cert audit for contractors could cost your clinic - · pdf filecert audit for contractors...

CERT audit for contractors could cost your clinicAudit program puts providers at risk

With so much attention on the recovery audit con-

tractors (RAC) and other new audits that could cause

rehab providers to lose money, therapy managers

sometimes overlook older programs that could have

similar effects.

It’s more likely that a program could be overlooked

when the goal of the program isn’t to review providers,

but contractors. However, when CMS established the

Medicare Comprehensive Error Rate Testing (CERT)

program in 2003, the program had unintended con-

sequences for providers, says Nancy J. Beckley, MS,

MBA, CHC, president of Bloomingdale Consulting

Group in Brandon, FL.

Established to monitor and report the accuracy of

Medicare payments, the CERT program audits Medicare

contractors to ensure that they are reviewing and pay-

ing claims correctly. But when an error is found, the

contractors can return to the provider and request repay-

ment of the reimbursement, says Beckley. “In trying to

assess the payment error rate of contractors, the auditors

have to look at claims,” she says. “So inadvertently, rehab

claims end up getting checked and errors are found.”

CERT rundown

CMS states that it calculates the Medicare fee-for-

service error rate and estimate of improper claim pay-

ments using a methodology approved by the Office of In-

spector General.

The CERT meth-

odology includes:

Random- ➤

ly selecting a

sample of ap-

proximate-

ly 120,000

submitted

claims from all

providers

Requesting medical records from providers who ➤

submitted the claims

Reviewing the claims and medical records to ensure ➤

compliance with Medicare coverage, coding, and

billing rules

Auditors send letters to providers requesting a set num-

ber of claims (see p. 4 for a sample letter). Similar to RAC

audits or claims reviews, providers have a fixed number

of days to respond and return the specified documenta-

tion from the requested claims, says Connie Ziccarelli,

chief operating officer of Rehab Management Solutions in

Kenosha, WI.

CERT has recently established that providers no lon-

ger must fax documentation, but can now scan copies

“ In trying to assess the

payment error rate of

contractors, the auditors

have to look at claims.

So inadvertently, rehab

claims end up getting

checked and errors

are found.”

—Nancy J. Beckley,

MS, MBA, CHC

> continued on p. 2

IN THIS ISSUE

p. 4 CERT medical record requestSee a sample letter CMS may send you if your records are audited as part of the Comprehensive Error Rate Testing program.

p. 6 Dry needling Some therapists are using this treatment technique to relieve patients’ pain. Learn whether the technique is approved for PTs in your state and how to become certified.

p. 10 Therapy studies Two recent studies that point to the efficacy of PT can help you promote your practice and profession.

p. 12 BRRR coding corner Rick Gawenda, PT, answers questions about billing Medicare for VitalStim therapy and “incident to” billing.

April 2009 Vol. 14, No. 4

Briefings on Outpatient Rehab Reimbursement and Regulations April 2009

© 2009 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

of the charts and mail the documentation on a CD-ROM,

Beckley says. “When you’re faxing over copies of docu-

mentation, you’re looking for a lot of quality, and they

can be hard to read,” she says. “By scanning in the doc-

uments and sending over in a PDF format, you’re less

likely to have the reviewers stating errors because of il-

legibility or because they couldn’t find where you wrote

a note.”

However, unlike RAC audits and other claim reviews,

you may never receive the results of a CERT review that

you are part of because the auditors are more focused on

the contractors, says Beckley.

You will only receive a response if the contractors

return to request repayment of the reimbursement, but

at least you won’t be under the direct scrutiny of the

auditor.

CERT program < continued from p. 1

CMS publishes CERT reports quarterly, and it’s becom-

ing clear that contractors make a large portion of their

errors on rehab claims, which could shine the spotlight

even brighter on the rehab industry soon, says Beckley.

(To read the reports and learn more about the CERT pro-

gram, go to www.cms.hhs.gov/CERT.)

A rehab problem

In a 2008 CERT quarterly report, CPT code 97140 for

manual therapy was listed as one of the top 20 services

without sufficient documentation to support the claim,

says Beckley. It resulted in a 9.9% paid claims error rate

valued at $20,941,788.

The same report identified the highest paid claims

error rate of 21.2% for OT in private practice, resulting

in a projected $18 million in improper payments, with

88.9% resulting from inadequate documentation and

10.8% resulting from improper coding, says Beckley.

“Reports like that have to be a warning sign to the

industry,” says Beckley. “When RAC auditors see num-

bers like that, they may be more inclined to look specif-

ically at rehab services as part of their audits in coming

years.”

Part of the problem is that rehab isn’t the biggest

fish in the pond, so many contractors haven’t always

paid as much attention to rehab claims as others be-

cause their costs are less than fees for surgery or other

services.

But when errors are consistently found on rehab

claims—even when the errors aren’t typically fraud,

but due to a lack of complete documentation—the

claims will be examined more closely, says Beckley.

Group Publisher: Emily Sheahan, [email protected]

Associate Editor: Emily Beaver, [email protected]

Editor: Kevin Moschella, [email protected]

Briefings on Outpatient Rehab Reimbursement and Regulations

Nancy J. Beckley, MS, MBA, CHC PresidentBloomingdale Consulting Group Brandon, FL

Kate Brewer, PT, MBA, GCSVice President of Rehabilitation ServicesGreenfield Rehabilitation Agency Greenfield, WI

Peter ClendeninExecutive Vice PresidentNational Association for the Support of Long Term Care Alexandria, VA

Rick Gawenda, PTDirector of Rehabilitation ServicesDetroit Receiving Hospital Ypsilanti, MI

Peter R. Kovacek, MSA, PTPresident Kovacek Management Services, Inc. Harper Woods, MI

David O. Lane, PT, MHSAdministrative Director of Outpatient ServicesGaylord Hospital Wallingford, CT

Ken Mailly, PTMailly & Inglett Consulting, LLC Wayne, NJ

Christina MetzlerChief of Public AffairsAmerican Occupational Therapy Association Bethesda, MD

Angie Phillips, PTPresident and CEOImages and Associates Amarillo, TX

Lynn Steffes, PTPresidentSteffes & Associates Consulting Group New Berlin, WI

Briefings on Outpatient Rehab Reimbursement and Regulations (ISSN: 1089-4705 [print]; 1937-7398 [online]) is pub-lished monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $259 per year. • Briefings on Outpatient Rehab Reimbursement and Regulations (BRRR), P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2009 HCPro, Inc. • All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BRRR. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

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April 2009 Briefings on Outpatient Rehab Reimbursement and Regulations


Providers can enter their provider ID number and en-

sure that CMS has their correct practice address at the

CERT Web site, www.certprovider.org. This is important be-

cause CERT is linked into the CMS provider directory.

“You’d be surprised how many therapists change loca-

tions or create a provider ID and never check to ensure

CMS has the correct address information,” says Beckley.

Because providers who bill Medicare must have their cor-

rect address on file, you risk sanctions from CMS by not

ensuring that your address is accurate, she says.

Even if you are getting reimbursed at the correct ad-

dress, you could be incorrectly listed in another loca-

tion and get in trouble. If the CERT auditors request your

charts via mail, you must respond within 30 days. If you

don’t, you are in violation of your Medicare contract.

“I’ve seen cases where the error was on CMS’ end, but

the clinic can still face some trouble,” Beckley says. “One

of my clients found out that a renal clinic was assigned the

same provider number in the system as their therapy clin-

ic, so all correspondence was going to the wrong address.”

As with the RAC audits, claims reviews, and general

good practice, it is most important to remember that good

documentation reduces stress. Payers can look at as many

charts as they want, and although it might cost you some

time to find and send them to the requester, if you know

you practice ethical therapy and take good, quality notes,

you shouldn’t worry about giving back money or facing

any more serious infractions, says Ziccarelli. n

Putting CERT to good use

Although the thought of a contractor asking for

money back is scary, especially in these trying economic

times, the CERT program isn’t all bad for providers.

For example, it makes the contractors more account-

able, says Ziccarelli. For providers who are detailed and

careful with their documentation, it helps justify the time

they spend if contractors review claims more closely and

start catching problems earlier.

Also, with all the budgetary issues CMS faces, if the

CERT program starts catching billing errors in other

medical specialties, it could help clean up the health-

care industry.

A more direct benefit is that rehab providers can learn

from the CERT program, says Beckley. By reviewing the

quarterly CERT reports, providers can see their colleagues’

mistakes and ensure that they have compliance programs

to stave off making the same mistakes.

Because it’s likely most providers will never have their

claims reviewed by the CERT program, reading about the

process and being familiar with how the CMS audit pro-

cess works could be more beneficial when the RAC audits

are in full effect or for other claims reviews, Beckley says.

For example, if you see that the CERT report has found

that claims for therapeutic exercise are commonly misre-

imbursed, you should be aware that contractors are more

likely to perform a probe review of claims with that code,

she says.

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CERT letter

Under the Medicare Comprehensive Error Rate Testing (CERT) program, CMS audits Medicare contractors by reviewing

claims submitted by providers to ensure that contractors are processing claims correctly. The following is a sample letter auditors

may send to providers requesting to review claims as part of the CERT program.



Source: CMS.

CERT letter (cont.)



radiates in a distribution typical of the specific muscle

harboring the trigger point.

The aim of dry needling is to achieve a local twitch re-

sponse to release muscle tension and pain, Dommerholt

says. “The main advantage of dry needling is that it’s

truly specific in that it gets right to the source of the pain,”

he says.

Dommerholt was one of the first PTs to use dry nee-

dling in the United States and runs one of the two dry

needling certification programs in the country. “It’s the

fastest way I know to reduce a patient’s pain,” he says,

adding that dry needling can be used for several muscu-

loskeletal problems.

Common areas in which dry needling can be effective

include but are not limited to:

Neck, back, and shoulder pain ➤

Arm pain (e.g., tennis elbow, carpal tunnel, and ➤

golfer’s elbow)

Headache (e.g., migraines and tension-type headaches) ➤

Jaw pain ➤

Buttock pain ➤

Leg pain (e.g., sciatica, hamstring strains, and calf ➤

tightness/spasms)

Most patients do not feel the insertion of the needle,

Dommerholt says. The local twitch response elicits a brief

(i.e., less than one second) painful response. Some pa-

tients describe this as a little electrical shock; others feel

it more like a cramping sensation, he says.

Dry needling sessions take about 30–45 minutes, a

length of time similar to other therapy sessions. The

number of sessions is typically less than conventional

techniques, but varies greatly based on how long the pa-

tient has been dealing with the pain, says Dommerholt.

Although similar to acupuncture, dry needling is more

of a Western medicine. Many acupuncturists use dry nee-

dling as part of their practice, but PTs are not typically

trained in all the aspects of acupuncture.

From strengthening muscles to rehabilitating from

heart surgery, there are almost an endless amount of

conditions PTs can help improve. But the most common

issue patients come to a therapist for is reducing pain.

Whether the pain is from a torn hamstring, sore back,

or hip replacement, therapists have several modalities

and exercises to choose from to help patients return to a

normal life.

Most therapists treat the pain in noninvasive ways,

leaving more invasive procedures to surgeons and other

physicians. But a growing number of therapists are using

a more invasive technique to treat their patients’ pain.

The effective, but somewhat controversial, technique

of dry needling is an option therapists are beginning to

learn more about and are considering incorporating as

part of their practice.

Although currently only legal for PTs to perform in

11 states (Alabama, Colorado, Georgia, Maryland, New

Hampshire, New Mexico, Ohio, Pennsylvania, South

Carolina, Texas, and Virginia), growing evidence indi-

cates dry needling can be a fast, effective way to treat

any patient in which the pain is a result of a trigger

point.

Dry needling explained

Dry needling certainly isn’t for every PT, says Jan

Dommerholt, PT, DPT, MPS, DAAPM, president and

PT at Bethesda (MD) Physiocare, Inc. It involves using

needles to penetrate the skin and palpate trigger points

of pain, resetting pain sensors.

The term “trigger point” refers to pain related to a

discrete, irritable point in skeletal muscle or fascia, not

caused by acute local trauma, inflammation, degenera-

tion, neoplasm, or infection.

The painful point can be felt as a tumor or band in the

muscle, and a twitch response can be elicited on stimu-

lation of the trigger point. Palpation of the trigger point

reproduces the patient’s complaint of pain, and the pain

Dry needling may end your patients’ painTreatment rising in popularity as states start to allow use



University in Atlanta is one of the first schools to begin

educating students about dry needling, thus letting stu-

dents know it is an option.

Adding dry needling to your practice

If you live in one of the 11 states where dry needling

is already allowed as part of your practice act, it won’t

take much to start incorporating dry needling into your

regular practice.

You can start by taking one of the accredited dry nee-

dling courses as though you were going to add any other

specialty service to your practice, says Adler. “I had been

practicing physical therapy for 25 years and just always

felt I could help my patients more if I could get deeper,”

she says. “I heard about dry needling about five years

ago, took the course, and it immediately became one of

the most popular services I provided.”

Dry needling became so popular at Adler’s practice

that she’s had to leave most of the more common PT ser-

vices to her other therapists. “I started out treating one

patient with dry needling a week, but now I have five to

10 patients a day coming in for dry needling treatment,”

she says.

Once you’re certified in the technique, the costs of

adding dry needling to your practice are minor, says

Dommerholt.

To start, you will need:

Several different-sized needles (needles typically cost ➤

about $12 per 100 needles)

A place to properly dispose of the needles (state ➤

laws vary)

Cotton balls and bandages for the rare times the ➤

patient bleeds

Rubber gloves ➤

Other than the items listed above, you don’t have to

change much about your practice, says Dommerholt.

Dry needling can be performed in regular treatment

rooms, and it shouldn’t affect your insurance status with

payers or malpractice insurance. Most insurers reimburse

The reason dry needling is still considered controver-

sial in some facets of the world of therapy is that most

PTs are not accustomed to using needles as part of their

practice.

But most state practice acts don’t specifically state

that PTs can’t use needles, allowing therapists to peti-

tion to include dry needling in their practice act. On-

ly some states (i.e., California, Nevada, Tennessee, and

Florida) have specifically stated that dry needling is not

allowed by PTs.

Physicians are allowed to perform dry needling in any

state, although Dommerholt says he believes PTs are the

most appropriate clinicians to perform the treatment be-

cause PTs are more familiar with performing palpations

and know where the muscle trigger points are.

“Learning to insert the needle is minor,” says Tracey

Adler, DPT, owner and director of Orthopedic Physical

Therapy, Inc., in Richmond, VA. “Learning to palpate the

trigger point and where to put the needle is what makes

it effective.”

Getting educated

Although dry needling has become much more com-

mon worldwide in the past 10 years, it still occupies a

small niche in the United States. Part of that reason is

because there are only two places to become certified

in the technique—Dommerholt’s Myopain Seminars

(www.myopainseminars.com) based in Atlanta and Glob-

al Education of Manual Therapies (www.gemtinfo.com) in

Brighton, CO.

Both programs offer intensive training on the tech-

niques of dry needling. The skills can be taught in a few

days, but it takes a lot of time and practice to perfect the

technique, says Adler. “If you can get past inserting a

needle into patients, the general concept isn’t too differ-

ent than manual therapy,” she says. “It’s about finding

the source of the pain and going right at it. But just like

any technique, the success depends on your skill level.”

One reason why dry needling may not have yet taken

off in the United States is that most PT schools are not

teaching students about the technique. Georgia State > continued on p. 8



But in most cases, getting approval will require pro-

viding evidence that it works and showing that thera-

pists are qualified.

Dommerholt says although he doesn’t start the battle

in each state, he’s willing to testify and provide the evi-

dence if there are therapists who want to make the push

to legalize dry needling by PTs in a specific state.

The fight often comes from physician boards who feel

they are the only ones qualified to penetrate the skin,

but as more states allow dry needling, that argument be-

comes more difficult to make, Dommerholt says. (See

“Dry needling guidance” on p. 9 for guidance Colorado

created on the issue.)

Creating a balance

It’s important to note that dry needling alone will not

return a patient to full strength, says Dommerholt. Dry

needling alleviates the pain that makes functioning diffi-

cult for many patients.

Adler says dry needling, combined with more conven-

tional therapy exercises and modalities, has been work-

ing well for her during the past five years.

“I typically perform dry needling on a patient once a

week, and they see another therapist for manual thera-

py or other therapy sessions another one or two times a

week,” she says.

The dry needling allows the patient to forget about the

pain and focus on performing the exercises that will be-

gin to heal the muscle or other injury, Adler says.

Dommerholt says he performs dry needling and man-

ual therapy on many of his patients, but he does dry nee-

dling on 90% of his patients because it’s the quickest,

most effective way he knows to treat pain.

“I know it’s still not widely accepted across the indus-

try,” says Adler. “But I believe it’s because some people

are scared of change, and using needles in an invasive

way is a major change for some therapists. However,

you can’t grow in your profession if you don’t take cal-

culated risks.” n

for dry needling under its own code or the manual thera-

py code (CPT code 97140), he says.

However, some therapists, such as Adler, don’t feel

comfortable billing for dry needling under the manual

therapy code because it doesn’t fit the normal definition.

Adler makes it a cash-based service, charging the fee

she would charge for any therapy service to a patient

without insurance. “I never have problems getting pa-

tients to pay cash for dry needling because they see its

effectiveness,” she says. “It’s something you can tell is

working after one or two treatments, so we don’t contin-

ue with it if the patient isn’t feeling better quickly.”

But Dommerholt says he and many of the other

therapists who use dry needling bill it under manual

therapy, provide the proper documentation, and don’t

get denied.

As for malpractice insurance, Adler says hers nev-

er increased because the risks are no greater than most

other techniques, with bruising as the biggest side effect

and the only dangerous, yet uncommon, side effect a

collapsed lung.

Adding dry needling to your practice can also give

you a marketing advantage similar to adding any other

specialty. Because there are only about 350 therapists

licensed to perform dry needling in the United States,

being able to offer the service can drive in new clientele

and offer current patients another option for their care,

says Dommerholt.

“It changed my practice drastically,” says Adler. “In-

stead of physician referrals now, I get most of my refer-

rals from other patients. I advertised the service at first,

but word spread quickly that patients were really seeing

results.”

For therapists in states where dry needling has yet to

be approved but hasn’t been denied, sometimes getting

approval is as easy as writing to your state board, says

Dommerholt. “There’s been a couple states where all it

took was a therapist asking for permission to perform dry

needling for it to be allowed,” he says.

Dry needling < continued from p. 7



Dry needling guidance

Thirty-nine other states have not yet to allowed PTs to use

dry needling. Of those states, four (California, Nevada, Ten-

nessee, and Florida) have expressly stated that PTs may not

perform the dry needling technique.

If your state has not yet approved dry needling, but has

not specifically denied PTs from using it, writing to your state

board may help PTs in your state get permission to use the

technique. When writing to your state board, using guid-

ance from other states that have approved dry needling for

PTs may help you formulate an argument.

In February 2008, Virginia passed guidance on the use of

dry needling by PTs. If you’re interested in getting dry nee-

dling approved in your state, consider the Virginia guidance

below to explain why PTs should be able to use dry needling

to help patients relieve pain. Upon recommendation from the

Task Force on Dry Needling, the board voted that dry nee-

dling is within the scope of practice of PT, but should only be

practiced under the following conditions:

Dry needling is not an entry-level skill, but an advanced ➤

procedure that requires additional training.

A PT using dry needling must complete at least 54 hours ➤

of post professional training, including providing evi-

dence of meeting expected competencies that include

demonstration of cognitive and psychomotor knowl-

edge and skills.

The licensed PT bears the burden of proof of sufficient ➤

education and training to ensure competence with the

treatment or intervention.

Dry needling is an invasive procedure and requires physi- ➤

cian referral and direction specific for dry needling. Phy-

sician referral should be in writing and specific for dry

needling; if the initial referral is received orally, it must be

followed up with a written referral.

If dry needling is performed, a separate procedure note ➤

for each treatment is required, and notes must indicate

how the patient tolerated the technique as well as the

outcome after the procedure.

A patient consent form should be utilized and should ➤

clearly state that the patient is not receiving acupuncture.

The consent form should include the risks and benefits of

the technique, and the patient should receive a copy of

the consent form. The consent form should contain the

following explanation: “Dry needling is a technique used in

physical therapy practice to treat trigger points in muscles.

You should understand that this dry needling technique

should not be confused with a complete acupuncture

treatment performed by a licensed acupuncturist. A com-

plete acupuncture treatment might yield a holistic benefit

not available through a limited dry needling.”

But getting your state to allow PTs to perform dry nee-

dling may require more than a letter requesting permis-

sion; you may need to show evidence that the dry needling

technique works and PTs are appropriate professionals to

perform the task. Jan Dommerholt, PT, DPT, MPS, DAAPM,

president and PT at Bethesda (MD) Physiocare, Inc., is will-

ing to help therapists trying to legalize dry needling in their

states by testifying to the treatment’s efficacy.

Dommerholt runs one of the only dry needling certifica-

tion programs in the country. For more information, visit his

Web site at www.myopainseminars.com.

Source: Adapted from the Virginia Board of Physical Therapy-

Guidance Document.

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Therapists have a lot on their minds due to declining

reimbursements, rapidly changing managed care con-

tracts, and the large amount of information supplied by

CMS. Too often, the reason therapists entered the busi-

ness gets lost in the shuffle: the desire to help patients

and practice medicine. So sometimes, instead of reading

about regulatory and reimbursement changes, therapists

should read clinical studies and literature reviews that

affect their profession.

Two such recent studies published in the Journal of the

American Academy of Orthopaedic Surgeons can help thera-

pists reaffirm their career choice and show that jumping

through all the red tape is a small price to pay for the dif-

ference they can make in patients’ lives.

The first article was published in the February issue of

the journal and dealt with the benefits of PT for patients

with lower back pain; it was lauded by the American

Physical Therapy Association (APTA). The second article

was published in March and stressed the importance of

rehab and therapists in treating patients with medial col-

lateral ligament (MCL) knee injuries.

Articles such as these should be used to promote the

benefits of rehab to patients, physicians, and insurers

who may be trying to reduce therapy benefits, says APTA

spokesperson Julie Fritz, PT, PhD, ATC, clinical out-

comes research scientist at Salt Lake City’s Intermoun-

tain Healthcare and associate professor at the University

of Utah.

Payers want to see the use of evidence to support treat-

ments and justify services, so using evidence-based articles

can help get therapy the respect it deserves in the health-

care industry, says Fritz.

Lower back pain

The February article about lower back pain showed

that PT is most often the best as the frontline treatment

for symptomatic lumbar degenerative disc disease, a com-

mon cause of lower back pain.

The review looked at many treatment methods and

concluded that in most patients with lower back pain,

symptoms are resolved without surgical intervention

when the patient receives PT, especially when used in

combination with nonsteroidal anti-inflammatory drugs

(NSAID). The review also concludes that PT and NSAIDs

are the cornerstones of nonsurgical treatment.

“While the review didn’t tell us a lot that we didn’t

already know as therapists, what it did do was offer a

sign that there’s an increasing recognition from the out-

side world of the benefits of physical therapy,” says Fritz.

“The fact that it was an orthopedic journal and written

by orthopedists outside of the therapy world is what’s

important and telling.”

In the review, PT intervention included strengthening

core muscle groups such as the abdominal wall and lum-

bar musculature, which can have positive effects in pa-

tients with this condition. The review also showed that

exercise and manual therapy, including spinal manipu-

lation, can benefit many patients. In addition, patient

education to remain active and use appropriate body

mechanics is beneficial.

Having documented evidence that PT, rather than sur-

gery, should be considered as a first option can help you

with patients or physicians when going over a plan of

care, says Fritz.

Although other studies exist that show similar results,

having the most current and updated studies is always

helpful in making a case. Posting similar articles around

your office can reassure patients that they are making

the right choice to go through sometimes painful exercis-

es and remind staff members that what they are doing is

beneficial, says Fritz.

MCL therapy

The March clinical study of athletic MCL injuries was

more proof that with most injuries, therapy should be

part of the discussion prior to surgery. The study showed

Recent studies provide evidence for therapy benefitsTherapists should use current literature in marketing and with insurers



that for patients with Grade I and II MCL tears, inten-

sive therapy often eliminated the need for surgery. For

patients with Grade III and above tears, receiving ther-

apy services sometimes eliminated the need for surgery

and almost always made the recovery faster, regardless

of whether surgery was performed.

“We found that the heavy majority of MCL injuries

can be treated nonsurgically,” says Ryan G. Miyamoto,

MD, lead author on the study and sports medicine fel-

low at Steadman Hawkins Clinic in Vail, CO.

By emphasizing early range of motion, strengthen-

ing muscles around the knee in the early or later phases

of healing, and using modalities such as ultrasound, PT

can improve the process and help the patient with any

grade of MCL tear.

Although the study mostly examined athletic injuries,

Miyamoto says the concepts should hold true with any

type of MCL injury. In addition, therapists and orthope-

dists working together rather than competing is best for

the patient.

“Communication between the orthopedist and ther-

apist is crucial,” says Miyamoto. “In a hospital setting,

there should be almost daily interaction with the two

specialties working together. And then after the initial

visits or surgery, orthopedists often rely on therapists for

their information.”

Because therapists will typically see a patient more of-

ten than orthopedists, physicians use the therapists’ notes

and tests to make many of their judgments on how to al-

ter patients’ plan of care, says Miyamoto.

“I know some therapists don’t always believe that

orthopedists read over their notes and that sometimes

all the writing is for naught, but a good orthopedist

knows how valuable that information is,” Miyamoto

says. “Therapists have time to perform tests and really

see the difference treatment is making on a day-to-day

basis.”

However, therapists should not try to treat MCL inju-

ries without working with an orthopedist, as there may

be more involved than a therapist can tell without imag-

ing tests, Miyamoto says. “We did see that it’s probably

best that all MCL injuries are overseen by an orthopedist

because of the risk MCL injuries pose to the anterior cru-

ciate ligament if not treated properly,” he says.

If a therapist assumes that only the MCL is dam-

aged, other parts of the knee could be further damaged

if a physician examination hasn’t taken place, says

Miyamoto.

“What we found was that it really has to be a collab-

orative process, where the therapist sets benchmarks

and works as the eyes and ears for the orthopedist and

the orthopedist can make sure all the ligaments and

muscles are repaired and are recovering correctly,” he

explains.

Takeaways

The important aspects of both studies for therapists

are not the clinical recommendations of the studies, but

the practical implications of what they represent.

Neither study presents new ways to treat a back or

knee injury, but they offer advice for working with pa-

tients and physicians to provide the best care possible,

says Fritz.

Therapists too often feel that they are isolated and are

working against insurers and physicians, but by staying

current in the literature, therapists can be on equal foot-

ing and have proof that what they are doing works, is

medically necessary, and should be reimbursable like any

other medical procedure. n

If you’ve developed a unique way to save mon-ey at your outpatient facility, created a new policy that has saved you time, or started a program that improved patient care, we’d love to hear about it. Send us your brilliant ideas and your facility may be featured in BRRR. The person with the best idea will receive a copy of The Pocket Guide to Thera-py Documentation.

Contact Associate Editor Emily Beaver by telephone at 781/639-1872, Ext. 3406, or e-mail [email protected].

Share your bright idea and win a book!



Editor’s note: Rick Gawenda, PT, director of rehabilita-

tion services at Detroit Receiving Hospital and owner of Gawenda

Seminars in Ypsilanti, MI, answered the following coding ques-

tions. Submit questions to Associate Editor Emily Beaver at

[email protected].

I have a question regarding billing for VitalStim ther-

apy on Medicare patients. Recently, we have been

receiving denials for provided outpatient therapy ser-

vices. Up until now, I have always billed for a dysphagia

treatment (92526) and an electrical stimulation attended

charge (97032).

I include documentation in all of my SOAP notes re-

garding both types of treatment. Can you give me guid-

ance as to the correct billing on this subject?

CMS does not knowingly reimburse separately for

VitalStim therapy in the treatment of dysphagia pa-

tients. VitalStim therapy is electrical stimulation that SLPs

began using in 2003 as an adjunct to accepted reasonable

and necessary dysphagia treatment interventions. At first,

most CMS contractors were reimbursing separately for

VitalStim therapy when billed under G0283 (unattend-

ed electrical stimulation) or 97032 (electrical stimulation-

manual). Once the CMS contractors determined what

they were reimbursing, they stopped paying separately

for VitalStim therapy since the efficacy has yet to be prov-

en in independent research, in CMS’ opinion.

CMS contractors now consider VitalStim therapy to be

included in the reimbursement for 92526 (treatment of

swallowing dysfunction). Most non-Medicare payers also

follow CMS guidelines and do not knowingly reimburse

separately for VitalStim therapy.

In addition, 97032 is considered a component of the

more comprehensive code 92526 and is not separately

reimbursed. This is a Correct Coding Initiative edit that

can be bypassed by appending modifier -59 to 97032 on

the claim form when billed on the same day as 92526.

It is not something I would recommend doing for the

BRRR coding cornerreasons I previously stated. Modifier -59 is allowed be-

cause if the PT or OT billed 97032 on the same day that

the SLP billed 92526, the provider could be reimbursed

for the manual electrical stimulation provided by the PT

and OT.

When PT assistants (PTA), PTs, and physicians are

working out of the same organization, do PTs bill

under the physician’s name and the PTAs bill under the

PT’s name to Medicare? I had always thought that the

PTAs and the PTs were supposed to bill under the physi-

cian’s name. Can you point me to where Medicare clari-

fies what it deems appropriate billing for this condition?

Under Medicare Part B therapy benefits, services pro-

vided by PTs and OTs in the private practice setting

may be billed “incident to” a physician or nonphysician

practitioner (NPP). An NPP under the Medicare program

is a physician assistant, nurse practitioner, or clinical

nurse specialist.

To be billed as “incident to” the physician or NPP, the

physician or NPP must be on the premises and provide

direct supervision of the therapy services provided by the

therapists. All other outpatient therapy rules and regula-

tions apply as in other outpatient therapy settings.

Services provided by PTAs and OT assistants (OTA)

may not be billed “incident to” a physician or NPP. Ser-

vices provided by a PTA or OTA employed by a physi-

cian office may be billed under the PT’s or OT’s National

Provider Identifier number when directly supervised by

that therapist if the therapist is enrolled in the Medicare

program. If the PT or OT is not enrolled, Medicare shall

not pay for the services of a PTA or OTA billed “incident

to” the physician’s service because the services do not

meet the qualification standards in 42 CFR 484.4.

For more information on “incident to” billing under

the Medicare program, please refer to CMS Pub. 100-02,

Chapter 15, Section 230.5 (www.cms.hhs.gov/manuals/

Downloads/bp102c15.pdf). n

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