Coding, Billing and Documentation. Official Disclaimer. Start the Story 4/10/2014

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1 Coding, Billing and Documentation Beth Sarfaty, PT, MBA VP Clinical Services and Quality Management Select Medical Hospital Based OP 1 Official Disclaimer The views expressed in this presentation and the accompanying materials are solely that of the author and should not be represented as the policy or opinion of either APTAnj, Kessler Rehabilitation Institute or Select Medical. 2 Start the Story Diagnosis Coding is the code that defines the condition Classifies information for statistical purposes Describes and communicates the person s s health care condition Is the basis for medical necessity of services Impacts reimbursement 3 1

2 Diagnosis coding specification The code is considered the title or heading for a category of codes Codes are further defined dfi din their hispecificity i and detail by additional digits If there is additional digits assigned, they should be used as appropriate 4 Keep in mind A V Code (surgical code) or Medical Diagnosis code should not be the only ICD9 code chosen for therapy Therapist should include a functional (or treatment) diagnosis code to further define the need for therapy Codes chosen must be clearly supported in the documentation 5 If no medical diagnosis given, or if not the primary reason for rehab, a therapeutic or functional diagnosis code that describes the patient s signs and symptoms is OK to use Is there a correct order to use? If available: medical diagnosis current condition current problem (or reason for the need of therapy) any additional code that describes a coexisting condition that will impact need for rehab or expected outcome 6 2

3 Choosing the best codes Identify the codes that best match the diagnosis 1 st code chosen should be the one that best describesthe cause of symptoms Then chose a code that describes any manifestations, complications, late effect symptom that may impact treatment time, prognosis, outcomes, etc. 7 Include medical diagnosis from the MD when appropriate to the condition being treated Include any and all treatment and functional diagnoses (assessment) codes that is pertinent to the care being furnished Make sure all is supported in the documentation Should reflect signs and symptoms being treated 8 Functional Diagnosis code Identifies the result or reason the patient is being referred for therapy Needs to be specific to what is found during the evaluation Examples Joint stiffness, difficulty walking, hemiparesis, joint contracture, muscle wasting, pain in limb 9 3

4 Continuing the Story CPT codes define the treatment intervention being provided Bill for what htthe therapist t is providing, NOT what ht the patient is doing Select the code that best describes the clinical intent of the treatment 10 Service vs. Time Based Codes Service Based Reimbursed same amount regardless of time spent delivering the service Unlimited body parts Direct contact not required throughout the service Time Based Billed in per unit increments Documentation must support the time billed Includes more than just the delivered treatment time 11 Included in Time based codes TIME for billing The provider s total time required to perform the service including skilled: pre service i work (P) intra service work (I) post service work (P) 12 4

5 Pre Service Work may include Chart reviews for medical treatment Set up of activities, equipment and area to be used Positioning patient on equipment or table Education of the patient relating to his/her condition or treatment Review of previous documentation Communication with other health care professionals (i.e., case manager) Discussions with family Calls to the referring physician for additional information or clarification of direction Pre service work that is skilled may only be considered billable if the patient is present 13 Intra Service Work includes Direct contact (visual, verbal or manual) delivery of the treatment procedure, status check of the patient s symptoms and assessment of response to treatment 14 Post Service work may include: Repositioning patient off table Assessing patients response to treatment Discharging the patient from treatment Calls to referring physician to report progress and communication i with ihother team members. Documentation of treatment or report writing time must be skilled time and performed while the patient is present in order to be billable 15 5

6 NOT Included in Time based time for billing Rest time / non treatment time cell phones, texting, restroom breaks Time spent delivering service based modalities or procedures Time spent by patient performing independent activities unsupervised/ unskilled 16 What code should I use? Consider the goal of your activity to determine which CPT code to select Choose a code based on the intent of the treatment inclusive of physiologically what is involved as well as the actual service performed and the anticipated outcome Documentation must support the code Billable time is direct one on one time 17 Therapeutic Exercise Therapeutic procedure to develop strength and endurance, ROM, and flexibility to one or more body areas (ea code 15 min) Generallyused to describe servicesdelivered to improve a single parameter such as strength, or ROM 18 6

7 TE Considered reasonable & necessary if the patient has an identified impairment such as Weakness, pain, contracture, muscle imbalance Limitationsin in mobility, strength, dexterity, ROM, endurance Novitas Solutions LCD L27513 printed 2/27/14 19 Neuromuscular Re education Addresses movement, balance, fine or gross motor coordination, kinesthetic sense, posture, motor skill and/or proprioception for sitting and/or standing activities (ea 15 min) Desensitization Kinesiotaping/patellar taping 20 Aquatic Therapy Uses therapeutic properties of water (buoyancy, resistance) Use for restrictions of joint motion, strength, mobility or function 1:1 contact code Do not use for Hubbard Tank or WP 21 7

8 Gait Training Training the biomedical and kinesiological components of walking, including balance, cadence, symmetry, motor control, speed, energy and efficiency Includes stair climbing May be reasonable and necessary to improve/restore or compensate for impairment of walking ability due to neurological, muscular or skeletal abnormalities 22 Massage Therapy Designed to facilitate healing of muscle, reduce edema, improve joint motion and/or relieve muscle spasm (ea 15 min) Includes effleurage, petrissage and/or tapotement (stroking compression, percussion) Documentation must support the need for medical necessity May be used for desensitization 23 Manual Therapy Techniques Includes but not limited to mobilization/manipulation, manual lymphatic drainage, manual traction (ea 15 min) Joint/soft tissue mobs, MFR, scar mobilization, transverse friction, lymphatic taping Documentation must include the specific techniques performed, the tissues/area treated and the total time the intervention occurred 24 8

9 Be specific with Manual Therapy What are the goals of the treatment? Modulate pain Increase joint range of motion Reduce/eliminate soft tissue swelling, inflammation or soft tissue restriction Induce muscular relaxation Improve contractile and non contractile extensibility 25 Group Therapy For Medicare ONLY Constant attention but not 1:1 contact Therapist working with more than one patient at a time Providing SKILLED services Patients do not need to be receiving same type of treatment/procedure Service based code 26 Community/Work Reintegration Shopping, transportation, money management, vocational activities, work environment/modification analysis, work task analysis, use of assistive technology devices/adaptive e equipment Not typically used to describe HEP instruction Describe all aspects of training, level of understanding How the intervention is related to functional goals 27 9

10 Community/Work Reintegration Shopping Transportation Money management A vocational activities Work environment modification analysis Work task analysis 28 Therapeutic Activity Using dynamic activities to improve, restore or compensate for loss of one s functional performance ability (ea code 15 min) Describes the activities that use multiple parameters (strength, ROM, balance, coordination, etc) simultaneously to achieve a functional activity or movement Can be for a specific body part or multiple body parts 29 Development of Cognitive Skills Interventions used to enhance cognitive skills Attention Memory Problem solving Not covered Use of memory aids such as memory books, memory boards or communication books is sole treatment plan 30 10

11 Sensory Integrative Techniques Used to enhance sensory processing and to promote adaptive responses to environmental demands Often denied if used for desensitization in Hand Therapy Documentation must include the patient s deficit in processing input from a sensory system (vestibular, proprioceptive, tactile) that may decrease their ability to make adaptive sensory, motor and behavioral responses appropriately within the environmental demand 31 Self Care/Home Management ADL and compensatory training, meal prep, safety procedures and instructions in use of assistive technology devices/adaptive equipment (ea 15 min) Must be documented as part of an active treatment plan directed at a specific outcome Patient and/or caregiver must have the capacity to learn from instruction Excessive use of the code may be denied as not medically necessary 32 TENS Fitting for home use Charge for your time to instruct the patient Application of surface (transcutaneous) neurostimulator Treatments > Modalities > TENS placement / application Service based code 33 11

12 Wheelchair Management Assessment for need Determination of type of WC and components Measuring and fitting Making adjustments Training in use for safety, mobility and transfers 34 Work Hardening/Conditioning 97545/ initial 2 hours each additional hour Rl Relate solely ll to work skills Not covered by Medicare 35 Wound Care Management Debridement open wound, including topical applications, wound assessment, use of WP, when performed and instructions for ongoing care, per session, total wound(s) surface area, first 20 sq cm or less as above, each additional 20 cm, or part thereof(list separately in addition to Removal of devitalized tissue, nonselective debridement 36 12

13 Wound Care Management negative pressure wound therapy (vacuum assisted drainage collection), include topical application, wound assessment, instructions for ongoing care. Charge per session, total surface area < or = 50 sq cm total wound area > 50 sq cm 37 Documenting Wound Care Document wound size, condition Document specific method of intervention (selective tech, non selective, VAC) and tools used (high pressure water jet, forceps, p, scissors) Document outcome of interventions on the wound and how the wound is addressed following the intervention (dressing, medications applied, etc) 38 Physical Performance Test Used to provide additional objective documentation of a patient s condition or status Require a separate report from the other evaluations done Must document problem requiring the test, specific test performed, time to administer test, test results and how the information affects the treatment plan 39 13

14 Orthotic Management and Training Assessment and determination of most appropriate device Design and fabrication Fitting and Training L Code includes assessment, fabrication, fitting and supplies. Education and training billed separately under orthotic management code 40 Prosthetic Training Includes training and education Upper/lower extremities Pre and post Prosthetic 41 Checkout for Orthotic/prosthetic An end service for established Patient Time spent to ensure correct fit, adjust or repair device when using device during functional activity Reasonable & Necessary when a modification or re issue of a device or re assessment of a newly issued device 42 14

15 Canalith repositioning Epley, Semont manuever Do not report with (spontaneous nystagmus including gaze) or with (positional nystagmus test) is a separately reportable service by PT s per 2011 PFS 43 Assistive Technology Assessment Assess the need for a technological interface b/w the patient and their environment or mobility system Patient s voluntary motions (oral motor strength, head/neck ROM and strength, ocular motor control, quality of voice output) are identified and assessed Not covered if provided by a therapy assistant 44 Assistive Tech Written report must include: Goal of the assessment Technology/component/system involved A description of the processinvolvedin assessing the patient s response Outcome of the assessment Documentation of how this information affects the treatment plan 45 15

16 Reporting Timed Codes and Documenting Effectively The work of a QHCP consists of face to face time with the patient (or caregiver if applicable) delivering skilled services. For determining total time of a service, incremental intervals of treatment at the same visit can be accumulated. AMA CPT Documenting Each DOS should indicate total treatment time 8 minute rule can be used to determine total units for all payors Documentation of un billed services not part of total treatment time not required but recommended for liability services» CMS MPBM Ch 15 Sec » MR Claims Policy Manual Ch 5 Part B OP 47 Total Time Intervals for Federal Funded Payors 1 unit = 8 to 22 minutes 2 units = 23 to 37 minutes 3 units = 38 to 52 minutes 4 units = 53 to 67 minutes 5 units = 68 to 82 minutes 6 units = 83 to 97 minutes 7 units = 98 to 112 minutes 8 units = 113 to 127 minutes 48 16

17 FSC FFP Billing rules CPT/AMA Billing Rules Total Time Rounding Rules 15 min increments = 1 unit 49 Reporting Timed Codes Total Treatment Time: 47 min Direct Contact Time: 24 min of NMR 97112, 23 min of TE Total Direct Treatment time: 47 min Number of units = 3» CMS MPBM Ch 15 sec and MR Claims Policy Manual Ch 5 Part B OP 50 Reporting Timed Codes Total Treatment Time: 28 min Direct Contact Time: 10 min of TE 97110, 10 min of MT 97140, 8 min of US Total Direct Treatment Time: 28 min Number of Units = 2» CMS MPBM Ch 15 sec and MR Claims Policy Manual Ch 5 Part B OP 51 17

18 Reporting Timed Codes Total Treatment Time: 40 min Direct Contact Time: 20 min of TE 97110, 20 min of MT Total Direct Treatment time: 40 min Number of units = 3» CMS MPBM Ch 15 sec and MR Claims Policy Manual Ch 5 Part B OP 52 Documenting Direct 1:1 contact Should include specific treatment and direct patient interaction Include area of body treated, technique used, patient response and outcome of treatment Cannot be provided simultaneously with more than one patient at a time 53 Stretch Break 54 18

19 Accurate Documentation Select the code that most accurately identifies the service performed Report the code that best describes the outcome to be achieved or the intent of the intervention 55 What else do I need to include? Time to support the units billed when reporting direct contact 1:1 codes Flow sheets are part of the medical record Need dto show skill Proper ID of provider Should describe therapists intervention not just patient doing activity 56 Consider treating environments Direct Contact (1:1 care) Intermittent Group When you are billing 1:1 interventions with a FFP patient no other patient can be billed during that same time interval 57 19

20 What if I am seeing more than one patient? 1:1 treatment FFP patient FFP patient No Charge or supervised modality Group Group 1:1 treatment Vise versa (minus the time you are instructing the other patient) Bill only the time it takes you to instruct them in the exercise 58 Non FFP with a FFP Non FFP Patient NC or supervised modality 1:1 intervention time FFP patient 1:1 Intervention time Group 1:1 treatment (minus the time you are instructing the other patient) Vise versa Bill only the time it takes you to instruct them in the exercise 59 What code? What s the Intent? THERAPEUTIC PROCEDURE Strength, endurance, ROM, flexibility NEUROMUSCULAR RE EDUCATION Balance, coordination, kinesthetic sense, posture, proprioception THERAPEUTIC ACTIVITIES functional activities Improved functional performance, lifting, pulling, function, steps, squatting, etc MANUAL THERAPY Mobilization joint or soft tissue, manual traction, specific technique 60 20

21 Wall Slides: Which code? Wall Slides to strengthen the LE Supporting Documentation: Decreased LE strength to support the need to perform LE strengthening Therapeutic Exercise Wall Slide ld with the intent of improving the patients squatting or transferring ability Supporting documentation: squatting or transferring deficit and specific skills/techniques used to improve this ability Therapeutic Activity 61 UBE: Which code? UBE with intent of improving pushing/pulling Supporting documentation: Decreased pushing/pulling ability and indication of how UBE is being used to address the deficit Therapeutic Activities UBE to increase ROM Supporting Documentation: Objective UE ROM goniometric measures demonstrate support for UBE to improve ROM Therapeutic Exercise 62 BAPS board: which code? Baps board for improving ankle ROM Supporting Documentation: Decreased Ankle ROM to support the need to improve ankle ROM Therapeutic Exercise Baps Board for proprioception after ankle sprain Supporting documentation: Improper balance reactions for involved ankle. Specific techniques utilized. Neuromuscular Re education 63 21

22 What about education? Currently, there is no CPT code for education or is there Professional time spent educating a patient in issues pertaining to their diagnosis is skilled treatment and is billable. It should be billed under the intent of the education (ie, NMR for posture, etc.) 64 Service based Modalities Hot/cold packs Mechanical Traction Unattended E Stim Vasopneumatic Device Paraffin Whirlpool/ Fluidotherapy Biofeedback 90901/ Constant Attendance Modalities Billed as 1:1 timed units Ultrasound Iontophoresis Manual E Stim Contrast bath

23 Documenting Modalities Document the impact using the modality will have on the patients functional goals Document the parameters and desired effect of the application Document body position Document to support the continued use (clinical decision making) 67 Questions about coding? Billing? Scheduling multiple li l patients when treating Medicare/FFP? 68 Documenting Medical Necessity Therapy is designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functions that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital abnormalities or injuries. Therapy emphasizes a form of rehabilitation focused on treatment of dysfunction involving NM, MS, CV/P or integumentary systems through the use of therapeutic interventions to optimize functioning levels.» Guide to PT Practice 69 23

24 Documentation A basic need for the profession and required It is not real if it is not written It s a justification of medical necessity which equals reimbursement Must be objective and functional 70 What is expected? Objective information in measurable terms or a clear explanation as to the limited progress or function Must include baseline data Linked to functional status include specific info that details residual problems that warrant treatment Individually based on patient outcomes 71 Must haves Sufficient info to IDENTIFY the patient SUPPORT the DIAGNOSIS JUSTIFY treatment Define the COURSE and RESULT of the treatment Explain the NEED and RESULTS from the CONTINUITY of care among all HCP SUPPORT for CHARGES why each code used 72 24

25 Evaluations Reason for referral/diagnosis Relevant medical history PLOF and CLOF and potential for improvement indicate QOL Documentation to indicate patient s social support Where they live Who they live with In a new living environment Learn new ADLs Functional assessments Measure impairments, activity restrictions and outcomes expected document a functional outcome measure Documentation to support the illness severity or complexity 73 Evaluation Record of DC from Part A qualifying IPR, SNF, HHA (within 30 days of start of OP) Whether patient seen for same condition previously by same therapy discipline Describegoals from a functional perspective Write a plan for achieving the functional improvement Clinicians clinical judgment Determination if treatment is or is not needed MPBM Ch 15 Sect Rev 179 Issued 1/14/14 74 Goal Writing Describe the outcome, not the means to get there Connected to the dysfunction, impairment or functional limitation Need to be concrete and measurable Should predict a time frame for achievement 75 25

26 Goals need to include Area of body Impairment Goal Functional activity Target performance Why they need to do it Target timeframe Be concrete and measurable 76 Questions to identify functional goals Ask the patient about their desired outcome Determine which are most important Include self care, work, leisure activities and the environment for each Establish goals with the patient Goals should be patient centered 77 The patient s bilateral UE strength will increase to at least 4 /5 to allow her to reach for items in the kitchen cabinets to facilitate independent preparation of meals in 3 weeks Fearon & Levine APTA

27 The patient s right shoulder flexion active ROM will increase to at least 135 degrees to allow improved ability to reach items in her closet to dress independently in 4 weeks Fearon & Levine APTA The patient s hip extensor strength will increase to 4 /5 to allow independent transfers with improved control to avoid potential fall and further injury in 3 weeks Fearon & Levine APTA The patient s low back pain level will reduce to 2/10 to enable her to sleep uninterrupted dfor 6 hours in 4 visits Fearon & Levine APTA

28 The patient s sitting tolerance will increase to 45 minutes to allow for use of community transportation/driving to attend work and other obligations in 8 visits Fearon & Levine APTA High Level Activity for Medicare Mowing the yard, running the vacuum, walking 3 miles daily, playing tennis May be PLOF but NOT essential to ADLs Will be denied How document? Identify the impairment(s) or functional limitation associated with the high level activity Document the functional piece vs. the activity 83 Examples Patient to improve core stability, strength and flexibility to allow her to participate for 15 minutes a day in necessary home based sanitary requirements of cleaning and maintaining a hazard free environment. MPBM Ch

29 Patient to improve balance, endurance and safe independent gait pattern to allow for 1.5 mile walk to bus stop 2x a week to independently shop. The patient s shoulder limits her ability to maintain a clean home with vacuuming. Shoulder weakness/limited ROM/decreased stability and increased pain prevent vacuuming as she was able to do prior to injury. 85 Focus on Function Functional goals are a meaningful activity that the patient can no longer perform Are necessary to show that we are not treating the dysfunction alone and that it impacts ADLs Shows that addressing and achieving the impairment alone may not lead to functional improvements 86 Questions to identify functional goals Ask the patient about their desired outcome Determine which are most important Include self care, work, leisure activities and the environment for each Establish goals with the patient Goals should be patient centered 87 29

30 Contents of Plan of Care Diagnosis Long Term Treatment Goals Type, amount, duration and frequency of therapy services MPBM Ch 15 Sec Rev 179 Issued 1/14/14 88 Daily Note Document the description of the service provided Changes made to the treatment due to patient s progression Document the patient s response to treatment Show parameters of treatment 89 Observations noted Describe type and amount of manual, visual and verbal cues needed Constant verbal and tactile cues given for shoulder flexion without substitution. TE resulted in an increase of shoulder flexion to 120 degrees to comb hair. Still unable to reach into cupboards at home

31 Factors that will require modification of frequency, intensity or progression of treatment program performing shoulder flex and abd ex incorrectly resulting in increased dimpingement i painted BR with repeated OH movements increased pain computer station ergonomic corrections not made, enhances poor posture and muscle imbalances, aggravating symptoms BCBS of Kansas Documentation Guidelines 91 Assessment Include a statement of clinical decision making and problem solving poor control and contraction of transverse abdominal muscles resulting in continued compression and sheering, causing LS pain and radicular symptoms poor blood sugar control resulting in fatigue and avoidance of exercises (speak to MD) quad control in open chain good, transition into controlled functional closed chain in prep for running BCBS of Kansas Documentation Guidelines 92 Progress notes and Re certifications Progress notes not billable, part of regular documentation requirements Re certification also not billable but required if care if additional care needed beyond initial POC Should include specifics in regards to patients progress made and rationale for extending the POC 93 31

32 Progress Notes Includes assessment of improvement, extent of progress (or lack thereof) of each goal Plans for continuing treatment Changes to long or short term goals Functional documentation (including G Codes) Re eval should only come from this if changes not anticipated are noted MPBM Ch 15 Sect Rev 179 Issued 1/14/14 94 Re evaluation Per the APTA definition Is a focused evaluation process of examination of subjective and objective findings Results in the therapist making a professional judgment about continued care, altering goals, altering treatment or terminating services Process of performing selected tests and measures after the IE to evaluate progress and to modify or redirect interventions Reports significant change in the patient s condition Includes new clinical findings or failure to respond to interventions 95 A Re eval is a formal re assessment Cannot just summarize objective findings Need for continued care must come from your skilled assessment Can be billed/charged when: New clinical findings exist Significant deviation from the course of therapy or level of function as note in IE A new body part added Significant deterioration or improvement that was not expected and thus necessitates change of treatment or LTG Progress is significantly slower than expected, or absent Lapse in care due to hospitalization At planned d/c if documenting the progress the patient has made over their episode of care 96 32

33 Re evaluations Describe objective measurements which when compared to previous documentation, show Improvements in function Decrease in severity Progress toward goals Rationalization to justify continued treatment Modify/Update goals and/or treatment plan NOT routine or re occurring re assessment 97 When can I charge a Re eval? Significant deviation for the course of therapy or function as projected at the initial eval Addition of a new body part or clinical condition to be treated Significant deterioration or improvement that was not expected that therefore necessitates change of treatment and long term goals Failure to respond to the therapeutic interventions outlined in plan of care 98 Re evals A planned discharge to determine if goals have been met, or for use of the MD or treatment setting at which treatment will be continued Necessary to determine that frequency, durations and treatment durations are still Reasonable Specific to the diagnosis and acuity level 99 33

34 Re assessment A routine component of therapy Performed on a regular basis to assess a patient s response to treatment and progression towards their stated goals 100 Capturing Re assessment time When not billable as a re evaluation Include your skilled assessment time in billable time for the treatment procedures provided Documentas a separate treatment, but charge as treatment procedure it corresponds to Additional detail should describe the measure that was performed; indicate purpose of the test, time spent and applicable charge option 101 Discharge Summary Reason for DC Functional status at DC Identify patient progressed and achieved goals as stated in POC Future recommendations Communication with other HCP

35 What do payors look for when they review the documentation? Evaluation supports all DOS and services provided Treatments changing as progress is met Proof of skilled interventioni Patients functional status How much time the therapist spends with the patient How modalities are used 103 What abbreviations mean How can I tell from flow sheets if progress being made If interventions i on flow sheet are skilled Are re evals done? DC summary or explanation if self DC 104 What must be in each medical record? What is wrong with the patient? What do you plan to do with the patient? What skilled interventions are required that you will be performing? What progress is being made? What is the final result?

36 Don t forget the basics Services provided Services are skilled and medically necessary Services provided by QHCP Services require the skill of QHCP Interventions appropriate for DX Appropriate frequency and duration Patient expected to make significant functional improvement 106 Reviewers want to see Clinical reasoning is demonstrated Treatment interventions are related to functional limitations Functionalgoals identified Documentation supports codes chosen and billed Documented changes in functional limitations New clinical findings Lack of progress 107 Why might I get denied or audited? Lack of reporting time in documentation Lack of support in documentation for interventions Lack of progress noted Too much passive care (modalities) Lack of functional information

37 So to avoid denials Create a complete POC Document when the POC is modified, including how it has been modified and why the previous goals were not or could not be met Confirm POC is certified Clearly document, in minutes, total treatment time for the timed codes and the total treatment time (timed and untimed codes) in the medical record MLN Fact Sheet Sept Just because I have a RX Does that mean it is medically necessary? PT determines medical necessity, not MD Based on functional status We must be able to be effective in our treatment Goals must be to improve function, minimize loss of future function and/or decrease risk of injury and disease Fearon & Levine APTA Don t confuse unskilled and skilled care Unskilled Repetitive procedures Reinforcing previously learned skills Maintaining function after maintenance program developed No POC developed Services don t require the skills of a QHCP

38 Reasonable & Necessary Patient s condition will improve significantly in a reasonable time frame Improvement is evidenced by successive objective measurements whenever possible. If the expected rehab potential is insignificant in relation to the extent and duration of therapy required to achieve such potential, rehabilitative services are not R&N» MPBM Ch 15 Sect Rev 179 Issued 1/14/ Skilled Rehabilitative Therapy Evaluations and Re evaluations Establishment of treatment goals specific to the patient s disability or dysfunction Design of a POC addressing patient s disorder Continued assessment and analysis Instruction leading to establishment of compensatory skills Selection of devices to replace or augment a function Training of patient and family to augment rehabilitative treatment MPBM Ch 15 Sect Rev 179 Issued 1/14/ Maintenance Program A program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress s/he has made during therapy or to prevent or slow further deterioration due to a disease or illness. MPBM Ch 15 Section 220 Rev. 179, Issued 1/14/

39 Skilled Maintenance Maintenance Therapy no improvement expected but skilled care necessary to maintain the patient s current level of function The performance of a safe and effective maintenance program can only be established and carried out by a QHCP and PT only. CMS MM /7/14 CMS Transmittal /6/ Skilled Maintenance Program Skills of a therapist are necessary to maintain, prevent or slow further deterioration of the patient s current functional status Servicescannot cannot be safely and effectively carried out by the patient with the assistance of non therapists, including unskilled caregivers CMS MM /7/14 CMS Transmittal /6/ Documenting skilled care & medical necessity Assessed Added Cueing Demonstrated Educated Facilitated Instructed Modified Progressed Provided Reviewed Trained

40 Remember The person paying the claims makes the rules Decisions aren t made by payment policies (not ok to withhold care just b/c won t get paid) No auth doesn t = no care, pt can still get care w/o 3 rd party payer 118 Questions? 119 References 2004 Coding and Payment Guide for the Physical Therapist BCBS of Kansas, Documentation Guides for Physical Therapists, 9/21/09 Defensible Documentation Elements, PT Magazine, APTA Documenting Medical Necessity of Physical Therapy, Retrieved from 3/21/13 Drummond Dye, R, Lee, G, Smith, H, Frohlich, M, Emerging Issues in Medicare and Federal Affairs: What Every PT Needs to Know, January Fearon, H, CPT, ICD9 and Reporting Physical Therapy Services, APTA 2013 Guide to Physical Therapy Practice, 2 nd Edition, 2003 Guidelines for Medical Necessity Determination for Physical Therapy, Mass Health, 6/05 Lee, G, Medicare Payment Policy Update February 15, 2013 Levine, S, Payment Policy and Compliance for Today and Tomorrow, NY, NY 2/15/13 Medicare Benefits Manual, Chap 15, Sec 220 and 230 MLN, Fact Sheet, OP Rehab Services: Complying with Documentation Requirements, ICN , Sept 2011 Novitas LCD L27513 Physical Medicine & Rehabilitation Services, Physical Therapy and Occupational Therapy