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



Similar documents
Outpatient Therapy Services

Preparing for Therapy Required Functional Reporting Implementation in CY 2013

Making Medicare Work for Physical, Occupational and Speech Therapists Workshop Q&As

Physical, Occupational, and Speech Therapy Services. September 5, 2012

Functional Reporting: PT, OT, and SLP Services Frequently Asked Questions (FAQs)

I. SUMMARY OF CHANGES:

Reciprocal Billing and Locum Tenens. Presented by: Medicare Part B Provider Outreach and Education (POE) May 2016

New Outpatient Therapy Evaluation and Intervention E&I Codes. An introduction to the new policy and new claims coding requirements

Carol Novak, RN, CHC Martin Yuson, DPT, JD. Tips for Effective Auditing/Monitoring of Medicare Documentation for OT, PT and Speech 4/24/2013

Regulatory Compliance Policy No. COMP-RCC 4.20 Title:

Inpatient Rehabilitation Facility (IRF) Services. Part A Provider Outreach and Education September 2015

By: R.L. Ramsdell, Ph.D., FACFEI, DABFE, CFC, LFMAAMA

Table of Contents. Respiratory, Developmental,

Medicare Outpatient Therapy Billing

New Functional Limitation Reporting Requirements Under Medicare Part B

G-Codes Functional Reporting: Are You Compliant

Medicare Claims Processing Manual Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Services

Critical Care Billing and Coding. Date: February 2015 Presented by: Part B Provider Outreach & Education (POE)

Advanced Therapy Management

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 88 Date: May 7, 2008

Rehabilitation Regulatory Compliance Risks

MEDICARE G-CODES. Implementation of the Claims Based Data Collection on Therapy Services. Rhonda Reininger, M.A., O.T.R, C.H.T.

NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES POLICY GUIDELINES

Medicare Secondary Payer Calculations Presented by: Provider Outreach and Education (POE) September 2015

Rehabilitation Compliance Risks. Agenda - Rehabilitation Compliance Risks

Chronic Care Management (CCM) Services. Presented by Noridian Part B Medicare Provider Outreach and Education December 2015

An Update on Outpatient Therapy Services

Physical Therapy (PT) Modalities and Evaluation

Using FOTO for Reporting Medicare Functional Limitation G-Codes/Severity Modifiers

Frequently Asked Questions Recovery Auditor Outpatient Therapy Claims As of April 17, 2013

Outpatient Therapy 8/29/07 Complex Billing Workshop - Q and As

Medicare 101: Basics of Modifier Billing. Part B Provider Outreach and Education February 26, 2014

PROVIDER MANUAL Rehabilitative Therapy Services

4. PROGRAM REQUIREMENTS

Section 2. Physical Therapy and Occupational Therapy Services

New Patient Visit. UnitedHealthcare Medicare Reimbursement Policy Committee


Chapter 101 MAINECARE BENEFITS MANUAL CHAPTER II SECTION 68 OCCUPATIONAL THERAPY SERVICES ESTABLISHED 9/1/87 LAST UPDATED 1/1/14

Chapter. CPT only copyright 2010 American Medical Association. All rights reserved. 20Home Health Services

Subtitle 09 WORKERS' COMPENSATION COMMISSION Guide of Medical and Surgical Fees

School Based Health Services Medicaid Policy Manual MODULE 6 OCCUPATIONAL AND PHYSICAL THERAPY SERVICES

Medicare Physician Fee Schedule Modifiers

Telehealth Services. Part B Provider Outreach and Education January 2016

Midlevel Practitioner Billing and Incident To

The following references are used throughout the billing scenarios that follow:

State Operations Manual Appendix E - Guidance to Surveyors: Outpatient Physical Therapy or Speech Pathology Services

Certifying Patients for the Medicare Home Health Benefit

Basic Training: Home Health Edition. Defining and Documenting, Medical Necessity. March 28, 2013

Overview of the Florida Medicaid Therapy Services Coverage and Limitations Handbook

Comments and Responses Regarding Draft Local Coverage Determination: Outpatient Physical and Occupational Therapy Services

Physical Medicine and Rehabilitation

Therapist in Private Practice or Group Practice

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY

SECTION 2 PHYSICAL THERAPY SERVICES. BY INDEPENDENT PHYSICAL THERAPISTS (including Group Practices) Not in Rehabilitation Centers

Transitional Care Management (TCM) Presented by Noridian Part B Medicare Provider Outreach and Education May 2016

Administrative Guide

Public Policy HCA Public Policy No

HCPCs Require G Codes and C Modifiers

Competitive Acquisition Program (CAP) for Part B Drugs & Biologicals Training for Supplemental Insurance Companies August 2007

Billing App Update: Version 2.012

Physical Therapists and Medicaid

IMPROPER PAYMENTS FOR EVALUATION AND MANAGEMENT SERVICES COST MEDICARE BILLIONS

PROVIDER BULLETIN No

Speech-Language Pathology (SLP)

Prior Authorization for Therapy Policy effective

Provider Delivered Care Management Payment Policy and Billing Guidelines for Medicare Advantage

Occupational Therapy Protocol Checklist

MEDICARE LOW VISION REHABILITATION DEMONSTRATION. Contact: James Coan, Project Officer

Incident To Services Documentation and Correct Billing July Presented by: Ellen Berra, Outreach Senior Analyst Karen Kroupa, Outreach Analyst

Report a number that is zero filled and right justified. For example, 11 visits should be reported as 011.

PROTOCOLS FOR OCCUPATIONAL THERAPY PROVIDERS

MediServe. More than 25 Years Serving the Rehab and Respiratory Communities

130 CMR: DIVISION OF MEDICAL ASSISTANCE

Note: This article was updated on June 5, 2013, to reflect current Web addresses. All other information remains unchanged.

Chapter 17. Medicaid Provider Manual

Jimmo v. Sebelius. Glenda Mack, Division Vice President Clinical Operations

Medicaid Electronic Health Records (EHR) Incentive Program FAQ

Sunshine Act reporting: Minimizing consulting and royalty payment risks. Stephanie J. Kravetz

Report a number that is zero filled and right justified. For example, 11 visits should be reported as 011.

[NPINumber] [Date] «PROVIDERNAME» «PROVIDERADDRESS» «PROVIDERCITYSTATEZIP» ATTENTION: COMPLIANCE. Subject: Additional Documentation Request (ADR)

Incident To, Non Physician Practitioners, Locum Tenens and Reciprocal Billing

Medicare Preventive Services National Provider Call: The Initial Preventive Physical Exam and the Annual Wellness Visit.

Division of Medicaid /HealthSystems of Mississippi Outpatient Physical Therapy, Occupational Therapy, and Speech- Language Pathology (Speech Therapy)

Medicare Enrollment By Dr. Ron Short, DC, MCS-P

Medicare Pulmonary Rehabilitation (PR) Benefit Frequently Asked Questions June 2010 (Latest Updates: December 18, 2013 and February 12, 2014)

Federally Qualified Health Centers (FQHC) Billing 1163_0212

Transmittal 36 Date: JUNE 24, 2005

Prior Authorization for Therapy (OT, PT, ST) Updates Effective November 1, 2013

Handbook for Providers of Therapy Services

Complimentary Wi-Fi is available: Connect to HYATT-MEETING or MEYDENBAUER WELCOMES PNDC. Use Password: PNDC2015.

Recovery Audit Contractors (RACs) and Medicare The Who, What, When, Where, Why and How?

External Breast Prosthesis Copyright, CGS Administrators, LLC.

HOSPICE FACE-TO-FACE QUESTIONS & ANSWERS

T- 09 Up Up and Away with Mediocre Therapy Documentation

Procedure code billed is not approved for the therapy/pathology assistant.

Changes for Master s-level Psychotherapists

Billing Guidelines Manual for Contracted Professional HMO Claims Submission

PROTOCOLS FOR SPEECH THERAPY PROVIDERS

Transcription:

Outpatient Therapy Services Presented by Part B Provider Outreach and Education (POE) 2016 1

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 http://www.noridianmedicare.com and the CMS website at http://www.cms.gov 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. 2016 2

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

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 2016 4

General Therapy Guidelines 2016 5

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 220.1.3); 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 220.1.2); and Services are or were furnished while the individual is or was under the care of a physician* (see 220.1.1); and 2016 6

Outpatient Therapy Services must be furnished on an outpatient basis. (see 220.1.4) 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. 2016 7

CAP for 2016 2016 8

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 9448-1/1/16 2016 9

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 2016 10

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 2016 11

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. 2016 12

Manuel Reviews New Contractor 2016 13

G Code Sets and Reporting Modifiers 2016 14

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 1/1/2012 2016 15

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. 2016 16

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. 2016 17

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 2016 18

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 G8989 2016 19

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 G9161 2016 20

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 G9176 2016 21

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 2016 22

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 2016 23

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. 2016 24

Impairment Limitation Restriction Modifiers 2016 25

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 2016 26

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 2016 27

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 2016 28

Billing Claim Example HCPCS MODIFIER SERVICE DATE TOTAL UNITS TOTAL CHARGE 97001 GP 011416 1 80.00 G8978 GPCL 011416 1 0.00 97140 GPXU or 59 011416 1 30.16 G8979 GPCI 011416 1 0.00 No special sequencing of functional modifiers KX modifier and xu modifier are not added to the functional G-code line item 2016 29

Reporting Requirements

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 SE1307 2016 31

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 2016 32

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 2016 33

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 2016 34

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, 97003 and 97004 2016 35

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 2016 36

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 2016 37

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 2016 38

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 2016 39

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. 2016 40

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. 2016 41

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. 2016 42

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. 2016 43

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. 2016 44

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 2016 45

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 2016 46

Documentation Requirements for Therapy MBPM 100-02 Chapter 15 section 230.3

Therapy Evaluations Initial and New evaluations Encompass all conditions when referred by one or more physicians New injury/unrelated condition New episode of care 2016 48

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 2016 49

Plan of Care Requirements Minimum required elements for plan of care: Diagnosis Type Amount/frequency/duration Long term goals 2016 50

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 2016 51

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 2016 52

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 2016 53

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 2016 54

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 2016 55

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 2016 56

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 2016 57

*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. 2016 58

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) 2016 59

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 2016 60

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 2016 61

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 2016 62

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 2016 63

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 2016 64

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) 2016 65

Plan of Care Requirements Minimum required elements for plan of care: Diagnosis Type Amount/frequency/duration Long term goals 2016 66

Plan of Care Changes Insignificant Alteration Report to physician prior to next certification Significant Alteration Requires physician approval within 30 days of implementation 2016 67

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 2016 68

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 2016 69

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 2016 70

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 2016 71

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 2016 72

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 2016 73

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 2016 74

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 2016 75

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 2016 76

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 2016 77

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 2016 78

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? 2016 79

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 2016 80

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 2016 81

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 2016 82

Group and Individual Services Performed on Same Day 97150 -Therapeutic procedure (s) Group billed once per day per patient 97140 - Manual therapy techniques each 15 min Use of Modifier 59 2016 83

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. 2016 84

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. 2016 85

Aides and Students Medicare Part B does not pay for the services provided by aides regardless of the level of supervision. 2016 86

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

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 2016 88

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 2016 89

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 2016 90

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 2016 91

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 2016 92

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 2016 93

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 2016 94

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, 97003 and 97004 http://www.cms.gov/medicare/billing/therapyservic es/annualtherapyupdate.html 2016 95

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 2016 96

Advance Beneficiary Notice of Non Coverage (ABN) 2016 97

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. 2016 98

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 2016 99

2016 New Provider Portal

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 2016 101

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

Noridian Medicare Portal Home Page 2016 103

Portal Registration Re-registration required for every user 7-step process to create account Verify provider information and approval 2016 104

Portal Online Recording Video Tutorial completed (18 mins.) Many NMP webinars full Education/Schedule of Events (left corner) 2016 105

Enrollment Changes 2016 106

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 emails/mail will still be sent 2 months to validation date. Unsolicited revalidations more than 6 months will be returned 2016 107

Revalidation Cycle 2 Go to https://data.cms.gov/revalidation 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 2016 108

Medicare Revalidation Tool 2016 109

Locate Your Date 2016 110

Enrollment Appeals 2016 111

Resources 2016 112

www.cms.gov/therapyservices 2016 113

www.cms.hhs.gov Therapy information: www.cms.gov/home/medicare.asp CMS - Top 10 Links Medicare - Billing - Therapy Services Center www.cms.gov/therapyservices Outpatient Therapy Functional Reporting http://www.cms.gov/outreach-and-education/medicare- Learning-Network- MLN/MLNMattersArticles/downloads/SE1307.pdf ABN link : www.cms.gov/medicare/medicare-general- Information/BNI/ABN.html 2016 114

CMS References Transmittal 2622, Change Request (CR) 8005 dated December 21, 2012; Internet Only Manuals IOM Medicare Benefit Policy Manual, 100-2 Chapter 15 sections 220-230 Medicare Claims Processing Manual, 100-4 Chapter 5, Section 10.6 Functional Reporting. Medicare Claims Processing Manual, 100-4 Chapter 5 section 20 National Coverage Determinations, 100-3 Chapter 30.1 & 30.1.1, 160.12 2016 115

Noridian Likes Website Feedback! Provide constructive/complimentary feedback to continue Noridian website growth and improvement 2016 116

What questions do you have? Thank you.