Outpatient Therapy Services

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1 Outpatient Therapy Services Presented by WPS Medicare Provider Outreach and Education Updated March

2 Module 1 General Guidelines Acronyms OT Occupational Therapy PT Physical Therapy OTA Occupational Therapy Assistants PTA Physical Therapy Assistants POC Plan of Care SLP Speech Language Pathology CMS Website Always therapy files MPFSDB CCI IOM Applicable HCPCS Codes Check the annual updates list Checks in column 5 are always therapy and always require modifiers o GN services provided under an outpatient speech language pathology POC o GO services provided under an outpatient occupational therapy POC o GP services provided under an outpatient physical therapy POC Medicare Physician Fee Schedule Database (MPFSDB) Can be accessed on CMS Website See the resource sheet Used to determine Procedure Code Status Professional and technical indicators Relative Value Units (RVUs) National Correct Coding Initiative (NCCI) Can be accessed on CMS Website Website listed on the resource list Used to determine Bundled codes Whether modifier will override CMS Internet Only Manual (IOM) Outpatient financial limitations are listed on the CMS website Publication , Chapter 5, Section 10.2 $1900 PT and SLP combined $1900 OT Automatic exceptions process KX modifier use WPS Medicare Outpatient Therapy Services 2 of 18

3 Care Requirements Services must be furnished on an outpatient basis Outpatient therapy must be under the care of a physician/nonphysician practitioner (NPP) Physician Requirement No order or referral from a physician is required for therapy Payment is based on the certification of the Plan of Care (POC) rather than on an order Outpatient therapy must be under the care of a physician/nonphysician practitioner (NPP) certification Evaluation and Reevaluation When to complete Start of treatment Patient has a significant change in functional status Intermittent re-evaluation of maintenance program when revisions need to be made Plan of Care (POC) Requirements Establish before treatment begins. Who can establish the plan? Physician/NPP Therapist providing services Must be Signed Dated Contain the professional s designation (MD, PT, OT) POC Contents Diagnoses (treatment and medical that may affect therapy) Results of any measurement instruments used Long-term treatment goals (objective and measurable) Type, amount, duration, and frequency of therapy services POC Changes Must be made in writing Require a signature and professional designation May require re-evaluation and recertification Can only be made by a clinician WPS Medicare Outpatient Therapy Services 3 of 18

4 Certification/Recertification Initial certification Every 90 days or at the end of the duration of the initially certified plan of care Whenever significant changes are made to the initial plan of care Denials due to certification Certification/Recertification Who can certify? Physicians and NPPs Optometrists for low vision services Podiatrists consistent with scope of practice Delayed Certifications May include one or more certifications or recertification on a single signed/dated document Physician documented reason for delay Therapy Caps 2 Separate caps PT/SLP combined OT separate Limit to Medicare Outpatient therapy cap $1920 for 2014 Use the exception process, when in place for current year Append the KX Modifier for Medically Necessary over cap amount No need to submit documentation for each service Therapy Cap Applies Therapists private practices Offices of physicians and certain nonphysician practitioners Part B skilled nursing facilities Home health agencies (Type of Bill (TOB) 34X) Rehabilitation agencies (also known as Outpatient Rehabilitation Facilities- ORFs) Comprehensive Outpatient Rehabilitation Facilities (CORFs) Hospital outpatient departments (HOPDs) Critical Access Hospitals (CAHs) (TOB 85X) - (2014) Manual Medical Review Per beneficiary, services above $3,700 threshold PT and SLP services combined OT services alone WPS Medicare Outpatient Therapy Services 4 of 18

5 Medical Review When requested Medicare Administrative Contractor (MAC) Recovery Auditor (RA) Comprehensive Error Rate Testing (CERT) Contractor Office of Inspector General (OIG) Other Contractors Patients in a Skilled Nursing Facility (SNF) All outpatient therapy services are billed by the SNF Do not bill Medicare for payment Review Questions 1) Which one of the following resources is not maintained by CMS? a. Correct Coding Initiative (CCI) b. Local Coverage Determination (LCD) c. Medicare Physician Fee Schedule Database (MPFSDB) d. National Coverage Determination (NCD) 2) Which resource will tell a provider if a procedure code is considered an always therapy code by Medicare? a. Annual Updates b. IOM c. MPFSDB d. CCI 3) What does the acronym POC stand for? a. Personal Occupational Care b. Plan of Care c. Point of Care d. Physical Outpatient Care 4) Part B therapy services must be. a. On an outpatient basis b. Under the care of physician c. Medically necessary d. All of the above 5) The modifier is reported for services provided under an outpatient occupational therapy POC. a. GA b. GN c. GO d. GP WPS Medicare Outpatient Therapy Services 5 of 18

6 Week 2 Documentation Therapy Documentation Initial Evaluation and Re-evaluations Plan of Care Certification and Recertification Treatment Note Progress Reports (when necessary) General Documentation Requirements Evaluations/Re-evaluations and Plan of Care May be one document or two Written by the clinician May include observations made by the PTA or COTA Objective and measureable Includes physician certification List conditions and complexities that impact therapy Contain a diagnosis/description of condition Results of any measurement instruments used (if applicable) Current and past functional status Prognosis Re-evaluations are not routine, recurring service Supports need for further tests and measurements New clinical findings, significant functional change Progress Reports Written by the clinician Either the physician/npp who provides or supervises the services, or by the therapist who provides the services and supervises an assistant Minimum report period at least every 10 treatment days Discharge note or summary Date of current progress note Date reporting began Objective reports/measurements Assessment of improvement Plans for continued treatment Changes/updates to the POC Signature NEW Functional G-Code reporting WPS Medicare Outpatient Therapy Services 6 of 18

7 Treatment Encounter Notes (Daily treatment note) Date of treatment Description of intervention/modality Total treatment time Total time spent using time-based codes Signature and professional credentials of each person who contributed Clinician documentation of any treatment added or changed Documentation Requirements Complete Legible Pre-existing Note: It is the billing provider s responsibility to provide the required pre-existing documentation within 45 days of the contractor s request. Substantiate the medical necessity for the service provided Dated and signed by performing provider Support the diagnosis and procedure code billed Insufficient documentation may result in an overpayment Down-coding may occur if the documentation does not: support the services billed support the level of service billed support the frequency of services billed WPS Medicare Outpatient Therapy Services 7 of 18

8 Evaluation Documentation WPS Medicare Outpatient Therapy Services 8 of 18

9 Evaluation Documentation cont. Treatment Note - Example WPS Medicare Outpatient Therapy Services 9 of 18

10 Treatment Note Example WPS Medicare Outpatient Therapy Services 10 of 18

11 Documentation Example WPS Medicare Outpatient Therapy Services 11 of 18

12 Documentation Example Cont. WPS Medicare Outpatient Therapy Services 12 of 18

13 Review Questions 6) Which of the following is not required for therapy services? a. Physician order or referral b. Plan of Care c. Physician Certification d. None of the above 7) When must the plan of care be established? a. After the certification is obtained b. At the same time the progress notes are written c. After initial evaluation, but before the first treatment occurs d. After the first treatment 8) How often is a recertification needed? a. Every 10 days b. Every 30 days c. Every 60 days d. Every 90 days 9) What is the minimum number of visits between progress notes? a. Every treatment day b. Every 5 treatment days c. Every 10 treatment days d. Every 20 treatment days 10) Which of the following is a documentation requirement? a. Substantiate the medical necessity for the service provided b. Dated and signed by performing provider c. Support the diagnosis and procedure code billed d. All of the above 11) Complete the following: It is the billing provider s responsibility to provide the required pre-existing documentation within days of the carrier s request. a. 15 b. 30 c. 45 d. 60 WPS Medicare Outpatient Therapy Services 13 of 18

14 Functional Reporting Functional Reporting Section 3005(g) of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA) Collect data during course of therapy To understand conditions, outcomes and expenditures To develop improved payment system Effective for therapy on or after January 1, 2013 Facilities Affected Hospitals Skilled Nursing Facilities (SNFs) Comprehensive Outpatient Rehabilitation Facilities (CORFs) Critical Access Hospitals (CAHs) Rehabilitation Agencies Home Health (HH) Agencies When beneficiary not under HH plan of care Professionals Affected Therapists in private practice (PT,OT, SLP) Physicians (MD, DO, DPM, OD) NPPs (NP, CNS, PA) Functional Related G-Codes Always Therapy codes Require therapy modifiers (GP, GO, GN) Each set contains Current status Projected goal status Discharge status Non payable codes Functional Related G-Code Sets 42 total G-codes 14 sets of 3 codes 6 typically used for PT and OT 8 typically used for SLP WPS Medicare Outpatient Therapy Services 14 of 18

15 PT/OT Sets 4 sets for categorical functional limitations: Mobility G8978, G8979 and G8980 Changing & maintaining body position G8981, G8982, G8983 Carrying, moving & handling objects G8984, G8985, G8986 Self care G8987, G8988, G sets for other functional limitations Other PT/OT primary G8990, G8991, G8992 Other PT/OT subsequent G8993, G8994, G8995 SLP Sets 7 sets for categorical measures Swallowing G8996, G8997, G8998 Motor speech G8999, G9186, G9158 Spoken language comprehension G9159, G9160, G9161 Spoken language expressive G9162, G9163, G9164 Attention G9165, G9166, G9167 Memory G9168, G9169, G9170 Voice G9171, G9172, G set for other Other speech language pathology G9174, G9175, G9176 Severity/Complexity Modifiers Required for each G-code Reflect percentage of impairment Used for current, anticipated and discharge status WPS Medicare Outpatient Therapy Services 15 of 18

16 Severity/Complexity Modifiers Modifier Impairment Limitation Restriction CH 0 percent impaired, limited or restricted CI At least 1 percent but less than 20 percent impaired, limited or restricted CJ At least 20 percent but less than 40 percent impaired, limited or restricted CK At least 40 percent but less than 60 percent impaired, limited or restricted CL At least 60 percent but less than 80 percent impaired, limited or restricted CM At least 80 percent but less than 100 percent impaired, limited or restricted CN 100 percent impaired, limited or restricted Timing of Reporting Reporting required at certain points Outset of therapy (DOS for initial therapy) At least once every 10 treatment days When evaluation or re-evaluation is done At discharge from therapy On the same DOS a particular functional limitation is ended and further therapy needed At the same time reporting is done on a different functional limitation in same episode Billing Normally 2 G-code HCPCS at required reporting interval Current status and goal status Discharge status and goal status Exceptions o Services under more than 1 POC o One-time visit Each G-code must also have Functional severity modifier Modifier for discipline Date of service Nominal charge ($.01) Claim must also have a payable therapy service KX and 59 are not for functional G-codes References 42 CFR , 60 and 62 Medicare Internet-Only Manual (IOM), Publication , Claims Processing Manual, Chapter 5, Section 10.6 Change Request 8005 Change Request 8126 WPS Medicare Outpatient Therapy Services 16 of 18

17 Review Question 12) When were the functional codes required to be submitted? a. 1/1/13 b. 4/1/13 c. 7/1/13 d. 10/1/13 13) Each functional G-code set contains: a. Current status b. Projected goal status c. Discharge status d. All of the above 14) What are the two G-codes needed on a claim representing? a. Current status and goal status b. Discharge status and goal status c. Current status and discharge status d. Both A & B 15) When must a G-code be reported on a claim? a. Onset of a therapy episode of care b. On or before the 10th treatment day c. Evaluation/re-evaluation d. Discharge from therapy episode of care 16) Who cannot complete the documentation for G-codes? a. Qualified therapist furnishing the therapy service b. Physician personally furnishing the therapy service c. NPP personally furnishing the therapy service d. PTA, OTA personally furnishing the therapy service WPS Medicare Outpatient Therapy Services 17 of 18

18 Resources CMS Therapy Cap Information Programs/Medicare-FFS-Compliance-Programs/Medical- Review/TherapyCap.html CMS Therapy Homepage CMS Therapy Annual Updates ml CMS Internet only Manual Publication , Chapter 15, Sections 220 and Guidance/Guidance/Manuals/Downloads/bp102c15.pdf CMS Functional Reporting FAQs Reporting-PT-OT-SLP-Services-FAQ.pdf CMS Advanced Beneficiary Notice of Noncoverage (ABN) FAQs Noncoverage-FAQ.pdf NCCI MPFSDB Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html DISCLAIMER The information presented and responses to the questions posed are not intended to serve as coding or legal advice. Many variables affect coding decisions and any response to the limited information provided in a question is intended only to provide general information that might be considered in resolving coding issues. All coding must be considered on a case-by-case basis and must be supported by appropriate documentation in the medical record. The CPT codes that are utilized in coding claims are produced and copyrighted by the American Medical Association (AMA). Specific questions regarding the use of CPT codes may be directed to the AMA. WPS Medicare Outpatient Therapy Services 18 of 18

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