Outpatient Therapy Services. Presented by Part B Provider Outreach and Education (POE)

Transcription

1 Outpatient Therapy Services Presented by Part B Provider Outreach and Education (POE)

2 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply

3 ACRONYM ABN CCI CERT CR EDISS IOM MACRA MPFS SMRC DESCRIPTION Advance Beneficiary Notice of Non Coverage Correct Coding Initiative Comprehensive Error Rate Testing Change Request Electronic Data Interchange Support Services Internet Only Manual Medicare Access and CHIP Reauthorization Act of 2015 Medicare Physician Fee Schedule Strategic Health Solutions Medical Review Contractor 3

4 Agenda General Therapy Guidelines CAP and Exception Information G codes and Functionality Modifiers Documentation Plan of Care Certifications Signatures Common Errors Contractor Updates Provider Portal Enrollment Additional Medicare Information

5 General Therapy Guidelines

6 Outpatient Therapy Outpatient therapy services furnished to a beneficiary by a provider or supplier are considered for payment only when the following conditions are met: Services are required because the individual needed therapy services (see ); and A plan for furnishing such services has been established by a physician/npp or by the therapist providing such services and is periodically reviewed by a physician/npp (see ); and Services are or were furnished while the individual is or was under the care of a physician* (see ); and

7 Outpatient Therapy Services must be furnished on an outpatient basis. (see ) All of the conditions are met when a physician/npp certifies an outpatient plan of care for therapy. Certification is required for coverage and payment of a therapy claim

8 CAP for

9 Therapy Cap Values for 2016 $1,960 combined for Physical and Speech Therapy Services $1,960 Occupational Therapy Service Manual exceptions will continue after the $3,700 threshold has been met Extension granted until 12/31/2017 CR /1/

10 Therapy Modifiers These modifiers are for use with outpatient services GN - Services delivered under an outpatient speech language pathology plan of care GO - Services delivered under an outpatient occupational therapy plan of care GP - Services delivered under an outpatient physical therapy plan of care

11 KX Modifier Therapy providers are instructed to use the KX modifier to indicate the services that they are rendering are: Medically necessary and that justification is documented in the medical record The therapy financial limitation cap of $1,960 for PT/Speech or 1,960 for OT has been met, The beneficiary s condition is such that he/she requires further treatment

12 Over Utilization of the KX Important to recognize that most conditions would not ordinarily result in services exceeding the cap. Use the KX modifier only in cases where the condition of the individual patient is such that services are APPROPRIATELY provided in an episode that exceeds the cap. Routine use of the KX modifier for all patients will likely show up on data analysis as aberrant and invite inquiry. Be sure that documentation is sufficiently detailed to support the use of the modifier

13 Manuel Reviews New Contractor

14 G Code Sets and Reporting Modifiers

15 Claim Data Collection for Outpatient Therapy Services Reporting and collection of 42 non-payable G- codes and 7 modifiers required for PT, OT, SLP services MPFSDB status indicator Q therapy functional information code CR 8005 effective 1/1/

16 G- Code Sets and Reporting Modifiers These G-codes and related modifiers are required on specified claims for outpatient therapy services not just those over the therapy caps

17 Required Functional Code Editing Claims for therapy services, that do not contain the functional G- code/modifier information will be returned or rejected, as applicable. To avoid returned or rejected claims submit claims in order by treatment date of service

18 G-Code Sets and Reporting Modifiers The same DOS that an evaluative /reevaluation Discharge from the therapy episode of care, if data is available and/or a functional limitation has ended. Further therapy is necessary

19 Functional G-Codes Reported for PT/OT Mobility: G8978 G8980 Changing & Maintaining Body Position: G8981 G8983 Carrying, Moving and Handling Objects G8984 G8986 Self Care: G8987 G

20 Functional G-Codes (cont) Reported for PT/OT Other Primary: G8990 G8992 Other Subsequent: G8993 G8995 Reported for SLP Swallowing: G8996 G8998 Motor Speech: G8999, G9186, G9158 Spoken Language Comprehension: G9159 G

21 Functional G-Codes (cont) Reported for SLP Spoken Language Expressive: G9162 G9164 Attention: G9165 G9167 Memory: G9168 G9170 Voice: G9171 G9173 Other functional limitation: G9174 G

22 Selecting Functional G-Codes Reflect the predominant limitation that the furnished therapy services are intended to address Primary functional limitation being treated or Primary reason for treatment More than one limitation? the therapist may need to make a determination as to which functional limitation is primary

23 Functional G-Codes Pairs Code pairs must be selected from the same group at the outset of the therapy episode of care, including projected goal status, at specified points during treatment, and at the time of discharge Continued subsequent treatment select the set of G-codes to report the second functional limitation

24 Use of the Other Category If the patients limitation is not defined by one of the four categories. When a patient receiving therapy services that are not intended to treat a functional limitation (wound care, lymphedema) When the therapist uses a composite functional assessment tool (such as AMPAC or FOTO) and does not clearly represent a functional limitation as defined by the four categorical codes

25 Impairment Limitation Restriction Modifiers

26 Selecting Severity/Complexity 7 point scale Modifiers Use the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat a functional limitation Use the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument

27 Severity Modifiers Therapist will use valid and reliable functional assessments and/or objective measures in addition to their clinical judgment in selecting the severity modifier and must document accordingly If therapy services are not intended to address a functional limitation then use other G- code and the CH modifier

28 Claim Submission Reported as a separate line item Functional limitation data is comprised of three pieces of information: G code Severity modifier Therapy modifier (GP,GO,GN) Do not report KX or 59 on these line items Non payable codes - $0.00 amounts

29 Billing Claim Example HCPCS MODIFIER SERVICE DATE TOTAL UNITS TOTAL CHARGE GP G8978 GPCL GPXU or G8979 GPCI No special sequencing of functional modifiers KX modifier and xu modifier are not added to the functional G-code line item

30 Reporting Requirements

31 Reporting Requirements Reporting Frequency Outset of therapy episode of care Initial therapy claim Once every 10 treatment days At the end of progress/functional reporting period SE

32 Reporting Requirements (cont) Reporting episode Period of time based on dates of service May contain more than one reporting period Per patient, therapy discipline and NPI Reporting period Same as progress reporting Time from first functional coding to the 10th treatment day

33 Reporting Requirements (cont) At the time an evaluation or re-evaluation is furnished & billed At the time of discharge At the time reporting a particular function limitation is ended In cases where further therapy is necessary Reporting a different functional limitation

34 Reporting Requirements (cont) Two functional G-codes under one therapy plan of care (POC) Current status and goal status Discharge status and goal status May have more than two non-payable G- codes when patient receives therapy under more than one POC Same date of service and provider

35 Reporting Requirements (cont) Evaluative Procedures Codes on claim for evaluation or re-valuation require reporting functional G-codes and modifiers for the same date of service : 92506, 92597, 92607, 92608, 92610, 92611,92612, 92614, 92616, 96105, 96125, 97001, 97002, and

36 Reporting Requirements (cont) Beneficiary reaches the goal on first reported functional limitation; treatment continues for a second functional limitation using another set of G-codes Therapist may treat more than one functional level Only one can be reported at a time

37 Discharge Status G Codes Required at end of the functional limitation reporting period. Patient ends without notice Goal as been attained Prior to a new functional limitation period begins

38 Functional Reporting Discharge from First Limitation Discharge reporting for one functional limitation during an episode of care Goal Status G-code and severity modifier at last episode of care Discharge G-code and severity modifier would reflect the beneficiary s functional status at the time of progress reporting period

39 Discharge Reporting Less than 60 Days Less than 60 calendar days pass and the beneficiary returns to same NPI provider Provider did not bill a discharge claim Actions to take Resume same functional limitation reporting; use the same G-code set Start different functional limitation; discharge previous reporting and begin different functional limitation next treatment visit

40 Functional Limitation Q&A On a patient that self discharges and then returns for a different functional limitation BEFORE the 60 days, do you bill the discharge G-codes of the original functional limitation on the last date of service of the original functional limitation before they stopped coming to therapy? Yes. Once one functional limitation is discharged and further therapy is medically necessary reporting of the subsequent functional limitation begins on the next treatment DOS

41 Functional Limitation Q&A So to clarify...a clinician is to make an educated guess as to what the patient status is if they do not return for therapy? It does not seem right to assume their status if there is no way of knowing due to patient not returning for any follow-up care. Treatment encounter notes (sometimes referred to by clinicians as visit notes or progress notes ) describe each treatment session or individual patient visit. The last encounter note could be used to provide the G- code and modifier, if needed

42 Single Discipline Treated Two Diagnosis We have a patient that is being seen by two different PT's for two different reasons or diagnosis with two different functionality's but the billing NPI is the same, how would we bill these? One discipline, in this case physical therapy, under one or more POCs only two G-codes are required when billing the claim

43 Single Discipline Treated When reporting the second functional limitation should the severity modifier at the time of the initial evaluation be used or the one from the time the reporting began? The severity modifier used to indicate the patient s current status, reflects the severity of the functional limitation at the time of the visit for which Functional Reporting occurred

44 One or More Plan of Care (POC) When two therapists of the same discipline (e.g. two physical therapists) treat a patient concurrently for different services, it is anticipated that one therapist will complete a single thorough initial patient evaluation. This will include an assessment for all of the medical conditions identified at the time of the evaluation. A Current and Goal non-payable functional reporting G-codes and severity modifiers will be required

45 One or More Plan of Care (POC) Multiple Disciplines Under more than one POC for multiple disciplines (PT, OT and/or Speech Language Pathology (SLP)) include two G-codes for each discipline: Current Status and Goal Status or Goal Status and Discharge Status along with the severity modifiers During this episode of care one discipline may end, then include all three codes Current, goal and discharge status and modifier

46 Billing One-time Therapy Visit Beneficiary is seen and future therapy services are Not medically indicated or Furnished by another provider Three G-codes are billed with severity modifiers to indicate Current status, goal status, and discharge status

47 Documentation Requirements for Therapy MBPM Chapter 15 section 230.3

48 Therapy Evaluations Initial and New evaluations Encompass all conditions when referred by one or more physicians New injury/unrelated condition New episode of care

49 Additional Evaluative Services Re-evaluations, re-assessments, re-testing Routine services of expected progression in accordance with the plan of care are not separately reimbursable as an evaluative service Completed by therapist

50 Plan of Care Requirements Minimum required elements for plan of care: Diagnosis Type Amount/frequency/duration Long term goals

51 Certification Mandatory Legible dated signatures Initial certification and Significantly modified Plans of Care Signature must be obtained within 30 days of the initial therapy treatment

52 Recertification When is the recertification due? Duration on the initial plan of care OR 90 calendar days, whichever is less Recertification for services extending beyond the certified duration

53 Progress Reports Interval reporting is mandatory Can be in a separate Progress Report Can be in Treatment Encounter Notes Required on or before every 10th treatment day Do not typically need to be reviewed or require a physician signature

54 Progress Report Requirements Date of current Progress Note Date reporting began and ended Objective reports/measurements Assessment of improvement Plans for continued treatment Changes/updates to Plan of Care Legible Signature

55 Medical Necessity Begins with Legible documentation Gather and document objective, measurable information and goals Document a clear picture of the patient s condition/abilities from before and with therapy Support why skilled therapy is necessary at this point in the patient s life Document progress in relation to the measurable goals

56 Treatment Encounter Note Required for each visit Minimum elements include: Date of treatment Description of modality/intervention Total minutes of direct service Total minutes of time-based code services Legible signature and professional credentials of each person who contributed Can include the information required for the Progress Report

57 Physician Involvement Physician: Doctors of Medicine, Osteopathy, Podiatry, Optometry (for low vision only) Nurse Practitioner, Physician Assistant, Clinical Nurse Specialist) Order for therapy services Physician visit Certification

58 *Order/Referral No order or referral is required for outpatient therapy services. An order/referral where it exists for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. If the signed order includes a plan of care no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order

59 Required Documentation Initial evaluation Plan of care prior to treatment Physician certification and recertification Treatment Encounter Note Interval Progress Report Re-evaluations & additional assessment (when appropriate)

60 Who Documents Qualified PT, OT, SLP therapist furnishing the therapy services Provided incident to physician/npp Must meet incident requirements Physician/NPP personally furnishing the therapy services

61 What is Documented Document on the applicable dates of service Specific non-payable G-code and severity modifier How the modifier was selected Examples of modifier selections used Single functional assessment tool Measurement instrument for severity modifier Clinical judgment for severity modifier

62 Where to Document Onset of the episode of care Evaluation, POC or treatment note End of each progress reporting period Document in the progress report Re-evaluation due to significant change in the patient s functional condition Document in the re-evaluation or treatment note

63 Where to Document (cont) Discharge from therapy episode or to end reporting one functional limitation before reporting a different limitation Document in the discharge note or summary Progress note related to the end of the functional limitation

64 Where to Document (cont) First treatment day after progress report that ended the previous functional limitation Document in the treatment note of the initial service at the time the reporting of a new functional limitation begins

65 Plan Of Care Services must relate directly and specifically to a written treatment plan and Must be established by: Therapist who will provide the services (PT,OT, SP) Physician/NPP Must be : Signed Dated, and have the professional s identification (e.g. MD, PT, OT)

66 Plan of Care Requirements Minimum required elements for plan of care: Diagnosis Type Amount/frequency/duration Long term goals

67 Plan of Care Changes Insignificant Alteration Report to physician prior to next certification Significant Alteration Requires physician approval within 30 days of implementation

68 Certification Mandatory Legible dated signatures Initial certification and significantly modified Plans of Care (POC) Signature must be obtained within 30 days of the initial therapy treatment

69 Certifications Certification / re-certification may be signed by: Physicians and NPPs Optometrists may certify only low vision services Podiatrists consistent with the scope of professional services as authorized by applicable state law Note - Chiropractors and Dentists may not refer patient for therapy services nor certify therapy plans of care

70 Recertification When is the recertification due? Duration on the initial plan of care OR 90 calendar days, whichever is less Recertification for services extending beyond the certified duration

71 Delayed Certifications CMS states: Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/npp makes a certification accompanied by a reason for the delay. Certifications are acceptable without justification for 30 days after they are due. Delayed certification should include one or more certifications or recertification's on a single signed and dated document

72 Medical Necessity Begins with Legible documentation Gather and document objective, measurable information and goals Document a clear picture of the patient s condition/abilities from before and with therapy Support why skilled therapy is necessary at this point in the patient s life Document progress in relation to the measurable goals

73 Medical Necessity Not Met Services provided by : Professionals or personnel who do not meet the qualification standards, and services by qualified people that are not appropriate to the setting or conditions are unskilled services Services that are unskilled. Services provided for : General exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes. Services that are : Not provided under a therapy plan of care, or are provided by staff who are not qualified or appropriately supervised, are not covered or payable therapy services. Services that are : Provided to patients who's cognitive performance is impaired

74 Treatment Encounter Note Required for every therapy visit Minimum elements include: Date of treatment Description of modality/intervention Total time spent providing direct service Total time spent providing time-based code services Signature and professional credentials of each person who contributed Can include information required for Progress Report

75 Measurable Advancements Documentation should indicate measurable progress Acceptable: decreased pain from 5/5 to 1/5 at Rt. Shld. Patient should be able to independently comb hair in 4 weeks. Unacceptable: decreased pain, increased strength, improved mobility

76 Progress Reports Interval reporting is mandatory Can be in a separate Progress Report Can be in Treatment Encounter Notes Required on or before every 10th treatment day Do not typically need to be reviewed or require a physician signature

77 Progress Report Requirements Date of current Progress Note Date reporting began and ended Objective reports/measurements Assessment of improvement Plans for continued treatment Changes/updates to Plan of Care Legible Signature

78 Interval Progress Reports Do not require physician signature (unless services are provided incident to physician/npp by qualified non-therapist staff) Interval information is mandatory Can be in a separate Progress Report Can be in Treatment Encounter Notes Required every 10 treatment days

79 Questions You Might Ask 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?

80 Supervision Therapist can not work under another therapist Bill under own NPI Services must be supervised and coordinated by a therapist PTA and COTA Services performed solely by a student or therapy aide for outpatient therapy services are not reimbursable Students can work with licensed therapists

81 Signature Requirements Longstanding guidelines have not been changed: Medicare requires services provided/ordered be authenticated by author Method is handwritten or electronic Stamp signatures are not acceptable Legible full signature Legible first initial and last name Illegible signature over a typed or printed name

82 Signatures Missing or invalid signatures Attestation should be used Signature log CERT and Recovery Auditor Do not sign after the fact and send in requested documentation

83 Group and Individual Services Performed on Same Day Therapeutic procedure (s) Group billed once per day per patient Manual therapy techniques each 15 min Use of Modifier

84 Team Therapy Therapists or therapy assistants can not each bill separately for the same or different service at same time to same patient If physical and occupational therapist both provide services to one patient at the same time, the entire service be billed by only one therapist or the PT and OT can divide the service units

85 Supervision A therapist or therapist assistant can not bill for supervising a patient is independently performing therapeutic exercises program. Services must be medically necessary services delivered by a therapists or appropriately supervised therapy assistants

86 Aides and Students Medicare Part B does not pay for the services provided by aides regardless of the level of supervision

87 Reporting Requirements Tips to Remember Functional G-Codes and Severity Modifiers

88 Reporting Requirements Reporting Frequency Outset of therapy episode of care Initial therapy claim Once every 10 treatment days At the end of progress/functional reporting period

89 Reporting Requirements At the time an evaluation or re-evaluation is furnished & billed At the time of discharge At the time reporting a particular function limitation is ended In cases where further therapy is necessary Reporting a different functional limitation

90 Reporting Requirements Two functional G-codes under one therapy plan of care (POC) Current status and goal status Discharge status and goal status May have more than two non-payable G- codes when patient receives therapy under more than one POC Same date of service and provider

91 Reporting Requirements Beneficiary reaches the goal on first reported functional limitation; treatment continues for a second functional limitation using another set of G-codes Therapist may treat more than one functional level Only one can be reported at a time

92 Selecting Functional G-Codes Reflect the predominant limitation the furnished therapy services are intended to address Primary functional limitation being treated or Primary reason for treatment More than one limitation? the therapist may need to make a determination as to which functional limitation is primary

93 Selecting Severity/Complexity Modifiers Therapists can use their clinical judgment in the assignment of the appropriate modifier Document in the medical record how the modifier selection was made the same process can be followed at succeeding assessment intervals

94 Selecting Severity/Complexity Modifiers Use the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat a functional limitation Use the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument

95 Reporting Requirements Evaluative Procedures Codes on claim for evaluation or re-valuation require reporting functional G-codes and modifiers for the same date of service 92506, 92597, 92607, 92608, 92610, 92611,92612, 92614, 92616, 96105, 96125, 97001, 97002, and es/annualtherapyupdate.html

96 Billing One-time Therapy Visit Beneficiary is seen and future therapy services are Not medically indicated or Furnished by another provider Three G-codes are billed with severity modifiers to indicate Current status, goal status, and discharge status

97 Advance Beneficiary Notice of Non Coverage (ABN)

98 ABN Usage Q. When are therapists required to issue the mandatory ABN for therapy services? A. Therapists are required to issue the ABN to Medicare beneficiaries prior to providing therapy that is not medically reasonable and necessary regardless of the therapy cap

99 ABN When a patient has met their goal but wants continued therapy: Therapy cap has been met - ABN Mandatory Use GY Therapy cap is not met ABN Mandatory Use the GA When patient has not met their goal and therapy meets medically necessity Therapy cap met - No ABN required Use KX

100 2016 New Provider Portal

101 Noridian Portal Replacing Endeavor Endeavor was Noridian s first portal Aged technology CMS Expedited Life Cycle Activities Preliminary Design Review (August 2014) Detailed Design Review (December 2014) Security Controls Assessment (August 2015) Authorization to Operate (November 2015) New Registration Providers have more control New look and feel

102 Portal Roles and Descriptions Role Provider Administrator Provider End User Vendor Administrator Vendor End User Dual Access 2016 Description This role is responsible to review and approve/deny of End User registration and data access requests and Vendor Administrators. Provider Administrator does not have access to functionality. Provider End User role uses the portal functions for the provider accounts they were authorized to access. Administrative role only without access to portal functions or data. This role is responsible to review and approve/deny of Vendor End User registration requests. Vendor End User role uses the portal for the provider accounts and functions they were authorized to access. Small Provider/Supplier (self-identified) who can be an Administrator and an End User. 102

103 Noridian Medicare Portal Home Page

104 Portal Registration Re-registration required for every user 7-step process to create account Verify provider information and approval

105 Portal Online Recording Video Tutorial completed (18 mins.) Many NMP webinars full Education/Schedule of Events (left corner)

106 Enrollment Changes

107 Revalidation What's Changing Effective 3/1/16 Providers responsible for tracking own due dates CMS is providing a website link to check on revalidation date Notification s/mail will still be sent 2 months to validation date. Unsolicited revalidations more than 6 months will be returned

108 Revalidation Cycle 2 Go to Utilize the search tool If a Due Date is listed Submit the Revalidation 60 days from the due date Submit application via Internet-based PECOS If TBD is listed, a Due Date is coming Do Not submit a Revalidation application If there are further questions Contact the Enrollment Contact Center

109 Medicare Revalidation Tool

110 Locate Your Date

111 Enrollment Appeals

112 Resources

113

114 Therapy information: CMS - Top 10 Links Medicare - Billing - Therapy Services Center Outpatient Therapy Functional Reporting Learning-Network- MLN/MLNMattersArticles/downloads/SE1307.pdf ABN link : Information/BNI/ABN.html

115 CMS References Transmittal 2622, Change Request (CR) 8005 dated December 21, 2012; Internet Only Manuals IOM Medicare Benefit Policy Manual, Chapter 15 sections Medicare Claims Processing Manual, Chapter 5, Section 10.6 Functional Reporting. Medicare Claims Processing Manual, Chapter 5 section 20 National Coverage Determinations, Chapter 30.1 & ,

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