Reimbur$ement: Show Me the Money!

1. Reimbur$ement: Show Me the Money! Carolyn A. Dobson, MT-BC AMTA Reimbursement Committee Representative WRAMTA Conference - Long Beach, CA April 1, 2011

2. Reimbursement Sources • Medicare • Partial Hospitalization (PHP) • Healthcare Common Procedure Coding System (HCPCS) • Activity Therapy Code: G0176

3. Reimbursement Sources • Medicare • Prospective Payment System (PPS) • In-Patient Rehab & Psychiatry • Hospice • Skilled Nursing Facilities (SNFs)

4. Reimbursement Sources • Medicare • Minimum Data Set (MDS) • Restorative Care • Section O: Special Treatments, Programs, And Procedures O0400: Therapies

5. MDS 3.0 Section OImportance of O04001 Item Rationale • Health-related Quality of Life • Maintaining as much independence as possible in activities of daily living, mobility, and communication is critically important to most people. Functional decline can lead to depression, withdrawal, social isolation, breathing problems, and complications of immobility, such as incontinence and pressure ulcers, which contribute to diminished quality of life. The qualified therapist, in conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents. • Rehabilitation (i.e., via Speech-Language Pathology Services and Occupational and Physical Therapies) and respiratory, psychological, and recreational therapy can help residents to attain or maintain their highest level of well-being and improve their quality of life.

6. MDS 3.0 Section OCriteria for Applicable Treatments, Procedures, & Programs Applicable treatments/ procedures include: • Services provided by or under the direction of a qualified occupational or physical therapist • Skilled therapy services only • Respiratory, psychological, and recreational therapy that meet specific criteria only Applicable treatments/ procedures do not include: • Services provided solely in conjunction with surgical services and diagnostic services • Non-skilled services Minimum Data Set (MDS) 3.0 Section O August 2010

7. Purpose of O0400 TherapiesConduct the Assessment Determine : • Therapy(ies) the resident received • Mode for each therapy received • How many minutes the resident spent in each mode of therapy during the look-back period • Number of days of therapy during the look-back period • Document the start and end date of each therapy. • Review the resident’s medical record. • Rehabilitation therapy evaluation • Treatment records • Recreation therapy notes • Mental health professional progress notes • Consult with each of the qualified care providers.

8. Special Treatments and Therapies: Section O The RAI Version 3.0 Manual states that Recreation Therapy is NOT a skilled service according to the Security Act however, for purposes of the MDS, providers should record services for recreational therapy when the conditions for the provision of recreation therapy are as follows: • The physician orders Recreation Therapy that provides therapeutic stimulation beyond the general activity program; • The physicians order must include a statement of frequency, duration, and scope of treatment; • The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a therapeutic recreation specialist; • The services are required and provided by a state licensed or nationally certified therapeutic recreation specialist or therapeutic recreation assistant who is under the direct supervision of a therapeutic recreation specialist; and • The services must be reasonable and necessary for the resident’s condition.

9. Remember……… • The assessor records the number of days and the minutes that recreation therapy was administered over the 7 day look back period. Sessions must be at least 15 minutes in length. The RAI Version 3.0 Manual states that therapy logs are not a MDS requirement but is standard of good clinical practice by all therapy professionals. • It’s also important to note that when two clinicians work together, which may be common with a recreational therapist and an occupational therapist, the clinicians must split the time between the two disciplines. • Music Therapy is included under Recreational Therapy as well.

10. Reimbursement Sources • Medicaid • Approved Providers • Waiver Programs

11. Reimbursement Sources • Private Insurance • Indemnity • Preferred Provider Organization (PPO) • Health Maintenance Organization (HMO) • Point of Service (POS)

12. Reimbursement Sources • Workers’ Compensation • TRICARE • Automobile Insurance

13. Reimbursement Sources • Adoption Subsidy • State and County Boards/Departments • Health • Social Services • Developmental Disabilities

14. Reimbursement Terminology • Diagnostic Codes • ICD 9 (CM) • Procedural Coding • CPT 2011 • HCPCS • Revenue Codes

15. Reimbursement Process Step One: Obtain your National Provider Identifier Number (NPI) “Respiratory, Developmental, Rehabilitative and Restorative Service Providers” https://nppes.cms.hhs.gov/NPPES/Welcome.do

16. Reimbursement Process Step Two: Seek Referrals Physicians, Psychologists, Social Workers, Case Managers, Parents, Clients, Allied Healthcare Providers Step Three: Collect Insurance Information Music Therapy Pre-Approval Form Assignment of Benefits Form HIPAA Notice

17. Reimbursement Process Step Four: Determine Client Needs Initial Assessment: Brief or Full Define the scope, duration, and frequency of music therapy treatment Determine Medical/Behavioral Necessity

18. Reimbursement Process Step Five: Prepare Marketing Materials Music Therapy Definition Supportive Research Health Care Industry Recognition Qualifications

19. Reimbursement Process Step Six: Contact Primary Care Physician Provide MT information Seek Written Referral Request Diagnostic Codes International Classification of Diseases- 9th Revision (ICD-9)

20. Reimbursement Process Step Seven: Select Procedure Codes that best describe MT interventions Current Procedural Terminology (CPT) Determine Rates/Fees Per Code

21. Reimbursement Process Step Eight: Call the Insurance Company Request Case Manager Review Present Diagnostic (ICD-9) and Procedure Codes (CPT) Review Pre-Approval Process Negotiate Rates Request Reporting Requirements

22. Reimbursement Process Step Nine: Provide MT Interventions Document all elements of treatment Assessment Treatment Descriptions Potential Cost Savings Client Response to Treatment Functional Outcomes Achieved

23. Reimbursement Process Step Ten: Complete Claim Forms CMS 1500 http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf Step Eleven: Submit Claim Include Required Attachments

24. Reimbursement Process Step Twelve: Follow-up with Payer Appealing an Adverse Decision What was the reason for denial? Who made the initial decision? What is the appeals process? What additional information is needed to review the appealed case? Involve the referring physician Involve the patient/family

25. Reimbursement Tips Don’t Stop at “NO” Develop Relationships with Insurance Company Case Managers Present Clear and Accurate Information Respond to All Communication in a Timely and Professional Manner

26. Resources • www.musictherapy.org • www.cbmt.org • www.cms.hhs.gov • www.ingenixonline.com • www.amapress.com

27. AMTA Reimbursement Committee Representative Carolyn A. Dobson, MT-BC carolynwebb@earthlink.net 214-923-2477