Self-Audits of Part B Therapy Services

Transcription

1 Self-Audits of Part B Therapy Services Are you looking for the right things? 2 Sponsors HPA The Catalyst Academy of Geriatric Physical Therapy Speaker Jaclyn Warshauer, PT National Clinical Director Aegis Therapies jaclyn.warshauer@aegistherapies.com 1

2 3 Today s Objectives Identify and understand the current scope of Medicare agencies conducting audits Develop effective strategies for conducting technical and quality audits of therapy documentation Identify risk areas in G-code completion before receiving a claim rejection APTA s Integrity in Practice Your patients trust you to use your expert training to improve, maintain, restore, and enhance health for optimal function and quality of life Payors expect you to use your clinical judgment to provide patients with appropriate services and to submit proper claims for payment with accurate information 2

3 APTA s Integrity in Practice The few who abuse the system are placing patients health at risk and costing payers and consumers billions of dollars This leads to Increasing regulation Increased administrative burden on all therapists APTA s Integrity in Practice Campaign Comprehensive campaign to promote high quality of care Tools and resources available Evidence-based practice Ethics Professionalism Prevention of fraud, abuse, and waste 3

4 Medicare Statistics: million individuals $604 billion cost $50 billion in improper payments Improper payment rate increased from 8.5 percent in FY 2012 to 10.1 percent in FY The 10.1 percent improper payment rate in Medicare fee-for-service programs represented a dramatic increase in improper payments, compared to the previous five years. 8 Improper Payments 63% - Administrative and Documentation errors Doc submitted is inadequate to support payment Specific element of doc is missing 37% - Authentication and Medical Necessity errors Medically unnecessary services Necessary, but could have been provided in a less intensive setting 4

5 HHS Error Rate Reduction Plan 1. Expanding the role of RACs 2. Instituting the prior authorization pilot program for power mobility devices 3. Changing payment policies related to inpatient hospital claims 4. Reducing administrative and documentation errors by building the Healthcare Fraud Prevention Partnership 5. Providing educational events for providers and beneficiaries 6. Intensifying reviews in certain claim types prone to error: Home health, hospital outpatient, SNF and hospice 7. Supplemental Medical Review Contractor to perform reviews for identified program vulnerabilities 8. Requiring mandatory medical review when outpatient therapy thresholds are exceeded 9. Allowance for MACs and RACs to review more claim types than in previous years (and monitoring those decisions) 10. Issuing comparative billing reports to providers Predictive Analytics is Paying Off Medicare s Fraud Prevention System All Medicare fee-for-service claims run through the program Attempts to identify fraudulent billing before payment is made Monitors Which Medicare ID numbers are used and by who Billing frequency that is outside norms Patterns of billing Links between a provider and other known providers that are on the radar Saved $210 million in improper payments in

6 11 From CMS Website 12 Review Program How Selected Volume Type of Review Purpose of Review CERT Random Small MAC Targeted Depends on # of claims with possible improper payments for this provider Postpay- Complex Pre & Postpay- Automated & Complex To measure improper payments To prevent future improper payments Recovery Auditors (RAC) Targeted Depends on # of claims with possible improper payments for this provider Pre & Postpay- Automated & Complex To detect and correct past and future improper payments 6

7 13 Review Program How Selected Volume Type of Review Purpose of Review ZPIC Targeted Depends on # of claims with possible improper payments for this provider Pre & Postpay- Automated & Complex To identify potential fraud OIG Targeted Depends on # of claims with possible improper payments for this provider Postpay- Complex To identify fraud RACs Recovery Auditors Data on the savings is conflicting In part because of the appeal BACKLOG ~$8.9 BILLION since inception $2.4 billion in improper payments After fees - $1.9 billion saved Provider error rates ranged from 0 100% RACs do not use error rates of individual facilities to determine how frequently they should be audited 7

8 How are RAC s paid?? Contingency fee basis: Base fee: 9% and 12.5% in contingency fees for Medicare FFS % for DME RAC Appeals Go through the normal Medicare appeals process starting with the Redetermination level at the MAC % appealed 44 % overturned in the provider s favor % overturned in the provider s favor With BACKLOG could be 3 years before you get paid 56% of all appeals, regardless of source, overturned at ALJ 8

9 Are RACs on Hold?? Feb 2014 Announced RACs would stop ADR ing claims while working already ADR d claims - due to contracts June 2014 RACs no longer reviewing. Working thru appeals. Announced New CMS Provider Relations Coordinator: Latesha Walker. RAC@cms.hhs.gov (for Recovery Auditor review process concerns/suggestions) MedicareMedicalReview@cms.hhs.gov (for MAC review process concerns/suggestions) Aug 2014 Sept 2014 While awaiting final awards, CMS modified contracts to re-start limited reviews including Part B therapy services Federal judge blocked proceeding with new RAC contracts in some Regions will it effect all Regions??? 18 Supplemental Medical Review Contractor (SMRC) Strategic Health Solutions was awarded the contract SMRC s provide support for medical review tasks and are aimed at increasing efficiencies of the Medical Review functions of the Medicare and Medicaid programs Look more at national claims data vs jurisdictional data 9

10 19 SMRC s Current Projects Home Health physician/npp face-to-face encounter SNF Ultra High RUG billed with dates of service October 1, 2011 to September 30, SMRC s Completed Projects Part B Therapy - August 2012 to March 2013 therapy services that either stopped or delayed just under the allowed therapy cap Random sample totaled 7,090 claims consisting of 357 unique providers Findings Lack of comprehensive evaluation Lack of identification of specific intervention/modality Inappropriate application of units Missing or illegible signatures 10

11 21 SMRC s Completed Projects Inpatient Rehab Facility (IRF) Looking for deficiencies in key documentation elements during CYs Sampled 186 claims for 164 beneficiaries Findings Top reason: documentation did not contain all the required elements within the preadmission screen and post-admission evaluations Lacking in documentation of individualized overall plan of care and interdisciplinary team meetings 22 Increased Reviews = Increased Appeals What does this equal = BACKLOG! 1 st : Redetermination at the MAC 2 nd : Reconsideration at the QIC 3 rd : Administrative Law Judge Hearing (ALJ) ALJ increases: (BACKLOG!) 2011: 59,601 total appeals 2013: 384,651 total appeals Once the ALJ Hearing is requested, takes about 28 months before put on the hearing docket Then about another 6+ months for the hearing 11

12 23 So many things to think about The auditing, regulation and oversight is administratively challenging Keeping up to date with regulations, LCDs, coverage/coding/documentation changes Communicating the changes to staff Ensuring staff follow through Ensuring electronic documentation and billing vendors are up to date and have programs coded correctly and timely for any changes you re in the paper! In recent years, outpatient physical therapy payments have increased annually with total payments to physical therapists in private practice (therapist) totaling $1.7 billion in Calendar Year (CY) Past Office of Inspector General (OIG) reviews have identified claims for outpatient physical therapy services that were not reasonable, medically necessary, or properly documented, and vulnerable for fraud, waste, and abuse. After analyzing Medicare claims data for CY 2011, we selected multiple physical therapists for review, including this therapist located in the State of Illinois. Our analysis indicated that, among other selected criterion, this selected therapist was among the highest Medicare therapy billers in the State of Illinois. Our objective was to determine whether outpatient physical therapy services provided by an Illinois physical therapist in private practice were paid in accordance with Medicare requirements. 12

13 Illinois PT The sampling frame consisted of 4,298 outpatient physical therapy service claims,totaling $645,966, of which we reviewed a simple random sample of 100 claims. 97 claims did not meet Medicare s plan of care requirements 95 claims did not meet Medicare s treatment note requirements 49 claims had progress reports that were untimely or not contained in the medical record 44 claims had therapy services that were not medically necessary 39 claims did not meet Medicare s physician certification requirements Illinois PT 13

14 Illinois PT The Illinois Payback OIG recommended that the therapist: Refund $634,837 to the Federal Government and establish adequate policies and procedures to ensure that outpatient physical therapy services billed to Medicare are medically necessary, correctly coded, and adequately documented 14

15 29 30 Know what s going on in your facility/practice! 15

16 Know Your Risk Before Someone Else Does What are your risk areas? Do you know? Are all your processes tight for timely and complete documentation? How do you know? Do you have orders and certifications signed timely? How do you know? What are your Outliers? How do you find them? Utilization Risk Areas Do you know YOUR averages? Where do you stand against the benchmarks? Be Cautious of Averages! Even if your averages mimic the national or state averages, you still have risk in your OUTLIERS! 32 16

17 Outliers What are your OUTLIERS? Outlier an appreciable distance from the norm Outliers are unique It s very acceptable to be unique and away from the norm as long as the documentation tells the story of a patient s condition that requires more than a typical amount of therapy services VALIDATE! Purpose of Documentation and Billing Audits Identify areas of risk Documentation not meeting quality for supporting medical necessity and skilled services Incomplete documentation/compliance Billing Integrity Identify areas of opportunity Documentation that passes but could be better More Clear More Concise More Convincing 17

18 35 Convincing Documentation Tell the patient s story in a clear, concise and convincing way That this patient s condition is so complex that it will only improve through the skilled intervention of a therapist That the treatments we are providing are indeed skilled could not be provided by anyone but a therapist 36 Completing Audits Mix it up between spreading the wealth and focusing on your Outliers Emphasis on narrative feedback to create behavior change Ensure that those that were involved in the care are engaged in receiving the feedback Audit outside your discipline you re probably best there Occasionally validate completed audits 18

19 37 Scoring Audits Question by Question Overall Pass / Fail Grade (A,B,C, D, F) You passed but you got a C. Some combination of the above Consider developing/using an electronic auditing system Ease in analytics via reports 38 How to make an audit useless Incentivizing excellent audit outcomes Selecting best documenters for audits Only auditing the cases that are not outliers Not looking with a critical eye Not providing narrative feedback Not ensuring that the therapists that were involved in the care review the audit findings and feedback 19

20 Common Reasons for Denial Documentation did not include a specific, objective measurement of the patient's level of function prior to their current functional decline or illness. Documentation did not support a significant decline in function. Lack of sufficient medical justification for services rendered: Denied because the documentation did not support that the patient had functional deficits that would require the skills of a licensed therapist. Documentation does not support the frequency and duration of the therapy services provided was reasonable or necessary. Documentation does not support the need for skilled therapy. Time was not allowed for spontaneous recovery. Documentation does not support continued need for skilled therapy services. Plan of care was well established and additional therapy to increase endurance, safety and monitoring does not require the skills of a therapist. Documentation did not support skilled therapy was realistic for significant practical improvement and/or the patient made very minimal gains with the treatment provided. Poor potential for improvement, lack of significant progress, need for frequent cueing, and routine, repetitive services do not contain the complexity or sophistication requiring the skills of a licensed therapist. Non-skilled personnel are qualified to provide functional maintenance programs. Documentation does not support the services billed required the skills of a qualified therapist Audit Forms Technical Review Evaluation Review Therapist Progress Report Could also be used for discharge summary, updated plans of care Add a question or two 20

21 41 Technical Review Basic Part B guidelines for: Certifications 10 visit therapist treatment and Progress Report Signatures Dated and legible Treatment time recorded each day To the minute Correct billing of units, based on type of CPT code and minutes provided 42 Technical Review Functional Limitation Reporting: G-codes Required G-codes: Outset of the Part B therapy episode At least once every 10 treatment days Whenever an eval or re-eval code is billed SLP On the last treatment day (discharge) unless unable to determine If you don t enter the d/c g-code, and the patient returns less than 60 days later have to continue reporting on the same functional limitation category G-code note describing the specific function/outcome that was measured to determine the Severity Modifier 21

22 43 While we re on G-codes U5452 Issues have been reported with Reason Code U5452 rejecting in error Some MACs have reported that they have deactivated this reason code If you have a claim rejected for U5452 and everything appears correct, try re-submitting the claim 44 Evaluation Audits STGs ICD-9 LTG Underlying Impairments in SOP Functional Change Reason for Referral As discussed in the 1 st presentation, some elements in our documentation are used by reviewers more in determining medical necessity 22

23 STGs 45 ICD-9 LTG Evaluation Audit Form Underlying Impairments in SOP Functional Change Reason for Referral Quality audit looking for establishment of the need for therapy to get involved And the appropriateness of therapy beginning treatment with the treatment plan established The questions are generally in a logical flow for most eval forms Some questions are worth more than others but all are required STGs 46 ICD-9 For Example Reason for Referral (RFR) is the largest section of the medical necessity pyramid A poorly written RFR can lead to denials if the rest of the evaluation documentation is not stellar LTG Underlying Impairments in SOP Functional Change Reason for Referral YES NO Is there a description of the recent history and events, and the functional changes/problems that lead to the need for the therapy evaluation (Reason for Referral)? 23

24 47 RFR Examples "Recent hospitalization due to pneumonia and respiratory failure, resulting in overall decline in functional status. Resident will benefit from OT skilled services to return to PLOF. "Pt is a 55 yo female presenting with L diabetic foot ulcer. YES NO Is there a description of the recent history and events, and the functional changes/problems that lead to the need for the therapy evaluation (Reason for Referral)? 48 RFR Example Patient is a 64 year old previously independent male who presents with a decline in transfers due to decreasing strength and likely an exacerbation of his Parkinsons Disease which was originally diagnosed 2 years ago. This current decline started approximately 3 weeks ago without a known precipitating even and has since resulted in the patient now requiring assistance for the completion of transfers especially from lower surfaces. Due to decreased strength and impaired functional mobility, this patient will require the skilled intervention of a therapist in order to regain the lost function/ safety. YES NO Is there a description of the recent history and events, and the functional changes/problems that lead to the need for the therapy evaluation (Reason for Referral)? 24

25 49 Progress Report Audit Form Rational to Continue Skilled Treatments Provided Progress Toward Goals Progress Reports are relatively evenly divided between needing to support: That the patient is making progress That the treatment provided is indeed skilled That it s not appropriate to discharge the patient now there are more things to be addressed that require our skill 50 Progress Report Audits Rational to Continue Skilled Treatments Provided Progress Toward Goals It s not enough that the patient is making progress, it must require your skill to make that progress Repetitive treatment is generally considered non-skilled Lack of documentation of adjustments, progressions and modification suggests that the treatment is not changing = non-skilled 25

26 51 Why were YOU there? What were YOU doing? When documenting skilled services it requires documentation about YOU 52 YES NO Is there a summary describing the skilled services (in terms of what the therapist was doing) related to each CPT code billed? In the Progress Report summarize the skilled nature of each intervention/cpt code provided (since the last report) Focus on what was new or done differently since the last progress report Progressions, adjustments, modifications What did YOU: Change Facilitate Train (be specific to the technique) Modify Advance Analyze what were the results of the analysis and what did you adjust based upon that analysis 26

27 53 Skilled Services? YES NO Is there a summary describing the skilled services (in terms of what the therapist was doing) related to each CPT code billed? (97110, 97530, 97116) "Ther ex, transfer training, gait training, standing tol." (92507) "Resident participated in skilled speech therapy to increase cognitive abilities." 54 Skilled Services YES NO Is there a summary describing the skilled services (in terms of what the therapist was doing) related to each CPT code billed? (97116) Gait trng over various surfaces in prep for return home, with tactile cues to improve cadence and occas VCs for safety awareness as surface changes. (97112) Provided progressive balance challenges to facilitate stability during gait direction changes. (97110) Focused on glut and hip abd strengthening activities, advancing from supine to standing closed chain ex s. 27

28 55 Skilled Services YES NO Is there a summary describing the skilled services (in terms of what the therapist was doing) related to each CPT code billed? (92526) Modeled and instructed patient in lingual strengthening ex s. Required feedback to improve ex accuracy. Thermal stim initiated to improve swallow strength. Patient and staff education on strategies to reduce risk for aspiration (eg. Small bites and sips, 90 degrees posture during and 30 minutes after PO intake). 56 Skilled Services YES NO Is there a summary describing the skilled services (in terms of what the therapist was doing) related to each CPT code billed? (97530) Facilitated activities to improve transition sit <> supine toward weak R side. Used tactile cuing for scapula and shldr joint mvmt to improve push up to short sit. (97535) Worked on progressing patient to ambulatory level dressing, including carrying clothing and supplies while determining most effective compensatory techniques for safe performance. 28

29 57 Updated Treatment Approach Next steps to be taken Describe the changes to or focus of the upcoming treatment that will advance progress toward goals This next week treatment will focus on NOT: Continue with POC Continue toward goals Pt. needs continues therapy for ther ex, ther act, neuromuscular reeducation, Does not justify that your skill is required YES NO Is the treatment approach updated to demonstrate progression and focus of treatment? 58 Updated Treatment Approach Treatment this next week will focus on Such things as: New or upgraded goals Addition of a new intervention Specific advancements to more challenging activities Specific plans to reduce assist provided Plans to introduce new, more challenging tasks or tasks related to a different deficit area that was not addressed yet or recently Discontinuation/transition of any ex s or activities 29

30 59 Updated Treatment Approach Treatment this next week will focus on progressing balance activities to outside of the parallel bars. Based on limited improvement in ROM, manual therapy techniques and more advanced stretching of right gastroc will be implemented to improve heel toe progression and stability during gait. Treatment this next week will attempt to progress grooming tasks from sitting bedside to standing at sink. Treatment this next week will focus on implementing SLP trials of thin liquids. 60 EVERY patient, EVERY day has to be Justified Remember the pyramid STGs ICD-9 LTG Underlying Impairments in SOP Functional Change Reason for Referral Rational to Continue Skilled Treatments Provided Progress Toward Goals 30

31 61 Thank You! 31

32 Facility/Site: Patient: Reviewer: Date: Episode Dates Reviewed Discipline Therapists/Assistants Medicare Part B - Technical Review of Therapy Chart YES NO Review Item Comments Certification: Is the treatment plan valid (includes all required elements), and signed and dated by the physician timely? Recertification: Is the updated treatment plan valid (includes all required Recert Date(s): elements), and is signed and dated by the physician timely? Is there a signed cert/re cert to cover each billed treatment day? Is the frequency of services in line with the certified plan, or if changes were made is there rationale or explanation for the changed frequency/missed visits? Does the therapist provide a billable treatment at least once every 10 treatment visits? Does the therapist complete a Progress Report at least once every 10 treatment visits? Is the documentation legible including all signatures? If signatures not legible, is there a signature log/attestation on file? Is each entry signed, including credentials? If an applicable LCD includes covered ICD 9 codes, is a covered ICD 9 used? Is treatment time documented each day reflective of actual treatment time (not rounded to 5 or 15 minute increments)? Does it appear that the correct CPT codes were used to reflect the services provided and in line with any applicable LCD guidelines? Are units appropriately applied for service based codes and timed services (following 8 min rule)? Is the KX modifier added appropriately (because the services are medically necessary) once approaching or over the therapy cap? Are modifier 59 s added to the appropriate code when CCI edit pairs are present? Are G codes present every time an eval or re eval code is billed, or on the first Part B treatment day if a change in payor? Are G codes present a least every 10 visits? Are G codes present only on days in which a billable service was provided? Are G codes present on the last treatment day? Note NA if unplanned d/c and therapist unable to determine patient status. Does the G code note describe the specific measure/outcome tool used to determine the Severity Modifier?

33 Facility/Site: Patient: Reviewer: Date: Eval Date: Therapist: Evaluation Documentation Quality Review Form YES NO Review Item Comments Are the diagnoses relevant to the patient s problem identified? Is there a description of the recent history and events, and the functional changes/problems that lead to the need for the therapy evaluation (Reason for Referral)? Is there a clear difference between PLOF and CLOF or, if not, is it explained why therapy needs to get involved? Are the Underlying Impairments indentified and measured? Is each STG objective and measurable, and based upon measured functional deficits/underlying impairments? Does the LTG present objective, functional criteria for D/C and is based upon problems identified/measured? Is the prognosis for achieving the LTG identified? Is each intervention in the treatment plan supported as necessary (e.g., is there an identified/measured impairment that would be treated by that intervention)? Is the planned frequency appropriate based upon the patient s condition described and the type of interventions required?

34 Facility/Site: Patient: Reviewer: Date: Progress Report Date: Therapist: Therapist Progress Report Documentation Quality Review Form YES NO Key Criteria Comments Is a status update provided for each goal, and if the goal is met as stated is it upgraded or discontinued? Is progress toward goals evident? Or, if the patient did not progress or declined, is there an explanation for why the patient did not progress as anticipated? Is there skilled analysis to explain the reason for progress or lack of progress? Is there a summary describing the skilled services (in terms of what the therapist was doing) related to each CPT code billed? Are there objective measures for each functional deficit and underlying impairment addressed (since the last Report)? Is the treatment approach updated to demonstrate progression and focus of treatment?