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DOCUMENTATION AND CODING

DRAYER PHYSICAL

THERAPY INSTITUTE

Leading the Way to Good Health

DPTI EXPECTATIONS FOR CORRECT CLINICAL CODING

Each clinician is responsible to code in a legal and ethical manner for all services provided.

Each clinician must take the initiative to increase his/her awareness of applicable coding rules and regulations.

Documentation must include an assessment as to why PT, OT, or SLP services are medically necessary.

Documentation must support the services charged.

The clinician must know each payer’s expectations in terms of coding.

OBJECTIVES OF CLINICAL CODING TRAINING

Instruct our providers to code in a legal and ethical manner in compliance with local, state, and federal guidelines.

Instruct each provider in the definition of the CPT codes applicable in our profession.

Educate our team of providers in the correct use of CPT codes.

Educate our providers in the correct use of modifiers.

Educate providers in correct medical record documentation in compliance with local, state, and federal guidelines.

Accurately code in patient scenarios with regard to AMA and CMS guidelines.

CPT CODES

Current Procedural Terminology.

Developed and defined by the American Medical Association (AMA).

Intended to provide a uniform method of reporting and billing for services.

AMA CPT Coding Manual provided for each facility

AMA GUIDELINES FOR CORRECT CLINICAL CODING

Select the appropriate 5 digit CPT code based upon its definition.

Add a modifier when appropriate.

Be specific!

Be consistent!

Total time must support the units billed.

Documentation must support the codes selected.

CLINICAL CODING TERMINOLOGY

Encounter: One episode of treatment.

Direct Contact: Visual, verbal, and/or manual contact between the patient and the provider.

Provider: The therapist, assistant, or other support personnel as defined by state regulations and the payer.

Time Based Codes: Charged in increments based on the time spent providing the service. Include a unit of time assigned to them, such as “each 15 minutes”. Include pre-, intra-, and post-service time.

– Medicare only considers intra-service time as billable time

Service Based Codes: Intended for use only once during an encounter regardless of the time spent delivering the service or the number of areas treated.

TIME BASED CODES

Pre-service Time: Includes the following examples

on the same date of service as the encounter:

– Chart reviews for treatment.

– Set-up of activities.

– Set-up of equipment and area to be used.

– Review of previous documentation.

– Communication with other healthcare professionals.

– Calls to referring physicians.

– Discussions with family members.

TIME BASED CODES

Intra-service Time: Includes the following: – Direct contact (visual, verbal, and/or manual) delivery of the

treatment.

– Status check of patient’s symptoms.

– Assessment of patient’s response to treatment.

Post-service Time: Includes the following examples on the same date of service as the encounter:

– Discharge patient from treatment.

– Documentation of treatment.

– Write up of report if necessary.

– Communication with physician to report progress.

– Communication with other team members.

TIME BASED CODES

Time Based Procedures performed

concurrently can not be billed as if they were

performed consecutively.

For example, Combo (E-Stim., Attended and

US) can only be coded as 97032 E-Stim.,

Attended OR 97035 Ultrasound, NOT BOTH.

PHYSICAL MEDICINE AND REHABILIATION

(CPT CODES 97001 – 97799)

These are the codes most commonly used by PT and OT.

PT and OT not restricted to the use of codes in this section.

Consist of the following headings:

– 97001 – 97004 Evaluation and Re-evaluation

– 97010 – 97039 Modalities

Supervised

Constant Attendance

– 97110 – 97546 Therapeutic Procedures

– 97597 - 97602 Active Wound Management

– 97550 Test and Measurements

– 97760 – 97762 Orthotic Management and Prosthetic Management

EVALUATION AND RE-EVALUATION (CPT CODES 97001 – 97004)

These codes result in the formulation of a treatment plan.

SERVICE BASED procedural codes.

No other test and measurement codes should be used on the same day as an Evaluation code (i.e., ROM, MMT, Physical Performance Testing).

Re-Evaluations must be performed a minimum of once every 30 days to meet Medicare, State, and DPTI guidelines.

Documentation time is considered to be a part of these codes and should never be charged separately.

EVALUATION AND RE-EVALUATION (CPT CODES 97001 – 97004)

97001 Physical Therapy Evaluation

97002 Physical Therapy Re-Evaluation

97003 Occupational Therapy Evaluation

97004 Occupational Therapy Re-

Evaluation

MODALITIES – SUPERVISED (CPT CODES 97010 – 97028)

Defined as any group of agents that may include thermal, acoustic, radiant, mechanical, or electrical energy to produce physiologic changes in tissue for therapeutic purposes.

These codes do NOT require direct (one-on-one) patient contact by the provider once the patient is set-up.

SERVICE BASED procedural codes.

Can only be charged once per encounter regardless of the number of areas treated or the number of times used.

MODALITIES – SUPERVISED (CPT CODES 97010 – 97028)

97010 Hot or cold packs

97012 Traction, mechanical

97014 Electrical stimulation, unattended

97016 Vasopneumatic devices

97018 Paraffin bath

97022 Whirlpool

97026 Infrared (i.e., Anodyne, Revitamed)

97039 Unlisted Modality (i.e., near-infrared diode)

90901 Biofeedback

90911 Biofeedback Pelvic Floor

97014 ELECTRICAL STIMULATION, UNATTENDED

Some payers recognize the code G0283 to denote Electrical Stimulation, unattended.

Medicare only recognizes the G0283 code for Electrical Stimulation, unattended.

Many payers will reimburse for a separate electrode charge A4556 Electrodes, per pair.

Some payers include electrodes in the 97014 code and will not reimburse for a separate charge (i.e., Medicare).

Medicare will reimburse for Electrical Stimulation, unattended for the treatment of wounds for only stage III and IV chronic ulcers under the G0281 code.

97022 WHIRLPOOL

This code is accepted by all payers, including

Medicare, as the appropriate CPT code to

choose when providing fluidotherapy.

97026 INFRARED AND 97039 NEAR-INFRARED

The use of infrared and/or near-infrared light

and/or heat is non-covered by MEDICARE

(and some other payers) for the treatment,

including symptoms such as pain arising

from these conditions, diabetic and/or non-

diabetic peripheral sensory neuropathy,

wounds and/or ulcers of the skin and/or

subcutaneous tissue

BIOFEEDBACK

90901 Biofeedback training by any modality

– SERVICE BASED CODE.

– Medicare will cover BFB services only if reasonable and

necessary for re-education of specific muscle groups or for

treating pathological muscle abnormalities of spasticity,

incapacitating muscle spasm, or weakness, and more

conventional treatments have failed. It is not covered for

ordinary muscle tension or psychosomatic conditions.

90911 Biofeedback Pelvic Floor


– BFB is only covered with urge incontinence when patient

has failed a documented trial of pelvic muscle exercise

training.

MODALITIES – CONSTANT ATTENDANCE

(CPT CODES 97032 – 97039)

These codes do require direct (one-on-one) contact by the provider.

These codes can be reported once for each 15 minute time period spent providing the service.

Defined by “each 15 minutes”.

When two constant attendance modalities are applied simultaneously, only one procedure should be charged as each is a timed service and the concurrent time you are providing time based services can only be charged once.

MODALITIES – CONSTANT ATTENDANCE

(CPT CODES 97032 – 97039)

97032 Electrical stimulation, Attended – A4556 Electrodes, per pair, are not included in this code

and may be charged separately; reimbursement will be dependent upon the payer.

97033 Iontophoresis – A4556 Electrodes, per pair, are not included in this code

and may be charged separately; reimbursement will be dependent upon the payer.

97034 Contrast baths

97035 Ultrasound

97039 Unlisted modality (i.e., near-infrared hand-held)

THERAPEUTIC PROCEDURES (CPT CODES 97110 – 97546)

Defined as a manner of affecting change through the

application of clinical skills and/or services that

attempt to improve function.

Require direct (one-on-one) contact by the provider.

Time based procedural codes.

Time coded should include any pre-, intra-, and post-

service time that occurs on the same date as the

encounter.

Time units are designated by “each 15 minutes”.


97110 Therapeutic procedures – Describes services aimed at improving a single parameter, such

as ROM and strength.

97112 Neuromuscular re-education – Describes services aimed at improving movement, balance,

coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

97113 Aquatic therapy

97116 Gait training – Requires skilled services, not routine, repetitive ambulation.

– Must include specific gait deviations – antalgic gait alone does not support the need for skilled gait training.

97124 Massage


97140 Manual therapy techniques

– Joint mobilization

– Manipulation

– Myofascial release

– Manual traction

– Passive range of motion can be included in this

code per AMA and CMS guidelines.

– “Hands on Therapy”

THERAPEUTIC PROCEDURES (CPT CODES 97110-97546)

97530 Therapeutic Activities

– Focus is functional outcome vs. exercise

– Activities that use multiple parameters (i.e.

strength, ROM, balance, etc.) and that focus on

achieving a functional activity


97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training)

– The provider instructs and trains the patient in a variety of tasks, in a manner that facilitates the development of cognitive reasoning.

– Allows individuals with impairments related to TBI, CVA, and psychiatric disorders to live independently and function safely in their environment.

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands

– Often associated with a pediatric population.

– Activities focus on enhancing sensory processing input and promote adaptive responses to environmental demands of one or more of the sensory systems (i.e., vestibular, proprioceptive, tactile, visual, or auditory).

– Used with treatment for autism, over-reactivity to stimuli, ADD, CP, and motor apraxia.


97535 Self care/Home management – NOT the universal home exercise program code.

– Intended for training in life skills and assistive devices for ADL’s.

97537 Community/Work reintegration training – Examples include shopping, transportation, money management,

avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment.

– Use this code for work site evaluations.

– The provider instructs and trains the patient in community reintegration activities.

97542 Wheelchair management/propulsion training – The provider provides assessment, instruction and training in

proper wheelchair skills (i.e., propulsion and safety techniques) in their home, facility, work, or community environment.


97545 Work Hardening/conditioning; initial 2 hours

97546 each additional hour

– Program where the injured worker is put through a series of conditioning exercises and job simulation tasks in preparation for return to work.

– Endurance, strength, and proper body mechanics are emphasized.

– The patient is educated in problem solving skills related to job task performance and employing correct lifting and positioning techniques.

– Report 97546 for each additional hour after the initial two hours.


97150 Group Therapy – SERVICE BASED CODE.

– Involves constant attendance but does not require one-on-one direct care by the provider.

– The traditionally accepted clinical definition of this code is two or more individuals performing the same therapeutic procedure at the same time.

– Individuals are considered to have the same treatment plan.

– Examples include lumbar stabilization class, aquatic arthritis class.

– Medicare (CMS) has further defined this code with regard to their client base (See Group Therapy – Medicare Section).

TEST AND MEASUREMENTS (CPT CODES 97750)

97750 Physical Performance test or measurement, with written report – Time Based CPT Code that is designated in

increments of “each 15 minutes”

– Includes Functional Capacity Exams.

– Should not be charged on the same day as an Initial Evaluation or a Re-Evaluation.

– Does NOT result in the formation of a treatment plan.

– Should not be coded if insurance provider does not recognize 97002 Re-Evaluation.

ACTIVE WOUND CARE MANAGEMENT (CPT CODES 97587 – 97602)

97597 Selective Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudates, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 square centimeters or less

97598 Selective Debridement, each additional 20 square centimeters;

The CPT code 97598 cannot be billed without also billing the CPT code 97597.

97602 Non-selective debridement, without anesthesia (e.g. wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instructions for ongoing care, per session

Dressing changes are considered to be a “bundled” service with Medicare and should not be charged separately.

Codes 97597 and 97598 include the term “may include use of a whirlpool”; therefore, it is not appropriate to code separately for 97022 Whirlpool when performing Selective Wound Debridement as outlined in codes 97597 and 97598.

ORTHOTIC MANAGEMENT AND

PROSTHETIC MANAGEMENT (CPT CODES 97760 – 97762)

97760 Orthotic(s) management and

training, upper extremity(ies), lower

extremity(ies), and/or trunk

– Orthotics are used to provide mobility with

support.

– This code identifies the fitting and training

required to properly use the device.

– Can be a custom made or prefabricated device.

ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT (CPT CODES 97760 – 97762)

97760 Orthotic(s) Management and Training – Gait training is considered to be a fundamental

component and should not be coded separately.

– Any time spent performing gait training should be included in the time spent fitting and training the device.

– Exception: If an orthotic is fitted for the UE and gait training is performed for the LE, both can be coded separately using the 59 modifier.


97760 Orthotic(s) management and training

– Fabrication is not recognized as a distinct service.

If the orthotic is fabricated at the time of the fitting while the

patient is in the clinic, the fabrication time may be included as

part of the fitting and training time when coding.

If the provider bills for the HCPCS Level II code (i.e., L Code),

fabrication time is considered to be a component of the L Code

billed and is NOT separately billable.

If the orthotic is fabricated while the patient is not present, or

the orthotic is made off-site, the fabrication time is considered

to be a provision of materials/supplies and should NOT be

charged separately or incorporated into the fitting and training

time.


97761 Prosthetic training, upper and/or lower extremity(ies)

97762 Checkout for orthotic and/or

prosthetic use, established patient

– The provider evaluates the effectiveness of an

existing device and makes recommendations for

change, prn.

– This code does not include provision of materials;

therefore supplies should be coded with an

appropriate HCPCS Level II code or with the

99070 code.

OTHER SERVICES

64550 Application of a TENS unit


– Used for the set-up of a home TENS unit.

– Is not intended to be coded with in-clinic treatment (instead,

code 97014 E Stim, unattended if the patient receives

supervised treatment while in the clinic).

– This code does not include evaluation; therefore, if you are

evaluating a patient for the first time to issue a home TENS

unit, a separate evaluation charge 97001 or 97003 should

be coded.

OTHER SERVICES

95992 Canalith Repositioning Procedure (s) (eg)

Epley Maneuver, Semont Maneuver), per day

- This CPT code had previously been deactivated and

therapists had been instructed to use the 97112 CPT code

when performing the Epley or Semont maneuvers. Effective

January 1, 2011 the 95992 code has been reactivated and

therapists are expected to use this CPT code when performing

the Epley or Semont maneuvers.

-This is a service based code and can only be billed once per

treatment encounter.

OTHER SERVICES

A4556 Electrodes, per pair

– The reimbursement for electrodes is payer

specific.

– This code is defined “per pair”. Therefore, when

dispensing electrodes, if a patient receives 4

electrodes, as with interferential electrical

stimulation, it is appropriate to code A4556 X 2.

CLINICAL CPT CODING EXAMPLES

DRAYER PHYSICAL THERAPY

INSTITUTE


MODIFIERS


INSTITUTE


MODIFIERS

Definition: A modifier provides the means

by which the provider can indicate that a

service or procedure that has been

performed has been altered by some specific

circumstance, but not changed in its

definition or code.

MODIFIER CODING

IT IS THE RESPONSIBILITY OF THE CLINICIAN TO INCLUDE THE MODIFIER WHEN CODING.

IT IS NEVER APPROPRIATE FOR THE BILLING OFFICE TO ADD A MODIFIER WHEN ENTERING CHARGES IF THE THERAPIST HAS NOT INDICATED THE MODIFIER ON THE ENCOUNTER FORM.

Expectations for modifier coding is payer specific.

Failure to include the appropriate modifier when required will result in denial of payment for services.

WHEN DO I USE A MODIFIER?

To indicate that a service/procedure has both a

technical and professional component.

To indicate a service was increased or reduced.

To indicate only part of a service was performed.

To indicate unusual events occurred.

To designate a service as a distinct procedural

service.

To indicate a service was provided bilaterally.

59 MODIFIER

Definition: Used to designate that two services normally not performed together were provided in two distinctly separate periods of time.

– Different sessions

– Different patient encounter

– Different procedure or surgery

– Different anatomical site

– Separate injury

Please refer to the attached table for appropriate use of the 59 modifier.

52 MODIFIER

Used to indicate reduced services when the

normal course of treatment is shortened.

Should be used infrequently.

Used when extenuating circumstances occur

or when the well-being of the patient is

threatened.

LT AND RT MODIFIERS

Used to indicate that the clinician is treating

bilateral body parts.

Allows the clinician to denote which

services/procedures were provided to each

right or left body part.

GO, GP, AND GN MODIFIERS

This is the only instance when coding a

modifier becomes the function of the

business office vs. the clinician.

Used to delineate which services are

allocated to physical, occupational, or

speech therapy for Medicare providers.

Initially implemented to track services for the

therapy cap.

MEDICARE CODING STRATEGIES


INSTITUTE


OBJECTIVES

Code in a legal and ethical manner in compliance

with state and federal guidelines for federally funded

programs.

– CMS’s interpretation of the Group Therapy code 97150.

– Correct application of the “8 minute rule”.

– Appropriate use of the 59 modifier.

– Correct medical record documentation to support coding.

Illustrate correct coding with examples.

CODING FOR FEDERALLY FUNDED PROGRAMS

What are the federally funded programs?

– Medicare

– Medicaid

– Champus/Tricare

– Medicare Advantage

In this presentation, “Medicare” refers to any

federally funded program or insurance carrier

who follows CMS guidelines with coding.

WHICH SERVICES ARE CONSIDERED TO BE NONSKILLED AND

NONBILLABLE BY MEDICARE?

Treatment that does not require the skilled care of the qualified therapist or assistant under the supervision of the qualified therapist.

Groups directed or assisted by a student, therapy aide, ATC.

Treatment as part of a maintenance program although recent legislation may change this.

Treatment without any direct intervention by the therapist.

Continued treatment after the patient has met treatment goals.

Wait/Rest time.

CMS TRANSMITTAL AB-00-14

The policy was originally released in Program

Memorandum Transmittal AB-00-14.

Has come to be known as the “8 minute rule”.

Provides guidance when coding for TIME BASED

PROCEDURAL CODES.

This is CMS’s interpretation of the 15 minute unit for

physical medicine modalities and procedures.

SUMMARY OF THE 8 MINUTE RULE

Units of service less than 8 minutes are not SEPARATELY billable.

The total number of time based units billed is constrained by the total time spent performing time based procedures.

Treatment time is defined as intra-service time.

The time spent providing a time based procedure/modality that is less than 8 minutes can be added to the time spent performing other time based procedures to calculate total time based treatment time.

When choosing the appropriate codes, the therapist should assign more units to the service that took the most time.

When treatment time for services are equal, it is up to the discretion of the therapist to charge for the service that he/she feels was more beneficial for the patient’s plan of care.

BILLABLE UNITS/TOTAL TIME BASED MINUTES

– 1 unit = 8 to 22 minutes

– 2 units = 23 to 37 minutes







– Service based procedures are billed separately. Service based and non-billable time is subtracted from total treatment time to arrive at total time based minutes.

DRAYER POLICY REGARDING DOCUMENTATION OF TREATMENT

TIME

Document time in and time out of the treatment session.

Document time spent providing each service based procedure on the flow sheet.

Subtract the total service based and/or nonbillable time from the total treatment time to determine the total time spent providing time based procedures.

Assign units based on the “8 minute rule”.

Always perform a careful self-review of your coding.

CMS INTERPRETATION OF GROUP THERAPY

CMS has implemented its own interpretation

of the group therapy code.

These guidelines only apply to those

individuals insured by federally funded

programs.

CMS has chosen to apply this policy when

CPT TIME BASED PROCEDURES are

delivered.

CMS GUIDELINES WHEN USING THE 97150 GROUP THERAPY CODE

Patients may be performing the same exercises OR individualized exercise programs.

If a Medicare patient is treated with a service based procedure, the one-on-one requirement does not apply when another Medicare patient is receiving a time based procedure. You can bill the service based procedure and the time based procedure for each patient, respectively.

CMS recognizes only those services performed by qualified licensed providers (PT/PTA, OT/OTA).

MEDICARE REQUIREMENT FOR PTA/OTA SUPERVISION

Medicare requires that a qualified PT or OT must provide direct on-site supervision of a PTA or OTA in an outpatient environment.

Direct supervision is defined as the physical presence of the PT or OT on the premises where the PTA or OTA is providing the patient-care services, so that the therapist is immediately available to provide supervision, direction, and control.

In states where the level of PTA/OTA supervision is less stringent than CMS, CMS’s requirement will supersede the State Practice Act when Medicare patients are treated.

MEDICARE POLICY REGARDING THERAPY TECHNICIANS

CMS has stated that the services provided by

a therapy technician are considered unskilled

services- no matter the level of supervision

provided by the qualified therapist or therapy

assistant under the supervision of the

qualified therapist.

MEDICARE POSITION REGARDING STUDENTS

No services individually provided by a student are reimbursable by Medicare, even those performed under the line of sight of the qualified therapist.

For services to be recognized by Medicare, the qualified therapist must be in the room, directing the services performed by the student and making the skilled decisions regarding care.

DRAYER PHYSICAL THERAPY INSTITUTE POLICY REGARDING

STUDENTS AND MEDICARE

It is the policy of Drayer Physical Therapy

Institute that no physical, speech, or

occupational therapy or assistant student will

participate in the care of a Medicare or

federally funded beneficiary in any other role

than that of an observer.

CMS GUIDELINES WHEN USING THE 97150 GROUP THERAPY CODE

Group therapy is a SERVICE BASED procedural code and can only be coded once per encounter, no matter the length of time spent in the group setting.

Because the Group Code is service based, it has no time requirement.

CMS REQUIREMENT OF THE 59 MODIFIER WHEN CODING GROUP

THERAPY 97150

If the therapist uses the Group Therapy code 97150

and one-on-one TIME BASED procedures on the

same date of service, he/she must also select the 59

modifier on the encounter form.

The 59 modifier should be checked by the therapist

in the space provided next to each time based

procedure that is provided on the same date of

service as the Group Therapy 97150 code.

DRAYER DESIRES TO PROVIDE ONE-ON-ONE CARE FOR MEDICARE

PATIENTS BY:

Adequate staffing of qualified licensed caregivers at

each clinic (PT/PTA, OT/OTA, SLP).

Appropriate scheduling of Medicare patients.

Managing patient care to avoid group scenarios.

Appropriate use of ancillary staff to provide care (i.e.

PT techs, ATC, and students may not participate in

the care of any Medicare patient per Drayer Physical

Therapy policy).

DRAYER PHYSICAL THERAPY INSTITUTE POLICY REGARDING THE

GROUP THERAPY CODE

Whenever staffing and scheduling does not

permit one-on-one care, the Group Therapy

code 97150 MUST BE CODED by the

qualified provider to remain in compliance

with CMS guidelines.

MEDICAL RECORDS DOCUMENTATION

DRAYER PHYSICAL

THERAPY INSTITUTE


OBJECTIVES

Provide background information regarding the Office of the Inspector General’s office.

Identify areas of interest when the OIG audits False Claims.

Identify Medicare documentation requirements.

Identify DPTI documentation requirements.

Introduce the DPTI approved documentation forms.

Discuss the DPTI Chart Audit process.

OFFICE OF THE INSPECTOR GENERAL

Established by the Dept. of Health and Human Services by Congress in 1976.

Objective is to identify and eliminate fraud, waste, and abuse in the Dept’s programs and promote efficiency and economy in department operations.

Issues Special Fraud Alerts that identify segments of the healthcare industry that are particularly vulnerable to abuse.

OIG FRAUD AND ABUSE WORK PLAN

The annual Work Plan identifies OIG’s concerns and

audit focus areas for the upcoming year.

Typically, issues raised on the Work Plan appear in

False Claims Act cases and fraud enforcement

about 2 to 3 years after they appear in the Work

Plan.

Physical and Occupational Therapy services have

appeared on the OIG Fraud and Abuse Work Plan

as an area of audit focus.

REASONABLE AND NECESSARY CRITERIA

The services provided are of such a level of complexity and sophistication, or the patient’s condition must be such, that the services required can be safely and effectively performed only by a qualified therapist or an assistant under his direct supervision (in the Out Patient therapy setting).

The services must relate directly and specifically to an active written treatment plan and be reasonable and necessary to the treatment of the individual’s illness or injury.

Services must be:

– Accepted standards of medical practice.

– Specific, safe, and effective treatment for the dx.

– Reasonable amount, frequency (i.e., 3x/wk), and duration.

– Expectation exists that the condition will significantly improve in a reasonable amount of time.

– Services must relate directly to the treatment goals.

REASONABLE AND NECESSARY: DOCUMENTATION REQUIREMENTS

Documentation submitted to the insurance

providers must:

– Reflect the CPT and level II HCPCS codes and

units billed.

– Demonstrate significant gains.

– Justify the frequency and duration of therapy is

reasonable and necessary.

– Substantiate the actual treatment time.

THREE MAJOR AREAS OF OIG INTEREST WHEN ASSESSING FRAUD

Services are reasonable and medically

necessary.

Services are authorized by a physician.

Services are supported by medical record

documentation.

RESULTS OF OIG FRAUD CASES: REASONABLE AND NECESSARY

Services have been deemed not reasonable and necessary for the patient’s injury or illness for the following reasons:

– The patient’s medical condition did not require the skilled services of a therapist (i.e., services were provided by non-licensed personnel on some occasions; therefore all services denied).

– Patients had no potential for improvement.

– The patients did not have a loss of function or functional limitations documented.

– Chance of making improvement in a reasonable timeframe was not possible.

OIG FRAUD CASES: REASONABLE AND NECESSARY

CRITERIA (CON’T)

No specific medical history or specific episode requiring outpatient therapy services.

Treatment plans not individualized nor were goals measured.

Therapy continued after goals were met.

Documented that patient questioned need for therapy, but therapy continued for 2 months.

Patient’s medical record indicated that OT services were a duplication of PT services; therefore, OT services questioned.

OIG FRAUD CASES: REASONABLE AND NECESSARY

CRITERIA

Documentation did not demonstrate that the

therapy provided was an effective treatment

for the patient’s dx.

Patient was provided non-skilled repetitive

exercises (no exercise progression).

OIG FRAUD CASES: INADEQUATE DOCUMENTATION

FINDINGS

Medical records did not document that billed services were provided (i.e., flow sheets left blank).

When medical records are incomplete, no payment can be made for services.

No evaluations or POC outlined.

No physician authorization or supervision of services (i.e., signature).

No legible identifier or physician certifying plan of care or of the therapy provider.

OIG FRAUD CASES: INADEQUATE DOCUMENTATION

FINDINGS

No documentation of patient’s prior level of function.

Documentation supported the provision of one service but another billed (i.e., PT IE/POC but OT services billed).

Medical records did not support the patient’s potential benefit from therapy.

Documentation failed to establish the relationship of therapy to treatment goals.

OIG FRAUD CASES: PHYSICIAN AUTHORIZATION

DEFICIENCIES

Physician never signed the initial and/or updated POC.

No legible identifier.

Certifications not signed by MD in a reasonable amount of time.

Services claimed were not included in the POC.

Physician orders were not followed.

Therapy services continued after physician authorization expired.

Treatment plan authorization dates were altered.

MEDICARE DOCUMENTATION REQUIREMENTS

Initial Evaluation/POC: – Patient name

– Onset date

– SOC (Start of Care) date: will be the IE date

– Primary Dx

– Treatment Dx (if differs from the Primary Dx)

– Plan of Treatment/Functional Goals Includes major long term goals to reach overall long term

outcome.

Include major plan of treatment to reach stated goals and outcome.

Estimate Time Frames to reach goals when possible.

Amount, type, frequency, and duration of POC.

MEDICARE INITIAL EVALUATION and PLAN OF CARE DOCUMENTATION

REQUIREMENTS

Signature: Must include professional designation of the therapist establishing the POC.

Type/Amount/Frequency/Duration of POC

Physician’s Signature and Date: Must be obtained in a reasonable amount of time.

Prior Hospitalization / PMHx

Rehab Potential

MEDICARE INITIAL EVALUATION and PLAN OF CARE DOCUMENTATION

REQUIREMENTS

Initial Assessment:

– Current relevant history from patient interview/records.

– Major functional limitations.

– Objective baseline tests and measurements from which to

judge future progress or lack of progress.

Service Dates:

– From and Through dates which represent this billing period.

– Should be monthly.

MEDICARE PROGRESS REPORT DOCUMENTATION REQUIREMENTS

Updated POC/Progress Report

Requirements:

– Patient’s name

– Onset date

– SOC date

– Primary and/or Treatment Diagnosis

– Visits from SOC (i.e., total number of visits seen)

– Current Type/Amount/Frequency/Duration of POC


Current Plan Update, Objective/Functional Goals – Document interim goals to reach overall long term outcome.

– Justify intensity (i.e., number of visits per day or week) if appropriate.

– Estimate time-frames to meet goals.

Functional Level: – Enter pertinent progress made through the end of this

recertification cycle.

– Use objective terminology.

– Date progress when function can be consistently performed or when meaningful functional improvement is made.

– Document regression in function if appropriate.


Recertification: – Enter the inclusive dates when recertification is required (From

and Through Service dates).

Physician Signature and Date: – Must be obtained every 30 days to prove that POC has been

reviewed at least once every 30 days.

Reason(s) for Continuing Treatment: – Briefly state the patient’s need for specific functional improvement,

skilled training, reduction in complication or improvement in safety, and how long you believe this will take.

– Also include reason for recommending discontinuance if applicable.

Provider Signature and Date: Must include professional

designation.

MEDICARE CERTIFICATION/RE-CERTIFICATION

REQUIREMENTS

Written POC must be established prior to

treatment being delivered by the PT/OT.

The POC must indicate:

– Diagnosis

– Goals

– Specific modalities/procedures

– Expected amount, frequency, and duration of

services.

MEDICAL RECORDS DOCUMENTATION

Daily Notes General Guidelines: – Be specific and consistent.

– Documentation in general or subjective terms is insufficient.

– Documentation for each date of service must be complete or denials due to “No Proof of Services Rendered” may occur.

– Documentation must support the need for skilled services by qualified personnel.

– Documentation must correlate with the therapy POC, treatment time, and CPT/HCPCS codes billed.

– Documentation must support that the services delivered are reasonable and necessary.

– Documentation must indicate functional improvements to justify continuation of care.

REASONABLE AND NECESSARY CRITERIA

The services must require the skills of a qualified provider.

The services must relate directly and specifically to an active written treatment plan.

Services must be: – Accepted standards of medical practice

– Specific, safe, and effective treatment for the dx.

– Reasonable amount, frequency, and duration.

– Expectation exists that the condition will significantly improve in a reasonable amount of time.

DPTI DOCUMENTATION GUIDELINES

Subjective Reports/PMHX Forms should be given to the patient at check in for the IE. Patient responses should be reviewed with the PT.

Medicare only: PQRS, Functional G Codes, and the ICD 9 Forms must be completed by the end of the business day on the date of the Initial Evaluation so that charges may be entered appropriately and timely.

Initial Evaluations must be completed by the PT/OT/ST within 24 hours

of the IE.

The Initial Evaluation must be sent to the referring MD within 48 hours of the IE so that it is received within 72 hours.

The POC must be completed by the PT/OT/SLP on the date of the IE.

Completed POC must be sent to the referring MD within 48 hours of the IE so that it is received within 72 hours.


Progress Reports to the MD must be

completed on the same date of the Re-Eval.

by the PT/OT/ST.

Completed Progress Reports must be sent to

the MD within 24 hours or in time for the

NDV.

RE-EVALUATION

Medicare considers a Re-evaluation to be

separately payable and periodically indicated

during an episode of care when the

professional assessment of a clinician

indicates a significant improvement, or

decline, or change in patient’s condition or

functional status that was not anticipated in

the plan of care.

The decision to provide a Re-evaluation shall

be made by the clinician.


Flow sheets must be completed by the attending caregiver by the end of each business day.

All Flow sheets must be complete and include treatment parameters and the initials and signature of the attending caregiver.

CHECKMARKS ARE UNACCEPTABLE WHEN DOCUMENTING TREATMENT ON THE FLOW SHEET.


Encounter Forms including the SOAP note and appropriate charges must be completed by the therapist and returned to the Business Office by the end of each business day.

Contact Forms including a summary of the interaction must be completed on the date of occurrence.

Discharge Summaries must be completed within ONE week of patient discharge.


On the date of D/C, the therapist must clearly

indicate D/C on the upper right corner of the

Encounter Form.

The billing staff will then change the patient status

from active to inactive in the Raintree system by

entering a “2” as the patient status.

This process ensures that the patients listed on the

Patient Not Scheduled Report are only the active,

not inactive, patients.

DPTI CHART DOCUMENTATION

Subjective Report/PMHX Form

PQRS/Functional G Code/ICD 9 Form - Medicare

Initial Evaluation

Plan of Care

Progress Report/Re-evaluation

Flow Sheet

Encounter Form

Contact Form

Discharge Summary

Treatment Plans (payer specific)

CONCLUSION: WHAT ARE WE REALLY LOOKING FOR?

Documentation that consistently meets our

high internal standards and that will

withstand any outside scrutiny.

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