DOCUMENTATION AND CODING

Transcription

1 DOCUMENTATION AND CODING DRAYER PHYSICAL THERAPY INSTITUTE Leading the Way to Good Health

2 DPTI EXPECTATIONS FOR CORRECT CLINICAL CODING Each clinician is responsible to code in a legal and ethical manner for all services provided. Each clinician must take the initiative to increase his/her awareness of applicable coding rules and regulations. Documentation must include an assessment as to why PT, OT, or SLP services are medically necessary. Documentation must support the services charged. The clinician must know each payer s expectations in terms of coding.

3 OBJECTIVES OF CLINICAL CODING TRAINING Instruct our providers to code in a legal and ethical manner in compliance with local, state, and federal guidelines. Instruct each provider in the definition of the CPT codes applicable in our profession. Educate our team of providers in the correct use of CPT codes. Educate our providers in the correct use of modifiers. Educate providers in correct medical record documentation in compliance with local, state, and federal guidelines. Accurately code in patient scenarios with regard to AMA and CMS guidelines.

4 CPT CODES Current Procedural Terminology. Developed and defined by the American Medical Association (AMA). Intended to provide a uniform method of reporting and billing for services. AMA CPT Coding Manual provided for each facility

5 AMA GUIDELINES FOR CORRECT CLINICAL CODING Select the appropriate 5 digit CPT code based upon its definition. Add a modifier when appropriate. Be specific! Be consistent! Total time must support the units billed. Documentation must support the codes selected.

6 CLINICAL CODING TERMINOLOGY Encounter: One episode of treatment. Direct Contact: Visual, verbal, and/or manual contact between the patient and the provider. Provider: The therapist, assistant, or other support personnel as defined by state regulations and the payer. Time Based Codes: Charged in increments based on the time spent providing the service. Include a unit of time assigned to them, such as each 15 minutes. Include pre-, intra-, and postservice time. Medicare only considers intra-service time as billable time Service Based Codes: Intended for use only once during an encounter regardless of the time spent delivering the service or the number of areas treated.

7 TIME BASED CODES Pre-service Time: Includes the following examples on the same date of service as the encounter: Chart reviews for treatment. Set-up of activities. Set-up of equipment and area to be used. Review of previous documentation. Communication with other healthcare professionals. Calls to referring physicians. Discussions with family members.

8 TIME BASED CODES Intra-service Time: Includes the following: Direct contact (visual, verbal, and/or manual) delivery of the treatment. Status check of patient s symptoms. Assessment of patient s response to treatment. Post-service Time: Includes the following examples on the same date of service as the encounter: Discharge patient from treatment. Documentation of treatment. Write up of report if necessary. Communication with physician to report progress. Communication with other team members.

9 TIME BASED CODES Time Based Procedures performed concurrently can not be billed as if they were performed consecutively. For example, Combo (E-Stim., Attended and US) can only be coded as E-Stim., Attended OR Ultrasound, NOT BOTH.

10 PHYSICAL MEDICINE AND REHABILIATION (CPT CODES ) These are the codes most commonly used by PT and OT. PT and OT not restricted to the use of codes in this section. Consist of the following headings: Evaluation and Re-evaluation Modalities Supervised Constant Attendance Therapeutic Procedures Active Wound Management Test and Measurements Orthotic Management and Prosthetic Management

11 EVALUATION AND RE-EVALUATION (CPT CODES ) These codes result in the formulation of a treatment plan. SERVICE BASED procedural codes. No other test and measurement codes should be used on the same day as an Evaluation code (i.e., ROM, MMT, Physical Performance Testing). Re-Evaluations must be performed a minimum of once every 30 days to meet Medicare, State, and DPTI guidelines. Documentation time is considered to be a part of these codes and should never be charged separately.

12 EVALUATION AND RE-EVALUATION (CPT CODES ) Physical Therapy Evaluation Physical Therapy Re-Evaluation Occupational Therapy Evaluation Occupational Therapy Re- Evaluation

13 MODALITIES SUPERVISED (CPT CODES ) Defined as any group of agents that may include thermal, acoustic, radiant, mechanical, or electrical energy to produce physiologic changes in tissue for therapeutic purposes. These codes do NOT require direct (one-on-one) patient contact by the provider once the patient is set-up. SERVICE BASED procedural codes. Can only be charged once per encounter regardless of the number of areas treated or the number of times used.

14 MODALITIES SUPERVISED (CPT CODES ) Hot or cold packs Traction, mechanical Electrical stimulation, unattended Vasopneumatic devices Paraffin bath Whirlpool Infrared (i.e., Anodyne, Revitamed) Unlisted Modality (i.e., near-infrared diode) Biofeedback Biofeedback Pelvic Floor

15 97014 ELECTRICAL STIMULATION, UNATTENDED Some payers recognize the code G0283 to denote Electrical Stimulation, unattended. Medicare only recognizes the G0283 code for Electrical Stimulation, unattended. Many payers will reimburse for a separate electrode charge A4556 Electrodes, per pair. Some payers include electrodes in the code and will not reimburse for a separate charge (i.e., Medicare). Medicare will reimburse for Electrical Stimulation, unattended for the treatment of wounds for only stage III and IV chronic ulcers under the G0281 code.

16 97022 WHIRLPOOL This code is accepted by all payers, including Medicare, as the appropriate CPT code to choose when providing fluidotherapy.

17 97026 INFRARED AND NEAR-INFRARED The use of infrared and/or near-infrared light and/or heat is non-covered by MEDICARE (and some other payers) for the treatment, including symptoms such as pain arising from these conditions, diabetic and/or nondiabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissue

18 BIOFEEDBACK Biofeedback training by any modality SERVICE BASED CODE. Medicare will cover BFB services only if reasonable and necessary for re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments have failed. It is not covered for ordinary muscle tension or psychosomatic conditions Biofeedback Pelvic Floor SERVICE BASED CODE. BFB is only covered with urge incontinence when patient has failed a documented trial of pelvic muscle exercise training.

19 MODALITIES CONSTANT ATTENDANCE (CPT CODES ) These codes do require direct (one-on-one) contact by the provider. These codes can be reported once for each 15 minute time period spent providing the service. Defined by each 15 minutes. When two constant attendance modalities are applied simultaneously, only one procedure should be charged as each is a timed service and the concurrent time you are providing time based services can only be charged once.

20 MODALITIES CONSTANT ATTENDANCE (CPT CODES ) Electrical stimulation, Attended A4556 Electrodes, per pair, are not included in this code and may be charged separately; reimbursement will be dependent upon the payer Iontophoresis A4556 Electrodes, per pair, are not included in this code and may be charged separately; reimbursement will be dependent upon the payer Contrast baths Ultrasound Unlisted modality (i.e., nearinfrared hand-held)

21 THERAPEUTIC PROCEDURES (CPT CODES ) Defined as a manner of affecting change through the application of clinical skills and/or services that attempt to improve function. Require direct (one-on-one) contact by the provider. Time based procedural codes. Time coded should include any pre-, intra-, and postservice time that occurs on the same date as the encounter. Time units are designated by each 15 minutes.

22 THERAPEUTIC PROCEDURES (CPT CODES ) Therapeutic procedures Describes services aimed at improving a single parameter, such as ROM and strength Neuromuscular re-education Describes services aimed at improving movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Aquatic therapy Gait training Requires skilled services, not routine, repetitive ambulation. Must include specific gait deviations antalgic gait alone does not support the need for skilled gait training Massage

23 THERAPEUTIC PROCEDURES (CPT CODES ) Manual therapy techniques Joint mobilization Manipulation Myofascial release Manual traction Passive range of motion can be included in this code per AMA and CMS guidelines. Hands on Therapy

24 THERAPEUTIC PROCEDURES (CPT CODES ) Therapeutic Activities Focus is functional outcome vs. exercise Activities that use multiple parameters (i.e. strength, ROM, balance, etc.) and that focus on achieving a functional activity

25 THERAPEUTIC PROCEDURES (CPT CODES ) Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training) The provider instructs and trains the patient in a variety of tasks, in a manner that facilitates the development of cognitive reasoning. Allows individuals with impairments related to TBI, CVA, and psychiatric disorders to live independently and function safely in their environment Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands Often associated with a pediatric population. Activities focus on enhancing sensory processing input and promote adaptive responses to environmental demands of one or more of the sensory systems (i.e., vestibular, proprioceptive, tactile, visual, or auditory). Used with treatment for autism, over-reactivity to stimuli, ADD, CP, and motor apraxia.

26 THERAPEUTIC PROCEDURES (CPT CODES ) Self care/home management NOT the universal home exercise program code. Intended for training in life skills and assistive devices for ADL s Community/Work reintegration training Examples include shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment. Use this code for work site evaluations. The provider instructs and trains the patient in community reintegration activities Wheelchair management/propulsion training The provider provides assessment, instruction and training in proper wheelchair skills (i.e., propulsion and safety techniques) in their home, facility, work, or community environment.

27 THERAPEUTIC PROCEDURES (CPT CODES ) Work Hardening/conditioning; initial 2 hours each additional hour Program where the injured worker is put through a series of conditioning exercises and job simulation tasks in preparation for return to work. Endurance, strength, and proper body mechanics are emphasized. The patient is educated in problem solving skills related to job task performance and employing correct lifting and positioning techniques. Report for each additional hour after the initial two hours.

28 THERAPEUTIC PROCEDURES (CPT CODES ) Group Therapy SERVICE BASED CODE. Involves constant attendance but does not require one-onone direct care by the provider. The traditionally accepted clinical definition of this code is two or more individuals performing the same therapeutic procedure at the same time. Individuals are considered to have the same treatment plan. Examples include lumbar stabilization class, aquatic arthritis class. Medicare (CMS) has further defined this code with regard to their client base (See Group Therapy Medicare Section).

29 TEST AND MEASUREMENTS (CPT CODES 97750) Physical Performance test or measurement, with written report Time Based CPT Code that is designated in increments of each 15 minutes Includes Functional Capacity Exams. Should not be charged on the same day as an Initial Evaluation or a Re-Evaluation. Does NOT result in the formation of a treatment plan. Should not be coded if insurance provider does not recognize Re-Evaluation.

30 ACTIVE WOUND CARE MANAGEMENT (CPT CODES ) Selective Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudates, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 square centimeters or less Selective Debridement, each additional 20 square centimeters; The CPT code cannot be billed without also billing the CPT code Non-selective debridement, without anesthesia (e.g. wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instructions for ongoing care, per session Dressing changes are considered to be a bundled service with Medicare and should not be charged separately. Codes and include the term may include use of a whirlpool ; therefore, it is not appropriate to code separately for Whirlpool when performing Selective Wound Debridement as outlined in codes and

31 ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT (CPT CODES ) Orthotic(s) management and training, upper extremity(ies), lower extremity(ies), and/or trunk Orthotics are used to provide mobility with support. This code identifies the fitting and training required to properly use the device. Can be a custom made or prefabricated device.

32 ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT (CPT CODES ) Orthotic(s) Management and Training Gait training is considered to be a fundamental component and should not be coded separately. Any time spent performing gait training should be included in the time spent fitting and training the device. Exception: If an orthotic is fitted for the UE and gait training is performed for the LE, both can be coded separately using the 59 modifier.

33 ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT (CPT CODES ) Orthotic(s) management and training Fabrication is not recognized as a distinct service. If the orthotic is fabricated at the time of the fitting while the patient is in the clinic, the fabrication time may be included as part of the fitting and training time when coding. If the provider bills for the HCPCS Level II code (i.e., L Code), fabrication time is considered to be a component of the L Code billed and is NOT separately billable. If the orthotic is fabricated while the patient is not present, or the orthotic is made off-site, the fabrication time is considered to be a provision of materials/supplies and should NOT be charged separately or incorporated into the fitting and training time.

34 ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT (CPT CODES ) Prosthetic training, upper and/or lower extremity(ies) Checkout for orthotic and/or prosthetic use, established patient The provider evaluates the effectiveness of an existing device and makes recommendations for change, prn. This code does not include provision of materials; therefore supplies should be coded with an appropriate HCPCS Level II code or with the code.

35 OTHER SERVICES Application of a TENS unit SERVICE BASED CODE. Used for the set-up of a home TENS unit. Is not intended to be coded with in-clinic treatment (instead, code E Stim, unattended if the patient receives supervised treatment while in the clinic). This code does not include evaluation; therefore, if you are evaluating a patient for the first time to issue a home TENS unit, a separate evaluation charge or should be coded.

36 OTHER SERVICES Canalith Repositioning Procedure (s) (eg) Epley Maneuver, Semont Maneuver), per day - This CPT code had previously been deactivated and therapists had been instructed to use the CPT code when performing the Epley or Semont maneuvers. Effective January 1, 2011 the code has been reactivated and therapists are expected to use this CPT code when performing the Epley or Semont maneuvers. -This is a service based code and can only be billed once per treatment encounter.

37 OTHER SERVICES A4556 Electrodes, per pair The reimbursement for electrodes is payer specific. This code is defined per pair. Therefore, when dispensing electrodes, if a patient receives 4 electrodes, as with interferential electrical stimulation, it is appropriate to code A4556 X 2.

38 CLINICAL CPT CODING EXAMPLES DRAYER PHYSICAL THERAPY INSTITUTE Leading the Way to Good Health

39 MODIFIERS DRAYER PHYSICAL THERAPY INSTITUTE Leading the Way to Good Health

40 MODIFIERS Definition: A modifier provides the means by which the provider can indicate that a service or procedure that has been performed has been altered by some specific circumstance, but not changed in its definition or code.

41 MODIFIER CODING IT IS THE RESPONSIBILITY OF THE CLINICIAN TO INCLUDE THE MODIFIER WHEN CODING. IT IS NEVER APPROPRIATE FOR THE BILLING OFFICE TO ADD A MODIFIER WHEN ENTERING CHARGES IF THE THERAPIST HAS NOT INDICATED THE MODIFIER ON THE ENCOUNTER FORM. Expectations for modifier coding is payer specific. Failure to include the appropriate modifier when required will result in denial of payment for services.

42 WHEN DO I USE A MODIFIER? To indicate that a service/procedure has both a technical and professional component. To indicate a service was increased or reduced. To indicate only part of a service was performed. To indicate unusual events occurred. To designate a service as a distinct procedural service. To indicate a service was provided bilaterally.

43 59 MODIFIER Definition: Used to designate that two services normally not performed together were provided in two distinctly separate periods of time. Different sessions Different patient encounter Different procedure or surgery Different anatomical site Separate injury Please refer to the attached table for appropriate use of the 59 modifier.

44 52 MODIFIER Used to indicate reduced services when the normal course of treatment is shortened. Should be used infrequently. Used when extenuating circumstances occur or when the well-being of the patient is threatened.

45 LT AND RT MODIFIERS Used to indicate that the clinician is treating bilateral body parts. Allows the clinician to denote which services/procedures were provided to each right or left body part.

46 GO, GP, AND GN MODIFIERS This is the only instance when coding a modifier becomes the function of the business office vs. the clinician. Used to delineate which services are allocated to physical, occupational, or speech therapy for Medicare providers. Initially implemented to track services for the therapy cap.

47 MEDICARE CODING STRATEGIES DRAYER PHYSICAL THERAPY INSTITUTE Leading the Way to Good Health

48 OBJECTIVES Code in a legal and ethical manner in compliance with state and federal guidelines for federally funded programs. CMS s interpretation of the Group Therapy code Correct application of the 8 minute rule. Appropriate use of the 59 modifier. Correct medical record documentation to support coding. Illustrate correct coding with examples.

49 CODING FOR FEDERALLY FUNDED PROGRAMS What are the federally funded programs? Medicare Medicaid Champus/Tricare Medicare Advantage In this presentation, Medicare refers to any federally funded program or insurance carrier who follows CMS guidelines with coding.

50 WHICH SERVICES ARE CONSIDERED TO BE NONSKILLED AND NONBILLABLE BY MEDICARE? Treatment that does not require the skilled care of the qualified therapist or assistant under the supervision of the qualified therapist. Groups directed or assisted by a student, therapy aide, ATC. Treatment as part of a maintenance program although recent legislation may change this. Treatment without any direct intervention by the therapist. Continued treatment after the patient has met treatment goals. Wait/Rest time.

51 CMS TRANSMITTAL AB The policy was originally released in Program Memorandum Transmittal AB Has come to be known as the 8 minute rule. Provides guidance when coding for TIME BASED PROCEDURAL CODES. This is CMS s interpretation of the 15 minute unit for physical medicine modalities and procedures.

52 SUMMARY OF THE 8 MINUTE RULE Units of service less than 8 minutes are not SEPARATELY billable. The total number of time based units billed is constrained by the total time spent performing time based procedures. Treatment time is defined as intra-service time. The time spent providing a time based procedure/modality that is less than 8 minutes can be added to the time spent performing other time based procedures to calculate total time based treatment time. When choosing the appropriate codes, the therapist should assign more units to the service that took the most time. When treatment time for services are equal, it is up to the discretion of the therapist to charge for the service that he/she feels was more beneficial for the patient s plan of care.

53 BILLABLE UNITS/TOTAL TIME BASED MINUTES 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 Service based procedures are billed separately. Service based and non-billable time is subtracted from total treatment time to arrive at total time based minutes.

54 DRAYER POLICY REGARDING DOCUMENTATION OF TREATMENT TIME Document time in and time out of the treatment session. Document time spent providing each service based procedure on the flow sheet. Subtract the total service based and/or nonbillable time from the total treatment time to determine the total time spent providing time based procedures. Assign units based on the 8 minute rule. Always perform a careful self-review of your coding.

55 CMS INTERPRETATION OF GROUP THERAPY CMS has implemented its own interpretation of the group therapy code. These guidelines only apply to those individuals insured by federally funded programs. CMS has chosen to apply this policy when CPT TIME BASED PROCEDURES are delivered.

56 CMS GUIDELINES WHEN USING THE GROUP THERAPY CODE Patients may be performing the same exercises OR individualized exercise programs. If a Medicare patient is treated with a service based procedure, the one-on-one requirement does not apply when another Medicare patient is receiving a time based procedure. You can bill the service based procedure and the time based procedure for each patient, respectively. CMS recognizes only those services performed by qualified licensed providers (PT/PTA, OT/OTA).

57 MEDICARE REQUIREMENT FOR PTA/OTA SUPERVISION Medicare requires that a qualified PT or OT must provide direct on-site supervision of a PTA or OTA in an outpatient environment. Direct supervision is defined as the physical presence of the PT or OT on the premises where the PTA or OTA is providing the patient-care services, so that the therapist is immediately available to provide supervision, direction, and control. In states where the level of PTA/OTA supervision is less stringent than CMS, CMS s requirement will supersede the State Practice Act when Medicare patients are treated.

58 MEDICARE POLICY REGARDING THERAPY TECHNICIANS CMS has stated that the services provided by a therapy technician are considered unskilled services- no matter the level of supervision provided by the qualified therapist or therapy assistant under the supervision of the qualified therapist.

59 MEDICARE POSITION REGARDING STUDENTS No services individually provided by a student are reimbursable by Medicare, even those performed under the line of sight of the qualified therapist. For services to be recognized by Medicare, the qualified therapist must be in the room, directing the services performed by the student and making the skilled decisions regarding care.

60 DRAYER PHYSICAL THERAPY INSTITUTE POLICY REGARDING STUDENTS AND MEDICARE It is the policy of Drayer Physical Therapy Institute that no physical, speech, or occupational therapy or assistant student will participate in the care of a Medicare or federally funded beneficiary in any other role than that of an observer.

61 CMS GUIDELINES WHEN USING THE GROUP THERAPY CODE Group therapy is a SERVICE BASED procedural code and can only be coded once per encounter, no matter the length of time spent in the group setting. Because the Group Code is service based, it has no time requirement.

62 CMS REQUIREMENT OF THE 59 MODIFIER WHEN CODING GROUP THERAPY If the therapist uses the Group Therapy code and one-on-one TIME BASED procedures on the same date of service, he/she must also select the 59 modifier on the encounter form. The 59 modifier should be checked by the therapist in the space provided next to each time based procedure that is provided on the same date of service as the Group Therapy code.

63 DRAYER DESIRES TO PROVIDE ONE- ON-ONE CARE FOR MEDICARE PATIENTS BY: Adequate staffing of qualified licensed caregivers at each clinic (PT/PTA, OT/OTA, SLP). Appropriate scheduling of Medicare patients. Managing patient care to avoid group scenarios. Appropriate use of ancillary staff to provide care (i.e. PT techs, ATC, and students may not participate in the care of any Medicare patient per Drayer Physical Therapy policy).

64 DRAYER PHYSICAL THERAPY INSTITUTE POLICY REGARDING THE GROUP THERAPY CODE Whenever staffing and scheduling does not permit one-on-one care, the Group Therapy code MUST BE CODED by the qualified provider to remain in compliance with CMS guidelines.

65 MEDICAL RECORDS DOCUMENTATION DRAYER PHYSICAL THERAPY INSTITUTE Leading the Way to Good Health

66 OBJECTIVES Provide background information regarding the Office of the Inspector General s office. Identify areas of interest when the OIG audits False Claims. Identify Medicare documentation requirements. Identify DPTI documentation requirements. Introduce the DPTI approved documentation forms. Discuss the DPTI Chart Audit process.

67 OFFICE OF THE INSPECTOR GENERAL Established by the Dept. of Health and Human Services by Congress in Objective is to identify and eliminate fraud, waste, and abuse in the Dept s programs and promote efficiency and economy in department operations. Issues Special Fraud Alerts that identify segments of the healthcare industry that are particularly vulnerable to abuse.

68 OIG FRAUD AND ABUSE WORK PLAN The annual Work Plan identifies OIG s concerns and audit focus areas for the upcoming year. Typically, issues raised on the Work Plan appear in False Claims Act cases and fraud enforcement about 2 to 3 years after they appear in the Work Plan. Physical and Occupational Therapy services have appeared on the OIG Fraud and Abuse Work Plan as an area of audit focus.

69 REASONABLE AND NECESSARY CRITERIA The services provided are of such a level of complexity and sophistication, or the patient s condition must be such, that the services required can be safely and effectively performed only by a qualified therapist or an assistant under his direct supervision (in the Out Patient therapy setting). The services must relate directly and specifically to an active written treatment plan and be reasonable and necessary to the treatment of the individual s illness or injury. Services must be: Accepted standards of medical practice. Specific, safe, and effective treatment for the dx. Reasonable amount, frequency (i.e., 3x/wk), and duration. Expectation exists that the condition will significantly improve in a reasonable amount of time. Services must relate directly to the treatment goals.

70 REASONABLE AND NECESSARY: DOCUMENTATION REQUIREMENTS Documentation submitted to the insurance providers must: Reflect the CPT and level II HCPCS codes and units billed. Demonstrate significant gains. Justify the frequency and duration of therapy is reasonable and necessary. Substantiate the actual treatment time.

71 THREE MAJOR AREAS OF OIG INTEREST WHEN ASSESSING FRAUD Services are reasonable and medically necessary. Services are authorized by a physician. Services are supported by medical record documentation.

72 RESULTS OF OIG FRAUD CASES: REASONABLE AND NECESSARY Services have been deemed not reasonable and necessary for the patient s injury or illness for the following reasons: The patient s medical condition did not require the skilled services of a therapist (i.e., services were provided by nonlicensed personnel on some occasions; therefore all services denied). Patients had no potential for improvement. The patients did not have a loss of function or functional limitations documented. Chance of making improvement in a reasonable timeframe was not possible.

73 OIG FRAUD CASES: REASONABLE AND NECESSARY CRITERIA (CON T) No specific medical history or specific episode requiring outpatient therapy services. Treatment plans not individualized nor were goals measured. Therapy continued after goals were met. Documented that patient questioned need for therapy, but therapy continued for 2 months. Patient s medical record indicated that OT services were a duplication of PT services; therefore, OT services questioned.

74 OIG FRAUD CASES: REASONABLE AND NECESSARY CRITERIA Documentation did not demonstrate that the therapy provided was an effective treatment for the patient s dx. Patient was provided non-skilled repetitive exercises (no exercise progression).

75 OIG FRAUD CASES: INADEQUATE DOCUMENTATION FINDINGS Medical records did not document that billed services were provided (i.e., flow sheets left blank). When medical records are incomplete, no payment can be made for services. No evaluations or POC outlined. No physician authorization or supervision of services (i.e., signature). No legible identifier or physician certifying plan of care or of the therapy provider.

76 OIG FRAUD CASES: INADEQUATE DOCUMENTATION FINDINGS No documentation of patient s prior level of function. Documentation supported the provision of one service but another billed (i.e., PT IE/POC but OT services billed). Medical records did not support the patient s potential benefit from therapy. Documentation failed to establish the relationship of therapy to treatment goals.

77 OIG FRAUD CASES: PHYSICIAN AUTHORIZATION DEFICIENCIES Physician never signed the initial and/or updated POC. No legible identifier. Certifications not signed by MD in a reasonable amount of time. Services claimed were not included in the POC. Physician orders were not followed. Therapy services continued after physician authorization expired. Treatment plan authorization dates were altered.

78 MEDICARE DOCUMENTATION REQUIREMENTS Initial Evaluation/POC: Patient name Onset date SOC (Start of Care) date: will be the IE date Primary Dx Treatment Dx (if differs from the Primary Dx) Plan of Treatment/Functional Goals Includes major long term goals to reach overall long term outcome. Include major plan of treatment to reach stated goals and outcome. Estimate Time Frames to reach goals when possible. Amount, type, frequency, and duration of POC.

79 MEDICARE INITIAL EVALUATION and PLAN OF CARE DOCUMENTATION REQUIREMENTS Signature: Must include professional designation of the therapist establishing the POC. Type/Amount/Frequency/Duration of POC Physician s Signature and Date: Must be obtained in a reasonable amount of time. Prior Hospitalization / PMHx Rehab Potential

80 MEDICARE INITIAL EVALUATION and PLAN OF CARE DOCUMENTATION REQUIREMENTS Initial Assessment: Current relevant history from patient interview/records. Major functional limitations. Objective baseline tests and measurements from which to judge future progress or lack of progress. Service Dates: From and Through dates which represent this billing period. Should be monthly.

81 MEDICARE PROGRESS REPORT DOCUMENTATION REQUIREMENTS Updated POC/Progress Report Requirements: Patient s name Onset date SOC date Primary and/or Treatment Diagnosis Visits from SOC (i.e., total number of visits seen) Current Type/Amount/Frequency/Duration of POC

82 MEDICARE PROGRESS REPORT DOCUMENTATION REQUIREMENTS Current Plan Update, Objective/Functional Goals Document interim goals to reach overall long term outcome. Justify intensity (i.e., number of visits per day or week) if appropriate. Estimate time-frames to meet goals. Functional Level: Enter pertinent progress made through the end of this recertification cycle. Use objective terminology. Date progress when function can be consistently performed or when meaningful functional improvement is made. Document regression in function if appropriate.

83 MEDICARE PROGRESS REPORT DOCUMENTATION REQUIREMENTS Recertification: Enter the inclusive dates when recertification is required (From and Through Service dates). Physician Signature and Date: Must be obtained every 30 days to prove that POC has been reviewed at least once every 30 days. Reason(s) for Continuing Treatment: Briefly state the patient s need for specific functional improvement, skilled training, reduction in complication or improvement in safety, and how long you believe this will take. Also include reason for recommending discontinuance if applicable. Provider Signature and Date: Must include professional designation.

84 MEDICARE CERTIFICATION/RE-CERTIFICATION REQUIREMENTS Written POC must be established prior to treatment being delivered by the PT/OT. The POC must indicate: Diagnosis Goals Specific modalities/procedures Expected amount, frequency, and duration of services.

85 MEDICAL RECORDS DOCUMENTATION Daily Notes General Guidelines: Be specific and consistent. Documentation in general or subjective terms is insufficient. Documentation for each date of service must be complete or denials due to No Proof of Services Rendered may occur. Documentation must support the need for skilled services by qualified personnel. Documentation must correlate with the therapy POC, treatment time, and CPT/HCPCS codes billed. Documentation must support that the services delivered are reasonable and necessary. Documentation must indicate functional improvements to justify continuation of care.

86 REASONABLE AND NECESSARY CRITERIA The services must require the skills of a qualified provider. The services must relate directly and specifically to an active written treatment plan. Services must be: Accepted standards of medical practice Specific, safe, and effective treatment for the dx. Reasonable amount, frequency, and duration. Expectation exists that the condition will significantly improve in a reasonable amount of time.

87 DPTI DOCUMENTATION GUIDELINES Subjective Reports/PMHX Forms should be given to the patient at check in for the IE. Patient responses should be reviewed with the PT. Medicare only: PQRS, Functional G Codes, and the ICD 9 Forms must be completed by the end of the business day on the date of the Initial Evaluation so that charges may be entered appropriately and timely. Initial Evaluations must be completed by the PT/OT/ST within 24 hours of the IE. The Initial Evaluation must be sent to the referring MD within 48 hours of the IE so that it is received within 72 hours. The POC must be completed by the PT/OT/SLP on the date of the IE. Completed POC must be sent to the referring MD within 48 hours of the IE so that it is received within 72 hours.

88 DPTI DOCUMENTATION GUIDELINES Progress Reports to the MD must be completed on the same date of the Re-Eval. by the PT/OT/ST. Completed Progress Reports must be sent to the MD within 24 hours or in time for the NDV.

89 RE-EVALUATION Medicare considers a Re-evaluation to be separately payable and periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in patient s condition or functional status that was not anticipated in the plan of care. The decision to provide a Re-evaluation shall be made by the clinician.

90 DPTI DOCUMENTATION GUIDELINES Flow sheets must be completed by the attending caregiver by the end of each business day. All Flow sheets must be complete and include treatment parameters and the initials and signature of the attending caregiver. CHECKMARKS ARE UNACCEPTABLE WHEN DOCUMENTING TREATMENT ON THE FLOW SHEET.

91 DPTI DOCUMENTATION GUIDELINES Encounter Forms including the SOAP note and appropriate charges must be completed by the therapist and returned to the Business Office by the end of each business day. Contact Forms including a summary of the interaction must be completed on the date of occurrence. Discharge Summaries must be completed within ONE week of patient discharge.

92 DPTI DOCUMENTATION GUIDELINES On the date of D/C, the therapist must clearly indicate D/C on the upper right corner of the Encounter Form. The billing staff will then change the patient status from active to inactive in the Raintree system by entering a 2 as the patient status. This process ensures that the patients listed on the Patient Not Scheduled Report are only the active, not inactive, patients.

93 DPTI CHART DOCUMENTATION Subjective Report/PMHX Form PQRS/Functional G Code/ICD 9 Form - Medicare Initial Evaluation Plan of Care Progress Report/Re-evaluation Flow Sheet Encounter Form Contact Form Discharge Summary Treatment Plans (payer specific)

94 CONCLUSION: WHAT ARE WE REALLY LOOKING FOR? Documentation that consistently meets our high internal standards and that will withstand any outside scrutiny.