Wheelchair Seating Clinics: Strategies and Methodologies for Success

Transcription

1 Wheelchair Seating Clinics: Strategies and Methodologies for Success NRRTS CONTINUING EDUCATION THERESA F. BERNER, MOT, OTR/L, ATP NOVEMBER 8, 2018 Acknowledge Tina Roesler, ABDA, MPT OSU Medical Center Assistive Technology Center Objectives 1. The participant will be able to list one structure of a seating clinic that promotes revenue generation 2. The participant will be able to name 2 CPT codes that can be used in therapy billing to cover clinical time. 3. The participant will be able to identify one work flow model of services for seating service delivery. 1

2 The Future of Seating Clinics Programs fail because all the time and energy is focused on developing the clinical aspects and not the market analysis, program evaluation and sustainability over time. - Program Development and Beyond, AOTA 2009 Program Description All stakeholders need to understand the core elements Clear definition of your program Team Members Financial and space needs Services providers Market Analysis of Program Political Issues State or federal regulations Economic Issues Potential competitors, referral sources, number of clients, reimbursement, ability to market, available funding Social Factors Client demographic, community relationships, future demographics 2

3 Personnel for Program Management Need outward support of leadership Use language that has value for them Program Team Quality of program is based on expertise of your team If program is built on specific skill set of one employee have a contingency plan if they leave Support Staff Where are you pulling from for scheduling, billing, and IT support Costs Understand how your program fits into the budget. How many patients do you need to see to cover your costs? What are the RVU s associated with your billing codes? What is your schedule and how do you balance the patients per day? Valuable information What is your payer mix and what is your actual collection rate? What is your cost per cost per unit of service? How many new patients do you see vs treatments? Are you bringing new patients into your organization? 3

4 Risks and Trouble Spots Documentation Process and Tools EMR and work flow Supplier should communicate the funding/patient profile and what is required for procurement at initial time of eval How to handle denials and when to bring patients back Documentation Process and Tools What platform are you using? Are you documenting for your therapy note then trying to document for equipment? Are you focusing documentation of equipment and forgetting to cover you time? EMR and Work Flow; Epic Go to the Epic Community Library Ask your Epic Technical Analyst to help get any of our content from the data base Look for: AT Seating and Positioning Eval (This is a flow sheet) Progress Note Smart Text: OPR AT Seating and Positioning Eval AND OPR AT Components The AT Seating and Positioning Evaluation Smart Text pulls in data from The Flow sheet, activities within navigator (Diagnosis, Chief complaint, time in/out). If the value type is string type it means the row is a free test and therefore there will not be a list of choices. 4

5 LCD Clinical Services Describes the coverage limits of outpatient PT and OT services Medicare Part B, billed to either the Medicare Fiscal Intermediary (FI) Part A MAC, or Medicare Carrier Part B MAC when services are provided under a therapy plan of care. These limits include specific conditions under which certain PT and OT services may be considered covered by Medicare. LCD: Clinical Services Section 522 of the Benefits Improvement and Protection Act (BIPA) defines an LCD as a decision by a fiscal intermediary (FI) or carrier whether to cover a particular service on an intermediary-wide or carrierwide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (e.g., a determination as to whether the service or item is reasonable and necessary). LCD Clinical Services LCD Outpatient Physical and Occupational Therapy Services: (L 26884) LCD Physical Therapy for Home Health (L31542) LCD for Swallow Evaluation and Dysphagia Treatment (L27364) 5

6 Therapy CPT Codes PT Evaluation: (Low); (Mod); (High) PT Re-evaluation: OT Evaluation: (Low); (Mod); (High) OT Re-evaluation: Assistive Technology Assessment: Physical Performance Test or Measure: Therapy CPT Codes Wheelchair Management and Training: (2006 the word assessment was added) Self-care/home mgmt. training: Therapeutic Activities: Therapeutic Procedures:97112 Community work re-entry: Check out for orthotics/prosthetics: New Evaluation Codes 2017 January 1, New occupational and physical therapy CPT evaluation and re-evaluation codes are being proposed under the Physical Medicine and Rehabilitation section of the CPT Manual to replace existing CPT codes and

7 New Evaluation Codes 2017 The proposed rule, which covers Medicare Part B services that apply to OT s PT s, physicians, and other providers. The coding paradigm for evaluations is based on patient complexity (low, moderate, or high) 7

8 Misconceptions Wheelchair Evaluations are complicated and should all be high complex billing codes Levels must be determined specifically for each of the three components in order to choose the correct code. -AOTA Reasons for denials KX Modifier missing Incorrect G code/functional Limitation reporting Be aware of 60 day G-code term Incomplete Medicare Certification approvals Insurances that prevent treatments same day as evaluations Home health concurrent episode 97X65 : Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. 8

9 97X66 :Occupational Therapy evaluation, moderate complexity, requiring these components An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family - 97X67; Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identify 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. 97X68 ; Reevaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. 9

10 97542 Wheelchair Management (Assessment, fitting, training), each 15 minutes- Provider performs assessments, fitting, and adjustments, and instructs and trains the patient in proper wheelchair skills (propulsion, safety techniques) in their home, facility, work, or community environment. Typically 3-4 sessions are sufficient to teach the patient and/or caregiver these functional skills unless the patient is severely impaired or presents with another condition requiring additional treatment sessions. Those with progressive neurological diseases (ALS, MS, and Parkinson s) may need re-evaluation or modifications of the wheelchair management or propulsion of the wheelchair. Documentation must relate the training to expected functional goals that are reasonably attainable by the patient and caregiver Wheelchair Management (Assessment, fitting, training), each 15 minutes- This code is used to show the skilled intervention that is provided related to the assessment, fitting and/or training for patients who must use a wheelchair for mobility. Use this code to train the patient, family, and/or caregiver in functional activities that promote safe wheelchair mobility and transfers. May also be for positioning to avoid pressure points. In some instances there may be a patient that is seen for a one time visit for a wheelchair assessment, which is only an assessment related to their wheelchair needs. The therapist will bill with the units reflecting the time spent in the assessment Wheelchair Management (Assessment, fitting, training), each 15 minutes- There may be circumstances where a patient may be seen for one time for a wheelchair assessment. If it is not necessary to complete a full patient evaluation, but only as assessment related to specific wheelchair needs, this one-time only session may be billed under with appropriate units reflecting time in the session. (Region B Future LCD: Outpatient Physical and Occupational Therapy services, page 49 of 101 printed

11 97542 Wheelchair Management (Assessment, fitting, training), each 15 minutes- At some times an eval may be needed along with the wheelchair fitting and training. In this case the eval is billed and then only the time spent with should be billed for that assessment. Typically 3-4 visits should be sufficient to train the patient/caregiver. SUPPORTIVE DOCUMENTATION The recent event that prompted the need for a skilled wheelchair assessment. Any previous wheelchair assessments that have been completed Most recent prior functional level If applicable any previous interventions that have been tried and failed by any caregiver Functional deficits due to poor seating and positioning SUPPORTIVE DOCUMENTATION Objective assessments of applicable impairments such as ROM, strength, sitting balance, skin integrity, sensation, and tone Response of the patient or caregiver to the fitting and training Documentation must relate the training to expected functional goals that are attainable by the patient and/or caregiver Describe the interventions to show that the skills of a therapist were required 11

12 97750 Physical Performance Test or Measurement, each 15 minutes- (Musculoskeletal, functional capacity) The provider performs a test of physical performance (BTE, Gait analysis, Tinetti, Berg) determining function or one or more body areas or measuring and aspect of physical performance, including functional capacity evals. This is usually beyond the usual eval service performed Physical Performance Test or Measurement This code goes beyond the evaluation and a written report is required with this code. Examples of uses for this code include isokinetic testing, Functional Capacity Evaluation, and Tinnetti (Smart Wheel Propulsion Anaylsis) It is not reasonable and necessary for the test to be performed and billed on a routine basis There must be written evidence documenting.. the problem requiring the test, the specific test performed and a measurement report which a description of the test performed, purpose for the test, outcome of the test, how the information obtained from the test impacts the plan of care. 12

13 SUPPORTIVE DOCUMENTATION Problem requiring the test and the specific test performed Separate measurement report, including any graphic reports Application to functional activity How these impacts the plan of care This code cannot be used with another evaluation code. Must have a written report Assistive Technology Assessment, each 15 minutes- ( To restore, augment,or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility) The provider performs an assessment for the possibilities and benefits of acquiring assistive technology device that will help restore, augment, or compensate for existing functional ability in the patient; or that will optimize functional tasks and/or maximize the patient s environmental accessibility and mobility. Coverage is specifically for assessment of mobility and seating systems that require high level optimize, not for routine seating and mobility systems Assistive Technology Assessment This code cannot be used with another evaluation code. Must have a written report. Report codes and for augmentative and alternative communication. 13

14 97755 Assistive Technology Assessment This assessment may require more than one visit due to the complexity of the patient s condition Training for the use in assistive technology in the home environment should be coded as and for use in the community as is not covered on the same day as evaluations or re-evaluations. SUPPORTIVE DOCUMENTATION The goal of the assessment The technology/component/system involved A description of the process involved in assessing the patient s response The outcome of the assessment Documentation of how this information affects the treatment plan More on CPT codes CPT codes not tied to specific profession PT and OT services can also be provided by physicians, non-physician practitioners (NPPs), or incident to the services of physicians/npps when provided by PT or OT in the office or the home. 14

15 Provider: Facility or Agency such as: A rehabilitation agency; Private Practice-non hospital based/community based (Medicare B) Hospital (Medicare A) Critical access hospitals (CAH) (Medicare A) Skilled nursing facilities (SNF) (Medicare A and B) Assistive Living; Custodial Care; Group Home Comprehensive outpatient facilities (CORF) (Medicare B) Home Health agencies (? A or B?) Outpatient Rehabilitation Facilities (ORF) (Medicare B) Models Medical Model Hospital Based Clinic Inpatient Hospital Based Clinic Outpatient Private Practice / non-hospital based Free Standing Clinics - incident 2 billing Tele rehabilitation Federal/State Funding Programs Mobile Clinic Innovative State Funded VA International models Ireland Hub and Spoke Model Less resourced settings Free Standing Clinics - incident 2 billing Personnel: MD; NPP; OT/PT; scheduling Space: MD office Referral Sources: Physicians; More often consult Billing Model: Incident-to billing 15

16 What is a Provider-Based Department (aka Hospital Based Clinic/ Hospital Outpatient Department)? A. Department of a Hospital B. Physician Office C. A Combo of A & B D. I Have No Idea Provider Based Practice Hospitals and their provider-based facilities have to meet specific requirements described in 42 CFR and CMS Transmittal A to appropriately bill Governmental payers as a provider-based facility, and additional requirements apply to off-campus facilities. Hospitals and their provider-based departments are required to maintain supporting documentation indicating that its on- and offcampus provider-based departments comply with all provider-based requirements. If a hospital eventually submits an attestation that is denied, CMS may seek to recover overpayments. What are the penalties/consequences if my Department drifts out of compliance? Potential loss of reimbursements Potential repayments to CMS Potential for loss of 340B drug discount pricing 16

17 The CMS provider-based rules do not apply to the following types of services or facilities, and thus, no further action is necessary: Ambulatory Surgical Centers (ASCs) Comprehensive Outpatient Rehabilitation Facilities (CORFs) Home Health Agencies (HHAs) Skilled Nursing Facilities (SNFs) Hospices Inpatient Rehabilitation Units that are excluded from the inpatient prospective payment system for acute hospital services Independent Diagnostic Testing Facilities furnishing only services paid under a fee schedule End Stage Renal Disease (ESRD) facilities Departments of providers that perform functions necessary for the successful operation of the providers but do not furnish services of a type for which separate payment could be claimed under Medicare or Medicaid Timed Documentation: Once the minutes have been summed, use the chart below to determine the total allowable units, based on the total Timed Code Treatment minutes. 1 unit > 8 minutes through 22 minutes 2 units > 23 minutes through 37 minutes 3 units > 38 minutes through 52 minutes 4 units > 53 minutes through 67 minutes 5 units > 68 minutes through 82 minutes 6 units > 83 minutes through 97 minutes 7 units > 98 minutes through 112 minutes 8 units > 113 minutes through 127 minutes When the total Timed Code Treatment minutes for the day is less than 8 minutes, the service(s) should not be billed. It is important to allocate the total billable units Think Differently Seating Clinics can be a referral base into your outpatient clinic. Try not to do everything all in one visit. Develop Clinical Guidelines and Pathways using seating. Integrate with other departments. Think about volume and program growth. Use data to return demonstration for minor equipment and FTE s. The volume generated from referrals can pay back dollars spent on equipment. 17

18 Program Development Wheelchair Seating Clinic Power Wheelchair Training Propulsion Training Pressure Mapping Assessments Neuro Rehab Referrals Custom Molding Wheelchair Seating and Positioning Clinic Neuro-rehab referral Follow-up and final fitting Power Wheelchair Trails/Training Pressure Mapping Evaluation Propulsion Training Power Wheelchair Training Power Wheelchair Trial (97542 per 15 minutes) Power wheelchair training (97542 per 15 minutes) Continue as long as medically necessary Final Fitting (97002/4) 18

19 Propulsion training Identification of fitting and adjustments Investigating where they are wheeling and what they are doing/not doing Training on propulsion efficiency Advanced wheelchair training Final fitting and necessary follow up Format One time a week? Integrate into your schedule. When do you need/want the supplier present? Case Study 47 year old para comes to seating clinic for new manual wheelchair. Has been using a ultralight weight manual wheelchair and is very active. He is married, has 2 kids, works full time, and is very active in sports/wellness activities. PMH includes rotator cuff injury on right side, moderate lower back pain, and recent increase in wrist pain. 19

20 Case Study; Assessment Day of the assessment a full history and orthopedic screening occurred. Wheelchair skills test and analysis of current chair was completed. It was agreed upon to gather more diagnostic testing for submission of ultralight weight chair so follow up session was scheduled. Day one comprised 90 min of therapy intervention. Case Study; Gather Data Day 2 of assessment completed propulsion analysis to gather information on speed, push length, push style and tangential force of push. This was completed on ultralight weight manual chair as well an less costly alternative chair. Pain report of was recorded before and after every assessment. 90 min spent at this session. Therapist and patient had enough data to generate order so next session would include the wheelchair supplier for completion of order form. Case Study; Complete Order Day 3 included the wheelchair supplier, patient and clinician. A review of information was provided and all parties used the order form to complete the order of new ultralight weight manual chair. Through out the assessment other manual chairs in clinic were pulled to determine componentry. By the end of the session the clinical report was complete and order was submitted. Session was 60 min. 20

21 Case Study; Final Fitting After approval of funding and ordering of chair, the supplier, patient and clinician met for final fitting of equipment. Order was reviewed and patient participated in final adjustments. Wheelchair skills test was completed and final data was collected. Pt was educated to return in 6 months to review any concerns or further adjustments of chair. Sustainability of Programs What is your Product? The service you are delivering. What is the cost of your services? Where are you delivering your service? Ongoing Promotion; The art of understanding your customers needs and meeting your organizational goals References Cook, A.M., Polgar, J.M. Cook and Hussy s Assistive Technologies Principles and Practice. (2008). Mosby Cook, A.M., Polgar, J.M., Essentials of Assistive Technologies. (2012). Mosby. Eggers, S., Myaskovsky, L., Burkitt, K., Tolerico, M., Switzer, G., Fine, M., et al. (2009). A preliminary model of wheelchair service delivery. Arch Phys Med Rehabil, 90,

22 References Accessed 8/9/2017. * Affairs/Coding/evaluation-cpt-codes-descriptors.aspx/. Accessed 8/9/2017. * Accessed 8/9/2017. Thank you!!!! Theresa F. Berner, MOT, OTR/L, ATP 22