exercise of (list treatment provided). The words followed by let the Medicare contractor know that you provided aquatic therapy first and then the land-based therapeutic exercise. Q We are a comprehensive outpatient rehabilitation facility. We have two PTs treating a Medicare patient who started Page HCPro, Inc.

9 receiving outpatient physical therapy on her right hip in October. The patient then received an order from a different physician for therapy on her left knee, which she began on December 19. The PTs have been submitting charges on two different charge sheets to aid in the billing of the different ICD-9 codes. They are currently performing an eight-minute ultrasound on each region. Does this constitute one billable unit, whereas the other is a no-charge? Or do we charge for both because it is for a different region? And should we combine the charges for each date of service on one charge sheet? A According to the American Medical Association, ultrasound (CPT code 97035) is defined as application of a modality to one or more areas; ultrasound, each 15 minutes. Based on this definition, the total amount of ultrasound you provided to this patient was 16 minutes. Using Medicare s eight-minute rule, that amount of time would fall between at least eight minutes but less than 23 minutes, which means that the therapist would bill for one unit of ultrasound. By maintaining separate charge sheets as you indicate in your question, the therapists are actually overbilling Medicare one unit of ultrasound for each date of service that they provide ultrasound. Regarding your question concerning charge sheets, the important thing to remember is that you should send one claim for that date of service for that Medicare beneficiary to the Medicare contractor. List all ICD-9 codes on the claim form that support your treatment provided and services billed. I assume when you mention charge sheets that these are the sheets that contain the day s charges that are entered into your billing system. The problem with using two different charge sheets on the same patient seen on the same day is that therapists tend to overbill as you describe in your example. I recommend that the therapists only use one charge sheet to submit all charges for all services provided on the two different areas. Documentation in the patient s medical record must demonstrate the treatment they provided to each area and the medical necessity of each service for all diagnoses. News briefs New technology brings new injuries Physical therapists are starting to see an increase in injuries caused by modern devices that are meant to make life easier, according to the Delaware News Journal. Products such as BlackBerries, cell phones, and ipods are causing injuries that therapists attribute to overuse. The News Journal reported that people using a BlackBerry too much can sometimes experience pain between the thumb and forefinger. Others worry that ipods allow listeners to use them for too long, which can affect hearing, whereas using a cell phone for long periods of time can bring on elbow problems. Pediatric conference focuses on IDEA The American Physical Therapy Association joined the Section on Pediatrics in January to explore programs for children with disabilities under the Individuals With Disabilities Education Act (IDEA), reported PT Bulletin Online. Speakers during the two-day conference discussed aspects of IDEA programs that affect the practice of physical therapy in school-based settings. The 125 participants addressed the relationship between federal, state, and local regulations, and strategies for successful implementation of IDEA. Final regulations implementing IDEA reauthorization are expected to come out this year HCPro, Inc. Page 9

10 Beware of HIPAA when leaving messages When leaving appointment reminders over the phone, keep in mind that you don t know who will receive that phone call. That s why it s best to keep things simple and include only the most vital information in any reminder call to avoid bad Health Insurance Portability and Accountability Act of 1996 (HIPAA) practices, says Tessa Chenaille, CHC, president and chief executive officer of Chenaille Compliance Consulting, LLC, in Medford, MA. The reminder should contain only the patient s name, time and date of the appointment, and the facility s contact information. Just covering your bases in your HIPAA privacy program goes along way, but it won t ensure that you re totally secure without some other safeguards, she adds. Following are five tips Chenaille says you should keep in mind when making reminder calls: Know your state law. Before you consider any other aspect of your appointment-reminder policy, familiarize yourself with what your state allows. Although rare, a few states prohibit leaving phone messages that contain any type of medical information. Alert your patients. Inform patients of your reminder service at the time of their initial visit, Chenaille advises. This can be as simple as a sentence in your notice of private practices (NPP) that states, We may use or disclose your protected health information, as necessary, to contact you regarding upcoming appointments. Your NPP then leaves it up to the patient to ask any questions or bring up any concerns. Give your patients options. Not making reminder calls can cause missed appointments and confusion, so it s certainly worth picking up the phone. But if your patients aren t getting the messages or aren t comfortable with how you tell them, offer alternative modes of communication. Don t offer patients the chance to opt out of reminder calls ask how they would prefer that you contact them, says Chenaille. Ask whether a patient would rather give you a cell phone or work number instead of a house number. You could also obtain multiple numbers if patients have difficulty receiving messages. If need be, requesting addresses can work also, but obtain the authorization in writing and be sure that your system is set up to allow reminders. Whatever you and the patient decide, honor it and follow the guidelines you established regarding phone or , Chenaille says. Ensure that contracted services check out. More facilities use automated reminder services now than ever. If you have an internal automated system, you re all set as long as you run the necessary checks to be sure that you call the right number. But if you use a contracted, outside service, sign a business associate agreement with that service, Chenaille recommends. This ensures that the company with which you work will protect any information you give it and not share the information with anyone without the patient s consent. Also work with a service that is familiar with HIPPAA and has a solid reputation in the healthcare industry, to be on the safe side. Don t spend too much time worrying. Physician s offices have been making appointment-reminder phone calls for a long time, so most patients just expect them. If by a slim chance you or a contracted service leaves a message at the wrong number, the worst-case scenario is generally a slap on the wrist for incidental exposure, presuming that you followed the expected safeguards. 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 Editorial Assistant Kevin Moschella at kmoschella@ hcpro.com. Q In the January 2006 BRRR Q&A column, you wrote about comprehensive outpatient rehab facility (CORF) regulations. The question was, We recently have had a number of claims denied by our fiscal intermediary [FI]. We have been a CORF provider for several years and generally have not experienced any problems with reimbursement. I was told specifically that the physician not the therapist has to actually write the plan of care. Is this accurate? I was wondering whether your response is only valid for CORF regulations in the state of Florida as you referenced, or is this response more national and includes New York, where I am located? A You are not the only person to inquire whether this only applies to Florida. This is a global response for CORF regulations. A physician must write the plan of treatment for patients in the CORF. However, this stipulation does not apply to rehab agencies. I reference many sources when answering questions, using information from various carriers and FIs around the country. I often use the Florida intermediary because it has consistently posted and updated its local medical review policy for physical therapy and rehab. I try to reference a variety of contractors, and I also caution readers to seek the advice of their own Medicare payer, as CMS has allowed its contractors to develop local medical review policy. Q We are in an outpatient rehabilitation facility. When an OT fabricates a custom splint and also provides treatment, how do we bill this to our FI to get reimbursed for the splint as well as the treatment? We typically bill and another treatment such as We bill under type of bill 74X and our revenue code is 430 for OT. Recently we are getting denied for the What is the correct way to bill when fabricating a splint? A I checked the American Society of Hand Therapists Web site and it provides the following information about billing Medicare for splinting: For patients who receive splints from... CORFs and rehabilitation facilities, bills should be billed on the CMS 1450 forms to the provider s intermediary using the Medicare alpha-numeric Level II Healthcare Common Procedure Coding System [HCPCS] codes. Most of these codes are found in the L and A sections, and the charge for the splint should include the fabrication time. When applying the splint to the patient, the orthotics fitting and training code can be used in addition to the Level II HCPCS code. In place of the above, some intermediaries are also recognizing the CPT codes through for OTs and PTs. These are strapping and casting codes in the surgery section of the CPT. These codes are Correct Coding Initiative edited with I also recommend that you check with your FI to determine its preferred billing method and its specific policy regarding splint fabrication and therapy in the same treatment session. Q A Do evaluation codes include time for documentation, review, etc.? The codes you mention include physical therapy evaluation and reevaluation, as well as occupational therapy evaluation and reevaluation. These are service-based codes rather than timebased codes. The reimbursement you receive is for all services rendered, which includes the time it would take for documentation. Whether it takes the therapist 15 minutes or 45 minutes to complete the evaluation, providers may bill for only one procedure HCPro, Inc. Page 11

12 News briefs CMS will reprocess revised physician fee schedule claims Rehab providers will not have to resubmit claims to obtain correct payments for services provided since January 1, said Herb Kuhn, director of the Center for Medicare Management, in a recent letter to Congress, reported PT Bulletin Online. When Congress passed the Deficit Reduction Act, it reversed the 4.4% cut that went into effect January 1 by freezing physician fee schedule payments at the 2005 levels. CMS will reprocess any claims for 2006 services that were submitted prior to the bill s enactment. Kuhn said he expects the process to take several months, with the agency planning to complete claims adjustments by July. AOTA develops its plan for the future The American Occupational Therapy Association (AOTA) created a draft of its Centennial Vision statement in a January meeting as it gets set to celebrate 100 years of the association and the profession in The statement includes the following four strategic directions in which the association hopes to head: 1. Building the capacity to fulfill the profession s potential and mission 2. Demonstrating and articulating its value to individuals, organizations, and communities 3. Building an inclusive community of members 4. Linking education, research, and practice AOTA members developed the strategy after identifying relevant elements to a shared vision and barriers to achieving this vision. CPT codes, descriptions, and material only are Copyright 2001 American Medical Association. 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 We want to hear from you... 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 Rehab 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 (AOTA) Bethesda, MD Angie Phillips, PT President and CEO, Images and Associates Amarillo, TX Lynn Steffes, PT President, Steffes & Associates New Berlin, WI For news and story ideas: Contact Editorial Assistant Kevin Moschella Phone: 781/ , Ext Mail: 200 Hoods Lane, Marblehead, MA kmoschella@hcpro.com Fax: 781/ Group Publisher, Bob Croce 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, change 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.