February 2013 Jean C. Russell, MS, RHIT jrussell@epochhealth.com Richard Cooley, BA, CCS rcooley@epochhealth.com 518-430-1144 2 Payment Basics Agenda 2013 PT / OT / SP Codes Deleted Codes New Codes Significant Changes Therapy Cap Claims-based data collection for therapy services Modifiers 3 Claim Submission Medicare Claim Requirements Value Codes: Providers billing on Form CMS-1450 (UB92) should report Value Codes as appropriate in Field Locators 39-41. This value is used to document the cumulative total visits completed since services were started through the billing period. The appropriate value codes are as follows: 50: for physical therapy visits 51: for occupational therapy visits 52: for speech therapy visits 1
4 Claim Submission Medicare Claim Requirements Occurance Codes: Occurrence codes associate a date defining a significant event relating to the bill that may affect processing. Occurrence codes are reported in Field Locators 32-35 on Form CMS-1450 (UB92). 5 Occurrence Codes 11: The date the patient first became aware of symptoms or illness. When submitting outpatient claims for physical, occupational, or speech therapy, this code must be used to indicate the date of onset of symptoms of the primary medical diagnosis or most recent exacerbation. 17: The date an occupational therapy plan was established or last reviewed. 29: The date a physical therapy plan was established or last reviewed. 6 Occurrence Codes 30: The date a speech pathology plan was established or last reviewed. 35: The date services began at the billing provider for physical therapy. This date will remain the same on subsequent claims until discharge. 44: The date services began at the billing provider for occupational therapy. This date will remain the same on subsequent claims until discharge. 45: The date services began at the billing provider for speech therapy. This date will remain the same on subsequent claims until discharge. 2
Occurrence Codes Physical Therapy Occupational Therapy Occurrence Code: 11 (code/date) Onset of symptoms/illness. Enter the date the patient first became aware of symptoms/illness. Occurrence Code: 11 (code/date) Onset of symptoms/illness. Enter the date the patient first became aware of symptoms/illness. Occurrence Code: 29 (code/date) Date outpatient physical therapy plan established or last reviewed. (CR 3647) Occurrence Code: 35 (code/date) Date physical therapy started Occurrence Code: 17 (code/date) Date occupational therapy plan established or last reviewed. (CR 3647) Occurrence Code: 44 (code/date) Date occupational therapy started Value Code: 50 (code/units) Value Code: 51 (code/units) Enter this code to report outpatient physical therapy visits from the date of onset through this billing period. This value is CUMMULATIVE from claim to claim. Enter this code to report outpatient occupational therapy visits from the date of onset through this billing period. This value is CUMMULATIVE from claim to claim. 7 8 Medicare Payment Majority of codes are paid off the Physician Fee Schedule Some APC Services Majority of codes are timed codes Services must be performed under a plan of care New to hospitals Payment Caps Outcome reporting 9 Medicaid Payment Either paid under APGs or off Fee Schedule depending if facility has a clinic rate APG reimbursement higher than Fee schedule reinbursment 3
10 Medicaid Payment Units impact reimbursement for many therapy procedures Discounted, not consolidated E/M will not be packaged when reported with the therapies that is, both will be paid 11 Medicaid Payment Each visit should be separately reported Do not bill recurring therapies on different dates of service on separate claims Beginning July 1, 2010, therapies performed in hospital outpatient departments (even those that are referred amb) will be reimbursed under APGs Translation Bill the therapies with a rate code (e.g., 1432) 12 NONE Deleted Codes 4
13 New Codes CPT/HCPCS Description CPT/HCPCS Description G0456 Neg pre wound <50 sq cm G8998 Swallow D/C status G0457 Neg pres wound >50 sq cm G8999 Motor speech current status G8978 Mobility current status G9158 Motor speech D/C status G8979 Mobility goal status G9159 Lang comp current status G8980 Mobility D/C status G9160 Lang comp goal status G8981 Body pos current status G9161 Lang comp D/C status G8982 Body pos goal status G9162 Lang express current status G8983 Body pos D/C status G9163 Lang express goal status G8984 Carry current status G9164 Lang express D/C status G8985 Carry goal status G9165 Atten current status G8986 Carry D/C status G9166 Atten goal status G8987 Self care current status G9167 Atten D/C status G8988 Self care goal status G9168 Memory current status G8989 Self care D/C status G9169 Memory goal status G8990 Other PT/OT current status G9170 Memory D/C status G8991 Other PT/OT goal status G9171 Voice current status G8992 Other PT/OT D/C status G9172 Voice goal status G8993 Sub PT/OT current status G9173 Voice D/C status G8994 Sub PT/OT goal status G9174 Speech lang current status G8995 Sub PT/OT D/C status G9175 Speech lang goal status G8996 Swallow current status G9176 Speech lang D/C status G8997 Swallow goal status G9186 Motor speech goal status 14 Therapy Cap In 2013, the annual per beneficiary therapy cap amounts are: $1,900 for physical therapy and speech language pathology services combined There is a separate $1,900 amount allotted for occupational therapy services. 15 Therapy Cap In 2013, the therapy caps with an exceptions process applies to services furnished in the following outpatient therapy settings: Physical, Occupational and Speech Therapists in private practice, physician offices, skilled nursing facilities (Part B), rehabilitation agencies (or ORFs), and comprehensive outpatient rehabilitation facilities (CORFs), and outpatient hospital departments. Legislation included outpatient hospitals under the cap for calendar years 2012 and 2013. It is essentially being tested in this setting Will continue in 2014 and beyond only if Congress passes legislation continuing the application to this setting. 5
16 Therapy Cap Exception Exceptions applicable for therapy services in excess of the cap amount delivered any time during the 2013 calendar year. The 2 exceptions processes are: An automatic exception process A manual medical review exception process Applies to patients who meet or exceed $3,700 in therapy expenditures for PT/SLP combined and A separate $3,700 in occupational therapy expenditures. 17 Automatic Exceptions May be made when the patient's condition is justified by documentation that indicates the beneficiary requires continued skilled therapy to achieve their prior functional status or maximum expected functional status within a reasonable amount of time. Can be used for any diagnosis for which they can justify services exceeding the cap. 18 Automatic Exceptions The automatic exception can be used for claims that are between $1,900 and $3,700 Claims exceeding $3,700 will be subject to manual medical review in order to be paid 6
19 Submitting a Request for an Automatic Exception When the beneficiary qualifies for a therapy cap exception, the provider should apply the KX modifier to the therapy procedure code subject to the cap limits Codes subject to the therapy cap tracking requirements are listed in a table in the Medicare Claims Processing Manual, Chapter 5, Section 20(B) 20 Using the KX Modifier The KX modifier attests that the services billed: Qualified for the cap exception; Are reasonable and necessary services that require the skills of a therapist; and Are justified by appropriate documentation in the medical record. It should not be routinely applied 21 Additional Documentation Providers do not need to submit additional documentation for automatic exceptions Documentation justifying the services are necessary in response to any Additional Documentation Request (ADR) for claims that are selected for medical review. 7
22 Manual Medical Review Claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to a manual medical review. Criteria for medical review is based on current medical review standards. Medicare Administrative Contractors (MAC) have 10 business days to make decisions regarding whether services will be approved over the $3,700 threshold 23 Manual Medical Review If a decision is not made by the MAC within 10 business days, the MAC should notify the provider that they did not review the request and that claims beyond the $3,700 threshold will be approved. Advanced approval will allow an additional 20 treatment days beyond the $3,700 amount. Does not guarantee payment. May still be reviewed retrospectively When more than 20 days are required the provider must submit an additional request for more service. 24 Manual Medical Review Advanced approval should be requested before providing the service. When a provider did not request advanced approval prior to providing services over $3,700 Payment for the claims will stop Request for medical records will be sent to the provider Provider will be subject to prepayment review for those claims (approximately 60 day review period) 8
25 Manual Medical Review Refer to the MAC website for information on what is required for advanced approval Providers may and should submit the request to the MAC when the patient is close to exceeding the $3,700 if additional services are medically necessary. Submit the KX modifier on the claim form when therapy services exceed $3,700, the MACs will also give the provider a tracking number that should be placed on the claim 26 Identifying Cap Dollars The cap is an annual cap It does not reset with a change in diagnosis Providers may access the accrued amount of therapy services from the ELGA screen inquiries into CWF Providers may access the remaining therapy services limitation dollar amount through the 270/271 eligibility inquiry and response transaction Providers who bill to FIs will find the amount a beneficiary has accrued toward the financial limitations on the HIQA 27 Not Qualifying for Exception If the patient does not qualify for an exception to the cap, they can continue to receive services and pay for these services out of pocket The provider must obtain a signed Advanced Beneficiary Notice (CMS-R-131) (ABN) from the patient 9
28 Not Qualifying for Exception Providers should continue to submit the claim to Medicare with the modifier for a denial: GA (Waiver of Liability Statement Issued as Required by Payer Policy) GY (Notice of Liability Not Issued, Not Required Under Payer Policy) GX (Notice of Liability Issued, Voluntary Under Payer Policy) codes Can bill a secondary insurance 29 Therapy Changes Beginning January 1, 2013, practice settings that provide outpatient therapy services must include on claim forms information regarding the beneficiary s function and condition, therapy services furnished, and outcomes achieved. 30 Therapy Changes These changes apply to physical therapy, occupational therapy, and speech-languagepathology services furnished in hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and in private offices of therapists, physicians, and non-physician practitioners. 10
31 Therapy Changes CMS is required by law to implement a claims-based data collection strategy for therapy services. Must Include Information about: Beneficiary function and condition Therapy services furnished Outcomes achieved 32 Purpose of Therapy Changes Medicare will use this information to reform future payment structure for outpatient therapy services Through data collection of beneficiary function CMS hopes to: Understand who uses therapy services Understand how a patient s functional limitations change over time as a result of the therapy 33 Therapy Changes CMS is not currently changing the payment system, the rules governing therapy documentation and reimbursement, or coverage requirements, but they are changing what data therapists must report. The requirements go live January 1, hospitals have a six-month testing period. They will not be penalized for not following the requirements until July 1, 2013. 11
34 The G-Codes CMS will require providers to report G-codes to collect information on beneficiaries function and condition on claims forms 42 new G-codes were established to describe the patient s functional limitation that is the primary reason for the therapy services 35 New G Codes CPT/HCPCS Description CPT/HCPCS Description G0456 Neg pre wound <50 sq cm G8998 Swallow D/C status G0457 Neg pres wound >50 sq cm G8999 Motor speech current status G8978 Mobility current status G9158 Motor speech D/C status G8979 Mobility goal status G9159 Lang comp current status G8980 Mobility D/C status G9160 Lang comp goal status G8981 Body pos current status G9161 Lang comp D/C status G8982 Body pos goal status G9162 Lang express current status G8983 Body pos D/C status G9163 Lang express goal status G8984 Carry current status G9164 Lang express D/C status G8985 Carry goal status G9165 Atten current status G8986 Carry D/C status G9166 Atten goal status G8987 Self care current status G9167 Atten D/C status G8988 Self care goal status G9168 Memory current status G8989 Self care D/C status G9169 Memory goal status G8990 Other PT/OT current status G9170 Memory D/C status G8991 Other PT/OT goal status G9171 Voice current status G8992 Other PT/OT D/C status G9172 Voice goal status G8993 Sub PT/OT current status G9173 Voice D/C status G8994 Sub PT/OT goal status G9174 Speech lang current status G8995 Sub PT/OT D/C status G9175 Speech lang goal status G8996 Swallow current status G9176 Speech lang D/C status G8997 Swallow goal status G9186 Motor speech goal status 36 G-Code Examples Mobility: Walking & Moving Around G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset and at reporting intervals. G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. Swallowing G8996 Swallowing functional limitation, current status, at time of initial therapy treatment/episode outset and reporting intervals. G8998 Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation 12
37 G- Codes Therapists should familiarize themselves with all 42 of the new G- codes. Required for PT, OT and SP services 38 G-Code Modifiers With each G-code, a modifier must be reported to demonstrate the severity and complexity of the functional limitation. There are seven modifiers which could be selected (a seven point scale) The therapist bases the assessment on the score of an outcome measurement tool as well as their skilled clinical knowledge In addition to reporting G-codes and modifiers, the therapists must continue to report the GO, GP, and GN modifiers as appropriate 39 G-Code Modifiers 13
40 Other Relevant Modifiers HCPCS codes should be accompanied by the following modifiers in FL 44. The modifiers are: GN: Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care GO: Service delivered personally by an outpatient occupational therapist or under an occupational therapy plan or care GP: Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care 40 41 Always and Sometimes Therapy Codes The following codes are always therapy services. These codes always require therapy modifiers (GP, GO, GN): 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92607, 92608, 92609, 96125, 97001, 97002, 97003, 97004, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762, 97799, G0281, G0283, G0329. 41 42 Continued Sometimes Therapy No modifier is required if not performed by a therapist under a therapy plan of care. However, these codes when performed by a therapist require the use of a therapy modifier: 90901, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 96105, 96110, 96111, 97532, 97597, 97598, 97602, 97605, 97606, 0019T, 0029T 42 14
43 43 o o o Initial Evaluation Codes 97001 and 97003 Include all components necessary to evaluate the patient; all tests and measurements performed during the initial evaluation are inclusive of the code and should not be separately reported. Only one unit of an initial evaluation should be billed regardless of the time spent with the patient. Treatments performed in addition to the initial evaluation can be separately reported as long as Medicare requirements are met. 44 44 Billing Units Constant attendance" services require direct one-on-one provider-patient contact and generally fall within the 97032-97762 HCPCS ranges. The CDM Description should indicate these codes as timed codes When performed, medically necessary and documented, the therapist may bill for multiple units Patient Contact Time Time Interval Units Billed 8 22 Minutes 1 23 37 Minutes 2 38 52 Minutes 3 53 67 Minutes 4 68 82 Minutes 5 83 97 Minutes 6 98 112 Minutes 7* 45 *The time interval / units billed follow the same pattern should greater than 7 units be performed 15
46 Timed Codes (CPT Rules) The expected average time spent for these codes is 15 minutes Providers should not bill for services performed for less than 8 minutes If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time 46 47 Example 24 minutes of code 97112 and 23 minutes of code 97110 were furnished Total treatment time was 47 minutes; 3 units can be billed for this encounter. The correct coding is: 2 units of code 97112 1 unit of code 97110 Assign more units to the service that took the most time. 47 48 Specific Limits for HCPCS 48 16
49 Questions and Discussion 50 Richard Cooley Contact Us Phone: 518-430-1144 Email: RCooley@EpochHealth.Com Jean Russell Phone: 518-369-4986 Email: JRussell@EpochHealth.Com 51 http://www.epochhealth.com/ 17
52 CPT Current Procedural Terminology (CPT ) Copyright 2012 American Medical Association All Rights Reserved Registered trademark of the AMA 53 Disclaimer Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary. 18