Medicare Myths-Busters: Dispelling Common Compliance Misconceptions. Learner Objectives. Learner Objectives

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1 Medicare Myths-Busters: Dispelling Common Compliance Misconceptions Rick Gawenda, PT President Gawenda Seminars & Consulting, Inc. September 30, 2017 Learner Objectives Identify the supervision requirements of a student treating a Medicare outpatient Describe how you can schedule Medicare and non-medicare patient s Recite what you can and can t bill together during the same 15-minute time period Describe how you can bill more than 4 time-based units in an hour 2 Learner Objectives List what insurance carriers also follow the definition of group therapy and requires direct one-on-one contact Define what the Medicare program does require for payment (order or plan of care) Identify the criteria for a re-evaluation to be billed to Medicare and private insurance carriers Recite when maintenance therapy is covered under the Medicare program 3

2 Learner Objectives List when it is and is not appropriate to issue an ABN to a Medicare beneficiary Recite when you can and can t collect cash from a Medicare beneficiary for services or items that you provide 4 Twitter Twitter Hashtag 5 Myth #1: Students Can t Treat Medicare Part B Patients The Medicare program does allow students to participate in the treatment of Medicare Part B patient s Key is the qualified practitioner (therapist or therapist assistant) is present in the room for the entire treatment session directing the service, making the skilled judgment, and is responsible for the assessment and treatment The qualified practitioner is not engaged in treating another patient or doing other tasks at the same time 6

3 Myth #1: Students Can t Treat Medicare Part B Patients The qualified practitioner is responsible for all services provided to the Medicare Part B beneficiary and signs all documentation A student may also sign, but would require a co-signature of the qualified practitioner since payment is for the clinician s service and not the student s service dance/manuals/downloads/bp102c15.pdf Section 230B 7 Myth #2 You Can t Double Book Medicare Patient s The Medicare program has no rules or regulations dictating how you schedule Medicare Part B patient s The key is you only bill the appropriate number of time-based units based on the amount of time you spent one-on-one with the Medicare patient plus any untimed services provided that treatment session 8 Myth #3: You Can t Bill 2 CPT Codes During The Same 15-Minute Period It is possible to bill for more than one therapy service occurring in the same 15-minute time period One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact CMS Therapy Services Part B Billing Scenario s ervices/ 9

4 Myth #3: You Can t Bill 2 CPT Codes During The Same 15-Minute Period Example 1 During the same 15-minute time period, you can bill 1 or more supervised modality CPT codes ( ) and a 15-minute time based CPT code Example 2 During the same 15-minute time period, you can bill 2 or more supervised modalities ( ) 10 Myth #4: You Can t Bill More Than 4 Units per Hour Example 1 Patient A is seen from 8:00AM 8:25AM for therapeutic exercise. Patient B seen from 8:26AM 8:50AM for therapeutic exercise. Patient C seen from 8:51AM 9:00AM for therapeutic exercise You would bill 5 15-minute units in an hour. This example is true for all patient s, including Medicare Part B 11 Myth #4: You Can t Bill More Than 4 Units per Hour Example 2 Patient A is seen from 8:00AM 8:25AM for 15 minutes of therapeutic exercise and 10 minutes of manual therapy and is then placed on unattended electrical stimulation until 8:45AM. Patient B is seen from 8:30AM 8:55AM for 15 minutes of therapeutic exercise and 10 minutes of manual therapy and is then placed on mechanical cervical traction starting at 9:00AM In this example, you billed 6 units in an hour 12

5 Myth #4: You Can t Bill More Than 4 Units per Hour Example 3 Non 8-Minute Rule Payers Patient A is seen from 8:00AM 8:10AM for therapeutic exercise, 8:11AM 8:20AM for manual therapy and 8:21AM 8:30AM for gait training Patient B is seen from 8:31AM 8:40AM for therapeutic exercise, 8:41AM 8:50AM for manual therapy and 8:51AM 9:00AM for therapeutic activities 13 Myth #5: The Definition of Group Therapy Applies Only to Medicare Therapeutic procedure (s), group (2 or more individuals) (Group therapy procedures involve constant attendance of the physician or other qualified health care professional (i.e. therapist), but by definition do not require one on one patient contact by the same physician or other qualified health care professional) 14 Myth #5: The Definition of Group Therapy Applies Only to Medicare CPT codes are developed, owned and copyrighted by the American Medical Association and not the Medicare program or other insurance carriers All HIPAA covered entities must use the adopted standards that includes Current Procedural Terminology (CPT) This means the definition of group therapy applies to all insurance carriers, not just the Medicare program 15

6 Myth #6: The Definition of requires direct one-on-one contact Applies Only to Medicare A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Physician or other qualified health care professional (i.e. therapist) required to have direct (one on one) patient contact except for group therapy. Group therapy requires constant attendance. Therapeutic procedure, one or more areas, each 15 minutes; requires the therapist to maintain direct patient contact (ie, visual, verbal and/or manual contact) during provision of the service CPT Assistant December Myth #6: The Definition of requires direct one-on-one contact Applies Only to Medicare Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (i.e. Baps Board, Trampoline, Swiss Ball, Body Blade, PNF, NDT, etc.) Aquatic therapy with therapeutic exercise Gait training (includes stair climbing) Massage, including effleurage, petrissage and/or tapoment (stroking, compression, percussion) 17 Myth #6: The Definition of requires direct one-on-one contact Applies Only to Medicare Manual therapy techniques (eg. Mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Therapeutic activities, direct (one on one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Self care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct one on one contact, each 15 minutes 18

7 Myth #6: The Definition of requires direct one-on-one contact Applies Only to Medicare CPT codes are developed, owned and copyrighted by the American Medical Association and not the Medicare program or other insurance carriers All HIPAA covered entities must use the adopted standards that includes Current Procedural Terminology (CPT) This means the definition of direct one-on-one patient contact applies to all insurance carriers, not just the Medicare program 19 Myth #7: Medicare Requires an Order to Begin Outpatient Therapy Services There is no Medicare requirement for an order for outpatient physical, occupational and/or speech therapy services An order, if present, provides evidence that the patient both needs therapy services and is under the care of a physician Payment for outpatient therapy services is dependent on the certification on the plan of care and not a physician order A physician order can serve as a plan of care if it contains all the required elements CMS Publication , Chapter 15, Section Myth #7: Medicare Requires an Order to Begin Outpatient Therapy Services You must also look at your Conditions of Participation (CoP) under the Medicare program For example, Hospital COP Condition of participation: Rehabilitation services states: All rehabilitation services orders must be documented in the patient's medical record in accordance with the requirements at

8 Myth #7: Medicare Requires an Order to Begin Outpatient Therapy Services states: All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations 22 Myth #8: Medicare Requires a Reevaluation Every 10 Visits Reevaluations are not required by the Medicare program Under outpatient therapy, the Medicare program does require a Progress Report be completed, at minimum, once every 10 visits from the start of care Progress Reports and Reevaluations do not mean the same thing, but a medical record entry could serve as both a Progress Report and a Reevaluation is both were warranted 23 Myth #8: Medicare Requires a Reevaluation Every 10 Visits Reevaluations may be considered R & N in the following situations: The professional assessment indicates a significant improvement or decline or change in the patient s condition or functional status that was not anticipated in the plan of care for that interval New clinical findings Failure of the patient to respond to the treatment outlined in the current plan of care 24

9 Myth #9: Medicare Doesn t Pay For Maintenance Therapy CMS states therapy coverage does not turn on the presence or absence of a beneficiary s potential for improvement, but rather on the beneficiary s need for skilled care. Skilled care may be necessary to improve a patient s current condition, to maintain the patient s current condition, or to prevent or slow further deterioration of the patient s condition. 25 Myth #9: Medicare Doesn t Pay For Maintenance Therapy The Medicare statute and regulations have never supported the imposition of an Improvement Standard rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient s condition Coverage depends not on the beneficiary s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves The Jimmo vs Sebelius settlement agreement clarifies Medicare s longstanding policy that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration 26 Myth #9: Medicare Doesn t Pay For Maintenance Therapy Maintenance - Even if no improvement is expected, under the home health (HH), outpatient therapy (OPT) and skilled nursing facility (SNF) coverage standards, skilled therapy services are covered when an individualized assessment of the patient s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient s current condition or prevent or slow further deterioration 27

10 Myth #9: Medicare Doesn t Pay For Maintenance Therapy Maintenance Therapy is a covered Medicare benefit in the skilled nursing facility settings, home health setting and outpatient therapy settings Maintenance Therapy is not a covered Medicare benefit in the inpatient rehabilitation facility setting and Comprehensive Outpatient Rehabilitation Facility (CORF) setting 28 Myth #10: You Must Issue an ABN When a Medicare Patient Exceeds the Therapy Cap An ABN is issued when normally the services are covered by the Medicare program, but under the circumstance, you think Medicare will now deny these services By attaching the KX modifier to the CPT codes on the claim form, the therapist is attesting that therapy is still medically necessary which would contradict the issuing of an ABN 29 Myth #11: You Must Issue an ABN When a Medicare Patient Exceeds $3700 An ABN is issued when normally the services are covered by the Medicare program, but under the circumstance, you think Medicare will now deny these services By attaching the KX modifier to the CPT codes on the claim form, the therapist is attesting that therapy is still medically necessary which would contradict the issuing of an ABN 30

11 Myth #12: I Can Collect Cash from Medicare Patients for My Services and Items Therapists in private practice must enroll in the Medicare program and submit claims to the Medicare program for therapy services that are covered by the Medicare program Fitness, wellness, post-therapy exercise programs, yoga, pilates, etc. are statutorily non-covered by the Medicare program and you can collect cash from Medicare patients and no ABN is required Supplies such as theraband, cold packs, theraputty, biofreeze, etc. are statutorily non-covered by the Medicare program and you can collect cash from Medicare patients and no ABN is required 31 References - Students CMS Publication , Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services, Section 230.B /Manuals/Downloads/bp102c15.pdf Long-Term Care Facility Resident Assessment Instrument 3.0 Users Manual, Version 1.13, October 2015, Section O Assessment-Instruments/NursingHomeQualityInits/Downlo ads/mds-30-rai-manual-v113.pdf 32 References Medicare Billing Centers for Medicare and Medicaid Services, Therapy Services, 11 Part B Billing Scenarios for PT and OT (Individual vs Group Treatment) Services/billing_scenarios.html 33

12 Reference - Billing American Medical Association, CPT 2017 Professional Edition, Introduction, Time, Page XV American Medical Association, CPT Assistant December 1999, Medicine Therapeutic Procedures, page References CMS Transmittal 179 (Maintenance Coverage) ce/guidance/transmittals/downloads/r179b P.pdf MLN Matters SE1311 (Medicare Opt Out) n/medicare-learning-network-mln/mlnmatt ersarticles/downloads/se1311.pdf 35 References ABN Form and Instructions -Information/BNI/ABN.html CMS Pub , Chapter 30, Financial Liability Protections Guidance/Manuals/Downloads/clm104c30.pdf CMS ABN FAQ s rvices/downloads/abn-noncoverage-faq.pdf 36

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