My Presentation Title (this slide style also used to divide or to

Medicare Part B Outpatient
Therapy Services Webinar
March 27, 2013
CHA Webinar
Welcome and Program
Overview
Liz Mekjavich and Patricia Blaisdell
California Hospital Association
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Continuing Education Offered
for this Program
 Health Care Executives — CHA is authorized to award up to
2 hours of pre-approved ACHE Qualified Education Credit
(non-ACHE) for this program toward the advancement or
recertification in the American College of Healthcare Executives.
Participants in this program wishing to have the continuing
education hours applied toward ACHE Qualified Education
credit should indicate their attendance when submitting
application to the American College of Healthcare Executives for
advancement or recertification.
 Nursing — Provider approved by the California Board of
Registered Nursing, Provider #CEP 11924, for 2.4 contact hours.
 Nursing Home Administrators — CHA is authorized by the
State of California, Department of Public Health to award
2 contact hours of general credit. Provider Number 1142.
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Continuing Education Offered
for this Program
 Physical Therapist — This program may qualify as an
“alternate pathway” to receive continuing education (CE) credit.
Upon request, CHA will provide a Certificate of Attendance for
licensee to use when applying for individual CE units.
 Occupational Therapist — This program may qualify as a
professional development activity from which occupational
therapists may receive professional development units (PDU) of
continuing education. Upon request, CHA will provide a
Certificate of Attendance that licensee may submit to the
California Board of Occupational Therapy for PDU
consideration.
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2
Continuing Education
Requirements
 Full attendance, completion of online survey,
and attestation of attendance is required to
receive CEs for this webinar. CEs are
complimentary for registrant. If additional
participants under the same registration would
like to be awarded CEs, a fee of $20 per
person, will apply. Post-event survey will be
sent to registrant and provide information on
how to apply online for additional CEs.
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Faculty: Nancy Beckley, MS,
MBA, CHC
Nancy J. Beckley, MS, MBA, CHC, is president of
Nancy Beckley & Associates LLC, a firm specializing
in providing compliance program development in the
outpatient therapy, and DME. Ms. Beckley’s
background includes 15 years of hospital experience
serving in management capacities at two large inpatient
rehabilitation facilities and she has extensive program
management and managed care contracting experience.
She is the author of two books on managed care
contracting for rehabilitation providers and is a popular
speaker and author on compliance topics related to
outpatient therapy. In addition, she currently serves as a
compliance columnist for IMPACT, the magazine of the
APTA PPS.
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3
Faculty: Cheryl Bradley
Cheryl Bradley is a senior provider representative in
the Provider Outreach and Education Department for
Palmetto GBA, Jurisdiction J1 A/B Medicare
Administrative Contractor (MAC). As a Part B Training
Specialist, Ms. Bradley provides education and
problem-solving assistance to providers in California,
Hawaii and Nevada. She has over 20 years experience
in the Medicare Program, having worked as an
education and training specialist, professional relations
field representative, medical review analyst, and as a
customer service representative. Ms. Bradley has
presented before physicians, specialty organizations,
insurance billers, and other professionals in the
health care field.
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Medicare Part B:
Outpatient Therapy Update
Nancy J. Beckley, MS, MBA, CHC
President
Nancy Beckley & Associates, LLC
Cheryl Bradley
Senior Provider Representative
Palmetto, GBA
4
Today’s Agenda
 Therapy Caps and Exceptions Process
 Manual Medical Review — Update
 Palmetto ADR Process
 Functional Limitation Reporting —
Documentation and Claims
 Case Studies
 Resources
 Bonus Section
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Bonus Section
 Palmetto Appeals Process
 Palmetto Local Coverage
Determinations
 Palmetto Provider Outreach
& Education
 Palmetto J1 Resources
10
5
Manual Medical Review Update
11
Manual Medical Review (MMR)
— CMS Update 3/21/2013
 Recovery Auditors to conduct MMR at $3,700
thresholds (PT & SLP; OT)
 In RAC Prepayment Demo states: prepayment
review (California — here we go again!)
 In other states: post-payment review
 Reference:
http://www.cms.gov/research-statistics-dataand-systems/monitoring-programs/medicalreview/therapycap.html
12
6
What We Know
Prepayment Review:
 Claims submitted in the Recovery Audit Prepayment
Review Demonstration states will be reviewed on a
prepayment basis. This includes California
 MAC will send an Additional Documentation Request
(ADR) to the provider requesting ADR and documentation
be sent to the Recovery Auditor (unless another process
is used by the MAC and the Recovery Auditor)
 The Recovery Auditor will conduct prepayment review
within 10 business days of receiving the additional
documentation and will notify the MAC of the payment
decision
13
What We Aren’t Sure About …
 What does 10 “review” days really mean?
 If 100% review — do request limits (45 days) apply?
 Will review include any portion of $3,700 that previously
had been paid? Or only portion not paid?
 In prepayment demo will discussion period apply?
 Will “issue” be posted to RAC website?
 RAC original Statement of Work (SOW) indicated
review personnel include “therapists” — will charts be
reviewed by therapists?
 Will outreach be conducted? Will Palmetto provide
additional guidance?
 Will esMD be allowed? Or fax/mail option?
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7
What We Learned in 2012
 Documentation rules are the same, the reviewers
are not!
 Certified POC, means “now,” not in 30 days
 Orders are required even if POC certified
 Interaction of complexities and comorbidities must be
described as it relates to the need for more therapy
 Differentiate the PLOF in functional detail as it relates to
impairments and CLOF
 Identify therapy needs as specific, objective, and
measurable
 Document social history and support, and it may backfire
15
Outpatient Therapy Caps and the
Exceptions Process
16
8
2013 Therapy Caps
• 2013 Therapy Cap amounts:
– $1,900 for Occupational Therapy (OT)
– $1,900 combined Physical Therapy (PT) and
Speech Language Pathology (SLP)
• Determined for a beneficiary on a calendar
year basis
17
Extension of Exceptions Process
• Append KX Modifier to applicable claims for
services above:
–
–
The therapy caps of $1,900
The therapy thresholds of $3,700
• Applies to therapy services furnished in a
hospital outpatient department (OPD)
• Includes outpatient therapy services furnished
in a Critical Access Hospital (CAH)
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9
Manual Medical Review
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Manual Medical Review
• Manual medical review of therapy services
when $3,700 threshold reached (prepay)
• Two separate thresholds apply:
–
–
$3,700 for OT
$3,700 combined PT and SLP
• Provider will receive an additional
documentation request (ADR)
• No pre-approval process in place 2013
20
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Additional Documentation
Requests (ADR)
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Additional Documentation Requests
(ADR)
• When your medical records are requested:
–
–
–
–
–
Submit documentation justifying the services
rendered
Ensure all signatures are legible
Include a copy of the ADR
Respond within 30 days
Automatically denies on 45th day if no response
• www.Palmettogba.com/J1b
–
Browse by specialty
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ADR Therapy Checklist:
What is
Palmetto
looking for?
Can the ADR response be faxed,
mailed or submitted using esMD?
• Yes you may fax documentation in response to
Additional Documentation Request (ADR)
letters using the fax attachments for
electronic claims
–
J1 Part B Fax Numbers:


Northern California: (803) 462-3934
Southern California: (803) 462-3935
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12
What should I expect?
• Upon receipt of the all requested records,
Palmetto GBA will review the records and make
a decision
• Payment will be made based on coverage and
payment policy requirements contained within
Pub. 100 – 02, Section 220 of the Medicare
Benefit Policy manual and any applicable local
coverage decisions
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How do I determine if a patient is
close to the cap or $3,700 threshold?
• Total therapy dollars used is available in:
–
–
–
Interactive Voice Response(IVR)
Online Provider Services
Beneficiary eligibility lookup (HETS) 270/271
transactions
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13
Online Provider
Services (OPS)
• FREE online access to:
–
–
–
–
Eligibility
Claims status
Remittances online
Financial information (payment
floor and last three checks paid)
MMR Documentation Tips
1. $3,700 to be likely to be exceeded …

PT & SLP therapies both utilizing same cap

Complicated single episode of therapy

Multiple episodes of therapy this year

Impact of co-morbidities and complexities
2. Tee it up

Establish probability for more therapy in POC

Restate and “fine-tune” in first progress note

Emphasize in progress notes as approaching
$3,700
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14
Functional Limitation Reporting
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Functional Limitation Reporting
What is included?
 Therapist assessment of functional limitations
 Therapist assessment of impairment and goal
 Documentation of goals, assessment, impairment and
clinical judgment in the medical record
 Claim submission — trigger dates/codes
 Claim submission — proper codes and modifiers
 Audit trail clinically
 Audit trail operationally
30
15
Functional Limitation Reporting
for Outpatient
Therapy Services
31
When do I have to start using
the G-codes? Is it required?
32
• Effective for therapy services with dates of
service (DOS) on/after January 1, 2013
• Testing period January 1 – June 30, 2013
• Alert messages 4/1/13 – 6/30/13 when G-code
submitted without the severity modifier
• Claims will be returned/rejected for DOS
on/after July 1, 2013
• Separate CR will be issued for therapy claims on
and after July 1, 2013
16
Implementing the Requirement
• G-codes are “Always Therapy” Codes
• Require a therapy modifier:
–
–
–
GP — under a PT plan of care (POC)
GO — under an OT POC
GN — under an SLP POC
• Each functional G-code set contains:
–
–
–
Current Status
Projected Goal Status
Discharge Status
33
Why do I have to use modifiers in addition
to the new G-codes?
• The additional modifiers are used to denote
the patient’s degree of impairment/limitation/
restriction. If you do not expect your patient to
improve as a result of a degenerative disease,
for example, or expect limited improvement,
use the same modifier for the current status
and projected goal status.
34
17
Is there a particular order for modifiers
reported with a G-code?
• No. Each G-code must also include the
appropriate therapy modifier (GP, GO or GN)
and severity modifier on the claim line of
service. However, there is no specific order in
which they appear.
35
Is the KX modifier required on the G-code?
• No. The KX modifier is not applicable to the line
of service for the functional G-code. Only the
appropriate therapy modifier and severity
modifier is required with the G-code on the
claim line.
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18
Remittance Advice Messages
• CO – 246: This non-payable code is for required
reporting only
• Medicare Summary Notice will also contain
message informing beneficiary that they are
not responsible for any charge associated with
the G-codes
37
How to resubmit rejected claims?
• MA130 — Your claim contains incomplete
and/or invalid information, and no appeal rights
are afforded because the claim is
unprocessable.
• Simply transmit a new claim with the
complete/correct information.
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19
Frequently Asked Questions
(FAQs)
39
How often do I report these codes and
modifiers?
•
•
•
•
At the outset of a therapy episode of care
At least once every 10 treatment days
When an evaluative procedure is furnished and billed
At the time of discharge from the therapy episode
of care
• At the time reporting of a particular functional
limitation is ended (and further therapy is necessary)
• At the time reporting is begun on a different
(second, third, etc.) functional limitation
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20
Does functional reporting apply to
Medicare Secondary Payer (MSP) claims?
• Yes, the functional reporting of G-codes and
severity modifiers applies when Medicare is
both the primary and secondary payer.
• No, the functional reporting is not required for
Medicare Advantage patients?.
41
Is the functional reporting required for
Medicare Advantage patients?
• No, this is a requirement for beneficiaries that
receive Medicare FFS benefits, specifically
Medicare Part B benefits.
42
21
How do I report for observation
patients?
• Functional limitation reporting is required for
observation patients and reporting is the same
as if it were an outpatient.
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Functional Limitation Reporting
Documentation and Reporting
44
22
What Assessment Tools?
 CMS had previously identified
in Medicare Beneficiary Policy Manual
(MBPM):

AM-PAC

FOTO

Optimal

NOMS
 What else can be used?
 Arriving at impairment rating?
45
CMS on Assessment Tools:
Evaluation shall include:
 Results of one of the … four measurement
instruments are recommended, but not
required …
 If results of one of the four instruments
above is not recorded, the record shall
contain instead the following information
indicated by asterisks (*) and should contain
(but is not required to contain) all of the
following, as applicable.
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If Not One of the “Four” …
 *Documentation required to indicate objective, measurable
beneficiary physical function including, e.g.,



Functional assessment individual item and summary scores
(and comparisons to prior assessment scores) from
commercially available therapy outcomes instruments other
than those listed above; or
Functional assessment scores (and comparisons to prior
assessment scores) from tests and measurements validated
in the professional literature that are appropriate for the
condition/function being measured; or
Other measurable progress towards identified goals for
functioning in the home environment at the conclusion of
this therapy episode of care.
47
Functional Limitation:
Tied to LTG
 Long term treatment goals should be developed for the
entire episode of care in the current setting … Goals
should be measurable and pertain to identified
functional impairments. When episodes in the setting
are short, measurable goals may not be achievable;
documentation should state the clinical reasons progress
cannot be shown.
 The functional impairments identified and expressed in
the long term treatment goals must be consistent with
those used in the claims-based functional reporting, using
nonpayable G-codes and severity modifiers, for services
furnished on or after January 1, 2013. (Reference:
42CFR410.61 and 42CFR410.105 (for CORFs)
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Some (Deceivingly)
Simple Questions …
Per CMS: “… it will be
incumbent on the
therapist to learn to
translate the score from a
singular assessment tool
or the combined results
from multiple
tests/measures along with
other information
regarding their patient's
functional limitation to the
Medicare scale”
2013 MPFS Final Rule 11/1/2012
p.252
1.
2.
3.
4.
5.
6.
What is the patient’s primary functional
limitation? (Hint: try asking the patient) Is it
important? What was the patient’s prior level
of function?
What is the functional limitation category for
the primary limitation?
Based on your findings, what is the current
functional status (impairment modifier) on
the seven-point functional scale?
What is the rationale for your assessment of
the impairment/functional status?
What is the projected functional goal
(impairment modifier) on the seven-point
functional scale?
What is your rationale for the functional goal?
Why is it reasonable and achievable?
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PT/OT Functional Limitations
CURRENT
GOAL
DISCHARGE
Mobility: Walking &
Moving Around
PT/OT
G8978
G8979
G8980
Changing & Moving
Body Position
G8981
G8982
G8983
Carry, Moving &
Handling Objects
G8984
G8985
G8986
G8987
G8988
G8989
Other PT/OT PRIMARY
Functional Limitations
G8990
G8991
G8992
Other PT/OT SECONDARY
Functional Limitations
G8993
G8994
G8995
Self Care
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Severity Modifiers
Modifier
Impairment Limitation Restriction
CH
0 percent impaired, limited or restricted
CI
At least 1 percent but less than 20 percent impaired, limited or restricted
CJ
At least 20 percent but less than 40 percent impaired, limited or restricted
CK
At least 40 percent but less than 60 percent impaired, limited or restricted
CL
At least 60 percent but less than 80 percent impaired, limited or restricted
CM
At least 80 percent but less than 100 percent impaired, limited or restricted
CN
100 percent impaired, limited or restricted
Severity Scale
 Nancy Beckley & Associates LLC
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SLP Functional Limitations
SLP
CURRENT
GOAL
DISCHARGE
G8996
G8997
G8998
G8999
G9186
G9158
G9159
G9160
G9161
G9162
G9163
G9164
Attention
G9165
G9166
G9167
Memory
G9168
G9169
G9170
Voice
G9171
G9172
G9173
Other SLP PRIMARY Functional
Limitation
G9174
G9175
G9176
Swallowing
Motor Speech
Spoken Language
Comprehension
Spoken Language Expression
53
SLP — Scored to NOMS
Modifier
Impairment Limitation Restriction
NOMS Level
CH
0 percent impaired, limited or restricted
7
CI
At least 1 percent but less than 20 percent impaired, limited or
restricted
6
CJ
At least 20 percent but less than 40 percent impaired, limited or
restricted
5
CK
At least 40 percent but less than 60 percent impaired, limited or
restricted
4
CL
At least 60 percent but less than 80 percent impaired, limited or
restricted
3
CM
At least 80 percent but less than 100 percent impaired, limited or
restricted
2
CN
100 percent impaired, limited or restricted
1
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Multiple Functional Limitations
Per CMS: “… we have
decided to limit reporting to
one functional limitation at
this time.
Recognizing that therapists
treat the patient as a whole
and work on more than one
functional limitation at a
time, we believe that limiting
reporting in this way will
make it less burdensome in
the situations involving more
than one functional
limitation.”
 Each discipline may only report on
one functional limitation at
a time.
 If patient achieves goal, and more
therapy is medically necessary
additional functional limitation
must be reported.


“Discharge” patient from 1st
Functional Limitation on visit
Enter second functional
limitation on next visit
2013 MPFS Final Rule 11/1/2012 p.246
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APTA OPTIMAL
The “pitch”
 It is free
 CMS listed it as one of the four identified in the
MBPM documentation requirements
 Validated by APTA
 Crosswalked items to Functional Limitation
Category
 APTA guide to scoring impairment rating
OPTIMAL: Copyright © 2012, 2006, 2005 American Physical Therapy Association. All rights reserved.
Adapted/revised in July 2005, August 2006, and December 2012 with permission of APTA from Guccione AA,
Mielenz TJ, De Vellis RF, et al. Development and testing of a self-report instrument to measure actions: Outpatient
Physical Therapy Improvement in Movement Assessment Log (OPTIMAL). Phys Ther. 2005;85:515–530.
56
28
ASHA NOMS
National Outcomes Measurement System (NOMS)
 Voluntary data collection system
 In exchange for participating in NOMS data
collection, SLPs will have access to their data
benchmarked against the national data and system
data if applicable
ASHA’s Functional Communication Measures (FCMs).
 CMs are a series of disorder-specific, seven-point
rating scales designed to describe the change in an
individual’s functional communication and/or
swallowing ability over time
57
ASHA NOMS
The “pitch”
 It is free to ASHA members (certain
provisions apply)
 CMS listed it as one of the four identified in
the MBPM documentation requirements
 ASHA Instrument
 Crosswalked items to Functional Limitation
Category
 Crosswalked to Impairment Ratings
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29
Speech Language Pathology
Fee Schedule Analysis
 http://www.asha.org/uploadedFiles/2013Medicare-Fee-Schedule-SLP.pdf
Sample Case Studies
 http://www.asha.org/uploadedFiles/G-codeScenarios.pdf
NOMS Information
 http://www.asha.org/members/research/noms/
59
FOTO
For assisting G-code selection:
 Map all functional activities in assessments
to G-codes through the ICF
 Identify how much impairment reported by
patient for each
 List all G-codes possible for the impairment
of the patient
 Identify the number of items asked for
each G-code
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30
Functional Intake Summary
A closer look at sections related to Functional Limitation Reporting
Functional Activities
asked of the Patient
Amount of limitation
Reported
G-Code mapped to
functional activity
61
FOTO Links
Demos: Outcomes Manager or Patient Inquiry
 https://www.patient-inquiry.com/PatientInquiry-Marketing/live-demo.html
Paper forms and scoring algorithms
(public domain)
 http://www.fotoinc.net/index.php/nqf/fotopqrs-paper-short-forms-and-scoringalgorithm
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31
Sample Instruments
 Activity Card Sort
 American Shoulder and Elbow Surgeons Score
 AMPAC: Applied Cognitive
 AMPAC: Basic Mobility
 AMPAC: Daily Activity
 Barthel Index
 Berg Balance Scale
 Box and Block Test
 Disabilities of the Arm, Shoulder, and Hand
Questionnaire
 Executive Function Performance Test
63
Sample Instruments
 FOTO Elbow, Wrist, Hand
 FOTO Foot/Ankle Functional Status
 FOTO General Orthopedic
 FOTO Hip Functional Status
 FOTO Knee Functional Status
 FOTO Lumbar Functional Status
 FOTO Shoulder
 Functional Gait Assessment
 Functional Independence Measure
 Lower Extremity Functional Scale
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32
Sample Instruments
 Motor Assessment Scale
 Neck Disability Index
 Oswestry Disability Index
 Patient Specific Functional Scale
 Rancho Levels of Cognitive Functioning
 Shoulder Pain and Disability Index
 Spinal Cord Independence Measure
 Stroke Impact Scale
 Timed Up and Go
65
Sample Instruments
 Tinetti Falls Efficacy Scale
 Tinetti Gait and Balance
 Tinetti Performance Oriented
Mobility Assessment
 Upper Extremity Functional Index (UEFI)
 Upper Extremity Functional Scale (UEFS)
 Walking Index for Spinal Cord Injury
 Wolf Motor Function Test
 World Health Organization Disability Assessment
Schedule II
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33
Reporting Frequency
 Outset of therapy episode
 At the end of progress/functional
reporting period
 At the time an evaluation or re-evaluation is
furnished and billed
 At discharge
 To end reporting of one functional limitation
 To begin reporting of a different
functional limitation
67
What Must be on the Claims
 G-codes and severity modifiers must be on all
claims where Medicare is the primary or
secondary payer
 All disciplines should have at least two codes for
every 10th treatment day (but there could be
more depending on the number of functional
codes being tracked)
 Every G-code must have a severity modifier
 Discipline modifiers: GP, GO, and GN are
required, but KX and 59 are not
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34
Sample Functional Reporting
Changing & Maintaining Body Position
Physical Therapy — Neck Pain & Limited ROM Patient
(Instruments: Neck Disability Index + Professional Judgment)
1st Report (10 visits)
Admission
Discharge (23 visits)
G8981-CL (actual)
G8982-CJ (goal)
G8981-CL (actual)
G8982-CJ (goal)
G8982-CJ (goal)
G8983-CK (discharge)
69
Evaluation Only — SLP
Motor Speech Functional Limitation
SLP — CVA Patient — Reduced Speech Intelligibility
Admission
G8999-CJ (actual)
G9157-CJ (goal)
G9158-CJ (discharge)
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35
Wound Care Scenario
Other PT/OT Primary Functional Limitation
Physical Therapy — Wound Care Patient
1st Report (10 visits)
Admission
Discharge (13 visits)
G8990-CH (actual)
G8991-CH (goal)
G8990-CH(actual)
G8991-CH (goal)
G8991-CH (goal)
G8992-CH (discharge)
71
Multiple Therapies
PT
Mobility
Admit
Visit 10
OT
Self Care
D/C
Admit
Visit 10
SLP
Spoken Language-Exp
D/C
G8987CM
G878CN
G8979CJ
D/C
G9162CM
G8987CL
G8988CI
G8979CJ
G8980??
Visit 10
G9162C
N
G9163CJ
G8988CI
G878CN
G8979CJ
Admit
G9163CJ
G8988
G8989??
G9163CJ
G9164??
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36
PT-OT-SLP Example (UB-04)
73
Multiple Functional Limitations
Per CMS: “… we have
decided to limit reporting to
one functional limitation at
this time.
Recognizing that therapists
treat the patient as a whole
and work on more than one
functional limitation at a
time, we believe that limiting
reporting in this way will
make it less burdensome in
the situations involving more
than one functional
limitation.”
 Each discipline may only report
on one functional limitation
at a time
 If patient achieves goal, and more
therapy is medically necessary
additional functional limitation
must be reported


“Discharge” patient from 1st
Functional Limitation on visit
Enter second functional
limitation on next visit
2013 MPFS Final Rule 11/1/2012 p.246
74
37
Multiple Functional Limitations
“Thus, reporting on more than one functional limitation
may be required for some patients, but not
simultaneously.
Instead, once reporting on the primary functional
limitation is complete, the therapist will begin reporting
on a subsequent functional limitation using another set of
G-codes.
If this additional functional limitation is not described by
one of the specific categorical codes, one of the three
“other” codes should be used depending on the
2013 MPFS Final Rule 11/1/2012
circumstances.”
75
OT Example: Two Limitations
PT/OT
Carrying, Moving & Handling Objects
Admission
10th Visit
13th Visit
PT/OT
Self Care
14th Visit
D/C 18th Visit
G8984-CN (actual)
G8985-CI (goal)
G8984-CH(actual)
G8985-CI (goal)
G8985-CI (goal)
G8986-CI (d/c)
G8987-CM (actual)
G8988-CJ (goal)
G8988-CJ (goal)
G8989-CJ (d/c)
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38
Evaluation Only — SLP
Motor Speech Functional Limitation
SLP — CVA Patient — Reduced Speech Intelligibility
Admission
G8999-CJ (actual)
G9157-CJ(goal)
G9158-CJ(discharge)
77
Strange, But True Scenarios
1. Patient self discharge
2. Observation patient is admitted
3. Patient with two different PT POCs
4. Can assessment instruments change during
the episode of care
5. Observation BID — one visit or two visits
6. OT and PT both identify same limitation
7. OT identifies an “SLP” limitation (cognition)
78
39
Claim “Rejected or Denied,”
What Next
 Lack of G-codes on evaluation codes
 Lack of modifier on G-codes
 Not updated by 10th visit
 Other coding error related to G-codes
 Errors due to not having completed
functional limitation requirements vs.
forgetting to report timely
 Can claim be refiled?
79
Case Studies
Clinical & Operational
80
40
Case Study: Uncomplicated Anterior
Knee Pain in an 89-Year-Old Man
George is an 89 year old man living independently. He lives alone in a two story house and his bedroom is
upstairs. Within the past few months, he has developed right anterior knee pain and he is no longer able to get up
and down the stairs in his house without pain. He is concerned that if his knee pain continues to worsen, he will no
longer be able to continue living on his own. He is in otherwise excellent health, has no cognitive impairments,
and he has a strong desire to continue living independently.
Initial Evaluation: Establish Functional Limitation and Goal
Documentation Example
Identification of Primary
Functional Limitation
Elements
 Description of current and prior level of
function
 Rationale for Importance
Functional Limitation
Category
• Category
• Rationale for Category Assignment
“Inability to ascend and descend stairs places him in Functional
Limitation Category G8978: Mobility-Walking and Moving Around, and
a current impairment rating of …”
Current Impairment
Rating




“… CJ: 20% to < 40% Impaired. The rating is based on a LEFS Score
of 48, Anterior Step Down Test limited to two inches, Knee Flexion
AROM of 75 degrees, a positive patellar grind, and reports of inability
to ascend and descend stairs in his home.”
Primary Functional Goal
Projected Improvement in:
 Functional Instrument Score
 Projected Performance Testing Score
 Clinical Tests
 Patient Interview
Accepted Functional Instrument Score
Performance Testing Score
Clinical Tests
Patient Interview
“He is unable to walk up and down stairs in his house because of
anterior knee pain. Prior to this episode …”
“… well motivated and is otherwise healthy for his age. Since the knee
pain is relatively recent onset and there is no other significant
pathology other than the patello-femoral tracking issue, patient should
be able to achieve a functional goal of CI: 0% to < 20% Impaired.”
81
 Clinicient
Case Study: Uncomplicated Anterior
Knee Pain in an 89-Year-Old man
Goals
The goals listed below are achievable and realistic within the designated time frame and the treatments listed
here and referred to in the treatment plan are necessary to achieve these goals within the designated time
frame. The functional goals were created based on the patient's prior level of function. Clinical findings and
clinical goals are an indicator of progress toward addressing functional limitations and achieving functional
goals. The Functional Goals are based upon a correlation of Functional Assessment Tools with clinical tests
and performance based tests.
Limitation Category: G8978: Mobility-Walking and Moving Around
Current Impairment Rating: CJ: 20 – 39% Impairment
Goal Impairment Rating: CI: 0% to < 20% Impaired
Projected Goal Completion Date: 2/28/2013
Current Finding:
Goal:
Unable to ascend or descend stairs without
pain. He is concerned that if his knee pain
continues to worsen, he will no longer be able
to continue living on his own.
Demonstrated ability to ascend and descend stairs
with a normal reciprocal gait and no complaint of pain
 Pain Frequency
 Recent Symptom Trend
Constant
Sporadic, Less Than Weekly
Worsening
Improving
 Stair Climbing Gait
Has to lead with affected extremity when
descending stairs. Has to lead with unaffected
extremity when ascending stairs.
Ascends and descends stairs with normal reciprocal
gait.
 LEFS Score
 Patellar Grind Test
 Anterior Step Down Test
45
55
Positive
Negative
2 inches
8 inches
Primary Functional
Limitation
Clinical Findings
 Clinicient
82
41
Case Study: Uncomplicated Anterior
Knee Pain in an 89-Year-Old man
Discharge Evaluation: Functional Limitation Goal Met
Elements
Example
Update on Primary
Functional
Limitation
 Updated description of limitation
“Reports that he is able to ascend stairs with a
reciprocal gait with no pain, but still has
occasional pain descending stairs.”
Current Impairment
Rating




“… has met the functional goal we
established at the initial evaluation (CI: 0% to
< 20% Impaired). The improved rating is
based on a LEFS score improvement of eight
points, Step Down Test improvement from
two inches to five inches, pain free patellar
grind test, and the patient report on
improvement with ascending stairs.”
Functional Instrument Score
Performance Testing
Clinical Tests
Patient Interview
83
 Clinicient
Case Study: Post-Shoulder
Arthroplasty in a 65-Year-Old Woman
Sandra is a 65 year old right handed woman with rheumatoid arthritis living with her husband of 40 years.
She underwent a total shoulder arthroplasty six weeks ago. She has had prior bilateral hip and knee
replacements. In spite of all of her functional limitations, she enjoys cooking and she is determined to
resume cooking for family get togethers. Her kitchen has been extensively modified to accommodate her
poor upper extremity function. She has no other health problems or cognitive impairments.
Initial Evaluation: Establish Functional Limitation and Goal
Identification of Primary
Functional Limitation
Elements
 Description of current and prior level
of function
 Rationale for Importance
Documentation Example
“She is unable to do any kitchen tasks. Prior to surgery, she was able
to cook for her family in her specially modified kitchen …”
Functional Limitation
Category
• Category
• Rationale for Category Assignment
“Inability to perform kitchen tasks because of upper extremity strength
and mobility places her in a functional limitation category of G8984
…
Current Impairment
Rating








“… a current impairment rating of CN (100 percent impaired, limited
or restricted). The rating is based on a Shoulder Pain and Disability
Index Score of 99, 2/5 strength for all shoulder motions, post op
restrictions on active movement, and patient reports of …”
“… well motivated and has shown a capacity to perform beyond
expectations for someone with advanced RA. Patient should be able to
achieve a functional goal of CL (60% to 79% Impaired).”
Primary Functional Goal
Accepted Functional Instrument Score
Performance Testing Score
Clinical Tests
Patient Interview
Functional Instrument Score
Projected Performance Testing Score
Clinical Tests
Patient Interview
84
42
Case Study: Post-Shoulder
Arthroplasty in a 65-Year-Old Woman
10th Visit Progress Evaluation: Adequate Progress
Update on Primary
Functional Limitation
Elements
 Updated description of limitation
Current Impairment
Rating




Update on Primary
Functional Goal
 Professional Opinion
Functional Instrument Score
Performance Testing
Clinical Tests
Patient Interview
Example
“Reports that she is able to reach into
lower shelves of her refrigerator and
lower cupboards, but still has difficulty
reaching lower shelves or into deep
cupboards.”
“… CN: 80 to 99 percent impaired,
limited or restricted. The rating is based
on a Shoulder Pain and Disability Index
Score improvement to 81, 3/5 strength
for all shoulder motions, post op
restrictions on active movement being
removed, and patient reports of …”
“A functional goal of CL (60% to 79%
Impaired) is achievable based on …”
85
 Clinicient
Case Study: Post-Shoulder
Arthroplasty in a 65-Year-Old Woman
Discharge Evaluation: Functional Limitation Goal Met
Update on Primary
Functional Limitation
Current Impairment
Rating
 Clinicient
Elements
 Updated description of limitation




Functional Instrument Score
Performance Testing
Clinical Tests
Patient Interview
Example
“… able to reach into upper shelves of her
refrigerator and cupboards and she is
now able to cook for her family with
minimal assistance from her husband.”
“… has met the functional goal we
established at the initial evaluation (CK:
40% to 60% Impaired). The rating is
based on a Shoulder Pain and Disability
Index Score improvement to 55, 3+ to 4-/5
strength for all shoulder motions,
demonstrated ability to reach forward and
lift a 4 lbs. weight at kitchen counter
height and patient reports of …”
86
43
January 1 – June 30:
Test Period
“We note that this is a new
reporting system designed
to gather data on the
changes in beneficiary
function throughout an
episode of care. We are not
expecting therapists to
change the way they treat
patients because of our
reporting requirements.”
Clinical-Goals
ClinicalImpairment
Your
Hospital
Process
System Work Flow
2013 MPFS Final Rule 11/1/2012 :
p.246
Hospital Case Study
 Small system, multi-campus, IRF
 Multiple OP centers, Northern CA
88
44
Case Study: Therapists
Introduce to therapists 3 – 4 months out
 Introduce concept in positive light

Old methods may not be enough

More clarity to documentation

“ROM, strength no longer reason for therapy”
 Gather standardized tests, create toolbox
 Create “standards” for therapy disciplines
89
Case Study: Work Flow
 Finance

PFS, revenue cycle, revenue management
 Therapy

Outpatient therapy

Inpatient therapy

Women’s health therapy
 Information technology
 EMR vendor
90
45
Case Study: Kick Off Meeting
 Introduced regulations
 Concept of “must do”
 Handouts with regulatory citations
 “How do codes flow through system?”
 Every member left with deliverables
91
Case Study: Deliverables
and Tasks
 Revenue cycle — build out G-codes, CDM
 IT — configure interface from data entry
to claim
 Patient accounts — how to verify “C”
modifier on claim (modifiers not in CDM)
 Women’s health — different system —
creating different work flow
 Vendor — EMR updates (Therapy EMR)
92
46
Case Study: CDM
 New CDM? vs. Add on to CDM?
 Consideration and debate …
 “No simple way to do this”
 Decision:

New single CMD for all to access rather
than add-on CDM
93
Case Study — Check Points
 How does CDM look?
 How does charge capture happen?
 How do the modifiers attach?
 What are the variances?
 “Who has the magic wand?”
94
47
Hospital Case Study
 Large system, multi-campus, IRF, SNF,
 Multiple OP centers, Southern CA
95
Case Study: Committees
 Three system-wide committees
 Question: where does patient enter
system, and where does patient travel
to in system?

SNF, IRF, OP, Observation??
 To define the process have to
understand the context of patient
cross flow
96
48
Case Study: Plan of Care
 Keeping track of patients as they move through the
system, starting point?

SNF? Observation?

Plan of Care certification?
 Sensitivity to beneficiary and therapy cap $$
97
Case Study:
Competing Systems
Three “competing” systems need to become
“complementary” for functional reporting to flow onto
the claim
1. Hospital system (Cerner)
2. IRF system (Cerner/RIC)
3. OP system (Mediserve)
98
49
Case Study: Severity Modifier
 Context of functional reporting and
instruments

Are they adequate?

Role of therapist judgment?

Therapist v. therapist interpretation
 How does this impact the documentation and
reporting as the patient moves through the
system, or changes therapist?
99
References — CMS
 New: Transmittal 1196: Outpatient Therapy Functional
Reporting Non-Compliance Alerts MM8166
 Updated: Transmittal 165: Implementing the Claims-Based Data
Collection Requirement for Outpatient Therapy Services —
Section 3005(g) of the Middle Class Tax Relief and Jobs
Creation Act (MCTRJCA) of 2012 (previous Transmittal 163)
 Updated: Transmittal 2622: Implementing the Claims-Based
Data Collection Requirement for Outpatient Therapy Services —
Section 3005(g) of the Middle Class Tax Relief and Jobs
Creation Act (MCTRJCA) of 2012 (previous Transmittal 2603)
 Updated: MM8005: Implementing the Claims-Based Data
Collection Requirement for Outpatient Therapy Services
 CMS National Provider Call, “Preparing for Therapy Functional
Reporting Implementation in CY 2013” slides and audio
recording & transcript
100
50
References — APTA & ASHA
 APTA website:
http://www.apta.org/Payment/Medicare
/CodingBilling/FunctionalLimitation/
 NEW ASHA:
http://www.asha.org/uploadedFiles/201
3-Medicare-Fee-Schedule-SLP.pdf
101
Thank you
Nancy Beckley, MS, MBA, CHC
(414) 748-4376
[email protected]
Twitter: @nancybeckley
Linked in: www.linkedin.com/in/nancybeckley
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51
Bonus Section
103
Avoiding Therapy
Documentation Errors
104
52
Avoiding Therapy Documentation Errors
Current Top 3 Errors from Record Reviews
–
Part B
1.
2.
3.
Insufficient documentation
Incorrectly coded
Medical necessity
78%
21%
1%
105
Medical Review Findings
•
No documentation
–
•
Insufficient documentation
–
•
Provider/supplier fails to respond to repeated
attempts to obtain the medical records in support of
the claim
Medical documentation submitted is incomplete
Incorrect coding
–
Codes and/or units billed do not match the
modalities or times documented or are the
incorrect codes
106
53
Medical Review Findings
•
Lack of medical necessity
–
–
–
–
•
•
No documentation or functional progress
Functional deficits are not clearly documented
Excessive frequency and duration
No treatment notes for date billed
Maintenance treatments
Patient being treated for a chronic problem
without documentation of a new injury
or incident
107
Therapy CERT Errors
•
•
•
•
Therapy recertification not signed
The duration of therapy not specified
Documentation and DOS do not match
Initial evaluation and POC missing or incomplete
or not signed
• Signatures were missing or illegible
• Physician’s Certification was missing
108
54
Problematic Areas
• Excessive amount of time therapy is provided
• Excessive number of visits
• Services not reasonable and necessary
–
Unskilled services
• Utilization of unqualified individuals
–
“Incident to”
• Excessive use of KX modifier
• Excessive and improper use of modifier 59
109
RAC Issues Approved by CMS
55
Resources
• Region D Recovery Audit Contractor (RAC)
–
HealthDataInsights
–
Email: [email protected]
Telephone Number:
–
•
•
Part A: (866) 590‐5598
Part B: (866) 376‐2319
• Comprehensive Error Rate Testing
–
www.cms.gov/CERT
111
Appeals
112
56
Appeals
• Redetermination requests must be filed within
120 days of the remittance advice
• Submit all supporting documentation
–
Satisfy requirements of LCD 28290
• Redetermination form on website
–
www.palmettogba.com/J1b

Browse by topic
• Send request to Palmetto GBA
113
Appeals
• Part B Redetermination Requests via Fax
• Complete and print the online redetermination
request form
–
http://www4.palmettogba.com/pgx_forms/pdfs/AP-J1B-1000.pdf
• Complete this form in its entirety
• Limit one request per claim, not to exceed 150 pgs
• Fax: (803) 462-3914
114
57
Local Coverage Determination
115
Physical Therapy LCD
• LCD 28290:
–
–
–
Ensure requirements satisfied
Submit appropriate diagnosis codes
Limitation of liability

–
Advance Beneficiary Notice of Non-coverage (ABN)
www.Palmettogba.com/j1b
Medical Policies from Home Page
–
LCDs and NCDs
116
58
View Active
LCDs by area
Physical Therapy
LCD
59
Physical Therapy
LCD
Physical Therapy
LCD
60
Provider Outreach
and Education
121
POE Upcoming Events
• Our Learning and Education Portal offers a
wide variety of education
• Join us for workshops, teleconferences, and
webinars
• To view the most current calendar of events,
visit:
–
www.palmettogba.com/J1B

Learning and Education
–
Event Registration Portal
122
61
Contacting Palmetto GBA
Questions regarding claims denials or other issues should be directed
to:
• Provider Contact Center (PCC):
–
–
–
–
–
J1 Part A: (866) 931-3906
J1 Part B: (866) 931-3901
J11 Part A: (866) 830-3455
J11 Part B: (866) 830-3043
J11 HHH: (866) 830-3925
•
Palmetto GBA Website:
•
•
Online Provider Services (OPS)
Interactive Voice Response (IVR)
–
www.palmettogba.com/medicare
123
Provider Contact Center
• Handles provider issues that cannot be
resolved using Provider Self Service options
• Phone number: (866) 931-3901
• Hours of operation:
–
–
•
Monday through Friday
7 a.m. to 5 p.m. PST
IVR (866) 931-3903
124
62
Provider Self-Service
Interactive Voice Response (IVR)
 (866) 931-3903

–
–
–
–
Claims information
Payment information
Beneficiary information: eligibility,
deductible and benefits
Duplicate remittance advice request
125
Resources
126
63
Resources
• CMS Therapy Services
Annual Therapy Update
– Therapy Services Transmittals
http://www.cms.gov/Medicare/Billing/TherapyServices
–
• Palmetto GBA
–
www.palmettogba.com/Medicare

Functional Reporting Documentation Requirements
Job Aid
127
Resources
• PalmettoGBA Physical Medicine and Rehabilitation
LCD- L28290
• FAQs
–
www.palmettogba.com/j1b

Browse by specialty
• IOM Publication 100 – 2,Chapter 15, Sections 220 and 230
–
•
www.cms.gov/manuals/Downloads/bp102c15.pdf
IOM Publication 100 – 4, Chapter 5, Section 10.2
–
www.cms.gov/manuals/Downloads/clm104c05.pdf
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64
Disclaimer
The information provided in this presentation was
current as of today. Any changes or new information
superseding the information in this presentation will be
provided in articles/publications, at
www.PalmettoGBA.com/medicare.
All CPT codes, descriptors and other data only are
copyright 2009 American Medical Association (or such
other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS Apply. All CPT Codes and
indications are noted where applicable.
129
Thank you
Cheryl Bradley
(323) 753-4943
[email protected]
130
65
Questions
Online questions:
Type your question in the
Q & A box, hit enter
Phone questions:
To ask a question hit 14
To remove a question hit 13
CHA Publications
New Editions
 California Hospital Compliance Manual (2013 Edition)
 EMTALA: A Guide to Patient Anti-Dumping Laws (2012 Edition)
 Mental Health Law (2012 Edition)
 Minors and Health Care Law (2012 Edition)
New Updates for 2013
 Consent Law Manual (April 2013)
 Principles of Consent and
Advance Directives (April 2013)
 California Health Information
Privacy Manual (July 2013) —
The manual is currently being updated to reflect the
recently-released HIPAA/HITECH Final Rule.
Learn more at www.calhospital.org/publications
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66
Upcoming Programs
 Consent Law Seminar
April 17, San DiegoMay 16, Costa Mesa
April 18, Ontario
May 29, Sacramento
April 30, Pasadena May 30, San Ramon
 California Congressional Action Program
April 28 – May 1, Washington, D.C
 Hospital Finance and Reimbursement Seminar
June 6, Sacramento
June 12, Southern CA (location TBD)
June 13, Glendale
 Disaster Planning for California Hospitals
September 23 – 25, Sacramento
133
Thank You and Evaluation
Thank you for participating in today’s program.
An online evaluation will be sent to you shortly.
Reminder: evaluation completion is required to
receive continuing education credits.
For education questions, contact Liz Mekjavich at
(916) 552-7500 or [email protected].
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