Tennessee Therapists Dish Out Dough for Putting Quantity Before Quality

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

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Physician Recruitment: Planning Is Crucial

By Dixon Davis, MBA, MSHA, CPPM

Planning ahead when hiring new employees is a key human resources skill. When hiring new staff, you typically need a couple weeks of advertising and application gathering, some interview time, and often two weeks’ notice before this new person can actually start. Hiring a physician is a much more complex experience that should be started up to six months prior to their first day of work. Because physician employment can be complex and crucial to business success, here are a few timing hints to keep you out of hot water.

Who to Recruit

As you begin the physician recruitment process, consider whether you will be recruiting a new resident, an experienced physician from outside your community, or a physician with  an already established practice in the community.

• Recruiting a physician out of residency will generally require less compensation with a candidate who usually adapts to more easily to your culture; and, there are new candidates coming out every year from which to choose. New residents will need to be licensed in your state, credentialed with payers, and privileged at any participating hospitals. Most residents start looking for six months to a year prior to when they graduate. For the best applicant pool, recruitment should start at least six months prior to graduation (Graduation is generally in June.).
• An experienced physician outside your community may require higher initial compensation, and may or may not need state licensure and credentialing with payers. Practicing physicians on an average are not constrained by a calendar unless working under a provision of a prior contract.
• A physician already in the community will ideally already have a full practice (existing patients), already be licensed and credentialed, and be familiar with the community. This type of recruitment is generally the fastest and most financially beneficial to a practice.

Basic Licensure and Credentialing

When considering the timing of your recruitment efforts, keep these general requirements in mind as most of them will be required to get paid and to meet local laws.

Credentialing a physician with payers can take several months. This can be a complex process and one that needs to be monitored carefully. In most cases, if the provider is not credentialed prior to seeing patients, he or she will never get paid for his or her services. If a provider is employed and seeing patients for a couple months without being fully credentialed with payers, it could result in a loss of tens of thousands of dollars.

 The Contract

Physician employment almost always will include an employment contract that will both protect the practice as well as the physician. Key components to include in a physician contract are:

During the recruitment process, do not forget to include the physicians’ spouse early. It can be costly and timely to go through the whole process only to find out at the very end that the spouse does not want to move to your city. Well-planned and -timed physician recruitment efforts save a lot of time and money, both of which are very valuable when doing business.

February 22nd, 2013

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Choose with Clarity Hearing Loss Supply Codes

With so many devices to choose from,
knowing what’s out there is key to proper reimbursement.

By Marita Cable-Camilleis, CPC

You would think that someone who has a vested interest in audiology would be an authority on the subject. While attending a four-day National Hearing Loss Association of America (HLAA) Convention in Providence, R.I., June 21-24, 2012, however, I quickly realized that there is no such thing as too much information, and that I had a lot more to learn. I’d like to share with you some valuable tips for reporting hearing-assistance technology supplies that I picked up at the convention so that you, too, may code hearing loss equipment with clarity.

Many Aid Choices, Many Code Choices

Most familiar hearing aid HCPCS Level II codes are classified to V5030–V5267, but many prosthetic implant/hearing assist supply codes also fall into categories L8613–L8629 and L8690–L8693.

For example, new sound processor devices for cochlear implants and cochlear bone-anchored hearing aid (BAHA) implants are reported with L8614 Cochlear device, includes all internal and external components and L8690 Auditory osseointegrated device, includes all internal and external components, respectively. Replacement implants are reported with L8619 Cochlear implant, external speech processor and controller, integrated system, replacement and L8691 Auditory osseointegrated device, external sound processor, replacement.

Bonus tip: Report surgical implantation of cochlear implants with CPT® 69930 Cochlear device implantation, with or without mastoidectomy. For BAHA, 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy or 69715 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy. When implants are placed in both ears, you may append modifier 50 Bilateral procedure. A child under the age of five would wear a headband for BAHA (or Ponto Pro) without surgery.

In other examples for different body locations, HCPCS Level II code V5095 Semi-implantable middle ear hearing prosthesis is for Vibrant Soundbridge® (VSB), a semi-implantable electromagnetic hearing aid. Another middle ear implant, called Envoy Esteem®, is fully implantable with no external components. This implant is also coded like the VSB semi-implant with CPT® 69799 Unlisted procedure, middle ear. For an in-the-mouth (ITM) device called SoundBite, used for bone conductive loss, report L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code.

According to Consumer Reports (“How To Buy a Hearing Aid,” July 2009), you cannot truly “compare” hearing aids because no two people have the same kind of hearing loss (type, severity, and configuration). With so many hearing aids—classified as monaural, binaural, and bilateral—it is easier to keep track of them using a chart, like the one shown in Table A. If a patient is diagnosed as having unilateral hearing loss and one deaf ear, a choice of bilateral contra-lateral routing of signals (BICROS) may be appropriate. Contra-lateral routing of signals (CROS) is used when a patient has one ear with normal hearing and one deaf ear.

One side of chart has the body-location variable and the other side lists hearing loss diagnosis variables mixed with manufacturers’ variables. Some hearing aids may be adjusted for high and/or low frequency hearing losses.

V5298 Describes Aids NOC

Several increasingly popular hearing aids are not yet specifically described by HCPCS Level II codes, such as receiver-in-the-canal or receiver-in-the-ear (ITE) devices. A small version of ITE is called half shell. Slim-tubing behind the ear (BTE) devices without ear molds are called open fit or over the ear; they are also called mini-BTE aids. These new hearing aids have microphones located in the ear, rather than on the hearing aid itself, and create a more natural sound and less wind noise. The newest, smallest completely in-the-canal (CIC) devices are called mini-CICs or invisible in the canals. If these new hearing aids are not classified, they could be coded as V5298 Hearing aid, not otherwise classified.

Alternate Hearing Assistance Technologies

Not all assistive listening devices are specifically coded because of multi-functionality. Captioned telephones such as CapTel® and CaptionCall® may be included in the HCPCS Level II code V5274 Assistive listening device, not otherwise specified, or simply reported with V5268 Assistive listening device, telephone amplifier, any type. These codes may also include hearing aid compatible smartphones. A modern digital hearing aid may have the ability to be controlled remotely by the patient’s cell phone.

Some assisted listening devices have not yet been coded because they are geared more toward groups, rather than individuals. One example is the increasingly popular “looping” system that is more common in Great Britain and Scandinavia. In this setting, an electromagnetic wire is looped around a room (or a ticket booth) to the speaker microphone, so anyone nearby can turn on the telecoil (t-coil) switch of his or her custom-made hearing aid (or cochlear implant) to hear the speaker more clearly. Approximately 69 percent of all hearing aids have a t-coil, which can be turned on for hearing-aid compatible phones with optional neck loops plugged in. T-coils (including related batteries, feedback-suppression capability, and directional microphones) are not currently specified in HCPCS Level II codes for hearing aids.

Even a non-deaf person can hear better with a headphone and inductive loop receiver, which picks up signals from a loop system while cutting off background noise. There are also personal loops just for television, which may be reported with V5270 Assistive listening device, television amplifier, any type.

New Receivers, Transmitters, and Microphones

For 2013, the descriptor for V5267 Hearing aid or assistive listening device/supplies/accessories, not otherwise specified was revised and new codes V5281–V5290 were added to accommodate personal FM/DM auditory devices, which are most often used with hearing aids to improve the signal-to-noise ratio. This allows the listener to better hear in the presence of background noise.

FM/DM auditory devices direct sound from a transmitting device (FM/DM transmitter) via a frequency or digitally modulated signal to a receiving device (FM/DM receiver), which may be coupled to a hearing device. A complete FM/DM system typically consists of a transmitter and a receiving device. If the receiver is built into a new hearing aid, you may report V5288 Assistive listening device, personal FM/DM transmitter assistive listening device for the transmitter only.

Another system creates a “public address-type” system with a wireless microphone, transmitting sound to receivers attached to loudspeakers and/or to those attached to hearing aids. For example, Inspiro® is an FM transmitter for teachers to wear in the classroom, and the DynaMic is a cordless microphone designed to be used with it. To combine all three components (receiver(s), transmitter, and microphone), use V5281 Assistive listening device, personal FM/DM system, monaural, (1 receiver, transmitter, microphone), any type for one receiver or V5282 Assistive listening device, personal FM/DM system, binaural, (2 receivers, transmitter, microphone), any type for two receivers (one for each ear).

Personal amplifiers (V5274), such as Pocketalkers®, are useful when FM systems, infrared systems, and hearing loop (or induction loop) systems are not available.

February 1st, 2013

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Boost Your Knowledge of Lesser-used Modifiers

Overlooking these modifiers can result in improper reimbursement.

By Terri Brame, MBA, CHC, CPC, CGSC, CPC-H, CPC-I

Any coder worth his or her wage knows about modifiers 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service and 59 Distinct procedural service, but what about modifiers RR Rental (use the RR modifier when DME is to be rented) and LS FDA-monitored intraocular lens implant? In fact, there are dozens of lesser-known modifiers that can help you report certain services more accurately.

Modifiers Come in Two Flavors

There are two levels of HCPCS modifiers. What coders usually call CPT® modifiers are actually HCPCS Level I modifiers. These modifiers are always two digits, are published in the CPT® codebook as Appendix A, and are maintained by the American Medical Association (AMA).

HCPCS Level II modifiers are used less often, and tend to be less well known (two exceptions are modifiers LT Left side and RT Right side). These modifiers may be any combination of two alphanumeric characters—except for two numbers. Level II modifiers are published by the Centers for Medicare & Medicaid Services (CMS) as part of the annual HCPCS Level II update, and may be applied to either Level I (CPT®) or Level II service and procedure codes.

HCPCS Level I Modifiers

Although so-called “CPT® modifiers” are generally familiar and often applied, there are a few exceptions. Among the most important are modifiers 63 Procedure performed on infants less than 4 kgs and 66 Surgical team.

Modifier 63

When a surgeon performs a procedure on an infant weighing less than 4 kg (4,000 g, or approximately 8.8 lbs), you may append modifier 63 to the CPT® code to inform the payer of the increased complexity of the procedure due to the patient’s small size. At best, this could garner increased reimbursement. Be aware, however, that most CPT® procedure codes performed on small infants include the notation, “Do not report modifier 63 in conjunction with …” because the CPT® code has already been valued to include this increased complexity. For example, see the parenthetical notation following 33502 Repair of anomalous coronary artery from pulmonary artery origin; by ligation and 33503 Repair of anomalous coronary artery from pulmonary artery origin; by graft, without cardiopulmonary bypass.

Modifier 66

Modifier 66 is applied when three or more surgeons complete parts of a procedure described by a single CPT® code. Before solid organ transplantation codes were separated into codes for donor organ removal, backbench work, and recipient transplantation (e.g., the CPT® section guidelines for Liver Transplantation), modifier 66 was appended to the transplant code to represent the separate surgical teams involved in each transplant stage.

In the unusual situation, when there are three or more primary surgeons working on a procedure, ensure the medical necessity of multiple primary surgeons is documented. When submitting a claim with modifier 66, you’ll usually have to send the operative report, as well. Medicare and other payers that follow the National Correct Coding Initiative (NCCI), verify whether modifier 66 is allowed for the procedure by referring to the “Team Surgery” column in the Medicare Physician Fee Schedule Relative Value File (downloadable from the CMS website).

HCPCS Level II Modifiers

Level II includes quite a few modifiers beyond RT and LT (as shown in Table A) that may be used within certain specialties to allow payment for multiple procedures that would otherwise appear to be duplicate billing.

For example, a plastic surgeon may repair the extensor tendon in three fingers on the right hand following trauma. To identify which fingers were repaired and that three procedures were performed and reported with the same CPT® code (26418 Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon), the coder would report 26418-F7, 26418-F8, and 26418-F9.

Table A: Anatomic Level II Modifiers

Preventing or Overriding Edits

Some modifiers may be familiar to insurance specialists in the practice’s billing office, and are important to receiving correct payment:

CC Procedure code change (use ‘CC’ when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) is used when submitting a corrected claim to clarify the claim is not a duplicate or an attempt to double bill for the same service. For example, if a charge was found through the quality check process to have been keyed with the incorrect provider number, and the charge is resubmitted with the correct provider number, you should append the appropriate CPT® code with CC appended.

GD Units of service exceeds medically unlikely edit value and represents reasonable and necessary services is used to override medically unlikely edits (MUEs), when appropriate. In 2007, Medicare implemented a set of MUEs that are applied to CPT® codes to prevent reimbursement for more units of a service than are typically provided, but the edits may not apply in all circumstances.

For example, a Medicare beneficiary may have required a total thyroidectomy to treat thyroid cancer, reported with 60252 Thyroidectomy, total or subtotal for malignancy; with limited neck dissection. Fifteen years later, the patient has a recurrence of thyroid cancer in a very small amount of retained thyroid tissue. The surgeon removes the remaining tissue, and should report the service with 60260 Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of the thyroid because the previous surgery was not technically a total thyroidectomy. But there is an MUE for total thyroidectomy because the “total” thyroid can be removed only once. In the case described, the second surgeon has a legitimate claim to override the MUE and to be paid for his service, and reports 60260-GD to describe the situation. You will likely have to submit an operative report and clearly document medical necessity, but the service should be reimbursed.

GW Service not related to the hospice patient’s terminal condition is applied only for patients receiving hospice services. When a patient is in hospice care, physicians must report all services related to the hospice illness to the hospice provider. If the patient receives care for a non-related illness, append modifier GW to allow payment directly from the payer. For example, if a patient who is receiving hospice care at home for metastatic cancer is seen in a primary care office for an upper respiratory infection, the primary care office should report an evaluation and management (E/M) service with modifier GW.

Clinical Trials

Payers, particularly Medicare, often expect clinical research services to be identified on the claim with Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study and Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study. These modifiers identify whether the services are part of routine care for the patient’s condition (care that would have been provided regardless of the research) or care that is not routine, and is part of the research.

Surgical Misadventures

When it is appropriate to report (or internally track) a surgical misadventure, the coder should append the CPT® code with one of the following:

PA          Surgical or other invasive procedure on wrong body part

PB          Surgical or other invasive procedure on wrong patient

PC         Wrong surgery or other invasive procedure on patient

Trauma, Disaster,
and Catastrophe

Services provided following a traumatic event may be reimbursed from a separate fund, qualify for increased reimbursement, or in some way alter the requirements for reporting a code. For example, some payer contracts may include a reimbursement carve-out for trauma-related services increasing the payment rate. When considering the modifiers below, always verify with the billing office whether they are appropriate.

CR Catastrophe/disaster related [may currently apply to superstorm Sandy services]

CS Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico, including but not limited to subsequent clean up activities

ST Related to trauma or injury

Teaching Physicians

Coders in academic practices are very familiar with the GC, GE, and GR modifiers, and so should coders looking to make a career move to academic medicine. These modifiers describe services provided following Medicare or U.S. Department of Veterans Affairs’ (VA) rules for resident and attending physicians working together:

GC         This service has been performed in part by a resident under the direction of a teaching physician

GE         This service has been performed by a resident without the presence of a teaching physician under the primary care exception

GR         This service was performed in whole or in part by a resident in a department of veterans affairs medical center or clinic, supervised in accordance with VA policy

Miscellaneous

The true value of a Level II modifier (in my humble opinion) lies with the modifiers describing unusual payment situations. The following are just a few examples:

CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission. This modifier may be used when the hospital where the procedure was performed admits a patient after a surgery is completed rather than before.

FP Service provided as part of the annual family planning program is especially valuable when the patient only has Medicaid coverage for family planning.

A coder may need to append GT Via interactive audio and video telecommunication systems for telehealth services.

H9 Court-ordered notes services rendered due to a court order.

HJ Employee assistance program is appended for services provided as part of an employee assistance program.

Large sections of Level II modifiers also apply to mental health services, durable medical equipment (DME), anesthesia, etc. Hopefully, this sampling of CPT® and Level II modifiers will motivate you to review the two modifier sets in their entirety, ensuring proper reporting and appropriate reimbursement for your practice.

As with any code, policies for using modifiers may differ from payer to payer. Before applying any modifier, ensure the payer accepts the modifier and adhere to any published rules for its use.

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Imaging Use Decline Contributing to Health Care Inflation Cut

Lower Medicare reimbursements and fewer referrals for magnetic resonance imaging (MRI), computerized tomography (CT), and cardiac nuclear scans are contributing to the slower rise in health inflation, research indicates. A new study published in the Journal of the American College of Radiology shows a 21 percent plunge in spending—from $11.91 billion to $9.46 billion—on diagnostic imaging by Medicare Part B from 2006 to 2010.

(more…)

December 13th, 2012

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