medicare outpatient documentation: clearing up the myths

MedicareOutpatientDocumentation:ClearingUpthe

Myths

MPTASpringMeetingApril2017

Presenters

MichaelGorman,PhD,PT,DMT,FAAOMPTCEO-St.LouisPhysicalTherapy

JenniferSchnieders,DPTCEO-OutboundPhysicalTherapy&Rehab

**SomeofthisinformationisfromRobbieLeonard,PTlectureat2016PPSConference.

MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths

LectureObjectives

• ClearupthemanymythsofMedicareOutpatientDocumentationandBilling• ParticipantstohavefullunderstandingofallcomponentsoftheMedicarePlanofCare• ProvidelistofapprovedMedicarereferralsourcestooutpatientphysicaltherapy• DiscussFunctionalLimitationReportinginrelationtoMedicaredocumentation


References

• MedicareBenefitPolicy,Chapter15Section220-223• MedicareClaimsManual,Chapter5• WPS“NewtoMedicareTeleconference- MedicalReviewandDocumentation”March7,2017• Reallifeexperience!


Doesthislectureapplytoyou?

• Yesifyoutreatoutpatients• PrivatePractices

• PTPP(PhysicalTherapistinPrivatePractice)• ORF(RehabAgency)• CORF(ComprehensiveOutpatientRehabilitationFacility)

• Hospitalbased• Outpatientsofotherentities(SNF,HomeHealth,RehabHospital)


Don’tforgettheseguystoo…

• MedicareAdvantageplans• Tricare• FederalBCBS• Champus


Myth#1:PTAscantreatindependentlyinmyprivatepractice• MedicareonlyrecognizesthefollowingasqualifiedprofessionalsforprovidingPT• PTs• PTAsunderpropersupervision• MDsandNPPs

• Aides,tech,andathletictrainerscannotbillservicestoMedicare


PTASupervisionRules

• InPTPPsettingrequiredtohaveon-sitesupervisiontotreatMedicarepatients.• CORF/ORFPTAcantreatindependentlywithoutPTon-site.


Myth#2:PT/PTAstudentscan’ttreatMedicarepatients

• StudentscanperformtreatmentonpatientswithPT/PTApresent• ThecaremustbeoneononewithPT/PTAdirectingthecare.


Myth#3:Ican’ttreatthepatientwithoutasignedPlanofCare

• YoucanevaluateandtreatthepatientwithoutaPTprescription.• MedicarestatespaymentisbasedoncertificationofPOC,notorderorreferral• “Prudent”tohavescriptbutnotrequired…butknowyourMOPracticeActregardingDirectAccess“


Myth#3:Ican’ttreatthepatientwithoutasignedPlanofCare

• “Itisnotintendedthatneededtherapybestoppedordeniedwhencertificationisdelayed.”• 30-60daysafterstartofPOC-nojustificationneeded• 60-90daysafterstartofPOC-NeedevidencethatyouareattemptingtogetPOCsigned


Myth#4:PlanofCaresarealwaysgoodfor90days

• Goodforupto90days• Needtosetforamountoftimetherapistrealisticallyexpectstoseethepatient(mildanklesprainvs.postsurgicaltotalknee)• WhatifPOCisn’tdated?• YoucanwritereceivedonXXdatewhenPOCisreturnedor…• IfPOCisfaxed,thefaxdateissufficient.


Myth#5:AchiropractorcansignaPOC

• ChiropractorsandDentistscanNOTsignPOC-ifTMJpatienthavepatient’sPCPsignPOC(iftheyarewilling)• PhysicianscertifiedtosignPOC• MD• DO• Podiatrists(forfeetonly)• Ophthalmologistsoroptometrists(forlowvisionpatientsonly)• PhysicianAssistant• NursePractitioner


Myth#6:ImusthaveShortTermGoalsonthePOC

• POCrequirementisforLONGtermgoalsonly• Howeveriflongtermpatient(8-12weeks)shorttermgoalsareprudenttoassistinshowingprogress• Ifgoalsareaddedorchanged,POCshouldbere-sentforcertification


Myth#7:IcanbillMedicareevery30daysfordoingare-evaluationnote• Are-evalchargeisONLYbillablewhenthepatientisnotfollowingPOC(forbetterorworse)andthePOCneedstobemodifiedORifpatienthassignificantchangeintheirmedicalconditionrequiringnewPOC.• Nocalendartimelimitissetthattriggersprogressnote• ProgressnotetobedonebyPTevery10th visit(candoearlierifneeded)butdoesnotmeanyoucanbillare-eval.


Myth#8:StampedsignaturesworkforPOC

• Onlyhandwrittenorelectronicsignatureisaccepted.• Ifhandwrittensignatureisnotlegibleyoucanprintnameundersignature.• Stampedsignatureonlypermittedincaseofphysicianorotherproviderhavingaphysicaldisabilitywhocanprovideproofofinabilitytosign.


Myth#9:IfapatientselfdischargesIdon’tneedtodoadischargenote• Incorrect,dischargenoteisalwaysrequired.Hereislistofrequireddocumentation:• Eval• SignedPOC(orPOCs)• Progressreportevery10th visit• Treatmentnoteforeveryday• Justificationstatementifpatientgoesovercap.• Dischargenote


Myth#10:Mygoalsonlyneedtobeaddressedattimeofprogressnote

• Anychangesmadetogoals,ordeletionofgoalsneedtobeaddressedindailynotes.• Ifdeletinggoalneedtostatewhygoalisbeingdeleted.


Myth#11:IcandischargeapatientoncetheyhavemettheMedicarecap

• Notifpatienthasmedicalnecessity.• Capin2017is$1980forPTandSLPservicescombined• OThastheirowncap,$1980• “Hard”Capat$3700– claimsarenotautomaticallydeniedbutdocumentationmustdemonstratemedicalnecessityforpost-paymentreview


Myth#12:MedicarewillalwayspayfortherapyoncetheMedicarecapishit• Notnecessarily,mustdocumentmedicalnecessityinyourpatient’smedicalrecord.• KXmodifierneedstobeaddedtoclaims– thissupportsservicesare“medicallynecessary”• Thresholdlimitfor2017is$3700forPTandSLPcombined,OTonceagainhasitsowncap.• GoingabovethethresholdlimitdoesnotnecessarilytriggerMedicareaudit.• ABNisnotappropriatetojustifyservicesbeyondthecap


Myth#13:IneedtoaddressPQRSinmyprogressnotes• No,PQRSprogramended12/31/16.• Somebilling/codingexpertsrecommendcontinuingforsmoothertransitiontoMIPS• Whatneedstobeinprogressnote(10th visitorearlier)?• Assessmentofimprovement• Extentofprogresstowardseachgoal• Deletegoalsthatnolongerapply• Changestoanygoals• Planforcontinuingtreatment• Justificationforskilledcare&continuingcare• Functionallimitationreporting


Myth#14:FLRcodescanonlybedoneonvisit10

• No,FLRcanbereportedonorbeforethe10th visit.• Evalisvisit1• Ifyoureportatvisit8thennextdeadlinetoreportwillbevisit18.


Myth#15:IcanreportonmorethanoneGcodecategoryatatime• No,onlyonesetofGcodescanbereportedatatime.• Whenpatientisfinishedw/onecategoryyouneedtodischargethatcategoryonthatdateofserviceandreportNEWcategoryonnextdateofservice.• DependingonyourEMRthiswillaffectabilitytobepaidonMedicareclaims.• Gcodescanonlybesubmittedwithotherprocedurecodes– ifapatientself-discharges,thencomesbackforlaterthatyearforsomethingdifferent,youmustfirstdischargetheoldcodesattheeval,thenreportthenewcodesatthe2ndvisit


Myth#16:IcanuseclinicaljudgmentonlywhendeterminingFLRimpairmentpercentage• No,useofstandardizeoutcometoolisrequired;howeverclinicaljudgementusedaswell.• YouarerequiredtodocumentthespecificsofyourFLRcategoryandscoreandhowyoumadedeterminationofthatscore.• FLRgoalpercentagecanchangeaspatientimprovesordeclines.ReportnewFLRcodeandjustifyinyourdocumentation.• FLRgoalshouldbeaddressedinLTG’s/POC.


Myth#17:IonlyhavetoworryabouthavingMedicarespecificdocumentationifMedicareisprimarypayer• False• FLRcodes,POC,etc.allmustbedoneifMedicareisapayerofanysortforpatient’sclaims.• Medicarecanbethesecondarypolicytocommercial/privateinsuranceinsomecases


Myth#18:IcanbillthepatientforservicesthatMedicaredenies

• Notusually• NotunlessyouhadMedicarepatientsignABN(AdvancedBeneficiaryNoticeofnon-coverage)form• However,routineuseofABNsisnotallowed.• IfABNisonfile,thenmodifierisrequiredonyourclaims.


Myth#19:IcanhaveaMedicarepatientpaycashiftheywantandNOTbillMedicare

• Notusually• Ifapatienthastherapyneedsthataremedicallynecessary,thenyouareobligatedtoprovidethoseandbillMedicare• Youcanhaveapatientpayforservicesiftheyarenotmedicallynecessaryaslongaspatienthasbeennotifiedinwritingpriortostartingcare.• ABNissignedandappropriateGAmodifieraddedtoclaimstodenotethatservicesarenotmedicallynecessaryandthereforenotreimbursable


Myth#20:Icannottreat2Medicarepatientsinthegymatthesametime

• Wrong,butyoumustdoappropriatebilling.• Canonlybilltimedcodesduringoneononetimewitheachpatient.• Ifyousupervisebothatthesametime,youwouldbillgroup.• Tobill“grouptherapy”participantsmustbeperformingthesameskilledinterventions


Myth#21:Icanhavethepatientpayforsuppliesusedintheclinic,likestimelectrodes

• Wrong• Youcanhavepatientpayforsuppliesthatarepurchasedtouseathome,butsuppliesneededaspartoftreatmentinclinicarenotallowedtobebilledtothepatient.


Myth#22:MedicareContractorsreviewdocumentationwhenclaimsaresubmittedtodetermineifpayable

• PrePaymentReview– automatedthroughNCCIedits(gaittrainingandtheractonsamedate),maxnumberofunitsonagivendate• PostPaymentReview– morecomplex,basedonproblemareasidentifiedthroughdataanalysis• Yourdocumentationshouldsupporttheneedformedicallynecessaryskilledservicesduringapostpaymentreview• ADRLetter– requestforAdditionalDocumentationRequest


Myth#23:OnlyProgressNotes/10thvisitsneedtoincludeobjectivedata

• Useobjectiveandmeasurableterms(ROM,MMT,painscale,weightsused,distancewalked)• Documentationshouldbebasedonfactsinadditiontoobservation• Avoidthesetermswithoutobjectivedatatosupport:“doingwell,”“improving,”“lesspain,”“increasedstrength/ROM,”“toleratedtreatmentwell,”“requiredassistance.”


Resources• MedicareBenefitPolicyManual,Ch.15,Section220:https://www.coms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf• CMSClaimsManual(OPRehabServices)Chapter5:https://www.cms.gov/Regulations-and-Guidance/Manuals/downloads/clm104c05.pdf• CMSTherapyServicesWebsite:www.cms.gov/therapyservices• APTA,Paymentreform,andadvocacyresources:http://www.apta.org/uploadedFiles/APTAorg/Payment/APS/APSQA.pdf#search=%22Payment%20Reform%22• CMSABNForm:https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html


Thankyou

• Toallofyouforyourattentiononnotthemostexcitingoftopicintheworld!• TotheMPTAforthiswonderfulopportunitytoshareknowledge!


ContactInfo

MichaelGorman,PhD,PT,DMT,[email protected]

JenniferSchnieders,[email protected]


medicare outpatient documentation: clearing up the myths

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