2013 Quarter 1

Coding CornerFAQ1. How do I bill for Medicare Part B services delivered for contracture management patients?

Billing for Medicare Part B services delivered for contracture management is dependent on the skilled services provided. The most often skilled services may include: 97110, therapeutic exercise; 97112, neuromuscular reeducation; 97140, manual therapy; 97760, orthotic management and training; and 97762, checkout for orthotic/prosthetic use. Each skilled service is detailed below:

97110-Therapeutic Exercises to develop strength and endurance, range of motion and flexibility (one or more areas, each 15 minutes) may require the unique skills of a therapist to evaluate the patient’s abilities, design the program, and instruct the patient or caregiver in safe completion of the special technique. However, after the teaching has been successfully completed, repetition of the exercise, and monitoring for the completion of the task, in the absence of additional skilled care, is non-covered. Documentation should include not only measurable indicators such as functional loss of joint motion or muscle strength, but also information on the impact of these limitations on the patient’s life and how improvement in one or more of these measures leads to improved function. For many patients a passive-only exercise program should not be used more than 2-4 visits to develop and train the patient or caregiver in performing PROM.

97112-Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (one or more areas, each 15 minutes) would be used if PNF or techniques for tone reduction are delivered.

97140-Manual Therapy Techniques (e.g.,mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes. Joint Mobilization (peripheral and/or spinal) may be considered reasonable and necessary if

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restricted or painful joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure. Myofascial release/soft tissue mobilization, one or more regions, may be reasonable and necessary for treatment of restricted motion of soft tissue. Documentation should include the area(s) being treated; soft tissue or joint mobilization technique used; objective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on function.

97760- orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s), and/or trunk, each 15 minutes. Code 97760 includes initial fit and training, additional orthotic management and training during follow-up visits including instruction in skin care and orthotic wearing time, and time associated with modification of the orthotic due to healing of tissues, change in edema, or interruption in skin integrity. To bill for training the patient to use the orthotic the documentation must justify the need for a skilled qualified professional/auxiliary personnel to train the patient in the use and care of the orthotic. When the management of the orthotic can be turned over to the patient, the caregiver or nursing staff, the services of the therapist will no longer be covered. Once the initial fit is established and training is complete, any further visits for specific documented problems and modifications that require skilled therapy should be billed with CPT 97762. Supportive Documentation Recommendations for 97760 include: description of the patient’s condition (including applicable impairments and functional limitations) that necessitates an orthotic; any complicating factors; specific orthotic provided and the date issued; description of the skilled training provided; and response of the patient to the orthotic. Many contractors have determined that for uncomplicated conditions, the following services would not be considered reasonable and necessary as they would not require the unique skills of a therapist. • Issuingoff-the-shelfsplintsforfootdroporwristdrop • Issuingoff-the-shelffootorelbowcradlesforroutinepressure relief (these are not considered orthotics) • Issuing“carrots”(i.e.,cylindrical,cone-shapedforms)ortowel rolls for hand contractures for hygiene purposes

• Bedpositioning(e.g.,pillows,wedges,rolls,footcradlesto relieve potential pressure areas) • Repetitiverangeofmotionpriortoplacinganorthotic/ positioner to maintain the range of motion is not reasonable and necessary when the therapeutic intent is primarily to maintain range of motion within a chronic condition. • Ongoingtherapyvisitsforincreasingwearingtimeare generally not reasonable and necessary when patient problems related to the orthotic have not been observed.

97762-checkout for orthotic/prosthetic use, established patient, each 15 minutes. These assessments are intended for established patients who have already received their orthotic or prosthetic device and include patient’s response to wearing the device, whether the patient is donning/doffing the device correctly, patient’s need for padding, underwrap, or socks, and of the patient’s tolerance to any dynamic forces being applied. If the checkout assessment results in the need for further training in the use of the orthotic, code 97760 would be appropriate for the training. Supportive Documentation Recommendations for 97762 include: reason for assessment; findings from the assessment; specific device, modifications made, and instruction given.

2. I have begun to see patients for incontinence. Can you please review the billing regulations for use of electrical stimulation and biofeedback?

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8 provides guidance on the use of Non-implantable pelvic floor electrical stimulators to provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength. Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283. The patient’s medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training. Some patients can be trained

in the use of a home muscle stimulator for retraining weak muscles. Only 1-2 visits should be necessary to complete the training. Once training is completed, this procedure should not be billed as a treatment modality in the clinic.

Biofeedback is covered for the treatment of stress and/or urge incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. A failed trial of PME training is defined as no clinically significant improvement in urinary incontinence after completing four weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength. Medicare will allow biofeedback as an initial incontinence treatment modality only when, in the opinion of the physician, that approach is most appropriate and there is documentation of medical justification and rationale for why a PME trial was not attempted first. Biofeedback for incontinence should be billed with CPT code 90911 which describes biofeedback that is more involved than conventional biofeedback measures (code 90901) and includes evaluations of the EMG activity of the pelvic muscles, urinary sphincter and/or anal sphincter by using sensors and/or manometry (measure of pressure of gases or liquids by use of a manometer). When providing biofeedback procedures for urinary incontinence, use CPT 90901 when EMG and/or manometry are not performed.

Patient selection is a major part of the process and the patient should be motivated, cognitively intact, and compliant. In addition, there must be assurance that the pelvic floor musculature is intact. Biofeedback therapy has proven successful for urinary incontinence when all three of the following conditions exist: • thepatientiscapableofparticipationintheplanofcare; • thepatientismotivatedtoactivelyparticipateintheplanofcare, including being responsive to the care requirements (e.g., practice and follow-through by self or caregiver); and • thepatient’sconditionisappropriatelytreatedwithbiofeedback (e.g., pathology does not exist preventing success of treatment).

Biofeedback is non-covered for: • homeuseofbiofeedbacktherapy; • pelvicfloorelectricalstimulationlackingdocumentationofthe failure of a trial of pelvic muscle exercise (PME) training, unless there is physician documentation justifying the need to initiate treatment with biofeedback before PME is attempted; • patientswhodonothavesufficientcognitiveabilitytoadheretoand follow the PME protocol and/or cooperate in keeping a personal voiding diary.

Decoding CPT CodesEach quarter we focus on decoding the mystery of a specific CPT code. This quarter we will focus on CPT code 97140-Manual Therapy Techniques (e.g.,mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes. • Manual traction may be considered reasonable and necessary for cervical dysfunctions such as cervical pain and cervical radiculopathy. • Joint Mobilization (peripheral and/or spinal) may be considered reasonable and necessary if restricted or painful joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure. • Myofascial release/soft tissue mobilization, one or more regions, may be reasonable and necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems. • Manipulation, which is a high-velocity, low-amplitude thrust technique or Grade V thrust technique, may be reasonable and necessary for treatment of painful spasm or restricted motion in the periphery, extremities or spinal regions. • Manual lymphatic drainage/complex decongestive therapy (MLD/CDT) MLD / CDT is indicated for both primary and secondary lymphedema. Lymphedema in the Medicare population is usually secondary lymphedema, caused by known precipitating factors such as surgical removal of lymph nodes, fibrosis secondary to radiation, and traumatic injury to the lymphatic system. MLD/CDT consists of skin care, manual lymph drainage, compression wrapping, and therapeutic exercises. Coverage of MLD / CDT would only be allowed if all of the following conditions have been met: • thereisaphysician-documenteddiagnosisoflymphedema (primary or secondary); • thepatienthasdocumentedsignsorsymptomsof lymphedema; • thepatientorpatientcaregiverhastheabilityto understand and comply with the continuation of the treatment regimen at home.

MLD/CDT is not covered for: • conditionsreversiblebyexerciseorelevationoftheaffectedarea; • dependentedemarelatedtocongestiveheartfailureorother cardiomyopathies; • patientswhodonothavethephysicalandcognitiveabilities,or support systems, to accomplish self-management in a reasonable time; • continuingtreatmentforapatientnon-compliantwitha program for self-management.

Supportive Documentation Requirements for 97140: • Area(s)beingtreated • Softtissueorjointmobilizationtechniqueused • Objectiveandsubjectivemeasurementsofareastreated(may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on function • ForMLD/CDP,supportivedocumentationshouldinclude: •medicalhistoryrelatedtoonset,exacerbationandetiologyof the lymphedema • comorbidities • priortreatment • cognitiveandphysicalabilityofpatientand/orcaregiverto follow self-management techniques; • pain/discomfortdescriptionsandratings; • limitationoffunctionrelatedtoself-care,mobility,ADLs and/or safety; • priorleveloffunction; • limbmeasurementsofaffectedandunaffectedlimbsatstartof care and periodically throughout treatment; • descriptionofskincondition,wounds,infectedsites,scars.

Keeping Straight on the Regulation Road:MedPAC Recommends Reforming Outpatient Therapy PaymentThe Patient Protection and Affordable Care Act requires MedPAC to report recommendations to Congress on changes to outpatient therapy services by June 15, 2013. The Medicare Payment Advisory Commission recommended changes to reform the Medicare benefit for outpatient physical and occupational therapy and speech-language pathology. The final recommendations include reducing the therapy cap to $1,270 and applying a manual medical review process for all requests that exceed the cap amount; permanently including services delivered in hospital outpatient departments under the cap; and reducing the practice expense payment by 50% when multiple therapy services are provided to the same patient on the same day. The Commission stated that the changes would ensure program integrity of outpatient therapy services, ensure access to outpatient therapy services while managing Medicare’s cost, and improve management of the benefit in the longer term. Congress has not acted on any of these recommendations.

CMS released Calendar Year 2013 Final Rule for the Physician Fee Schedule on November 1, 2012

On November 1st, 2012 the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will update payment policies and rates for physicians and nonphysician practitioners (NPPs) for services paid under the Medicare Physician Fee Schedule (MPFS) in calendar year (CY) 2013. This is the same fee schedule used to pay for Part B therapies in outpatient and nursing facilities. Highlights of provisions in the final rule for the physician fee schedule that will impact therapy are discussed below.

CY 2013 payment rates face a 26.5% reduction

The final rule includes a 26.5% across-the-board reduction to Medicare payment rates for physicians, physical therapists, and other professionals due to the flawed sustainable growth rate (SGR) formula. Since 2003, Congress had enacted legislation preventing thereductioneveryyear.CMSannouncesthatitis“committedtofixing the SGR update methodology and ensuring these payment cutsdonottakeeffect.”Excludingthe26.5%projectedSGRpayment cut, the aggregate impact on payment of changes in the rule for outpatient physical therapy is a positive 4% in 2013.

Functional Limitation ReportingAs required by the Middle Class Tax Relief Jobs Creation Act of 2012, CMS will begin to collect data on claim forms about patient functional status for patients receiving outpatient physical therapy, speech therapy, and occupational therapy beginning January 1, 2013. Therapists will be required to report new G codes accompanied by modifiers on the claim form that convey information about a patient’s functional limitations and goals at initial evaluation, every 10 visits, and at discharge. This data is for informational purposes and not linked to reimbursement. Until July 1, 2013, claims will be processed regardless of the inclusion of functional limitation codes. Beginning July 1, 2013, all claims must include the functional limitation codes in order to be paid by Medicare.

Therapy Cap LimitationsThe dollar amount of the therapy cap in CY 2013 will be $1900. The exceptions process will no longer be in effect after December 31, 2012. Congressional action is necessary to extend the exceptions process. Multiple Procedure Payment Reduction (MPPR) No revisions were made to CMS’s policy regarding application of the MPPR to outpatient therapy services. MPPR is a reduction to the practice expense portion of the payment for a therapy procedure when more than one unit or procedure is provided to the same patient on the same date of service. The MPPR of 25% for services furnished in an institutional setting and 20% for services furnished in a non-institutional setting remains unchanged.

2013 Therapy Cap LimitationsThe Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) set annual caps for Part B Medicare therapy patients. These limits change annually. Therapy caps for 2013 will be $1900 for physical therapy and speech therapy combined and $1900 for occupational therapy.

Therapy Cap Exceptions Process Expires Dec. 31, 2012 Unless Congress Acts

Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, which added §1834(k)(5) to the Act, required payment under a prospective payment system (PPS) for outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). Section 4541(c) of the BBA required application of financial limitations to all outpatient rehabilitation services (except those furnished by or under arrangements with a hospital).

Since the creation of therapy caps, Congress has enacted several moratoria. The Deficit Reduction Act of 2005 directed CMS to develop exceptions to therapy caps for calendar year 2006 and the exceptions have been extended periodically. Exceptions to caps based on the medical necessity of the service are in effect only when Congress legislates the exceptions. In 2006, the Exception Processes fell into two categories, Automatic Process Exceptions, and Manual Process Exceptions. Beginning January 1, 2007, there is no manual process for exceptions. All services that require exceptions to caps shall be processed using the automatic process. All requests for exception are in the form of a KX modifier added to claim lines. The KX modifier is added to claim lines to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record.

The automatic process for exceptions will expire on December 31, 2012 if congress does not act to extend the exception process. This will result in Medicare Part B therapy patients being limited to a cap of $1900 for physical therapy and speech therapy combined and $1900 for occupational therapy in 2013.

2013 Medicare Copays and DeductiblesCMS released information on the copays and deductibles for Medicare Part A and Part B services in 2013. The Part A deductible paid by a beneficiary when admitted as a hospital inpatient will be $1,184 in 2013, an increase of $28 from this year’s $1,156 deductible. The Part A deductible is the beneficiary’s cost for up to 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries must pay an additional $296 per day for days 61 through 90 in 2013, and $592 per day for hospital stays beyond the 90th day in a benefit period. For beneficiaries in skilled nursing facilities, the daily co-insurance for days 21 through 100 in a benefit period will be $148.00 in 2013, compared to $144.50 in 2012. In 2013, the Part B deductible will be $147, an increase in $7.00 from 2012 and the Part B copay will remain 20%.

Functional Limitation Reporting Under Medicare Part B The Middle Class Tax Relief Act of 2012 included a mandate that CMS collect information on Medicare Part B claims regarding the beneficiaries function and condition, therapy services furnished, and outcomes achieved. CMS intends to utilize this information in the future to reform payment for outpatient therapy services. The policy applies to physical therapy, occupational therapy, and speech therapy services furnished in hospitals, Critical Access Hospitals (CAH’s), Skilled Nursing Facilities (SNF’s), 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 nonphysician practitioners. The reporting of the functional limitations on the claim form will be implemented on January 1, 2013. To assure smooth transition, CMS has set forth a testing period from January 1, 2013, until July 1, 2013. After July 1, 2013, claims submitted without the appropriate G-codes and modifiers will be returned unpaid.

Functional Limitation Reporting FAQs:

How is this information reported? Under this new rule nonpayable G-codes and modifiers will be included on the claim form to capture data on the beneficiary’s functional limitations.

How frequently must this information be reported? Nonpayable G-codes and modifiers will be included on the claim forms to capture data on the beneficiary’s functional limitations (a) at the outset of the therapy episode; (b) at a minimum every 10th visit; and (c) at discharge. In addition, the therapist’s projected goal for functional status at the end of treatment will be reported on the first claim for services and at the end of the episode. Modifiers will indicate the extent of the severity/complexity of the functional limitation.

What are the nonpayable G-codes for reporting functional limitation? G-Codes for Claims-Based Functional Reporting for CY 2013

Mobility: Walking & Moving Around

G8978 Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals

G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting

Changing & Maintaining Body Position

G8981 Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals

G8982 Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8983 Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting

Carrying, Moving & Handling Objects

G8984 Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals

G8985 Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8986 Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting

Self Care

G8987 Self care functional limitation, current status, at therapy episode outset and at reporting intervals

G8988 Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8989 Self care functional limitation, discharge status, at discharge from therapy or to end reporting

Other PT/OT Primary Functional Limitation

G8990 Other physical or occupational primary functional

limitation, current status, at therapy episode outset and at reporting intervals

G8991 Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8992 Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting

Other PT/ OT Subsequent Functional Limitation

G8993 Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals

G8994 Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8995 Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting

Speech Language Pathology Functional Limitation

G8996 Swallowing functional limitation, current status at time of

initial therapy treatment/episode outset and at eporting intervals

G8997 Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge or to end reporting

G8998 Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation

G8999 Motor speech functional limitation, current status at time of initial therapy treatment/episode outset and at reporting intervals

G9157 Motor speech functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9158 Motor speech limitation, discharge status at discharge from therapy/end of reporting on limitation

G9159 Spoken Language Comprehension functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9160 Spoken Language Comprehension functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9161 Spoken Language Comprehension functional limitation, discharge status at discharge from therapy/end of reporting on limitation

G9162 Spoken Language Expression functional limitation, current status at time of initial therapy treatment/episode outset and at reporting intervals

G9163 Spoken Language Expression functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9164 Spoken Language Expression functional limitation, discharge status at discharge from therapy/end of reporting on limitation

G9165 Attention functional limitation, current status at time of initial therapy treatment/episode outset and at reporting intervals

G9166 Attention functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9167 Attention functional limitation, discharge status at discharge from therapy/end of reporting on limitation

G9168 Memory functional limitation, current status at time of initial therapy treatment/episode outset and at reporting intervals

G9169 Memory functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9170 Memory functional limitation, discharge status at discharge from therapy/end of reporting on limitation

G9171 Voice functional limitation, current status at time of initial therapy treatment/episode outset and at reporting intervals

G9172 Voice functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9173 Voice functional limitation, discharge status at discharge from therapy/end of reporting on limitation

G9174 Other speech language pathology functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9175 Other speech language pathology functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9176 Other speech language pathology functional limitation, discharge status at discharge from therapy/end of reporting on limitation

What limitation category should I choose for my patient if I use a composite functional tool such as Focus on Therapeutic Outcomes (FOTO)?

In this instance, a composite score should be reported using G8990 (Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals), G8991(Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting) and G8992 (Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting). Should there be the occasion to report on a second condition after the reporting on the first had ended, the therapist would use the G-codesetfor“othersubsequent”functionallimitation,G8993-G8896.

If my patient has more than one functional limitation, do I report multiple categories of functional limitation?

No, at this time you only report one, primary functional limitation to Medicare for each patient. In situations where treatment continues after the treatment goal is achieved and reporting ended on the primary functional limitation, reporting will be required for another functional limitation. 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.

How is the patient’s functional limitation severity reported?

Functional limitation severity is reports using one of seven modifier codes seen in the table below.

Severity/Complexity Modifiers for CY 2013

Modifier Impairment Limitation Restriction CH 0 percent impaired, limited or restrictedCI At least 1 percent but less than 20 percent impaired, limited or restrictedCJ At least 20 percent but less than 40 percent impaired, limited or restrictedCK At least 40 percent but less than 60 percent impaired, limited or restrictedCL At least 60 percent but less than 80 percent impaired, limited or restrictedCM At least 80 percent but less than 100 percent impaired, limited or restrictedCN 100 percent impaired, limited or restricted

How do I determine the appropriate severity modifier for my patient?

Therapists must use a valid and reliable objective measure and/or assessment to quantify functional limitations. In some instances, therapists may use more than one assessment tool to determine the patient’s functional limitation severity. It is acceptable for therapists to use their professional judgment in the selection of the appropriate modifier.

Do I need to document how I selected the severity modifier?

Yes, therapists will need to document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.

How frequently must I submit functional limitation information to CMS on my patient?

Therapists must report the current functional limitation of their patients at outset (initial evaluation), every 10th visit, and at discharge.

How frequently do I report goals on my patient?

Therapists must report the projected goal of their patients at outset (initial evaluation), every 10th visit, and at discharge.

What if my patient does not return for their discharge appointment or discontinues therapy prior to formal discharge?

Discharge reporting is required except in cases where therapy services are discontinued by the beneficiary prior to the planned discharge visit.

Do I need to report function limitation information if I perform a re-evaluation?

Yes, the therapist is required to begin a new reporting period when submitting a claim containing a CPT code for an evaluation or a re-evaluation. In this instance the therapist must submit information on the current functional status and the projected patient goal.

When do I begin reporting a subsequent functional limitation if the primary limitation has resolved? If the primary functional limitation is resolved, but care continues to address another or subsequent limitation, the therapist reports that limitation after the primary limitation reporting is concluded.

Do I need to document the G-codes in the medical record?

Yes, the G-code descriptor and related modifier is required to be documented in the medical record. In cases where the therapist uses other information in addition to certain measurement tools in order to assess functional impairment, documentation of the relevant information used to determine the overall percentage of functional limitation to select the severity modifier should also be included in the record.

Do I need to include the GP, GO or GN modifier when I report the functional limitation G-code?

Yes, for each nonpayable G-code on the claim, that line of service would also need to contain one of the severity modifiers, the corresponding GO, GP, or GN therapy modifier to indicate the respective occupational, physical, or speech language therapy discipline and related plan of care; and the date of service it references.

What do I submit with each G-code?

When reporting the functional limitation of a patient to Medicare you must submit the G-code, a severity modifier, and the corresponding therapy modifier (GO, GP, or GN). Additionally, for each line on the institutional claim submitted by hospitals, SNFs, rehabilitation agencies, CORFs and HHAs, a charge of one penny, $0.01, can be added. For each line on the professional claim submitted by private practice therapists and physician/NPPs, a charge of $0.00 can be added.

CMS Released FY 2012 SNF PPS Monitoring Activities Report

CMS released a report detailing the FY 2012 SNF PPS Monitoring Activities which presents an updated look at the third quarter impact of the FY 2012 policy changes including the recalibration of the parity adjustment, allocation of group therapy and changes to the MDS including the introduction of the Change-of-Therapy (COT) Other Medicare Required Assessment (OMRA). Below are some of the highlights.

• Overallpatientcasemixisnotsignificantlydifferentfrom that observed in FY 2011--there have been small decreases in the Rehabilitation Plus Extensive Services categories, and increases in some of the medically-based RUG categories, most notably Special Care.

FY 2011 FY2012 QTR 1, 2, & 3

Rehabilitation Plus 2.5% 1.8% Extensive Services Rehabilitation 87.9% 88.5% Extensive Services 0.6% 0.7% Special Care 4.6% 5.1% Clinically Complex 2.5% 2.2% Behavioral Symptoms and 0.4% 0.3% Cognitive Performance

Reduced Physical Function 1.5% 1.4% • ThepercentageofresidentsinUltra-HighRehabilitationhas increased from FY 2011 and although there have been decreases in the High and Medium therapy RUG-IV categories, CMS stated that some of the decrease may be due to index maximization into the Special Care category.

FY 2011 FY 2012 QTR 1, 2, & 3

Ultra-High Rehabilitation 44.9% 46.9% (≥ 720 minutes of therapy per week)

Very-High Rehabilitation 26.9% 26.2% (500 – 719 minutes of therapy per week)

High Rehabilitation 10.8% 10.5% (325 – 499 minutes of therapy per week)

Medium Rehabilitation 7.6% 6.5% (150 – 324 minutes of therapy per week)

Low Rehabilitation 0.1% 0.1% (45 – 149 minutes of therapy per week)

• InitialFY2012dataindicatethataftertheallocationofgroup therapy facilities are providing individual therapy almost exclusively.

STRIVE FY 2011 FY 2012 QTR 1, 2, & 3 Individual 74% 91.8% 99.5% Concurrent 25% 0.8% 0.4% Group <1% 7.4% 0.1%

• CMSstatedinthisreportthatpriortotheimplementation of the COT OMRA, scheduled PPS assessments comprised the majority of the completed assessments. With the addition of the COT OMRA, scheduled PPS assessments continue to be the majority of the completed assessments; however, the COT OMRA is the most frequently completed unscheduled assessment.

FY 2011 FY 2012 QTR 1, 2, & 3

Scheduled PPS assessment 95% 84%

Start-of-Therapy (SOT) assessment 2% 2%

End-of-Therapy (EOT) assessment 3% 3% (w/o Resumption)

Combined SOT/EOT 0% 0%

End-of-Therapy assessment N/A 0% (w/ Resumption) (EOT-R)

Combined SOT/EOT-R N/A 0%

Change-of-Therapy (COT) assessment N/A 11%

Proposed Settlement Agreement Filed in “Improvement Standard” Case

Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) haveagreedtosettlethe“ImprovementStandard”case,Jimmov.Sebelius, No. 11-cv-17 (D.VT), filed January 18, 2011. A proposed settlement agreement was filed in federal District Court on October 16, 2012. When the judge approves the proposed agreement, a process that may take several months, CMS will revise the Medicare Benefit Policy Manual and other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary “improving”whichiscurrentlyoftenusedasadenialreason.AsCMS recognizes, the settlement does not change the underlying law and regulations governing the Medicare program. Accordingly, since the underlying Medicare law is not changed, health care providers should implement the maintenance standard now. Thus, health care providers should apply the maintenance standard and provide medically necessary nursing services or therapy services, or both, to patients who need them to maintain their function, or prevent or slow their decline.

TheJimmosettlementalsoestablishesaprocessof“re-review”forMedicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy) that became final and non-appealable after January 18, 2011 because of the Improvement Standard. Shortly after the federal district court approves the settlement, CMS will announce how beneficiaries can invoke the re-review process.

2013 OIG Work Plan Released

The Office of Inspector General Work Plan for Fiscal Year 2013 provides brief descriptions of activities that the Office of Inspector General (OIG) plans to initiate or continue with respect to the programs and operations of the Department of Health & Human Services in fiscal year 2013. For each review, the Work Plan describes the subject, primary objective, and criteria related to the topic. In 2013, the areas of focus for nursing homes are:

Nursing Homes—Adverse Events in Post-Acute Care for Medicare Beneficiaries

The OIG will estimate the national incidence of adverse and temporary harm events for Medicare beneficiaries receiving postacute care in SNFs and inpatient rehabilitation facilities (IRF). The OIG will also identify contributing factors to these events, determine the extent to which the events were preventable, and estimate the associated costs to Medicare.

Nursing Homes—Medicare Requirements for Quality of Care in Skilled Nursing Facilities

Federal laws require nursing homes participating in Medicare or Medicaid to use RAIs to assess each nursing home resident’s strengths and needs. Prior OIG reports revealed that about a quarter of residents’ needs for care, as identified through RAIs, were not reflected in care plans and that nursing home residents did not receive all the psychosocial services identified in care plans.

The OIG will review how SNFs have addressed certain Federal requirements related to quality of care. The OIG will determine the extent to which SNFs use the Residential Assessment Instruments (RAI) to develop care plans to provide services to beneficiaries in accordance with the plans of care and to plan for beneficiaries’ discharges. The OIG will also describe any instances of poor quality of care.

Nursing Homes—State Agency Verification of Deficiency Corrections (New)

Federal regulations require nursing homes to submit correction plans to the State survey agency or CMS for deficiencies identified during surveys. CMS requires State survey agencies to verify the correction of identified deficiencies through onsite reviews or by obtaining other evidence of correction. (State Operations Manual, Pub. No. 100-07, § 7300.3.) A prior OIG review found that one State survey agency did not always verify that nursing homes corrected deficiencies identified during surveys in accordance with Federal requirements.

The OIG will determine whether State survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys.

Nursing Homes—Oversight of Poorly Performing Facilities

The OIG will identify poorly performing nursing homes and determine the extent to which CMS and States use enforcement measures to improve nursing home performance. The OIG will also identify CMS and States’ follow up actions to ensure that poorly performing nursing homes implement corrective actions. The OIG will examine enforcement decisions by CMS and States resulting from surveys and complaint allegations

Nursing Homes—Use of Atypical Antipsychotic Drugs (New)

According to 42 CFR § 488.3, nursing homes must comply with Federal quality and safety standards, including requiring the monitoring of the prescription drugs prescribed to its residents. Federal requirements, 42 CFR § 483.25(l)(1), also require that nursing home residents’ drug regimens be free from unnecessary drugs.

The OIG will assess nursing homes’ administration of atypical antipsychotic drugs, including the percentage of residents receiving these drugs and the types of drugs most commonly received. The OIG will also describe the characteristics associated with nursing homes that frequently administer atypical antipsychotic drugs.

Nursing Homes—Hospitalizations of Nursing Home Residents

Hospitalizations of nursing home residents are costly to Medicare and may indicate quality-of-care problems at nursing homes. A 2007 OIG review found that 35 percent of hospitalizations during a SNF stay were caused by poor quality of care or unnecessary fragmentation of services. The OIG will determine the extent to which Medicare beneficiaries residing in nursing homes have been hospitalized. The OIG will also determine the extent to which hospitalizations were a result of manageable or preventable conditions.

Nursing Homes—Questionable Billing Patterns for Part B Services During Nursing Home Stays

The OIG will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents. A series of studies will examine podiatry, ambulance, laboratory, and imaging services.

Nursing Homes—Oversight of the Minimum Data Set Submitted by Long-Term-Care Facilities (New)

Certified nursing facilities are required to complete the MDS for all residents at specified intervals and submit data electronically to the State. States then submit data to CMS, which uses it for a number of programs, including payment, quality monitoring, and consumer information. The OIG will determine whether and the extent to which CMS and the States oversee the accuracy and completeness of Minimum Data Set (MDS) data submitted by nursing facilities.

Medicare Auditors Becoming More Active, Denying More ClaimsA new survey conducted by the American Hospital Association found that requests for medical records by Medicare’s recovery audit contractors (RACs) jumped sharply from the first- to the second-quarter of fiscal year 2012. RACs requested 546,000 medical records in the second quarter of 2012. That’s a 22% increase over the 448,000 the previous quarter. Providers also experienced an increase in the denial of claims, both automated and complex over that same time, AHA survey results showed. The survey found that more than half of the providers surveyed had spent $10,000 to oversee the audit process, and 9% spent over $100,000 on it.

New Bill Would Limit Power of Medicare Recovery Audit Contractors

In October, Reps. Sam Graves (R-MO) and Adam Schiff (D-CA) proposed the Medicare Audit Improvement Act (H.R. 6575) which would limit the power of Medicare Contractors. The bill was referred to House Ways and Means, House Energy and Commerce on October 16, 2012, which will consider it before possibly sending it on to the House or Senate as a whole.

HR 6575, if passed in the House and Senate and signed by the President, would: • Limitthenumberofadditionaldocumentationrequestsmade by Medicare contractors;

• Imposepenaltiesforfailuretomeetcertaintimeframesandfor overturned appeals;

• Requiremedicalnecessityauditstofocusonwidespread payment error rates;

• IncreasetransparencyofRACperformance;

• RestoredueprocessrightsundertheABrebilling demonstration;

• Requireaccuratepaymentforrebilledclaims;and

• Requirephysicianvalidationformedicalnecessitydenials.

Below is a summary of a number of these provisions as they pertain to RACs, specifically.

Limiting Documentation RequestsIf enacted, the Secretary of HHS (Secretary) must establish a process where the number of additional document requests of a hospital made by a Medicare contractor, as it relates to part A claims, in a year is the lesser of: 1. 2% of all of the claims for that year; or 2. 500 additional documentation requests during a 45-day period.

Importantly,thisstatuteappliestorequestsmadebya“Medicarecontractor”notjustaRAC.Medicarecontractor,forpurposesof this bill, means a Medicare administrative contractor, fiscal intermediary, carriers, RACs, Zone Program Integrity contractors, Program Safeguard Contractors, and Comprehensive Error Rate Testing program contractors.

Penalties and Audits on Widespread Payment ErrorsHR 6575 would require the contracts between the Secretary and the RACs to include the following: • ImpositionoffinancialpenaltiesiftheSecretarydetermines that the RAC exhibits a pattern of failure to: furnish a demand letter in a timely fashion or complete a determination with respect to each audit in a timely fashion;

• Impositionofpenaltiesforoverturnedappeals;

• TheSecretarywillnotapproveapost-paymentorprepayment medical necessity audit unless the review addresses a widespread payment error rate;

• TheRACwillterminateanauditifitisdeterminedthatthe applicable payment error rate is no longer a widespread payment error; and

• RACsmayonlyconductprepaymentreviewspursuantto guidelines established by the Secretary.

Transparency of RAC Performance

Information on RAC performance would be published annually on the CMS website and would, with respect to each RAC, display the information on audit rates, denials and appeals outcomes as well as the results of any performance evaluation audit conducted by an independent entity.

Requiring Physician Validation for Medical Necessity Denials

When a RAC denies a claim for medical necessity, that RAC would have to have a physician review each medical necessity denial and determine whether the denial by the non-physician RAC employee was appropriate, sign and certify the determination, and append the signed and certified determination to the claim file. If it is determined that the non-physician RAC employee’s denial was inappropriate, the claim would be deemed medically necessary.

CMS Released Fiscal Year-End Improper Payment Figures for Recovery Auditors

CMS releases Recovery Auditor overpayment and underpayment statistics at the close of each fiscal year (FY) quarter.

In FY 2010, Recovery Auditors collected $75.4 million in overpayments and identified $16.9 million in underpayments for a total correction amount of $92.3 million. Last year, Recovery Auditors recouped $797.4 million in overpayments and reported $141.9 million in underpayments for a total correction amount of $939.9 million. In FY 2012, Recovery Auditors collected a total of $2.29 billion in overpayments and identified $109.4 million in underpayments for a total of $2.4 billion in corrections. However, the report is somewhat incomplete since it does not reflect what was recouped after the appeals are done.

FY 2010 FY 2011 FY 2012 Total national Oct 2009- Oct 2010– Oct 2011– program Sept 2010 Sept 2011 Dec 2012 Overpayments $75.4M $797.4M $2,291.3M $3.16Bcollected

Underpayments $16.9M $141.9M $109.4M $268.2Mreturned

Total corrections $92.3M $939.M $2,400.7M $3.43B

CMS’ report each quarter includes the top Recovery Auditor issue per region. For this past quarter, the issues remained the same:

• RegionA:Cardiovascularprocedures

• RegionB:Cardiovascularprocedures

• RegionC:Cardiovascularprocedures • RegionD:Minorsurgeryandothertreatmentbilledasinpatient

CMS also provides a drilldown of total correction numbers for the past quarter for each Recovery Auditor region. Performant Recovery (Region A) and CGI (Region B) both saw their total quarter numbers dip slightly compared to the previous quarter, while Connolly (Region C) and HealthDataInsights (Region D) saw slight upticks. The following chart shows the overpayments, underpayments, and total corrections for the quarter and fiscal year to date, with figures provided in millions:

Overpayments Underpayments Total quarter FY to date collected returned corrections corrections

Region A $142.0 $10.9 $152.9 $475.6

Region B $42.1 $3.5 $45.6 $277.6

Region C $225.7 $22.1 $247.8 $792.5

Region D $238.2 $10.0 $248.2 $854.9

Nationwide $648.0 $46.5 $694.5 $2,400.7totals

Providers should prepare to face even more audits under healthcare reform

Providers need to have the appropriate staff and data analytics programs in place to defend against the onslaught of more Medicare and Medicaid claims audits, according to healthcare expert Robert Freedman. As more provisions of the Affordable Care Act are implemented, Medicare and Medicaid providers should expect more scrutiny from Recovery Audit Contractors (RAC), Medicare Administrative Contractors (MAC), and comprehensive error rate testing contractors.Freedman said provider compliance officers should be prepared to spend a lot more of their time appealing and defending audits, according to a report by the Bureau of National Affairs. Data mining and data analytics programs can help providers make sure their billing operations don’t stand out, Freedman advised.

Report Released on Shortfalls in Medicaid Funding for Nursing Center Care

The bleak Medicaid picture is unlikely to get better in 2013 for nursing home operators according to a report commissioned by the American Health Care Association and conducted by Eljay, LLC. Medicaid underpayments are expected to exceed $7 billion nationally in 2012, an average shortfall of $22.34 per resident day. That’s up from $18.54 in 2010,notesthe“ReportonShortfallsinMedicaidFundingforNursingCenterCare.”Brokendownintothecostsforatypical100-bedfacility,where 63% of residents are on Medicaid, the shortfall translates into $500,000 each year.

The report notes a few factors that will make Medicaid funding even more challenging moving forward: dual-eligible integration likely will have implications for both Medicaid long-stay occupants and Medicare-financed post-acute care average length of stay. The

federal government is also pushing for expansion of home- and community-based services, which also are expected to drive down average occupancy rates. Many states also are pushing for managed care plans for Medicaid beneficiaries.

Improvements are Needed at the Administrative Law Judge Level of Medicare Appeals

In a study that analyzed all ALJ appeals decided in fiscal year (FY) 2010, policies, procedures, other documents and data on CMS participation in ALJ appeals and consisted of structured interviews with ALJs and other staff; Qualified Independent Contractors (QIC), and CMS staff, the OIG found that providers filed the vast majority of ALJ appeals in FY 2010, with a small number accounting for nearly one-third of all appeals. For 56 percent of appeals, ALJs reversed QIC decisions and decided in favor of appellants; this rate varied substantially across Medicare program areas. Differences between ALJ and QIC decisions were due to different interpretations of Medicare policies and other factors. In addition, the favorable rate varied widely by ALJ. When CMS participated in appeals, ALJ decisions were less likely to be favorable to appellants. Staff raised concerns about the acceptance of new evidence and the organization of case files. Finally, ALJ staff handled suspicions of fraud inconsistently.

The OIG recommended that OMHA and CMS: (1) develop and provide coordinated training on Medicare policies to ALJs and QICs, (2) identify and clarify Medicare policies that are unclear and interpreted differently, (3) standardize case files and make them electronic, (4) revise regulations to provide more guidance to ALJs regarding the acceptance of new evidence, and (5) improve the handling of appeals from appellants who are also under fraud investigation and seek statutory authority to postpone these appeals when necessary. Further, the OIG recommended that OMHA: (6) seek statutory authority to establish a filing fee, (7) implement a quality assurance process to review ALJ decisions, (8) determine whether specialization among ALJs would improve consistency and efficiency, and (9) develop policies to handle suspicions of fraud appropriately and consistently and train staff accordingly. Finally, the OIG recommended that CMS: (10) continue to increase CMS participation in ALJ appeals. OMHA and CMS concurred fully or in part with all 10 of the recommendations.

All Eyes on Therapy Therapy remains the focus of many Medicare Administrative Contractors (MACs)/Fiscal Intermediaries (FIs) as well as the Regulatory and Law Enforcement Agencies of the Federal Government as the commitment to deterring fraud, waste and abuse in the Medicare and Medicaid systems has increased.

OIG Report: Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009

In recent years, the Office of Inspector General has identified a number of problems with billing by skilled nursing facilities (SNF), including the submission of inaccurate, medically unnecessary, and fraudulent claims. Further, the Medicare Payment Advisory Commission has raised concerns about SNFs’ improperly billing for therapy to obtain additional Medicare payments. In fiscal year (FY) 2012, Medicare paid $32.2 billion for SNF services.

The OIG based this study on a medical record review of a stratified random sample of SNF claims from 2009. The reviewers determined whether the information reported by the SNFs on the Minimum Data Set (MDS) was supported by and consistent with the medical record. The OIG found that SNFs billed one-quarter of all claims in error in 2009, resulting in $1.5 billion in inappropriate Medicare payments. The majority of the claims in error were upcoded; many of these claims were for ultrahigh therapy. The remaining claims in error were downcoded or did not meet Medicare coverage requirements. In addition, SNFs misreported information on the MDS for 47 percent of claims. SNFs commonly misreported therapy, which largely determines the RUG and the amount that Medicare pays the SNF.

The OIG recognized that CMS has recently made several significant changes to SNF payments and made the following recommendations to CMS to which CMS concurred with all six: (1) Increase and expand reviews of SNF claims, (2) Use its Fraud Prevention System to identify SNFs that are billing for higher paying RUGs, (3) Monitor compliance with new therapy assessments, (4) Change the current method for determining how much therapy is needed to ensure appropriate payments, (5) Improve the accuracy of MDS items, and (6) Follow up on the SNFs that billed in error.

Owner of Old Saybrook Physical Therapy Practice Pleads Guilty to Obstructing Federal Audit

The United States Attorney for the District of Connecticut announced that Todd Roberts, 47, of Old Saybrook, waived his right to indictment and pleaded guilty to one count of obstructing a federal audit.

According to court documents and statements made in court, Roberts is the owner and operator of Roberts Physical and Aquatic Therapy, located at 210 Main Street in Old Saybrook. On January 23, 2009, a Medicare contractor informed Roberts Physical and Aquatic Therapy that the contractor was performing an audit of the practice. Roberts instructed an employee to delay the audit by telling the contractor that medical records were stored at a nonexistent storage facility. Roberts then rented a storage unit at a local facility and used the delay to alter and augment patient records. Specifically, Roberts, and an employee at his direction, created and added patient progress notes when no notes had been created at the time of service. The notes made it appear as though Medicare beneficiaries had obtained direct, one-on-one service from a licensed physical therapist when, in fact, some of the services had been rendered by unlicensed auxiliary personnel.Judge Underhill has scheduled sentencing for December 18, 2012, at which time Roberts faces a maximum term of imprisonment of five years and a fine of up to $250,000.

Rajindera Sachdeva Added to Most Wanted Fugitives List

Rajindera Sachdeva was added to most wanted fugitives list. Sachdeva has been indicted on charges of health care fraud. From approximately January 2005 until December 2006, Rajindera Sachdeva was an occupational therapist who worked with various Medicare providers. Sachdeva was paid approximately $3.3 million from Medicare. According to investigators, Sachdeva created occupational and physical therapy files for services that were never provided to patients. SAT Rehabilitation Services billed Medicare for the physical and occupational therapy services that were not provided. The files were then sold to co-conspirator Ehsan Rana, the owner of Alternative Physical Therapy, Incorporated. Alternative Physical Therapy billed Medicare for occupational and physical therapy services that were not provided. Files were also sold to Tri-County Rehabilitation.

Fraudulent Billing for Manual TherapyJacqueline Wheeler was found guilty of one count of healthcare fraud and 34 counts of making false statements relating to healthcare matters and was sentenced to six years, three months in prison and

$6.34 million in fines and restitution. Wheeler also received three years’ probation and was banned from the healthcare industry.Wheeler filed more than $7 million in fake Medicaid claims listing herself as a medical doctor when she was actually a non-board-certified naturopath. Prosecutors charged that Wheeler filed claims that showed the center provided from 20 to 48.5 continuous hours of manual therapy for each patient in 24-hour periods.

Physical Therapist Ph.D. Sentenced to 13 Months of Prison and Pays More Than $3 Million Dollars in Restitution, Civil Penalties, and Back Taxes

Chyawan Bansil, P.T., Ph.D. of Farmington Hills, Michigan was sentenced to 13 months prison on charges of health care fraud and money laundering. The convictions arise from an Indictment which charged that between February 2007 and January 2012, Dr. Bansil defrauded Medicare, Medicaid, and Blue Cross Blue Shield of Michigan of more than $1 million by causing those programs to be billed for expensive nerve conduction studies and needle electromyography tests that Dr. Bansil did not perform.

Detroit-Area Physical Therapy Assistant Sentenced to 30 Months in Prison for Role in $13.8 Million Home Health Care Fraud Scheme

A Detroit-area registered physical therapy assistant was sentenced to serve 30 months in prison for her role in a nearly $13.8 million Medicare fraud scheme. In addition to her prison term, Barot was sentenced to serve two years of supervised release and ordered to pay $1,336,739 in restitution, jointly and severally with her co-defendants. Barot pleaded guilty on June 26, 2012, to one count of conspiracy to commit health care fraud. According to Barot’s plea agreement, beginning in approximately May 2009, Barot, a physical therapy assistant, was paid to falsify medical documentation for Physicians Choice Home Health Care LLC, a home health agency owned by her co-conspirators. Barot created evaluations, therapy revisit notes and other medical documentation memorializing purported physical therapy for patients she did not see or treat. According to court documents, she was instructed on how to falsify the medical documentation by a co-conspirator.

Barot also pleaded guilty to signing therapy revisit notes as a physical therapy assistant for patients she did not see or treat, knowing that the documents she falsified and the documents that she signed would be used to support false claims to Medicare for home health services.Barot was subsequently paid to sign falsified medical documentation and files for First Care Home Health Care LLC, Quantum Home Care Inc. and Moonlite Home Care Inc., which were Detroit-area home health care companies also owned by Barot’s co-conspirators that billed Medicare.

From approximately May 2009 through September 2011, Medicare paid approximately $1,336,739 to the four home health care companies for fraudulent physical therapy claims based on falsified files and notes signed by Barot. The four home health companies for which Barot worked were paid in total approximately $13.8 million by Medicare.

Nine of Barot’s co-defendants have pleaded guilty, and one has been sentenced. Three co-defendants are fugitives, and six co-defendants await trial.

Life Care Centers of America probed for Medicare fraud

Federal prosecutors allege that Cleveland, Tenn.-based Life Care Centers of America has bilked the federal government of hundreds of millions of dollars through a systematic Medicare fraud scheme since at least 2006. Court records detail allegations and a federal investigation that began in 2008 with two whistle-blower lawsuits filed by employees at facilities in Florida and in Morristown, Tenn.Prosecutors allege that top-level Life Care supervisors issued directives to max out unnecessary and often harmful therapies to patients for the highest possible Medicare reimbursement.

In an unsigned letter issued Friday to employees, Life Care disputed the government’s claims, saying that the combined whistle-blower lawsuitsappearedto“target”companiessuchastheirsanditsallegations“second-guess,afterthefact,thetrainedmedicalprofessionalswhoprescribedthelevelofcare.”

The letter also states that the way the company provides therapies actually saved Medicare an estimated $400 million in cost savings from 2006 to 2010.

Medicare Fraud Strike Force Charges 91 Individuals for Approximately $430 Million in False Billing

On 10/4/2012 Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius announced that Medicare Fraud Strike Force operations in seven cities led to charges against 91 individuals – including doctors, nurses and other licensed medical professionals – for their alleged participation in Medicare fraud schemes involving approximately $429.2 million in false billing,

Dozens of charged individuals were arrested or surrendered in the last 24 hours as indictments were unsealed across the country. Together, those indictments charge more than $230 million in home health care fraud; more than $100 million in mental health care fraud and more than $49 million in ambulance transportation fraud; and millions more in other frauds. HHS also suspended or took other administrative action against 30 health care providers following a data-driven analysis and based upon credible allegations of fraud.

The defendants charged are accused of various health care fraud-related crimes, including conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services.

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes never provided. In many cases, court documents allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided.

Shawn HalcsikDirector of Compliance

414.791.9122shalcsik@evergreenrehab.com

Contact Information:

Liz BarlowVice-President of Clinical Services

502.400.1619liz@evergreenrehab.com