Clinical and Compliance Bulletin

877.799.9595 | www.evergreenrehab.com
2012 Quarter 4

Coding Corner
FAQ
1. How often must a clinician see a Medicare Part B patient? CMS Benefit Policy Manual 100-02 Chapter 15 Section 220.3 states a clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each Progress Report Period. The minimum Progress Report Period shall be at least once every 10 treatment days or at least once during each 30 calendar days, whichever is less. Verification of the clinicians required participation in treatment during the Progress Report Period shall be documented by the clinicians signature on the Treatment Note and/or on the Progress Report. 2. Are re-evaluation minutes counted on the MDS for Medicare Part A patients? The CMS RAI Manual states that therapists time spent on subsequent re-evaluations conducted as part of the treatment process should be counted in the minutes of therapy documented on the MDS. 3. Are evaluation minutes counted on the MDS for Medicare Part A patients? The CMS RAI Manual states that therapists time spent on initial evaluations may not be included in the minutes of therapy documented on the MDS. 4. How are modality minutes counted on the MDS for Medicare Part A patients?

5. Will you please provide me with the diagnosis codes for joint replacements? Aftercare for joint replacements requires two codes. First code V54.81, aftercare for joint replacements, then code the site, V43.6X. This applies for elective joint replacements and joint replacements performed after a fracture. Code first: Aftercare for joint replacements Code V54.81 Code second: Site Code V43.61 V43.62 V43.63 V43.64 V43.65 V43.66 Description Shoulder Elbow Wrist Hip Knee Ankle Description Aftercare following joint replacement

Decoding CPT Codes

Each quarter we focus on decoding the mystery of a specific CPT code. This quarter we will focus on CPT code 97535, selfcare/home management training. CPT code 97535 requires direct one-on-one contact by the provider and is billed in units based on each 15 minutes.

This code should be used for skilled therapy services addressing activities of daily living (ADL), IADLs, compensatory training The CMS RAI Manual states that only skilled therapy time (i.e., require for ADLs/IADLs, safety procedures, and instructions in the use the skills, knowledge, and judgment of a qualified therapist and all of adaptive equipment and assistive technology for use in the requirements for skilled therapy are met) shall be recorded on the MDS. home environment. The documentation must support that the In some instances, the time a resident receives certain modalities is patient has a condition for which self-care/home management partly skilled and partly unskilled time; only the time that is skilled may training is reasonable and necessary. This is supported by objective be recorded on the MDS. For example, a resident is receiving electrical documentation of functional limitations and functional goals based on stimulation for pain management. The portion of the treatment that is the identified limitations. skilled, such as proper electrode placement and establishing treatment parameters shall be recorded on the MDS.

Supportive Documentation Recommendations for 97535 include: objective measurements of the patients activity of daily living (ADL)/instrumental activity of daily living (IADL) impairment to be addressed specific ADL and/or compensatory training provided specific safety procedures addressed specific adaptive equipment/assistive technology utilized instruction given and assist required (verbal or physical) progression in technique to more complex or less patient dependence

Phase I: October 1, 2012 - December 31, 2012 Phase II: November 1, 2012 - December 31, 2012 Phase III: December 1, 2012 - December 31, 2012 Early pre-payment requests can be submitted by Sept. 15th for Phase 1, Oct. 16th for Phase II, and Nov. 15th for Phase III. Requests shall not be reviewed any sooner than 15 days before the start of each Phase for providers within that phase. Each FI/MAC has provided information on where to send the authorization request and other related information on how the process is going to work in their jurisdiction. The following links will take you to each FI/MACs manual medical review form to fill out. Cahaba GBA http://www.cahabagba.com/documents/2012/09/part-b-pre-authorizationrequest-form.pdf CGS http://www.cgsmedicare.com/Articles/TCE_Request_Form.pdf First Coast Service Options http://medicare.fcso.com/Rehabilitation_services/243444.pdf NGS http://www.ngsmedicare.com/wps/wcm/connect/0e7308804ca306c 786b98e555e90c49f/1319_0912_TherapyServicesPreapprovalForm_ V2.pdf?MOD=AJPERES NHIC http://www.medicarenhic.com/ne_prov/med_review/J14%20Therapy%20 CAP%20Exception%20Cover%20Sheet%20Request%20form.pdf Noridian Administrative Services https://www.noridianmedicare.com/partb/coverage/docs/therapy_ threshold_pre-authorization_request_coversheet.pdf Novitas https://www.novitas-solutions.com/claims/therapy-cap/pdf/ther-cap-a.pdf Palmetto GBA http://www.palmettogba.com/Palmetto/Providers.nsf/docsCat/ Jurisdiction%2011%20Part%20B~Resources~Forms?open&Expand=1 WPS http://www.wpsmedicare.com/j5macpartb/forms/_files/therapy-capexception-preapproval-request.pdf

Keeping Straight on the Regulation Road:

Manual Medical Review begins October 1, 2012 for Part B Therapy Services The Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA) established a requirement for Manual Medical Review of Part B therapy claims over a $3,700 threshold with dates of service October 1, 2012 - December 31, 2012. Similar to the therapy cap, there is a threshold of $3,700 for OT services and another threshold of $3,700 for PT and SLP services combined. The threshold represents the total allowed charges under Medicare Part B for services furnished by independent practitioners and institutional services under Medicare Part B (hospital outpatient departments, skilled nursing facilities). Effective October 1, 2012 Part B hospital rehab charges provided since January 1, 2012 will be counted towards the cap and threshold amounts. The Manual Medical Review for therapy exceeding the $3,700 threshold requires that providers submit a pre-approval request for exception prior to initiation of the services provided in order to be paid for any additional visits. The provider may request pre-approval of up to 20 treatment days of services per discipline. The FI/MAC will make a decision and inform the provider and beneficiary within 10 business days of receipt of all requested documentation. If the FI/MAC cannot make a decision in 10 days, the therapy will be considered approved. If the request was not approved, the letter communicating the decision must be detailed. If the request was not approved, a provider may submit additional requests and provide additional information for consideration. This process will be phased in across providers over a three month period, with the first group of providers beginning on October 1, 2012. CMS published the list of providers (by NPI number only) and the Phase to which they are assigned. If the provider is not on the list, then that provider will be deemed to be in Phase III.

CMS Removes ZPIC Prepayment Review CMS issued a letter notifying AHCA that CMS lifted the prepayment reviews attached to ZPIC audits effective August 23rd. SNF claims received on or after August 23rd remain subject to post pay review. Zone Program Integrity Contractor (ZPIC) evaluations have been occurring throughout the country; however, a high number of evaluations focused on facilities in Florida. Due to the impact and burden on Florida providers, the American Health Care Association (AHCA) and the Florida Health Care Association (FHCA) worked together to communicate to the Centers for Medicare and Medicaid Services (CMS) concerns with several aspects of the audit process, including the prepayment review audits conducted by Medicare Administrative Contractors (MACs), as instructed by ZPICs. OIG Report: Medicare Overpaid Inpatient Rehabilitation Facilities Millions of Dollars for Claims with Late Patient Assessment Instruments for Calendar Years 2009 and 2010 Under the prospective payment system for inpatient rehabilitation facilities (IRF), the Centers for Medicare & Medicaid Services (CMS) requires IRFs to electronically transmit a patient assessment instrument (PAI) for each IRF stay to the National Assessment Collection Database (the Database). Each IRF must report the date that it transmitted the PAI to the Database on the claim that it submits to the MAC. If an IRF transmits the PAI more than 27 calendar days from (and including) the beneficiarys discharge date, the IRFs payment rate for the applicable case-mix group incurs a 25-percent late-assessment penalty, pursuant to 42 CFR 412.614(d) and CMS guidance in Transmittal A-01-131. The OIG sampled 108 claims with dates of service in calendar years 2009 and 2010 and found that 88 claims were not paid correctly. The IRF did not receive reduced case-mix-group payments for PAIs that were transmitted to the Database after the 27-day deadline. Overpayments occurred because IRF and Medicare payment controls were inadequate. Based on the OIG sample results, it is estimated that MACs made a total of $8.4 million in overpayments to IRFs.

In response to the audit findings, the OIG recommend that CMS: adjust the 88 sampled claims for overpayments of $696,371 to the extent allowed under the law; work with the Office of Inspector General to resolve the remaining 2,306 nonsampled claims with potential overpayments estimated at $7.7 million and recover overpayments to the extent allowed under the law; continue to provide specific education to IRFs on the importance of reporting the correct PAI transmission dates on their claims; complete the process that would allow the FISS to interface with the Database to identify, on a prepayment basis, IRF claims with incorrect PAI transmission dates; and support the MACs and Recovery Audit Contractors efforts to conduct periodic postpayment reviews of IRF claims.

All Eyes on Therapy

Therapy remains the focus of many Medicare Administrative Contractors (MACs)/Fiscal Intermediaries (FIs) as well as the Regulatory and Law Enforcement Agencies of the Federal Government as the commitment to deterring fraud, waste and abuse in the Medicare and Medicaid systems has increased. Former Physical Therapy Assistant Pleads Guilty To Health Care Fraud Patricia J. Boshears, 48, formerly of Knoxville, Tenn., and current resident of Monticello, Ky., pleaded guilty in U.S. District Court to engaging in a scheme to defraud Medicare by falsely billing for physical therapy services that were not performed or supervised by a licensed physical therapist. Boshears previously owned and operated Total Rehab, Inc., and worked there as a physical therapy assistant. Boshears faces a maximum term of 10 years in prison, along with monetary penalties, including forfeiture and restitution. As set forth in the plea agreement, Boshears admitted that from June 2009 through October 2010, she submitted reimbursement claims to Medicare for physical therapy services under the name and provider number of a physical therapist who no longer worked at Total Rehab. Boshears submitted these claims for payment without the knowledge or consent of that former physical therapist employee. The claimed physical therapy services were actually rendered by Boshears or other unsupervised non-physical therapist Total Rehab employees (namely, massage therapists and massage therapy students).

Contact Information:
Liz Barlow Vice-President of Clinical Services 502.400.1619 liz@evergreenrehab.com Shawn Halcsik Director of Compliance 414.791.9122 shalcsik@evergreenrehab.com