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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
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
References
• MedicareBenefitPolicy,Chapter15Section220-223• MedicareClaimsManual,Chapter5• WPS“NewtoMedicareTeleconference- MedicalReviewandDocumentation”March7,2017• Reallifeexperience!
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Doesthislectureapplytoyou?
• Yesifyoutreatoutpatients• PrivatePractices
• PTPP(PhysicalTherapistinPrivatePractice)• ORF(RehabAgency)• CORF(ComprehensiveOutpatientRehabilitationFacility)
• Hospitalbased• Outpatientsofotherentities(SNF,HomeHealth,RehabHospital)
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Don’tforgettheseguystoo…
• MedicareAdvantageplans• Tricare• FederalBCBS• Champus
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#1:PTAscantreatindependentlyinmyprivatepractice• MedicareonlyrecognizesthefollowingasqualifiedprofessionalsforprovidingPT• PTs• PTAsunderpropersupervision• MDsandNPPs
• Aides,tech,andathletictrainerscannotbillservicestoMedicare
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
PTASupervisionRules
• InPTPPsettingrequiredtohaveon-sitesupervisiontotreatMedicarepatients.• CORF/ORFPTAcantreatindependentlywithoutPTon-site.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#2:PT/PTAstudentscan’ttreatMedicarepatients
• StudentscanperformtreatmentonpatientswithPT/PTApresent• ThecaremustbeoneononewithPT/PTAdirectingthecare.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#3:Ican’ttreatthepatientwithoutasignedPlanofCare
• YoucanevaluateandtreatthepatientwithoutaPTprescription.• MedicarestatespaymentisbasedoncertificationofPOC,notorderorreferral• “Prudent”tohavescriptbutnotrequired…butknowyourMOPracticeActregardingDirectAccess“
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#3:Ican’ttreatthepatientwithoutasignedPlanofCare
• “Itisnotintendedthatneededtherapybestoppedordeniedwhencertificationisdelayed.”• 30-60daysafterstartofPOC-nojustificationneeded• 60-90daysafterstartofPOC-NeedevidencethatyouareattemptingtogetPOCsigned
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#4:PlanofCaresarealwaysgoodfor90days
• Goodforupto90days• Needtosetforamountoftimetherapistrealisticallyexpectstoseethepatient(mildanklesprainvs.postsurgicaltotalknee)• WhatifPOCisn’tdated?• YoucanwritereceivedonXXdatewhenPOCisreturnedor…• IfPOCisfaxed,thefaxdateissufficient.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#5:AchiropractorcansignaPOC
• ChiropractorsandDentistscanNOTsignPOC-ifTMJpatienthavepatient’sPCPsignPOC(iftheyarewilling)• PhysicianscertifiedtosignPOC• MD• DO• Podiatrists(forfeetonly)• Ophthalmologistsoroptometrists(forlowvisionpatientsonly)• PhysicianAssistant• NursePractitioner
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#6:ImusthaveShortTermGoalsonthePOC
• POCrequirementisforLONGtermgoalsonly• Howeveriflongtermpatient(8-12weeks)shorttermgoalsareprudenttoassistinshowingprogress• Ifgoalsareaddedorchanged,POCshouldbere-sentforcertification
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#7:IcanbillMedicareevery30daysfordoingare-evaluationnote• Are-evalchargeisONLYbillablewhenthepatientisnotfollowingPOC(forbetterorworse)andthePOCneedstobemodifiedORifpatienthassignificantchangeintheirmedicalconditionrequiringnewPOC.• Nocalendartimelimitissetthattriggersprogressnote• ProgressnotetobedonebyPTevery10th visit(candoearlierifneeded)butdoesnotmeanyoucanbillare-eval.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#8:StampedsignaturesworkforPOC
• Onlyhandwrittenorelectronicsignatureisaccepted.• Ifhandwrittensignatureisnotlegibleyoucanprintnameundersignature.• Stampedsignatureonlypermittedincaseofphysicianorotherproviderhavingaphysicaldisabilitywhocanprovideproofofinabilitytosign.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#9:IfapatientselfdischargesIdon’tneedtodoadischargenote• Incorrect,dischargenoteisalwaysrequired.Hereislistofrequireddocumentation:• Eval• SignedPOC(orPOCs)• Progressreportevery10th visit• Treatmentnoteforeveryday• Justificationstatementifpatientgoesovercap.• Dischargenote
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#10:Mygoalsonlyneedtobeaddressedattimeofprogressnote
• Anychangesmadetogoals,ordeletionofgoalsneedtobeaddressedindailynotes.• Ifdeletinggoalneedtostatewhygoalisbeingdeleted.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#11:IcandischargeapatientoncetheyhavemettheMedicarecap
• Notifpatienthasmedicalnecessity.• Capin2017is$1980forPTandSLPservicescombined• OThastheirowncap,$1980• “Hard”Capat$3700– claimsarenotautomaticallydeniedbutdocumentationmustdemonstratemedicalnecessityforpost-paymentreview
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#12:MedicarewillalwayspayfortherapyoncetheMedicarecapishit• Notnecessarily,mustdocumentmedicalnecessityinyourpatient’smedicalrecord.• KXmodifierneedstobeaddedtoclaims– thissupportsservicesare“medicallynecessary”• Thresholdlimitfor2017is$3700forPTandSLPcombined,OTonceagainhasitsowncap.• GoingabovethethresholdlimitdoesnotnecessarilytriggerMedicareaudit.• ABNisnotappropriatetojustifyservicesbeyondthecap
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#13:IneedtoaddressPQRSinmyprogressnotes• No,PQRSprogramended12/31/16.• Somebilling/codingexpertsrecommendcontinuingforsmoothertransitiontoMIPS• Whatneedstobeinprogressnote(10th visitorearlier)?• Assessmentofimprovement• Extentofprogresstowardseachgoal• Deletegoalsthatnolongerapply• Changestoanygoals• Planforcontinuingtreatment• Justificationforskilledcare&continuingcare• Functionallimitationreporting
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#14:FLRcodescanonlybedoneonvisit10
• No,FLRcanbereportedonorbeforethe10th visit.• Evalisvisit1• Ifyoureportatvisit8thennextdeadlinetoreportwillbevisit18.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#15:IcanreportonmorethanoneGcodecategoryatatime• No,onlyonesetofGcodescanbereportedatatime.• Whenpatientisfinishedw/onecategoryyouneedtodischargethatcategoryonthatdateofserviceandreportNEWcategoryonnextdateofservice.• DependingonyourEMRthiswillaffectabilitytobepaidonMedicareclaims.• Gcodescanonlybesubmittedwithotherprocedurecodes– ifapatientself-discharges,thencomesbackforlaterthatyearforsomethingdifferent,youmustfirstdischargetheoldcodesattheeval,thenreportthenewcodesatthe2ndvisit
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#16:IcanuseclinicaljudgmentonlywhendeterminingFLRimpairmentpercentage• No,useofstandardizeoutcometoolisrequired;howeverclinicaljudgementusedaswell.• YouarerequiredtodocumentthespecificsofyourFLRcategoryandscoreandhowyoumadedeterminationofthatscore.• FLRgoalpercentagecanchangeaspatientimprovesordeclines.ReportnewFLRcodeandjustifyinyourdocumentation.• FLRgoalshouldbeaddressedinLTG’s/POC.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#17:IonlyhavetoworryabouthavingMedicarespecificdocumentationifMedicareisprimarypayer• False• FLRcodes,POC,etc.allmustbedoneifMedicareisapayerofanysortforpatient’sclaims.• Medicarecanbethesecondarypolicytocommercial/privateinsuranceinsomecases
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#18:IcanbillthepatientforservicesthatMedicaredenies
• Notusually• NotunlessyouhadMedicarepatientsignABN(AdvancedBeneficiaryNoticeofnon-coverage)form• However,routineuseofABNsisnotallowed.• IfABNisonfile,thenmodifierisrequiredonyourclaims.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#19:IcanhaveaMedicarepatientpaycashiftheywantandNOTbillMedicare
• Notusually• Ifapatienthastherapyneedsthataremedicallynecessary,thenyouareobligatedtoprovidethoseandbillMedicare• Youcanhaveapatientpayforservicesiftheyarenotmedicallynecessaryaslongaspatienthasbeennotifiedinwritingpriortostartingcare.• ABNissignedandappropriateGAmodifieraddedtoclaimstodenotethatservicesarenotmedicallynecessaryandthereforenotreimbursable
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#20:Icannottreat2Medicarepatientsinthegymatthesametime
• Wrong,butyoumustdoappropriatebilling.• Canonlybilltimedcodesduringoneononetimewitheachpatient.• Ifyousupervisebothatthesametime,youwouldbillgroup.• Tobill“grouptherapy”participantsmustbeperformingthesameskilledinterventions
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#21:Icanhavethepatientpayforsuppliesusedintheclinic,likestimelectrodes
• Wrong• Youcanhavepatientpayforsuppliesthatarepurchasedtouseathome,butsuppliesneededaspartoftreatmentinclinicarenotallowedtobebilledtothepatient.
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#22:MedicareContractorsreviewdocumentationwhenclaimsaresubmittedtodetermineifpayable
• PrePaymentReview– automatedthroughNCCIedits(gaittrainingandtheractonsamedate),maxnumberofunitsonagivendate• PostPaymentReview– morecomplex,basedonproblemareasidentifiedthroughdataanalysis• Yourdocumentationshouldsupporttheneedformedicallynecessaryskilledservicesduringapostpaymentreview• ADRLetter– requestforAdditionalDocumentationRequest
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Myth#23:OnlyProgressNotes/10thvisitsneedtoincludeobjectivedata
• Useobjectiveandmeasurableterms(ROM,MMT,painscale,weightsused,distancewalked)• Documentationshouldbebasedonfactsinadditiontoobservation• Avoidthesetermswithoutobjectivedatatosupport:“doingwell,”“improving,”“lesspain,”“increasedstrength/ROM,”“toleratedtreatmentwell,”“requiredassistance.”
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
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
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
Thankyou
• Toallofyouforyourattentiononnotthemostexcitingoftopicintheworld!• TotheMPTAforthiswonderfulopportunitytoshareknowledge!
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths
ContactInfo
MichaelGorman,PhD,PT,DMT,[email protected]
JenniferSchnieders,[email protected]
MPTASpringMeeting2017:MedicareOutpatientDocumentation:ClearingUptheMyths