Clinical Coverage and Medical Review Findings Related to Therapy Services

1. Clinical Coverage and Medical Review Findings Related to Therapy Services Sally Rosiello March, 2011

2. Disclaimer This information release is the property of NHIC, Corp., J14 AB MAC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NHIC, Corp. and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the NHIC, Corp. web site at www.medicarenhic.com and the CMS web site at www.cms.gov. The identification of an organization or product in this information does not imply any form of endorsement.

3. Acronyms

4. Acronyms

5. Agenda Medical necessity Documentation Current topics and denials

6. Medical Necessity Treatment of illness or injury Significant change of condition Exacerbation of chronic illness Accepted standards of medical practice Specific and effective treatment for the patient’s condition Amount, frequency and duration to meet the patient’s medical needs

7. Medical Necessity Significant potential for improvement in response to therapy Restoration of impaired functions Amount of improvement anticipated should be reasonable when compared to amount of therapy required to achieve goals Realistic functional outcomes Not “optimal” potential Functional level of ADLs and applicable IADLs for patient to be safe in their environment Sufficient improvement to allow a patient to live at home independently or with family assist rather than in an institution Not to return to labor market, leisure, or play

8. Medical Necessity Requires unique skills of therapist to make functional improvements Complex patient condition Sophistication of treatment provided Services that can be performed by or taught to nonskilled persons or can be completed as an independent program are not skilled therapy

9. Documentation Requirements Evaluation and plan of care Certification and recertification Progress reports Treatment notes Discharge note Specific requirements for each piece of documentation defined in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3

10. Evaluation Presenting complaint/condition What brings the patient to therapy at this time? Subjective complaints and date of onset Prior level of function Prior therapy history for same diagnosis, illness, or injury Functional testing-objective measure of current level of function

11. Plan of Care Diagnosis Long Term Goals Type of Treatment Amount of Treatment Frequency of Treatment Duration of Treatment Signature and Credentials of the therapist, physician/NPP that developed the plan

12. Progress Reports Justify medical necessity of treatment Condition of patient and skilled nature of treatment Written by a clinician at least every 10 treatment days, or every 30 calendar days, whichever is less More frequent progress notes are encouraged to support medical necessity

13. Treatment Notes Date of treatment Identify each specific intervention in language that can be compared with CPT codes Record each service provided that is represented by a timed code, regardless of whether or not it is billed

14. Treatment Notes Total timed code treatment minutes Total treatment time (in minutes) Do not include time for services that are not billable (e.g., rest periods, documentation time) Reflects actual treatment time, not the time that the patient is in your facility “Time in/time out” not acceptable Signature and credentials of each individual that provided skilled interventions

15. Documenting Skilled Treatment Descriptions of the skilled interventions should be described somewhere in the medical record Plan of Care, Progress Report, Treatment Note, etc. Describe the skilled components of your intervention—the activity or technique that only the clinician has the knowledge to provide

16. Documenting Skilled Therapy “Skill” is not shown by only documenting the following: What patient or therapist did, i.e., dressed with moderate assist, transferred without physical assist Exercise name, number of repetitions, amount of weight, and distance ambulated Bottom line: Skilled treatment requires more documentation than just “ther ex” or “therapeutic activities”

17. Outpatient Therapy Certifications Required for coverage and payment A dated physician/NPP signature on the plan of care or some other document that indicates approval of the plan of care If signature is not dated, stamp the date approval was received

18. Certification and Recertification Interval length to be determined by the patient’s needs, not to exceed 90 days Should appropriately estimate the duration of care for the individual, even if it is less than 90 days 2 visits a week for 4 weeks would be 8 visits A significant change in the patient’s condition or treatment would require a recertification Patient treated for hip problem develops a new balance issue and vestibular rehab is needed A recertification would be necessary

19. Re-evaluations PT: CPT 97002 OT: CPT 97004 Requires the same professional skills as an evaluation Must be written by a clinician Is not a routine, recurring service Is not to be billed for completing a progress report

20. Re-evaluations Is separately payable when the assessment indicates a significant improvement or decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care New clinical findings Significant change in condition Failure to respond to the plan of care

21. Re-evaluations Denials occur when: Re-evaluations are billed for completion of routine progress notes or discharge summary There has not been a significant change of condition That was not anticipated Was not thorough enough to meet the requirements

22. Electrical Stimulation CPT: G0283 or 97032 Two codes for electrical stimulation billed to Medicare Note: 97014 is a valid CPT code, but not for Medicare

23. Electrical Stimulation (Non-wound Care) G0283 - Electrical Stimulation (unattended), to one or more areas, for indications other than wound care, as part of a therapy plan of treatment Untimed code, billable as one unit

24. Electrical Stimulation G0283 Most ES treatment IFC TENS as a clinical application Provided with an electrode Provided in a supervised manner

25. Electrical Stimulation 97032-Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes A “constant attendance” modality that requires the continuous (1:1) skilled intervention by the therapist throughout the treatment

26. Electrical Stimulation 97032 Probe Instructing a patient in the use of a home TENS unit Functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES)

27. Electrical Stimulation 97032 Constant, direct contact electrical stimulation modality is less frequent Clearly document the type of electrical stimulation provided to justify billing 97032 versus G0283 “Attending” cognitively impaired for safety reasons during ES does not upgrade a G0283 ES to a 97032 ES

28. Electrical Stimulation Denials of 97032 occur when: 97032 was billed, but the documentation supports G0283 The record does not clearly indicate the type of electrical stimulation provided for the reviewer to determine the correct code (G0283 vs. 97032) 97032 was billed because the patient is cognitively impaired and is not safe to be left alone Electrodes are billed separately

29. Iontophoresis 97033 Is covered only for intractable, disabling primary focal hyperhidrosis Denials occur when: Iontophoresis is billed without an appropriate ABN when the diagnosis is for anything but primary focal hyperhidrosis Good hygiene measures, extra-strength antiperspirants (for axillary hyperhidrosis), and topical aluminum chloride should initially be tried

30. Gait Training 97116 Requires a skilled gait assessment to support the need for therapist intervention Describe the gait cycle In the initial evaluation In treatment/progress notes Describe specific gait training techniques used, instructions given, assistance given, and patient’s response

31. Gait Training Denials occur when: There’s no skilled gait assessment or description of the skilled training provided “CGA x 100’ w/ WW” is not necessarily a skilled gait assessment or description of skilled gait training Gait training for “antalgic” gait is ongoing Limited gait training may be appropriate to teach improved gait patterns to reduce the stress on a painful area Documentation supports repetitive walk-strengthening Such as for feeble patients or to increase endurance

32. Failure to Return Records Timely A very common problem CMS requires providers to submit records requested for medical review within 30 days Records not received by day 45 result in auto denial Reason code 56900 Allow extra time for mail

33. Certification and Recertification Denials occur: Certification is not submitted with the other medical records A recertification was not obtained when there was a significant change in the patient’s condition that resulted in major changes to the plan of care The certification was not signed prior to the claim being billed Certification is a condition for payment-should be complete prior to billing A major cause of denials

34. Services Not Reasonable and Necessary There was no significant change of condition requiring the intervention of a therapist The patient has minimal potential to improve Has received a great deal of therapy for the same condition

35. Excessive Therapy Services Denials occur when: The treatment has continued despite the patient reaching a plateau The patient’s condition does not support the frequency of treatment 5x/wk therapy The patient’s condition does not support the amount of treatment provided in a given day Must meet but not exceed the patient’s needs

36. Unskilled Services These activities are usually done through repetitive activity or exercise: Increasing general activity tolerance Improving overall endurance Improving general fitness Increasing distance ambulating or of w/c propulsion Increasing upright tolerance

37. Needed Documentation Is Missing The timed code treatment minutes and total treatment time is missing The evaluation is not received Prior treatment notes, exercise logs and/or progress notes are not received Credentials of practitioner writing notes are missing Documentation is not legible

38. Incorrect Billing Incorrect units billed Follow the 8-minute rule to determine correct number of units Incorrect code billed Example - Documentation supports gait training but therapeutic activities billed

39. Questions

40. CMS References CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230 CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5 CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50

41. NHIC Reference NHIC Local Coverage Determinations Outpatient Physical and Occupational Therapy Services (L29833) Effective November 21, 2010

42. Future Questions CLINICAL questions e-mail hotline clinical.education@wellpoint.com

43. Follow-Up Please complete an assessment on the NHIC website http://www.medicarenhic.com/PA/PartA_assessment_form.shtml

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