A physical therapy (PT) operation in Tennessee has agreed to pay the federal government for medically unnecessary services.
Therapists have struggled with payment policies over the last three decades as legislative efforts have employed methods that “supposedly” aim to bring the cost of services down by paying for the quality, rather than quantity, of care. Lynn S. Berry, PT, CPC, said “Therapists must juggle clinical concerns with documentation burdens to meet the challenge” of reimbursement.
While most therapists are meeting these challenges, a few have bent under the pressure of lowered payments. For example, Grace Healthcare, LLC and its affiliate Grace Ancillary Services, LLC (Grace) in Chattanooga, Tenn. On March 8, the Department of Justice (DOJ) and Office of Inspector General (OIG) announced that Grace’s therapy providers agreed to pay $2.7 million, plus interest, to resolve allegations of false billing for medically unnecessary therapy services.
According to the DOJ press release:
“The settlement resolves claims that in ten nursing home facilities in which Grace provided physical, occupational, and speech therapy for periods ranging from 2007 through June of 2011, Grace pressured therapists to increase the amount of therapy provided to patients in order to meet targets for Medicare revenue that were set without regard to patients’ individual therapy needs and could only be achieved by billing for a large amount of therapy per patient.”
Don’t let this happen to you. While waiting for more positive changes in the reimbursement system, there are things therapists can do to improve the current situation.
Properly Document when Using New G Codes and Severity Modifiers
To ensure you are compliant when rendering PT services, Berry’s recommendation is to “provide an audit trail by documenting in the medical record the G codes and severity modifiers, their rationale for use, and the pertinent tests provided. After the primary impairment goal is reached, a secondary impairment may be noted and treatment continued until the goal for that impairment is met or final discharge occurs. The G codes and modifiers apply to all claims in which Medicare is the primary or secondary payer.” The G codes and severity modifiers for PT, occupational therapy, and speech-language pathology are noted in the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule.
Will Payment Challenges Get Better for PTs?
There is positive action taking place on the horizon. According to Berry:
“For PT, the American Physical Therapy Association (APTA) is already working on a new payment system. Their draft of an Alternative Payment System (APS), or the Physical Therapy Classification and Payment System (PTCPS), was released to members for comment March 15, 2012. The CPT® Editorial Panel in Memphis, Tenn., Oct. 2-3, 2012, fully supported their efforts. A workgroup will be started that is open to all advisors to rewrite the Physical Medicine and Rehabilitation Section of CPT®. This is a two-part, per session payment system: One set of codes for evaluations, and another set of per-session codes for treatments. Each combines consideration of the complexity of the visit and the severity or complexity of the patient’s condition. APTA expects this system to begin Jan. 1, 2015.”
When that system goes into effect, “therapists can then move forward to provide efficient, effective care for their patients and meet the challenge of high quality care at reasonable cost,” said Berry.
For more information on capturing proper reimbursement for therapy services, read the articles “Therapy Services: The Uphill Climb to Better Codes and Reimbursement” and “PTs Rise to 2013 G code Challenge” in March 2013 Cutting Edge.
March 14th, 2013
Trick question: How many days long is the Medicare 90-day global period? The surprising answer is 92.
“Count 1 day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery,” advises the Medicare Learning Network “Global Surgery Fact Sheet.” Bundled services within that 92-day period include:
• Pre-operative visits after the decision is made to operate, including pre-operative visits the day before the day of surgery
• Intra-operative services that are a usual and necessary part of a surgical procedure
• All medical or surgical services required of the surgeon during the post-operative period due to complications that do not require additional trips to the operating room
• Follow-up visits related to recovery from the surgery
• Post-surgical pain management by the surgeon
• Supplies, except for those identified as exclusions
• Miscellaneous services (e.g., dressing changes, removal of sutures, staples, casts, etc.)
Separate billing is not allowed for visits or other services that are included in the global package.
How is payment divided if two physicians split the work of the global period (for instance, one physician performs the operation and a second physician provides post-op care)? The answer depends on the relationship of the two physicians.
Per Medicare policy, physicians in the same group practice who are in the same specialty must bill and be paid as though they are one physician. When these conditions aren’t met, payment for the post-operative, post-discharge care is split between the two physicians—as long as they agree on the transfer of care. Both physicians must keep a copy of the written transfer agreement in the beneficiary’s medical record.
When there is no transfer of care, services of a physician other than the surgeon may be reported with the appropriate level E/M code. Medicare will separately reimburse properly documented, medically necessary services.
November 28th, 2012
Best practices dictate that providers should appeal any claims believed to be wrongfully denied, but if your practice has received a string of claims denials for certain Medicare Part B services rendered to skilled nursing facility (SNF) patients in the past 18 months, you may just need to sit back and wait. The Centers for Medicare & Medicaid Services (CMS) and your Medicare administrative contractor (MAC) are already at work identifying all claims erroneously denied because of a claims processing issue in the 2012 annual update of the HCPCS codes for SNF consolidated billing. (more…)
September 26th, 2012
The Centers for Medicare & Medicaid Services (CMS) recently posted a new interactive Provider Compliance Group Interactive Map aimed to allow providers to determine state and territory-specific organizations providing Medicare auditing and compliance services in each state, including their contact information, email, and websites.
The map includes the CMS divisions responsible for contractors and definitions of various contractors and their roles. If you roll your cursor over a state, applicable information for that state is listed, along with state-specific information.
August 9th, 2012
Faced with a proposed cut to Medicare fee-for-service rates—a whopping 27 percent come Jan. 1, per the 2013 Medicare Physician Fee Schedule (MPFS) proposed rule—physicians have been waiting for a sign indicating Congress will override the Sustainable Growth Rate (SGR) methodology that calls for the cut, as they have since 2003.
Getting the ball rolling earlier than in years past, Rep. Michael Burgess, MD, (R-TX), introduced the Assuring Medicare Stability and Access for Seniors Act of 2012 on July 18. (more…)
July 26th, 2012