Transcript Physical Medicine and Rehabilitation 97000 Series CPT Codes

Keeping a Seating & Mobility
Clinic Viable
Barbara Crume, PT, ATP
CarePartners Health Services
Member ATPA, Member CTF, Friend of NRRTS
May 23, 2013
Who am I?
First poll
• Who are you?
– PT or OT
– Rehab Technology Supplier/Technician
– Case Manager
– Manufacturer
– Other
CarePartners Health Services
Asheville, NC
• Not-for-Profit Post Acute
Care Facility
– 80 bed Inpatient
Rehabilitation Hospital
– Home Health Agency
– Hospice
– Adult Day Care
– Orthotics/Prosthetics
Clinic
– Outpatient Facility
located on main campus,
plus 4 satellite clinics
www.carepartners.org
Outpatient Seating Clinic
• PT’s: 1 full time and one part time, 2 days
a week for Outpatient clinic
• 1 full time Coordinator/Access staff
• Share rehab aide with Outpatient
department
• Inpatients needing CRT are seen by same
part time therapist the other 3 days a
week, or another IP PT trained in seating
Experience vs Expert
• Sharing my experience
• Numerous changes over past 20 years
• My desire is to help others provide this service
and get paid
• CarePartners uses LEAN
• 2009 department mapped out our services and
made many changes to improve our efficiencies
which helped us increase productivity from 34%
to 55%, current goal is now 75%
Second Poll
• If you are a therapist, how many hours a
week do you provide services in a
wheelchair seating clinic?
– 0-16
– 17-24
– 25-32
– 33-40
– 40+
Main Topics
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Prior Authorization
Reimbursement for Services
CPT Codes and Restrictions
Documentation
Other Strategies to stay Viable and Maximize
Reimbursement
Will ‘walk through’ CarePartners process
throughout the presentation.
Referrals
• Access staff manages referrals
– Receive phone calls/faxes/emails from doctors,
patients, caregivers, therapists, case managers,
suppliers
– Prefer patient/caregiver/supplier who referred obtain
MD order, but most often access staff faxes order to
MD for signature & requests copy of medical records
– Obtain demographic & insurance information
– Schedules evaluation with therapist only
– Inquires about Home Health services
Home Health Agencies
• Paid under PPS – per patient per
episode of care – Consolidated Billing
• Specialty Clinic at an Outpatient facility
may contract with a HH agency to
provide services for one of their clients
• Facility cannot bill Medicare directly
CarePartners Home Health
• CarePartners has a HH agency
– HH therapists contact HH Case Manager for
approval of referral to seating clinic
– SC Patient Access contacts HH Case
Manager for approval when referrals received
direct from doctors
– Procedures billed are transferred to HH
– Therapist time is transferred to HH
Other HH Agencies
• Other HH agencies contract with CP and
thus are billed the Medicare allowable rate
• Companies without a contract are billed
usual and customary rate
• Access staff obtains signed approval for
payment of services stating expected CPT
codes and cost per code
Acute Care Hospitals
Skilled Nursing Facilities
• Same principle applies for inpatient Acute
Care Hospitals and Skilled Nursing
Facilities (under Part A)
• OP SC cannot bill Medicare for an
outpatient visit when the patient is an
inpatient at another facility
• We do have a contract with our local acute
care hospital. Access Staff obtains signed
agreement for payment of services.
Prior Authorization
• Access staff contacts private insurance
prior to initial evaluation
• Insurance Verification Form
– Preferred provider
– Amount of deductible
– Co-insurance
– OOP met for year
– Visit limitations, visits used
Access Staff
• Obtain prior authorization for evaluation
and therapy visits
• Confirm if time limitation per visit
– Many Insurance companies only pay for 1
hour of therapy per visit
• Confirm CPT codes covered
– NC Medicaid does not cover 97755
– Some plans may not cover 97542 or 97760
• Alert therapist to obtain Medicaid PA
Access Staff
• Completion of
insurance forms
• Signatures
• Copy cards for our
records and supplier
• Collect co-pay
• Medical Intake Form
Third Poll
• Does your facility, or therapists that you
work with, keep you informed on
reimbursement issues such as Medicare
Cap, Sequestration and Multiple
Procedure Payment Reduction (MPPR)
affects on therapy reimbursement?
– Yes
– No
– I don’t know what you are talking about
Medicare Fee Schedule
• Fee Schedule: allowed charge, the lower
of the actual charge or fee schedule
amount.
• Medicare Payment is 80% of allowed
charge after deductible met.
• Medicare patients must meet deductible
($147) and pay 20%, or their secondary
insurance pays the 20%
Medicare Cap
• Therapy cap amount $1900 for OT and $1900
for PT and Speech therapy combined
• Recipients still pay $147 deductible and 20% of
the $1900 ($380)
• Evaluation to determine need for therapy is
covered even if patient has exceeded therapy
cap
• Automatic Exceptions Process($1900-$3700)
– when medially necessary and documented
– Provider must use KX Modifier with codes billed
Medicare Cap
• Manual medical review
– When the $3,700 threshold is exceeded
– No pre approval process
• Prepayment Review Demonstration in FL,CA,
MI, TX, NY, LA, Il, PA, OH, NC, MO
– Medicare Administrative Contractor (MAC) sends
Additional Development Request (ADR) to provider
requesting documentation be sent to Recover Audit
Contractor (RAC)
– RAC has10 days to notify MAC of payment decision
• Postpayment review – all other states; MAC
flags claim, sends an ADR and pays claim
Medicare Cap
• Exceptions Process expires December 31,
2013 unless Congress passes legislation
• Collecting Out of Pocket
– Patient doesn’t qualify for exception
– Obtain signed Advanced Beneficiary Notice
(ABN)
– Collect from beneficiary &/or bill secondary
insurance
– Insurance may require denial from Medicare
Sequestration
• 2% payment cut for all Medicare providers
• Began April 1, 2013
• Applies to the Medicare payment, not
beneficiary copayment
Multiple Procedure Payment
Reduction (MPPR)
• Originally went into effect January 1, 2011 with
25% reduction
• Applies to Practice Expense (PE) portion of each
code
• 50% reduction began April 1, 2013
• Example – 4 units 97542 billed in NC previous
payment $116.43, with MPPR and
Sequestration, payment is now $94.55
($21.88 less)
(APTA Fee Calculator)
Physical Medicine and
Rehabilitation
97000 Series CPT Codes
https://catalog.ama-assn.org/catalog/cpt/issue_search.jsp)
Codes primarily used for
Evaluation, Fitting and Training
• 97001or 97003 Evaluation PT or OT
• 97542 Wheelchair management
Will go over these and other codes utilized
by therapists for these services, along with
how the Correct Coding Initiative (CCI)
Edits affect their use and documentation
required.
Correct Coding Initiative
• National Correct Coding Policy Manual for
Medicare Part B Carriers
• Edits Updated quarterly
• Mutually Exclusive Edits - Problematic codes
that will not be reimbursed when rendered by
the same provider on the same date of service
as other codes. Effective April 1, 2012 these
were merged with column 1/column 2 CCI edits
Correct Coding Initiative
• Column 1/2 Edits
Modifiers may be used when these codes are
billed on the same day if there is a
superscript “1” next to the code (but not
recommended as this is like a “red flag”,
especially if used for every patient).
If there is a superscript “0” next to the code,
there are no circumstances in which a
modifier would be appropriate. The services
represented by the code combination will not
be paid separately.
Modifiers
• GP- Services delivered under an outpatient
physical therapy POC
• GO- Services delivered under an outpatient
occupational therapy POC
• GN- Services delivered under an outpatient
speech-language pathology POC
• Required on each CPT Code on the claim form
billed to Medicare contractor
• Some non Medicare payors utilize these
modifiers
97001 or 97003 Evaluation
• Use for first visit, but not on same day of service as
97002, 97004, 97750 , 97755 or 97762. Will not be
reimbursed. No modifier allowed.
• Untimed code, therefore bill 1 unit no matter how much
time is spent
• Generally bill one unit of Eval along with 1-2 units of
97542, depending on services provided
• Documentation must match codes with total
treatment time for timed codes and total treatment
time for timed and untimed codes documented.
• CarePartners considers an evaluation to be about 45
minutes in regards to productivity. Other facilities
consider this code to be an hour of productivity
97001 or 97003 Evaluation
• Paid the same for eval no matter how complex.
(MD’s have five levels of eval depending on #
body systems evaluated)
• Dynamic Process of making clinical judgments
based on data gathered including history,
systems review, tests and measures such as
ROM, MMT, motor function, joint integrity.
• Establishing treatment diagnosis, prognosis,
plan of care with goals, outcomes, interventions
and D/C plans.
97001 and 97003
• Payment in Manhattan
– 97001 $81.75
– 97003 $93.03
• Payment in NC
– 97001 $70.82
– 97003 $79.82
» (APTA Fee Calculator)
Fourth Poll
• How much time do you schedule for a
patient evaluation?
– 60 minutes
– 90 minutes
– 2 hours
Fifth Poll
• Is the supplier present for the therapy
evaluation majority of the time?
– Yes
– No
Evaluation at CP
• Scheduled for 90 minutes with therapist
only (unless w/c &/or seating received
within ~1 year and needs growth/position
adjustments)
• Patient requested to arrive 30 minutes
early to register
• Medical history form completed at
registration by patient/caregiver
– Diagnoses, impairments, medications,
surgeries past and future, current equip
receipt date/supplier, problems, goals
Evaluation
• Assessment of medical/functional status
• Current equipment status/effectiveness,
posture in w/c
• Mat assessment
• Pressure mapping if indicated
• May demonstrate &/or trial some products
• Complete minor adjustments to current
equipment. If supplier is present for growth
adj – completed while therapist does eval/mat
assessment or after eval prior to second visit
Evaluation
• Determine and document specific
equipment needed for second visit
• Complete the Plan of Care (POC)
• Print evaluation, intervention and POC and
provide copy to supplier along with patient
demographics and insurance information
• These documents are either scanned and
emailed confidentially or placed in folder
for pick up
Second visit
• Supplier responsible to set up equipment for
assessment based on evaluation notes, &/or
complete adjustments identified at evaluation
• Equipment trials and problem solving
• Supplier completes order forms with input from
team along with list of positioning components
and/or repair parts
• Therapist completes the LMN at same time. Our
custom template allows this to be done as the
parts are determined.
Paperwork
• Therapist prints the therapy intervention
note, LMN, supplier checklist and provides
all to the supplier usually prior to the
supplier leaving the clinic
• Supplier is responsible to send all
documents to physician for concurrence &
signature (except the POC)
97002 or 97004 Re-Evaluation
• May be used for subsequent visit of an established
patient every 30 days
• Documentation must reflect changes in examination
findings, goals and plan of care
• Do not use on same day of service as 97001, 97003,
97750, 97755, or 97762. Will not be reimbursed.
• Not recommended on same day as 97112, 97530,
97535, 97537, 97542 or 97760. Although a -59
modifier is allowed.
• Rarely used for patient being seen for w/c eval.
Therapeutic Procedures
• Therapeutic procedures are procedures that attempt to
reduce impairments and improve function through the
application of clinical skills and/or services.
• The expected goals documented in the written plan of
care, effected by the use of each of these procedures,
will help define whether these procedures are
reasonable and necessary.
• Therapist required to have direct (one-on-one) patient
contact.
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?
LCDId=31581&ContrId=225&ver=23&ContrVer=1&CoverageSelection=
Local&ArticleType=All&PolicyType=Final&s=North+Carolina&KeyWord=
Physical+therapy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=
gAAAABAAAAAA&
97112 Therapeutic
Procedure
• Neuromuscular reeducation of movement, balance,
coordination, kinesthetic sense, posture, and/or
proprioception for sitting and/or standing activities
• May be utilized for seating and access intervention
that includes assessing/training/facilitating to improve
postural stability, control, neuromuscular balance
and/or access issues.
• Not recommended on same day of service as 97002,
97004, 97760 (97760 is a component of 97112), or
97761. Requires a 59 modifier
• NC 1 unit $31.44
97530 Therapeutic Activities
• Therapeutic activities, direct (one on one) patient
contact by the provider (use of dynamic activities to
improve functional performance),
• Primarily used for functional activities – throwing,
squatting, lifting
• Know some therapists have used this for manual
wheelchair propulsion, transfer training but 97542
more appropriate – refer to your PT LCD
• Not recommended on same day as 97002, 97004,
97535, 97537,97542, 97750, or 97755. Requires a
59 modifier
• NC 1 unit $32.96
97535 Self Care/Home
Management Training
• (e.g. activities of daily living (ADL) and compensatory training,
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•
•
•
•
meal preparation, safety procedures, and instructions in use of
assistive technology devices/adaptive equipment) direct one on
one contact by provider, each 15 minutes
Often not covered by insurance such as BCBS
Utilized primarily for safety issues in the home
Fitting of AT and/or training/positioning that affects ADL, safety,
AT device use
For parent/caregiver training
Not recommended on same day as 97002, 97004, 97530, or
97755. Requires a 59 modifier
For Power wheelchair training use 97542
NC 1 unit $32.68
97537 Community/Work
Reintegration Training
• (eg, shopping, transportation, money management, avocational
activities, and/or work environment/modification analysis, work
task analysis, use of assistive technology device/adaptive
equipment), direct one on one contact by provider, each 15
minutes
• Even for w/c training outside such as curbs, grass, gravel,
inclines, use 97542
• Utilized for access and/or control training involving AT devices
for transportation issues, as well as worksite training.
• Not recommended on same day as 97002, 97004, 97530,
97755. Requires a 59 modifier
• There is an allowable established, but it is not covered under
Medicare.
• Allowable NC 1 unit $ 28.33
97542
Wheelchair Management
• (eg, assessment, fitting, training),each 15 minutes
• Utilized for assessment, fitting and instruction in the
use of mobility devices and seating systems,
including skin integrity, transfers, balance,
measuring, propulsion skills, etc.
• Not recommended on same day as 97002, 97004,
97530, or 97755. Requires a 59 modifier
• This therapeutic service is often provided on the
same day of service as the evaluation, for both
manual and power wheelchair assessments.
• NC 1 unit $28.64
– (2 units $50.61, 3 units $72.58, 4 units $94.55)
97542
Wheelchair Management
• Primary code used for fittings
• Majority of our patients have fitting done in clinic with
supplier
• “Consumer power” is usually delivered to home with
supplier only to fit & train patient
• These patients may be seen for evaluation, training and
recommendations in 1 clinic visit. Supplier will then
assess at home with PMD prior to finalizing paperwork
• Expectation is that supplier will arrive with almost all
components mounted and set close to patient sizing and
angle needs ready for adjustment and training
• Very important to confirm what was recommended is fit
correctly and meets the patients needs and goals
97750 Physical Performance
Test or Measurement
• (eg, musculoskeletal, functional capacity), with written
report, each 15 minutes
• Utilized for functional performance tests to assess
needs and identify problems. May include pressure
map measurement, Tinetti, TUG, Berg, Sitting
Functional Reach if done on a day other than eval
• Specify test and measures used, describe the data
collected and the implication on patient plan of care;
decisions made based on results.
• NC 1 unit $31.28
97750 Physical Performance
Test or Measurement
• Documentation is done with the person in the
room with you – remember “one on one,
direct hands-on” .
• Do not use on same day of service as 97001,
97002, 97003, 97004, or 97755. Will not be
reimbursed.
• Not recommended on same day as 97581
(ROMT), or 97530. Requires a 59 modifier
• With Medicare this is a form of evaluation
done on a separate day.
97755 Assistive Technology
Assessment
• (eg, to restore, augment, or compensate for existing
function, optimize functional tasks, and/or maximize
environmental accessibility), direct one-on-one contact
by provider, with written report, each 15 minutes
• For persons with multiple technology requirements or
significant physical impairments that require identification
of alternative controllers and system integration (i.e.
Augmentative Communication device mounted to power
wheelchair operated by alternative controller, computer
access with non-keyboard input, etc.)
• Not approved for coverage under some Medicaid
programs and private insurance
97755 Assistive Technology
Assessment
• Assess the technology interface with patient
• Utilized following a PT or OT Eval from which
a referral is made for AT Assessment
• Do not use on same day of service as 97001,
97002, 97003, 97004, 97750, or 97762. Will
not be reimbursed
• Not recommended on same day as 97530,
97535, 97537, 97542 or 97760. Requires a
59 modifier
• NC 1 unit $33.87
97760 Orthotics Fitting and
Training
• Upper extremity(ies), lower extremity(ies) and/or
trunk, each 15 minutes
• Utilized for interventions involving splints, corsets,
molding and fitting for custom-molded seating
systems; not fabrication
• Clinically working with the patient on fit and functional
use
• Not recommended on same day of service as 97002,
97004, 97112, 97755, 97761 (Prosthetic training), or
97762. Requires a 59 modifier
• NC 1 unit $35.94
97760 Orthotics Fitting and
Training
• Sometimes this service is provided on second
visit when patient is custom molded on simulator
to determine if will work for them
• Most of the time the molding is not completed
until all paperwork is signed by physician or
funding is approved
• Utilized for all custom molding including
capturing shape for fabrication by manufacturer
or Foam in Place completed at time of fitting
CPT Codes
• I strongly recommend referencing your
PT/OT Local Coverage Determination
regarding criteria for provision of these
services.
• To locate an LCD:
http://www.cms.gov/medicare-coveragedatabase/overview-and-quick-search.aspx
5 Minute Break
Documentation
• Demonstrate services are skilled level of care
• Medical record must support that the expertise and
knowledge of a qualified clinician was necessary and
was provided.
• Documentation needs to clearly indicate the clinician’s
unique professional contribution to the therapy services
i.e., Why did the patient require professional education
or training? What specialized education or training did
the clinician actually provide? How did the patient benefit
from the specialized knowledge applied by the clinician?
Documentation
• Clearly indicate the patient’s condition before,
during, and after the therapy episode
• Documentation of comparable objective &
functional measures
• Fitting note should include specific adjustments
made and how this impacted functional use
• Updated POC should include positioning and
functional skills achieved with new w/c and
seating in relation to goals
Documentation
• Therapist must document the skilled level
of care for therapy services to be
reimbursed and
• Same time document all necessary
information to qualify the patient for the
complex rehab equipment recommended
• This type of documentation is time
consuming and reason it is difficult for
seating clinic therapists to stay caught up!
Documentation
• CarePartners was very fortunate to have a staff
member who was able to customize Meditech to
meet our documentation needs
• Evaluation has checklists, comment boxes and
text boxes.
• Intervention text boxes titled re service provided
to match codes billed
• LMN is a template with text boxes for item
recommended, organized in categories and 1-2
word check boxes that link to a full sentence for
report printing
Sixth Poll
• On average, how much time do you spend
writing a Letter of Medical Necessity?
– 15-30 minutes
– 30-60 minutes
– 60 minutes or longer
Plan of Care (POC)
• Treatment may begin prior to the plan
being established in writing if the treatment
is performed or supervised by the therapist
who establishes the plan
• Payment for services provided before the
plan of care is established may be denied
by Medicare contractor
• Therefore complete initial POC day of
evaluation!
Plan of Care (POC)
• Physicians/NPP’s Certification (with or
without order) satisfies all certification
requirements for duration of POC, or 90
calendar days, whichever is less, from
date of evaluation/initial treatment
• Timely certification is met when
physician/NPP certification of POC is
documented by signature and dated within
30 days
Plan of Care (POC)
• must contain at a minimum:
– patients diagnosis
– functional goals
– type of therapy service
– specific intervention/procedure
– number of visits/frequency
– duration
– therapist’s and physician’s dated signature
Plan of Care (POC)
• Private insurance companies require specific
treatment techniques and/or exercises to be
used in treatment
• Updated POC for Medicare required every 90
days or when significant change is made in plan,
BCBS 30 days and NC Medicaid 6 months.
• Therefore important to know requirements of
funding source as well your States Practice Act
Functional Limitation Reporting
• Medicare requirement beginning July 1, 2013
• Submit Functional G code and modifier on the
claim forms
• At time of evaluation, re-evaluation, minimum of
10th visit, changing of primary limitation and at
time of discharge
• Documentation in the medical record must
include the G-code and modifier, and state how
the modifier was selected
Functional Limitation Reporting
• Based on International Classification of
Functioning, Disability and Health (ICF)
• At time of evaluation a G code must be selected
and a modifier selected for current status and
projected goal
• At time of discharge same G code is reported
along with the modifier
• Modifiers indicate patient’s percent of
impairment, limitation or restriction
• For a one time visit, all three statuses may be
reported with the same modifier
Functional Limitation Reporting
Mobility: Walking and Moving Around G-code set:
• G8978, Mobility: walking & moving around functional
limitation, current status, at therapy episode outset and
at reporting intervals.
– Short descriptor: Mobility current status
• G8979, Mobility: walking & moving around functional
limitation, projected goal status, at therapy episode
outset, at reporting intervals, and at discharge or to end
reporting.
– Short descriptor: Mobility goal status
• G8980, Mobility: walking & moving around functional
limitation, discharge status, at discharge from therapy or
to end reporting.
– Short descriptor: Mobility D/C status
Functional Limitation Reporting
Changing & Maintaining Body Position G-code set:
• G8981, Changing & maintaining body position functional
limitation, current status, at therapy episode outset and
at reporting intervals.
– Short descriptor: Body pos current status
• G8982, Changing & maintaining body position functional
limitation, projected goal status, at therapy episode
outset, at reporting intervals, and at discharge or to end
reporting
– Short descriptor: Body pos goal status
• G8983, Changing & maintaining body position functional
limitation, discharge status, at discharge from therapy or
to end reporting.
– Short descriptor: Body pos D/C status
Functional Limitation Reporting
7 levels ranging from 0 percent impaired to 100 percent impaired
Functional Limitation Reporting
• Modifier selected based on
– objective, measurable standardized test or
– by the therapist using his/her clinical judgment
based on multiple tools used during the
evaluation process
Clinician Task Force has a group working on
recommendations for therapists providing
wheelchair seating services
Physician Quality
Reporting System (PQRS) program
• Private Practice therapists can obtain a 0.5%
bonus payment in 2013 and 2014 if they report
on quality measures
• Those who do not report this data for 1-1-13 to
12-31-13 will be subject to 1.5% reduction in fee
schedule for 2015
• This year is pivotal to the changeover, as what
happens this year will affect both the 2013
bonus and the 2015 penalty
• APTA and AOTA websites have more
information on these quality measures
Seventh Poll
• What is your productivity, direct billable
time, expectation in clinic?
– 50%
– 55%
– 60%
– 65%
– 70% or greater
Productivity
• CP Seating Clinic first started as a part
time position while I still provided pediatric
therapy services.
• Within a year became full time, seeing
patients of all ages and diagnosis both
OP’s and IP’s, transferring time to IP Dept
• Within the past 2 years, increased our OP
capacity by training other therapists to
manage CRT for IP’s
Productivity
• Productivity goal initially was 50% and as previously
stated we were only reaching 34%
• Very difficult to achieve due to labor intensive and prior
to 2003 handwritten notes.New documentation system
required creating a format. Modified x 3 to current state.
• Current goal is 6 billable hours of care/day for a total of
410 procedures/month for our dept
• On average IF each therapist sees 5 patients/day, this
can be accomplished
• Our cancellation/no show rate averages less than 10%
• Utilize cx time for case management and replying to
emails and phone calls, Medicaid PA’s, maintaining
organization of equipment, calibrating FSA, etc
Productivity
• Would have to be 150+% productive to cover all
the salary and overhead costs
• Been very fortunate that CP considers our
services to be a ‘value added’ service
• Contractual adjustments average is 60%
• Our payor mix is 36% Medicare, 32% Medicaid
• Example:
–
–
–
–
Charge for evaluation is $215.00, our cost is $248.00
Medicare allowable is $ 70.82
Medicaid reimbursement is $61.83
BCBS reimbursement is $182.75
Appeals
• Very important to appeal denials in a timely
manner!
• A facility may submit an appeal to insurance
as the patient’s representative
• We now have access staff obtaining
authorization and checking to make sure the
policy covers the codes we might use prior to
providing the service
• If denied as not medically necessary, request an
explanation of scientific or clinical judgment for
the determination and the specific reason for the
denial
Marketing
• Has not been necessary!
• Developed relationships with physicians, therapists and
suppliers throughout the region just by providing quality
care and training
• Community therapists that have been mentored/trained
through our clinic to recognize when the client’s needs
are more complicated than they can manage
• These therapists then refer and often accompany their
client to our clinic as an important part of the team to
provide input for product selection. They rely on our
expertise to problem solve and recommend solutions
Marketing
• We have also trained many suppliers over the
years about diagnoses, mat assessments, pros
and cons of various products, adjustments that
can be made to improve function and
importance of pressure distribution
• Patient selects supplier to work with from several
national and local companies available
• Our clinic has become a regional referral
resource for ALL suppliers
Physician Education
• This continues to be a challenge especially for
PMD’s. We do not have a physician in clinic
• Our access person often explains the PMD
requirements to physician & their staff
• We have an OP Case Manager and
CarePartners Liaisons who have been trained
regarding the regulations to assist in process
• NC Medicaid is now requiring a Face-to-Face for
PMD (and an onsite home assessment)
Final Tidbits
• Units of service in excess of medically
reasonable daily allowable frequency may be
denied. May not be billed to the beneficiary and
cannot be waived nor subject to an
ABN. (i.e.,10 units of 97542 for fitting and
training with a complex power chair)
• At CarePartners, maximum time per evaluation
is now 1-1.25 hours (97001, plus 1-2 units of
97542 if appropriate) and for subsequent visits
we try to stay within an hour, but the maximum
we provide is 2 hours.
• Remember collect co-pay at time of visit!
Final Tidbits/Review
• Providers may charge different negotiated amounts for
Outpatient Rehab Services.
• May not charge substantially in excess of usual charge.
• If insurance is primary and pays more than
Medicare/Medicaid allowable, no additional dollars
reimbursed from Medicare/Medicaid.
• Some insurance companies do not reimburse for
97542
• Very important to communicate with your business office
to learn about your reimbursements. Denials should
always be appealed.
Strategies to Stay Alive
• Templates for evaluations, interventions and
LMNs
• Reminder calls to patients regarding appt to
reduce no show/cx
• Flexibility to schedule another patient when cx
occurs
• Review plan with supplier prior to appt to make
sure equipment is ready
• Consider double booking patients for fitting
appointments
Other Strategies
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Grant Support
Research
Book sale
Some clinics have specialty days for
teaching wheelchair skills or wheelchair
maintenance
References
• American Medical Association Current
Procedural Terminology; CPT 2012; Standard
Edition
• Outpatient Therapy CPT Coding, Billing &
Documentation for Rehabilitation
Reimbursement; Course Instructor Rick
Gawenda, PT
• New Functional Limitation Reporting
Requirements, Heather L Smith, PT, MPH;
APTA PT in Motion, March 2013, pgs 42-45
• APTA website
References
• Medicare Therapy Services:
– http://www.cms.gov/Medicare/Billing/TherapyServices
/index.html?redirect=/TherapyServices/
– http://www.cms.gov/outreach-andeducation/medicare-learning-networkmln/mlnmattersarticles/downloads/MM8206.pdf
• To locate an LCD:
– http://www.cms.gov/medicare-coveragedatabase/overview-and-quick-search.aspx
Contact Information
Barbara Crume, PT, ATP
CarePartners Health Services
68 Sweeten Creek Road
Asheville,NC 28803
[email protected]
828-274-9567 ext. 4151
Questions?
Thank you for participating in
today’s webinar!
I would appreciate your
constructive input to improve this
course
Post Test