evergreen rehabilitation contract therapy - clinical & compliance bulletin 2013 q1
TRANSCRIPT
7/30/2019 Evergreen Rehabilitation Contract Therapy - Clinical & Compliance Bulletin 2013 Q1
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2013 Quarter 1
Coding CornerFAQ
. How do I bill for Medicare Part B services delivered for
ontracture management patients?
Billing or Medicare Part B services delivered or contracture
management is dependent on the skilled services provided. Te
most oen skilled services may include: 97110, therapeutic exercise;
7112, neuromuscular reeducation; 97140, manual therapy; 97760,
rthotic management and training; and 97762, checkout or
rthotic/prosthetic use. Each skilled service is detailed below:
7110-Terapeutic Exercises to develop strength and endurance,
ange o motion and exibility (one or more areas, each 15 minutes)
may require the unique skills o a therapist to evaluate the patient’s
bilities, design the program, and instruct the patient or caregiver
n sae completion o the special technique. However, aer the
eaching has been successully completed, repetition o the exercise,
nd monitoring or the completion o the task, in the absence o
dditional skilled care, is non-covered. Documentation should
nclude not only measurable indicators such as unctional loss o
oint motion or muscle strength, but also inormation on the impact
these limitations on the patient’s lie and how improvement in
ne or more o these measures leads to improved unction. 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
perorming PROM.
7112-Neuromuscular Re-education o movement, balance,
oordination, kinesthetic sense, posture, and/or proprioception
or sitting and/or standing activities (one or more areas, each 15
minutes) would be used i PNF or techniques or tone reduction are
delivered.
7140-Manual Terapy echniques (e.g.,mobilization/
manipulation, manual lymphatic drainage, manual traction), one
r more regions, each 15 minutes. Joint Mobilization (peripheral
nd/or spinal) may be considered reasonable and necessary i
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restricted or painul joint motion is present and documented. It may
be reasonable and necessary as an adjunct to therapeutic exercises
when loss o articular motion and exibility impedes the therapeutic
procedure. Myoascial release/so tissue mobilization, one or more
regions, may be reasonable and necessary or treatment o restricted
motion o so tissue. Documentation should include the area(s) being
treated; so tissue or joint mobilization technique used; objective and
subjective measurements o areas treated (may include ROM, capsular
end-eel, pain descriptions and ratings,) and eect on unction.
97760- orthotic(s) management and training (including assessment
and tting when not otherwise reported), upper extremity(s), lower
extremity(s), and/or trunk, each 15 minutes. Code 97760 includes
initial t and training, additional orthotic management and training
during ollow-up visits including instruction in skin care and
orthotic wearing time, and time associated with modication o the
orthotic due to healing o tissues, change in edema, or interruption
in skin integrity. o bill or training the patient to use the orthotic
the documentation must justiy the need or a skilled qualied
proessional/auxiliary personnel to train the patient in the use and care
o the orthotic. When the management o the orthotic can be turned
over to the patient, the caregiver or nursing sta, the services o the
therapist will no longer be covered. Once the initial t is established
and training is complete, any urther visits or specic documented
problems and modications that require skilled therapy should be
billed with CP 97762. Supportive Documentation Recommendations
or 97760 include: description o the patient’s condition (including
applicable impairments and unctional limitations) that necessitates an
orthotic; any complicating actors; specic orthotic provided and the
date issued; description o the skilled training provided; and response
o the patient to the orthotic. Many contractors have determined that
or uncomplicated conditions, the ollowing services would not be
considered reasonable and necessary as they would not require the
unique skills o a therapist.
• Issuingo-the-shelfsplintsforfootdroporwristdrop
• Issuingo-the-shelffootorelbowcradlesforroutinepressure
relie (these are not considered orthotics)
• Issuing“carrots”(i.e.,cylindrical,cone-shapedforms)ortowel
rolls or hand contractures or hygiene purposes
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• Bedpositioning(e.g.,pillows,wedges,rolls,footcradlesto
relieve potential pressure areas)
• Repetitiverangeofmotionpriortoplacinganorthotic/
positioner to maintain the range o motion is not reasonable
and necessary when the therapeutic intent is primarily to
maintain range o motion within a chronic condition.
• Ongoingtherapyvisitsforincreasingwearingtimeare
generally not reasonable and necessary when patient problems
related to the orthotic have not been observed.
7762-checkout or orthotic/prosthetic use, established patient,
ach 15 minutes. Tese assessments are intended or established
patients who have already received their orthotic or prosthetic
device and include patient’s response to wearing the device, whether
he patient is donning/dofng the device correctly, patient’s need or
padding, underwrap, or socks, and o the patient’s tolerance to any
dynamic orces being applied. I the checkout assessment results in
he need or urther training in the use o the orthotic, code 97760
would be appropriate or the training. Supportive Documentation
Recommendations or 97762 include: reason or assessment;
ndings rom the assessment; specic device, modications made,
nd instruction given.
. I have begun to see patients for incontinence. Can you please
eview 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
n the use o Non-implantable pelvic oor electrical stimulators
o provide neuromuscular electrical stimulation through the
pelvic oor with the intent o strengthening and exercising pelvic
oor musculature. Pelvic oor electrical stimulation with a non-
mplantable stimulator is covered or the treatment o stress and/or
urge urinary incontinence in cognitively intact patients who have
ailed a documented trial o pelvic muscle exercise (PME) training.
A ailed trial o PME training is dened as no clinically signicantmprovement in urinary continence aer completing 4 weeks o
n ordered plan o pelvic muscle exercises designed to increase
periurethral muscle strength. Stimulation delivered by vaginal or
nal probes connected to an external pulse generator may be billed
s 97032. Stimulation delivered via electrodes should be billed as
G0283. Te patient’s medical record must indicate that the patient
eceiving a non-implantable pelvic oor electrical stimulator was
ognitively intact, motivated, and had ailed a documented trial o
pelvic muscle exercise (PME) training. Some patients can be trained
in the use o a home muscle stimulator or retraining weak muscles. On
1-2 visits should be necessary to complete the training. Once training i
completed, this procedure should not be billed as a treatment modality
the clinic.
Bioeedback is covered or the treatment o stress and/or urge incontin
in cognitively intact patients who have ailed a documented trial o pelv
muscle exercise (PME) training. A ailed trial o PME training is dene
as no clinically signicant improvement in urinary incontinence aer
completing our weeks o an ordered plan o pelvic muscle exercises to
increase periurethral muscle strength. Medicare will allow bioeedback
an initial incontinence treatment modality only when, in the opinion o
physician, that approach is most appropriate and there is documentatio
medical justication and rationale or why a PME trial was not attemp
rst. Bioeedback or incontinence should be billed with CP code 909
which describes bioeedback that is more involved than conventional
bioeedback measures (code 90901) and includes evaluations o the EM
activity o the pelvic muscles, urinary sphincter and/or anal sphincter b
using sensors and/or manometry (measure o pressure o gases or liqui
by use o a manometer). When providing bioeedback procedures or
urinary incontinence, use CP 90901 when EMG and/or manometry
not perormed.
Patient selection is a major part o the process and the patient should b
motivated, cognitively intact, and compliant. In addition, there must be
assurance that the pelvic oor musculature is intact. Bioeedback thera
has proven successul or urinary incontinence when all three o the
ollowing conditions exist:
• thepatientiscapableofparticipationintheplanofcare;
• thepatientismotivatedtoactivelyparticipateintheplanofcare,
including being responsive to the care requirements (e.g., practice
and ollow-through by sel or caregiver); and
• thepatient’sconditionisappropriatelytreatedwithbiofeedback
(e.g., pathology does not exist preventing success o treatment).
Bioeedback is non-covered or:
• homeuseofbiofeedbacktherapy;
• pelvicoorelectricalstimulationlackingdocumentationofthe
ailure o a trial o pelvic muscle exercise (PME) training, unless th
is physician documentation justiying the need to initiate treatme
with bioeedback beore PME is attempted;
• patientswhodonothavesucientcognitiveabilitytoadheretoa
ollow the PME protocol and/or cooperate in keeping a personal
voiding diary.
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Decoding CPT Codes
Each quarter we ocus on decoding the mystery o a specic CP
ode. Tis quarter we will ocus on CP code 97140-Manual
Terapy echniques (e.g.,mobilization/manipulation, manual
ymphatic drainage, manual traction), one or more regions, each 15
minutes.• Manual traction may be considered reasonable and necessary
or cervical dysunctions such as cervical pain and cervical
radiculopathy.
• Joint Mobilization (peripheral and/or spinal) may be
considered reasonable and necessary i restricted or painul
joint motion is present and documented. It may be reasonable
and necessary as an adjunct to therapeutic exercises when
loss o articular motion and exibility impedes the
therapeutic procedure.
• Myoascial release/so tissue mobilization, one or moreregions, may be reasonable and necessary or treatment o
restricted motion o so tissues in involved extremities, neck,
and trunk. Skilled manual techniques (active or passive) are
applied to so tissue to eect changes in the so 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 or treatment o painul spasm or restricted motion
in the periphery, extremities or spinal regions.
• Manual lymphatic drainage/complex decongestive therapy (MLD/CD) MLD / CD is indicated or both primary and
secondary lymphedema. Lymphedema in the Medicare
population is usually secondary lymphedema, caused by
known precipitating actors such as surgical removal o lymph
nodes, brosis secondary to radiation, and traumatic injury
to the lymphatic system. MLD/CD consists o skin care,
manual lymph drainage, compression wrapping, and
therapeutic exercises. Coverage o MLD / CD would only be
allowed i all o the ollowing conditions have been met:
• thereisaphysician-documenteddiagnosisoflymphedema(primary or secondary);
•thepatienthasdocumentedsignsorsymptomsof
lymphedema;
• thepatientorpatientcaregiverhastheabilityto
understand and comply with the continuation o the
treatment regimen at home.
MLD/CD is not covered or:
• conditionsreversiblebyexerciseorelevationoftheaecteda
•dependentedemarelatedtocongestiveheartfailureorother
cardiomyopathies;
• patientswhodonothavethephysicalandcognitiveabilities,support systems, to accomplish sel-management in a
reasonable time;
• continuingtreatmentforapatientnon-compliantwitha
program or sel-management.
Supportive Documentation Requirements or 97140:
• Area(s)beingtreated
• Sotissueorjointmobilizationtechniqueused
• Objectiveandsubjectivemeasurementsofareastreated(may
include ROM, capsular end-eel, pain descriptions and ratings,and eect on unction
• ForMLD/CDP,supportivedocumentationshouldinclude:
•medicalhistoryrelatedtoonset,exacerbationandetiology
the lymphedema
•comorbidities
• priortreatment
• cognitiveandphysicalabilityofpatientand/orcaregiverto
ollow sel-management techniques;
•pain/discomfortdescriptionsandratings;
• limitationoffunctionrelatedtoself-care,mobility,ADLs and/or saety;
• priorleveloffunction;
• limbmeasurementsofaectedandunaectedlimbsatsta
care and periodically throughout treatment;
•descriptionofskincondition,wounds,infectedsites,scars
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Keeping Straight on the Regulation Road:
MedPAC Recommends Reforming Outpatient Terapy Payment
Te Patient Protection and Aordable Care Act requires MedPAC
o report recommendations to Congress on changes to outpatient
herapy services by June 15, 2013. Te Medicare Payment Advisory Commission recommended changes to reorm the Medicare
enet or outpatient physical and occupational therapy and
peech-language pathology. Te nal recommendations include
educing the therapy cap to $1,270 and applying a manual medical
eview process or 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
o the same patient on the same day. Te Commission stated
hat the changes would ensure program integrity o outpatientherapy services, ensure access to outpatient therapy services
while managing Medicare’s cost, and improve management o the
enet in the longer term. Congress has not acted on any o these
ecommendations.
CMS released Calendar Year 2013 Final Rule for the Physician
Fee Schedule on November 1, 2012
On November 1st, 2012 the Centers or Medicare & Medicaid
ervices (CMS) issued a nal rule that will update payment policies
nd rates or physicians and nonphysician practitioners (NPPs) orervices paid under the Medicare Physician Fee Schedule (MPFS) in
alendar year (CY) 2013. Tis is the same ee schedule used to pay
or Part B therapies in outpatient and nursing acilities. Highlights
provisions in the nal rule or the physician ee schedule that will
mpact therapy are discussed below.
CY 2013 payment rates ace a 26.5% reduction
Te nal rule includes a 26.5% across-the-board reduction to
Medicare payment rates or physicians, physical therapists, and
ther proessionals due to the awed sustainable growth rate (SGR)
ormula. Since 2003, Congress had enacted legislation preventing
hereductioneveryyear.CMSannouncesthatitis“committedto
xing the SGR update methodology and ensuring these payment
utsdonottakeeect.”Excludingthe26.5%projectedSGR
payment cut, the aggregate impact on payment o changes in the
ule or outpatient physical therapy is a positive 4% in 2013.
Functional Limitation Reporting
As required by the Middle Class ax Relie Jobs Creation Act o 201
CMS will begin to collect data on claim orms about patient unctio
status or patients receiving outpatient physical therapy, speech thera
and occupational therapy beginning January 1, 2013. Terapists wil
required to report new G codes accompanied by modiers on the clorm that convey inormation about a patient’s unctional limitation
and goals at initial evaluation, every 10 visits, and at discharge. Tis
data is or inormational purposes and not linked to reimbursement
Until July 1, 2013, claims will be processed regardless o the inclusion
o unctional limitation codes. Beginning July 1, 2013, all claims mu
include the unctional limitation codes in order to be paid by Medic
Terapy Cap Limitations
Te dollar amount o the therapy cap in CY 2013 will be $1900. Te
exceptions process will no longer be in eect aer December 31, 20
Congressional action is necessary to extend the exceptions process.
Multiple Procedure Payment Reduction (MPPR)
No revisions were made to CMS’s policy regarding application o th
MPPR to outpatient therapy services. MPPR is a reduction to the
practice expense portion o the payment or a therapy procedure wh
more than one unit or procedure is provided to the same patient on
the same date o service. Te MPPR o 25% or services urnished
in an institutional setting and 20% or services urnished in a non-
institutional setting remains unchanged.
2013 Terapy Cap Limitations
Te Balanced Budget Act o 1997, P.L. 105-33, Section 4541(c) set
annual caps or Part B Medicare therapy patients. Tese limits chang
annually. Terapy caps or 2013 will be $1900 or physical therapy an
speech therapy combined and $1900 or occupational therapy.
Terapy Cap Exceptions Process Expires Dec. 31, 2012 Unless
Congress Acts
Section 4541(a)(2) o the Balanced Budget Act (BBA) (P.L. 105-33)
1997, which added §1834(k)(5) to the Act, required payment under
prospective payment system (PPS) or outpatient rehabilitation serv
(except those urnished by or under arrangements with a hospital).
Section 4541(c) o the BBA required application o nancial limitati
to all outpatient rehabilitation services (except those urnished by or
under arrangements with a hospital).
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ince the creation o therapy caps, Congress has enacted several
moratoria. Te Decit Reduction Act o 2005 directed CMS to
develop exceptions to therapy caps or calendar year 2006 and the
xceptions have been extended periodically. Exceptions to caps
ased on the medical necessity o the service are in eect only when
Congress legislates the exceptions. In 2006, the Exception Processes
ell into two categories, Automatic Process Exceptions, and Manual
Process Exceptions. Beginning January 1, 2007, there is no manual
process or exceptions. All services that require exceptions to caps
hall be processed using the automatic process. All requests or
xception are in the orm o a KX modier added to claim lines.
Te KX modier is added to claim lines to indicate that the clinician
ttests that services are medically necessary and justication is
documented in the medical record.
Te automatic process or exceptions will expire on December 31,
012 i congress does not act to extend the exception process. Tis
will result in Medicare Part B therapy patients being limited to a cap
$1900 or physical therapy and speech therapy combined and
1900 or occupational therapy in 2013.
013 Medicare Copays and Deductibles
CMS released inormation on the copays and deductibles or
Medicare Part A and Part B services in 2013. Te Part A deductible
paid by a beneciary when admitted as a hospital inpatient will
e $1,184 in 2013, an increase o $28 rom this year’s $1,156
deductible. Te Part A deductible is the beneciary’s cost or up
o 60 days o Medicare-covered inpatient hospital care in a benet
period. Beneciaries must pay an additional $296 per day or days
1 through 90 in 2013, and $592 per day or hospital stays beyond
he 90th day in a benet period. For beneciaries in skilled nursing
acilities, the daily co-insurance or days 21 through 100 in a benet
period will be $148.00 in 2013, compared to $144.50 in 2012. In
013, the Part B deductible will be $147, an increase in $7.00 rom
012 and the Part B copay will remain 20%.
Functional Limitation Reporting Under Medicare Part B
Te Middle Class ax Relie Act o 2012 included a mandate that
CMS collect inormation on Medicare Part B claims regarding the
eneciaries unction and condition, therapy services urnished,
nd outcomes achieved. CMS intends to utilize this inormation in
he uture to reorm payment or outpatient therapy services. Te
policy applies to physical therapy, occupational therapy, and speech
herapy services urnished in hospitals, Critical Access Hospitals
CAH’s), Skilled Nursing Facilities (SNF’s), Comprehensive
Outpatient Rehabilitation Facilities (CORFs), rehabilitation
agencies, home health agencies (when the beneciary is not under a
home health plan o care), and in private ofces o therapists, physic
and nonphysician practitioners. Te reporting o the unctional
limitations on the claim orm will be implemented on January 1, 20
o assure smooth transition, CMS has set orth a testing period rom
January 1, 2013, until July 1, 2013. Aer July 1, 2013, claims submitt
without the appropriate G-codes and modiers will be returned
unpaid.
Functional Limitation Reporting FAQs:
How is this inormation reported?
Under this new rule nonpayable G-codes and modiers will be
included on the claim orm to capture data on the beneciary’s
unctional limitations.
How requently must this inormation be reported? Nonpayable G-codes and modiers will be included on the claim o
to capture data on the beneciary’s unctional limitations (a) at the
outset o the therapy episode; (b) at a minimum every 10th visit; and
(c) at discharge. In addition, the therapist’s projected goal or unctio
status at the end o treatment will be reported on the rst claim or
services and at the end o the episode. Modiers will indicate the ext
o the severity/complexity o the unctional limitation.
What are the nonpayable G-codes or reporting unctional limitation?
G-Codes or Claims-Based Functional Reporting or CY 2013
Mobility: Walking & Moving Around
G8978 Mobility: walking & moving around unctional limitation,
current status, at therapy episode outset and at reporting
intervals
G8979 Mobility: walking & moving around unctional limitation,
projected goal status, at therapy episode outset, at reporting
intervals, and at discharge or to end reporting
G8980 Mobility: walking & moving around unctional limitation,
discharge status, at discharge rom therapy or to
end reporting
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Changing & Maintaining Body Position
G8981 Changing & maintaining body position unctional
limitation, current status, at therapy episode outset and at
reporting intervals
G8982 Changing & maintaining body position unctional
limitation, projected goal status, at therapy episode outset,at reporting intervals, and at discharge or to end reporting
G8983 Changing & maintaining body position unctional
limitation, discharge status, at discharge rom therapy or to
end reporting
Carrying, Moving & Handling Objects
G8984 Carrying, moving & handling objects unctional
limitation, current status, at therapy episode outset and at
reporting intervals
G8985 Carrying, moving & handling objects unctional
limitation, projected goal status, at therapy episode outset,
at reporting intervals, and at discharge or to end reporting
G8986 Carrying, moving & handling objects unctional
limitation, discharge status, at discharge rom therapy
or to end reporting
Self Care
G8987 Sel care unctional limitation, current status, at therapy
episode outset and at reporting intervals
G8988 Sel care unctional limitation, projected goal status, at
therapy episode outset, at reporting intervals, and at
discharge or to end reporting
G8989 Sel care unctional limitation, discharge status, at
discharge rom therapy or to end reporting
Other P/O Primary Functional Limitation
G8990 Other physical or occupational primary unctionallimitation, current status, at therapy episode outset and at
reporting intervals
G8991 Other physical or occupational primary unctional
limitation, projected goal status, at therapy episode outset,
at reporting intervals, and at discharge or to end reporting
G8992 Other physical or occupational primary unctional
limitation, discharge status, at discharge rom therapy or to
end reporting
Other P/ O Subsequent Functional Limitation
G8993 Other physical or occupational subsequent unctional
limitation, current status, at therapy episode outset and a
reporting intervals
G8994 Other physical or occupational subsequent unctional
limitation, projected goal status, at therapy episode outseat reporting intervals, and at discharge or to end reportin
G8995 Other physical or occupational subsequent unctional
limitation, discharge status, at discharge rom therapy or
end reporting
Speech Language Pathology Functional Limitation
G8996 Swallowing unctional limitation, current status at time
initial therapy treatment/episode outset and at
eporting intervals
G8997 Swallowing unctional limitation, projected goal status, a
initial therapy treatment/outset and at discharge or to en
reporting
G8998 Swallowing unctional limitation, discharge status, at
discharge rom therapy/end o reporting on limitation
G8999 Motor speech unctional limitation, current status at tim
o initial therapy treatment/episode outset and at reporti
intervals
G9157 Motor speech unctional limitation, projected goal statu
initial therapy treatment/outset and at discharge rom
therapy
G9158 Motor speech limitation, discharge status at discharge ro
therapy/end o reporting on limitation
G9159 Spoken Language Comprehension unctional limitation
current status at time o initial therapy treatment/episod
outset and reporting intervals
G9160 Spoken Language Comprehension unctional limitation
projected goal status at initial therapy treatment/outset a
at discharge rom therapy
G9161 Spoken Language Comprehension unctional limitation
discharge status at discharge rom therapy/end o reporti
on limitation
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G9162 Spoken Language Expression unctional limitation,
current status at time o initial therapy treatment/episode
outset and at reporting intervals
G9163 Spoken Language Expression unctional limitation,
projected goal status at initial therapy treatment/outset and
at discharge rom therapy
G9164 Spoken Language Expression unctional limitation,
discharge status at discharge rom therapy/end o reporting
on limitation
G9165 Attention unctional limitation, current status at time o
initial therapy treatment/episode outset and at reporting
intervals
G9166 Attention unctional limitation, projected goal status at
initial therapy treatment/outset and at discharge rom
therapy
G9167 Attention unctional limitation, discharge status at
discharge rom therapy/end o reporting on limitation
G9168 Memory unctional limitation, current status at time o
initial therapy treatment/episode outset and at reporting
intervals
G9169 Memory unctional limitation, projected goal status at
initial therapy treatment/outset and at discharge rom
therapy
G9170 Memory unctional limitation, discharge status at
discharge rom therapy/end o reporting on limitation
G9171 Voice unctional limitation, current status at time o initial
therapy treatment/episode outset and at reporting intervals
G9172 Voice unctional limitation, projected goal status at initial
therapy treatment/outset and at discharge rom therapy
G9173 Voice unctional limitation, discharge status at discharge
rom therapy/end o reporting on limitation
G9174 Other speech language pathology unctional limitation,current status at time o initial therapy treatment/episode
outset and reporting intervals
G9175 Other speech language pathology unctional limitation,
projected goal status at initial therapy treatment/outset and
at discharge rom therapy
G9176 Other speech language pathology unctional limitation,
discharge status at discharge rom therapy/end o reporting
on limitation
What limitation category should I choose or my patient i I use a
composite unctional tool such as Focus on Terapeutic Outcomes
(FOO)?
In this instance, a composite score should be reported using G89
(Other physical or occupational primary unctional limitation,
current status, at therapy episode outset and at reporting interval
G8991(Other physical or occupational primary unctional
limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting) and G8
(Other physical or occupational primary unctional limitation,
discharge status, at discharge rom therapy or to end reporting).
Should there be the occasion to report on a second condition a
the reporting on the rst had ended, the therapist would use the
G-codesetfor“othersubsequent”functionallimitation,G8993-
G8896.
I my patient has more than one unctional limitation, do I report multiple categories o unctional limitation?
No, at this time you only report one, primary unctional limitatio
to Medicare or each patient. In situations where treatment
continues aer the treatment goal is achieved and reporting ende
on the primary unctional limitation, reporting will be required
another unctional limitation. Tus, reporting on more than one
unctional limitation may be required or some patients, but not
simultaneously. Instead, once reporting on the primary unction
limitation is complete, the therapist will begin reporting on a
subsequent unctional limitation using another set o G-codes.
How is the patient’s unctional limitation severity reported?
Functional limitation severity is reports using one o seven modi
codes seen in the table below.
Severity/Complexity Modiers or CY 2013
Modier Impairment Limitation Restriction
CH 0 percent impaired, limited or restricted
CI 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 restricted
CK At least 40 percent but less than 60 percent
impaired, limited or restricted
CL At least 60 percent but less than 80 percent
impaired, limited or restricted
CM At least 80 percent but less than 100 percent
impaired, limited or restricted
CN 100 percent impaired, limited or restricted
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How do I determine the appropriate severity modifer or my patient?
Terapists must use a valid and reliable objective measure and/or
ssessment to quantiy unctional limitations. In some instances,
herapists may use more than one assessment tool to determine the
patient’s unctional limitation severity. It is acceptable or therapistso use their proessional judgment in the selection o the appropriate
modier.
Do I need to document how I selected the severity modifer?
Yes, therapists will need to document in the medical record how
hey made the modier selection so that the same process can be
ollowed at succeeding assessment intervals.
How requently must I submit unctional limitation inormation to
CMS on my patient?
Terapists must report the current unctional limitation o theirpatients at outset (initial evaluation), every 10th visit, and at
discharge.
How requently do I report goals on my patient?
Terapists must report the projected goal o their patients at outset
initial evaluation), every 10th visit, and at discharge.
What i my patient does not return or their discharge appointment or
discontinues therapy prior to ormal discharge?
Discharge reporting is required except in cases where therapy
ervices are discontinued by the beneciary prior to the planned
discharge visit.
Do I need to report unction limitation inormation i I perorm a
e-evaluation?
Yes, the therapist is required to begin a new reporting period when
ubmitting a claim containing a CP code or an evaluation or a re-
valuation. In this instance the therapist must submit inormation
n the current unctional status and the projected patient goal.
When do I begin reporting a subsequent unctional limitation i the
rimary limitation has resolved?
the primary unctional limitation is resolved, but care continues to
ddress another or subsequent limitation, the therapist reports that
mitation aer 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 modier is required to be
documented in the medical record. In cases where the therapist uses
other inormation in addition to certain measurement tools in order
to assess unctional impairment, documentation o the relevantinormation used to determine the overall percentage o unctional
limitation to select the severity modier should also be included in the
record.
Do I need to include the GP, GO or GN modifer when I report the
unctional limitation G-code?
Yes, or each nonpayable G-code on the claim, that line o service
would also need to contain one o the severity modiers, the
corresponding GO, GP, or GN therapy modier to indicate the
respective occupational, physical, or speech language therapy
discipline and related plan o care; and the date o service it reerences.
What do I submit with each G-code?
When reporting the unctional limitation o a patient to Medicare you
must submit the G-code, a severity modier, and the corresponding
therapy modier (GO, GP, or GN). Additionally, or each line on
the institutional claim submitted by hospitals, SNFs, rehabilitation
agencies, CORFs and HHAs, a charge o one penny, $0.01, can be
added. For each line on the proessional claim submitted by private
practice therapists and physician/NPPs, a charge o $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
o the FY 2012 policy changes including the recalibration o the parity
adjustment, allocation o group therapy and changes to the MDS
including the introduction o the Change-o-Terapy (CO) Other
Medicare Required Assessment (OMRA). Below are some o the
highlights.
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• Overallpatientcasemixisnotsignicantlydierentfrom
that observed in FY 2011--there have been small decreases in
the Rehabilitation Plus Extensive Services categories, and
increases in some o the medically-based RUG categories,
most notably Special Care.
FY 2011 FY2012 QR 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 Perormance
Reduced Physical Function 1.5% 1.4%
• TepercentageofresidentsinUltra-HighRehabilitationhas
increased rom FY 2011 and although there have been
decreases in the High and Medium therapy RUG-IV
categories, CMS stated that some o the decrease may be due to
index maximization into the Special Care category.
FY 2011 FY 2012 QR 1, 2, & 3
Ultra-High Rehabilitation 44.9% 46.9%
(≥ 720 minutes o therapy
per week)
Very-High Rehabilitation 26.9% 26.2%
(500 – 719 minutes o
therapy per week)
High Rehabilitation 10.8% 10.5%
(325 – 499 minutes o
therapy per week)
Medium Rehabilitation 7.6% 6.5%
(150 – 324 minutes o
therapy per week)
Low Rehabilitation 0.1% 0.1%
(45 – 149 minutes o
therapy per week)
• InitialFY2012dataindicatethataertheallocationofgroup
therapy acilities are providing individual therapy almost
exclusively.
SRIVE FY 2011 FY 2012 QR 1, 2, & 3
Individual 74% 91.8% 99.5%
Concurrent 25% 0.8% 0.4%
Group <1% 7.4% 0.1%
• CMSstatedinthisreportthatpriortotheimplementation
o the CO OMRA, scheduled PPS assessments comprised the
majority o the completed assessments. With the addition o the
CO OMRA, scheduled PPS assessments continue to be the
majority o the completed assessments; however, the CO
OMRA is the most requently completed unscheduled
assessment.
FY 2011 FY 2012 QR 1, 2, & 3
Scheduled PPS assessment 95% 84%
Start-o-Terapy (SO) assessment 2% 2%
End-o-Terapy (EO) assessment 3% 3%
(w/o Resumption)
Combined SO/EO 0% 0%
End-o-Terapy assessment N/A 0%
(w/ Resumption) (EO-R)
Combined SO/EO-R N/A 0%
Change-o-herapy (CO) assessment N/A 11%
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Proposed Settlement Agreement Filed in “Improvement
tandard” Case
Attorneys rom the Center or Medicare Advocacy, Vermont Legal
Aid and the Centers or Medicare & Medicaid Services (CMS)
haveagreedtosettlethe“ImprovementStandard”case,Jimmov.
ebelius, No. 11-cv-17 (D.V), led January 18, 2011. A proposed
ettlement agreement was led in ederal District Court on October
6, 2012. When the judge approves the proposed agreement, a
process that may take several months, CMS will revise the Medicare
Benet Policy Manual and other Medicare Manuals to correct
uggestions that Medicare coverage is dependent on a beneciary
improving”whichiscurrentlyoenusedasadenialreason.As
CMS recognizes, the settlement does not change the underlying
aw and regulations governing the Medicare program. Accordingly,
ince the underlying Medicare law is not changed, health care
providers should implement the maintenance standard now. Tus,
health care providers should apply the maintenance standard and
provide medically necessary nursing services or therapy services,
r both, to patients who need them to maintain their unction, or
prevent or slow their decline.
TeJimmosettlementalsoestablishesaprocessof“re-review”for
Medicare beneciaries who received a denial o skilled nursing
acility care, home health care, or out-patient therapy services
physical therapy, occupational therapy, or speech therapy) that
ecame nal and non-appealable aer January 18, 2011 because o he Improvement Standard. Shortly aer the ederal district court
pproves the settlement, CMS will announce how beneciaries can
nvoke the re-review process.
013 OIG Work Plan Released
Te Ofce o Inspector General Work Plan or Fiscal Year 2013
provides brie descriptions o activities that the Ofce o Inspector
General (OIG) plans to initiate or continue with respect to the
programs and operations o the Department o Health & Human
ervices in scal year 2013. For each review, the Work Plandescribes the subject, primary objective, and criteria related to the
opic. In 2013, the areas o ocus or nursing homes are:
Nursing Homes—Adverse Events in Post-Acute Care or Medicare Benefciaries
Te OIG will estimate the national incidence o adverse and
temporary harm events or Medicare beneciaries receiving postacute
care in SNFs and inpatient rehabilitation acilities (IRF). Te OIG will
also identiy contributing actors to these events, determine the extent
to which the events were preventable, and estimate the associated costs
to Medicare.
Nursing Homes—Medicare Requirements or Quality o 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 o residents
needs or care, as identied through RAIs, were not reected in
care plans and that nursing home residents did not receive all thepsychosocial services identied in care plans.
Te OIG will review how SNFs have addressed certain Federal
requirements related to quality o care. Te OIG will determine the
extent to which SNFs use the Residential Assessment Instruments
(RAI) to develop care plans to provide services to beneciaries
in accordance with the plans o care and to plan or beneciaries’
discharges. Te OIG will also describe any instances o poor quality
o care.
Nursing Homes—State Agency Verifcation o Defciency Corrections (New)
Federal regulations require nursing homes to submit correction plans
to the State survey agency or CMS or deciencies identied during
surveys. CMS requires State survey agencies to veriy the correction
o identied deciencies through onsite reviews or by obtaining other
evidence o correction. (State Operations Manual, Pub. No. 100-07, §
7300.3.) A prior OIG review ound that one State survey agency did
not always veriy that nursing homes corrected deciencies identied
during surveys in accordance with Federal requirements.
Te OIG will determine whether State survey agencies veried
correction plans or deciencies identied during nursing home
recertication surveys.
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Nursing Homes—Oversight o Poorly Perorming Facilities
Te OIG will identiy poorly perorming nursing homes and
determine the extent to which CMS and States use enorcement
measures to improve nursing home perormance. Te OIG will
lso identiy CMS and States’ ollow up actions to ensure that poorly
perorming nursing homes implement corrective actions. Te OIG
will examine enorcement decisions by CMS and States resulting
rom surveys and complaint allegations
Nursing Homes—Use o Atypical Antipsychotic Drugs (New)
According to 42 CFR § 488.3, nursing homes must comply with
Federal quality and saety standards, including requiring the
monitoring o the prescription drugs prescribed to its residents.
Federal requirements, 42 CFR § 483.25(l)(1), also require thatnursing home residents’ drug regimens be ree rom
unnecessary drugs.
Te OIG will assess nursing homes’ administration o atypical
ntipsychotic drugs, including the percentage o residents receiving
hese drugs and the types o drugs most commonly received. Te
OIG will also describe the characteristics associated with nursing
homes that requently administer atypical antipsychotic drugs.
Nursing Homes—Hospitalizations o Nursing Home Residents
Hospitalizations o nursing home residents are costly to Medicare
nd may indicate quality-o-care problems at nursing homes. A
007 OIG review ound that 35 percent o hospitalizations during
SNF stay were caused by poor quality o care or unnecessary
ragmentation o services. Te OIG will determine the extent to
which Medicare beneciaries residing in nursing homes have
een hospitalized. Te OIG will also determine the extent to
which hospitalizations were a result o manageable or preventable
onditions.
Nursing Homes—Questionable Billing Patterns or Part B ServicesDuring Nursing Home Stays
Te OIG will identiy questionable billing patterns associated with
nursing homes and Medicare providers or Part B services provided
o nursing home residents. A series o studies will examine podiatry,
mbulance, laboratory, and imaging services.
Nursing Homes—Oversight o the Minimum Data Set Submitted by Long-erm-Care Facilities (New)
Certied nursing acilities are required to complete the MDS or all
residents at specied intervals and submit data electronically to the
State. States then submit data to CMS, which uses it or a number o programs, including payment, quality monitoring, and consumer
inormation. Te OIG will determine whether and the extent to
which CMS and the States oversee the accuracy and completeness o
Minimum Data Set (MDS) data submitted by nursing acilities.
Medicare Auditors Becoming More Active, Denying More Claims
A new survey conducted by the American Hospital Association
ound that requests or medical records by Medicare’s recovery audit
contractors (RACs) jumped sharply rom the rst- to the second-quarter o scal year 2012. RACs requested 546,000 medical records in
the second quarter o 2012. Tat’s a 22% increase over the 448,000 the
previous quarter. Providers also experienced an increase in the denial
o claims, both automated and complex over that same time, AHA
survey results showed. Te survey ound that more than hal o 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 Schi (D-CA)
proposed the Medicare Audit Improvement Act (H.R. 6575) which
would limit the power o Medicare Contractors. Te bill was reerred
to House Ways and Means, House Energy and Commerce on October
16, 2012, which will consider it beore possibly sending it on to the
House or Senate as a whole.
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HR 6575, i passed in the House and Senate and signed by the
President, would:
• Limitthenumberofadditionaldocumentationrequestsmade
by Medicare contractors;
• Imposepenaltiesforfailuretomeetcertaintimeframesandforoverturned appeals;
• Requiremedicalnecessityauditstofocusonwidespread
payment error rates;
• IncreasetransparencyofRACperformance;
• RestoredueprocessrightsundertheABrebilling
demonstration;
• Requireaccuratepaymentforrebilledclaims;and
• Requirephysicianvalidationformedicalnecessitydenials.
Below is a summary o a number o these provisions as they pertain
o RACs, specically.
Limiting Documentation Requests
enacted, the Secretary o HHS (Secretary) must establish a process
where the number o additional document requests o a hospital
made by a Medicare contractor, as it relates to part A claims, in a
ear is the lesser o:
1. 2% o all o the claims or that year; or
2. 500 additional documentation requests during a 45-day period.
mportantly,thisstatuteappliestorequestsmadebya“Medicare
ontractor”notjustaRAC.Medicarecontractor,forpurposes
this bill, means a Medicare administrative contractor, scal
ntermediary, carriers, RACs, Zone Program Integrity contractors,
Program Saeguard Contractors, and Comprehensive Error Rate
esting program contractors.
Penalties and Audits on Widespread Payment Errors
HR 6575 would require the contracts between the Secretary and the
RACs to include the ollowing:
• ImpositionofnancialpenaltiesiftheSecretarydetermines
that the RAC exhibits a pattern o ailure to: urnish a demand
letter in a timely ashion or complete a determination with
respect to each audit in a timely ashion;
• Impositionofpenaltiesforoverturnedappeals;
• TeSecretarywillnotapproveapost-paymentorprepayment
medical necessity audit unless the review addresses a widespread
payment error rate;
• TeRACwillterminateanauditifitisdeterminedthatthe
applicable payment error rate is no longer a widespread payment
error; and
• RACsmayonlyconductprepaymentreviewspursuantto
guidelines established by the Secretary.
ransparency o RAC Perormance
Inormation on RAC perormance would be published annually on
the CMS website and would, with respect to each RAC, display the
inormation on audit rates, denials and appeals outcomes as well
as the results o any perormance evaluation audit conducted by an
independent entity.
Requiring Physician Validation or Medical Necessity Denials
When a RAC denies a claim or 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 certiy the determination, and append the
signed and certied determination to the claim le. I 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 forRecovery Auditors
CMS releases Recovery Auditor overpayment and underpayment
statistics at the close o each scal year (FY) quarter.
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n FY 2010, Recovery Auditors collected $75.4 million in
verpayments and identied $16.9 million in underpayments or
total correction amount o $92.3 million. Last year, Recovery
Auditors recouped $797.4 million in overpayments and reported
141.9 million in underpayments or a total correction amount $939.9 million. In FY 2012, Recovery Auditors collected a total
$2.29 billion in overpayments and identied $109.4 million in
underpayments or a total o $2.4 billion in corrections. However,
he report is somewhat incomplete since it does not reect what was
ecouped aer the appeals are done.
FY 2010 FY 2011 FY 2012 otal nationalOct 2009- Oct 2010– Oct 2011– programSept 2010 Sept 2011 Dec 2012
Overpayments $75.4M $797.4M $2,291.3M $3.16Bollected
Underpayments $16.9M $141.9M $109.4M $268.2M
eturned
otal 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 o total correction numbers or the
past quarter or each Recovery Auditor region. Perormant 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.
Te ollowing chart shows the overpayments, underpayments, and
otal corrections or the quarter and scal year to date, with guresprovided in millions:
Overpayments Underpayments otal quarter FY to datcollected returned corrections correction
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 underhealthcare reform
Providers need to have the appropriate sta and data analytics
programs in place to deend against the onslaught o more Medicare
and Medicaid claims audits, according to healthcare expert Robert
Freedman. As more provisions o the Aordable Care Act areimplemented, Medicare and Medicaid providers should expect
more scrutiny rom Recovery Audit Contractors (RAC), Medicare
Administrative Contractors (MAC), and comprehensive error rate
testing contractors.Freedman said provider compliance ofcers shou
be prepared to spend a lot more o their time appealing and deendin
audits, according to a report by the Bureau o National Aairs. 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 forNursing Center Care
Te bleak Medicaid picture is unlikely to get better in 2013 or nursin
home operators according to a report commissioned by the America
Health Care Association and conducted by Eljay, LLC. Medicaid
underpayments are expected to exceed $7 billion nationally in 2012,
an average shortall o $22.34 per resident day. Tat’s up rom $18.54
2010,notesthe“ReportonShortfallsinMedicaidFundingforNursi
CenterCare.”Brokendownintothecostsforatypical100-bedfacilit
where 63% o residents are on Medicaid, the shortall translates into
$500,000 each year.
Te report notes a ew actors that will make Medicaid unding even
more challenging moving orward: dual-eligible integration likely
will have implications or both Medicaid long-stay occupants and
Medicare-nanced post-acute care average length o stay. Te
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ederal government is also pushing or expansion o home- and
ommunity-based services, which also are expected to drive down
verage occupancy rates. Many states also are pushing or managed
are plans or Medicaid beneciaries.
mprovements are Needed at the Administrative Law JudgeLevel of Medicare Appeals
n a study that analyzed all ALJ appeals decided in scal year (FY)
010, policies, procedures, other documents and data on CMS
participation in ALJ appeals and consisted o structured interviews
with ALJs and other sta; Qualied Independent Contractors (QIC),
nd CMS sta, the OIG ound that providers led the vast majority o
ALJ appeals in FY 2010, with a small number accounting or nearly
ne-third o all appeals. For 56 percent o appeals, ALJs reversed
QIC decisions and decided in avor o appellants; this rate varied
ubstantially across Medicare program areas. Dierences between ALJ
nd QIC decisions were due to dierent interpretations o Medicare
policies and other actors. In addition, the avorable rate varied widely
y ALJ. When CMS participated in appeals, ALJ decisions were less
kely to be avorable to appellants. Sta raised concerns about the
cceptance o new evidence and the organization o case les. Finally,
ALJ sta handled suspicions o raud inconsistently.
Te OIG recommended that OMHA and CMS: (1) develop and
provide coordinated training on Medicare policies to ALJs and
QICs, (2) identiy and clariy Medicare policies that are unclearnd interpreted dierently, (3) standardize case les and make
hem electronic, (4) revise regulations to provide more guidance to
ALJs regarding the acceptance o new evidence, and (5) improve
he handling o appeals rom appellants who are also under raud
nvestigation and seek statutory authority to postpone these appeals
when necessary. Further, the OIG recommended that OMHA: (6)
eek statutory authority to establish a ling ee, (7) implement a
quality assurance process to review ALJ decisions, (8) determine
whether specialization among ALJs would improve consistency and
fciency, and (9) develop policies to handle suspicions o raudppropriately and consistently and train sta accordingly. Finally,
he OIG recommended that CMS: (10) continue to increase CMS
participation in ALJ appeals. OMHA and CMS concurred ully or in
part with all 10 o the recommendations.
All Eyes on Therapy
Terapy remains the ocus o many Medicare Administrative
Contractors (MACs)/Fiscal Intermediaries (FIs) as well as the
Regulatory and Law Enorcement Agencies o the Federal
Government as the commitment to deterring raud, waste and abusin the Medicare and Medicaid systems has increased.
OIG Report: Inappropriate Payments to Skilled Nursing Facilitie
Cost Medicare More Tan a Billion Dollars in 2009
In recent years, the Ofce o Inspector General has identied a
number o problems with billing by skilled nursing acilities (SNF),
including the submission o inaccurate, medically unnecessary,
and raudulent claims. Further, the Medicare Payment Advisory
Commission has raised concerns about SNFs’ improperly billing or
therapy to obtain additional Medicare payments. In scal year (FY)
2012, Medicare paid $32.2 billion or SNF services.
Te OIG based this study on a medical record review o a stratied
random sample o SNF claims rom 2009. Te reviewers determine
whether the inormation reported by the SNFs on the Minimum
Data Set (MDS) was supported by and consistent with the medical
record. Te OIG ound that SNFs billed one-quarter o all claims
in error in 2009, resulting in $1.5 billion in inappropriate Medicare
payments. Te majority o the claims in error were upcoded; many
these claims were or ultrahigh therapy. Te remaining claims in er
were downcoded or did not meet Medicare coverage requirements.
addition, SNFs misreported inormation on the MDS or 47 percen
o claims. SNFs commonly misreported therapy, which largely
determines the RUG and the amount that Medicare pays the SNF.
Te OIG recognized that CMS has recently made several signicant
changes to SNF payments and made the ollowing recommendation
to CMS to which CMS concurred with all six:
(1) Increase and expand reviews o SNF claims,
(2) Use its Fraud Prevention System to identiy SNFs that arebilling or higher paying RUGs,
(3) Monitor compliance with new therapy assessments,(4) Change the current method or determining how much
therapy is needed to ensure appropriate payments,
(5) Improve the accuracy o MDS items, and
(6) Follow up on the SNFs that billed in error.
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Owner of Old Saybrook Physical Terapy Practice Pleads
Guilty to Obstructing Federal Audit
Te United States Attorney or the District o Connecticut announced
hat odd Roberts, 47, o Old Saybrook, waived his right to
ndictment and pleaded guilty to one count o obstructing a
ederal audit.
According to court documents and statements made in court, Roberts
s the owner and operator o Roberts Physical and Aquatic Terapy,
ocated at 210 Main Street in Old Saybrook. On January 23, 2009, a
Medicare contractor inormed Roberts Physical and Aquatic Terapy
hat the contractor was perorming an audit o the practice. Roberts
nstructed an employee to delay the audit by telling the contractor that
medical records were stored at a nonexistent storage acility. Roberts
hen rented a storage unit at a local acility and used the delay to alter
nd augment patient records. Specically, Roberts, and an employee at
his direction, created and added patient progress notes when no noteshad been created at the time o service. Te notes made it appear
s though Medicare beneciaries had obtained direct, one-on-one
ervice rom a licensed physical therapist when, in act, some o the
ervices had been rendered by unlicensed auxiliary personnel.
udge Underhill has scheduled sentencing or December 18, 2012, at
which time Roberts aces a maximum term o imprisonment o ve
ears and a ne o up to $250,000.
Rajindera Sachdeva Added to Most Wanted Fugitives List
Rajindera Sachdeva was added to most wanted ugitives list.achdeva has been indicted on charges o health care raud. From
pproximately January 2005 until December 2006, Rajindera
achdeva was an occupational therapist who worked with various
Medicare providers. Sachdeva was paid approximately $3.3 million
rom Medicare. According to investigators, Sachdeva created
ccupational and physical therapy les or services that were never
provided to patients. SA Rehabilitation Services billed Medicare or
he physical and occupational therapy services that were not provided.
Te les were then sold to co-conspirator Ehsan Rana, the owner
Alternative Physical Terapy, Incorporated. Alternative Physical
Terapy billed Medicare or occupational and physical therapy ervices that were not provided. Files were also sold to ri-County
Rehabilitation.
Fraudulent Billing for Manual Terapy
acqueline Wheeler was ound guilty o one count o healthcare
raud and 34 counts o making alse statements relating to healthcare
matters and was sentenced to six years, three months in prison and
$6.34 million in nes and restitution. Wheeler also received three
years’ probation and was banned rom the healthcare industry.
Wheeler led more than $7 million in ake Medicaid claims listing
hersel as a medical doctor when she was actually a non-board-
certied naturopath. Prosecutors charged that Wheeler led claimthat showed the center provided rom 20 to 48.5 continuous hours
manual therapy or each patient in 24-hour periods.
Physical Terapist Ph.D. Sentenced to 13 Months of Prison and
Pays More Tan $3 Million Dollars in Restitution, Civil Penalti
and Back axes
Chyawan Bansil, P.., Ph.D. o Farmington Hills, Michigan was
sentenced to 13 months prison on charges o health care raud
and money laundering. Te convictions arise rom an Indictment
which charged that between February 2007 and January 2012, Dr.Bansil derauded Medicare, Medicaid, and Blue Cross Blue Shield
o Michigan o more than $1 million by causing those programs
to be billed or expensive nerve conduction studies and needle
electromyography tests that Dr. Bansil did not perorm.
Detroit-Area Physical Terapy Assistant Sentenced to 30 Month
Prison for Role in $13.8 Million Home Health Care Fraud Schem
A Detroit-area registered physical therapy assistant was sentenced
to serve 30 months in prison or her role in a nearly $13.8 million
Medicare raud scheme. In addition to her prison term, Barot was
sentenced to serve two years o supervised release and ordered to p
$1,336,739 in restitution, jointly and severally with her co-deendan
Barot pleaded guilty on June 26, 2012, to one count o conspiracy
to commit health care raud. According to Barot’s plea agreement,
beginning in approximately May 2009, Barot, a physical therapy
assistant, was paid to alsiy medical documentation or 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 purportedphysical therapy or patients she did not see or treat. According to
court documents, she was instructed on how to alsiy the medical
documentation by a co-conspirator.
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Barot also pleaded guilty to signing therapy revisit notes as a physical
herapy assistant or patients she did not see or treat, knowing that the
documents she alsied and the documents that she signed would be
used to support alse claims to Medicare or home health services.
Barot was subsequently paid to sign alsied medical documentationnd les or First Care Home Health Care LLC, Quantum Home Care
nc. and Moonlite Home Care Inc., which were Detroit-area home
health care companies also owned by Barot’s co-conspirators that
illed Medicare.
From approximately May 2009 through September 2011, Medicare
paid approximately $1,336,739 to the our home health care
ompanies or raudulent physical therapy claims based on alsied
les and notes signed by Barot. Te our home health companies or
which Barot worked were paid in total approximately $13.8 million by
Medicare.
Nine o Barot’s co-deendants have pleaded guilty, and one has been
entenced. Tree co-deendants are ugitives, and six co-deendants
wait trial.
Life Care Centers of America probed for Medicare fraud
Federal prosecutors allege that Cleveland, enn.-based Lie Care
Centers o America has bilked the ederal government o hundreds
millions o dollars through a systematic Medicare raud scheme
ince at least 2006. Court records detail allegations and a ederal
nvestigation that began in 2008 with two whistle-blower lawsuits led
y employees at acilities in Florida and in Morristown, enn.
Prosecutors allege that top-level Lie Care supervisors issued directives
o max out unnecessary and oen harmul therapies to patients or
he highest possible Medicare reimbursement.
n an unsigned letter issued Friday to employees, Lie Care disputed
he government’s claims, saying that the combined whistle-blower
awsuitsappearedto“target”companiessuchastheirsandits
llegations“second-guess,aerthefact,thetrainedmedical
rofessionalswhoprescribedthelevelofcare.”
Te letter also states that the way the company provides therapies
actually saved Medicare an estimated $400 million in cost savings
rom 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 Huma
Services (HHS) Secretary Kathleen Sebelius announced that Medic
Fraud Strike Force operations in seven cities led to charges against 9
individuals – including doctors, nurses and other licensed medical
proessionals – or their alleged participation in Medicare raud
schemes involving approximately $429.2 million in alse billing,
Dozens o charged individuals were arrested or surrendered in the la
24 hours as indictments were unsealed across the country. ogethe
those indictments charge more than $230 million in home healthcare raud; more than $100 million in mental health care raud and
more than $49 million in ambulance transportation raud; and
millions more in other rauds. HHS also suspended or took other
administrative action against 30 health care providers ollowing a da
driven analysis and based upon credible allegations o raud.
Te deendants charged are accused o various health care raud-
related crimes, including conspiracy to commit health care raud,
health care raud, violations o the anti-kickback statutes and money
laundering. Te charges are based on a variety o alleged raud
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 deendants allegedly participate
in schemes to submit claims to Medicare or treatments that were
medically unnecessary and oentimes never provided. In many cas
court documents allege that patient recruiters, Medicare beneciarie
and other co-conspirators were paid cash kickbacks in return or
supplying beneciary inormation to providers, so that the providercould submit raudulent billing to Medicare or services that were
medically unnecessary or never provided.
Shawn Halcsik
Director of Compliance
414.791.9122
shalcsik@evergreenrehabcom
Contact Information:
Liz Barlow
Vice-President of Clinical Services
502.400.1619
liz@evergreenrehabcom