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How to Survive the Medicare Therapy Caps and the Manual Medical Review Process
October 4, 2012
Featuring Guest Presenter: Nancy J. Beckley, MS, MBA, CHC
Welcome
• This session will be recorded
– Link to the recording and resources will be emailed to all registrants • Questions can be asked in the “Question panel”
Jim Plymale
CEO
Clinicient
– Webinar will be extended an additional 1/2 hour for Q & A
Welcome Nancy
• Compliance expert in the Rehab industry; certified in healthcare compliance
• Specializes in providing compliance program development for outpatient therapy and DME providers
• Popular industry speaker and author on compliance topics related to outpatient therapy
Nancy Beckley
President
Nancy Beckley and Associates
• Serves as a Compliance columnist for IMPACT ‐ the magazine of the APTA Private Practice Section
Today’s Objectives
• Why it is important to carefully and accurately monitor the therapy cap
• How to create documentation that supports medical necessity
• Compliantly converting the therapists time into Medicare billable units
• Why documentation must support claims, and what to watch for
• How to submit a claim so that it is "pre‐approved" and doesn’t require a pre‐payment review
• How an EMR and Practice Management system can minimize your audit risks
4
Why Are We Here?
• Balanced Budget Act of 1997
Distribution of Spending
OP Therapy ‐ 2011
• Methodology for bundled payment issues
– DX codes
– Outcomes
4%
11%
2%
Nursing Facility
37%
HOPD
16%
• Therapy claims continue an upward trend
• PPACA mandates
PT Private Practice
ORF, CORF, HHA
Physician NPP PT
OT, SLP PP
30%
Source: MedPAC, 9/2012
5
Ready, Set, Go…..
Manual Medical Review Process – Phase I
Manual Medical Review Process – Phase III
GAO Report on MMRP
Providers identified as phase 1 begin following the MMRP at the $3700 Therapy Threshold
Providers identified as phase 3 begin following the MMRP at the $3700 Therapy Threshold
Report issued on the implementation of the MMRP
Oct 1, 2012
Nov 1, 2012
Dec 1, 2012
Jan 1, 2013
May 1, 2013 June 15, 2013
Manual Medical Review Process – Phase II
Claims Based Data Collection
MedPAC Report
Providers identified as phase 2 begin following the MMRP at the $3700 Therapy Threshold
CMS starts collecting data on patient function during the course of therapy services
Report issued on how to improve the payment system
6
MCTRJCA Section 3005 Provisions
• Modifier – KX indicating “medical necessity”
• Manual medical review ‐ $3700 threshold
• Temporary expansion to hospitals, no later than 10/1
• NPI of physician who reviews therapy plan of care on claim
• MedPAC report on improved therapy benefits
• HHS collection of claims data
• GAO report on manual medical review process
7
2013 Medicare Physician Fee Schedule
• Proposed rule released, comment period open
– 3% uptick in therapy, SGR issue and pending 30%+ reduction if Congress does not act
• Therapy cap $ ‐ published in final rule
– Therapy caps exceptions process ends 12‐31 unless Congress acts – Therapy caps for hospitals end 12/31/2012 unless Congress acts
• NEW – claims based functional data collection – series of new Functional “G” codes
– Associated modifiers – to report severity/complexity
– Every 10 treatment days or 30 days, which is shorter
8
G Codes ‐ PROPOSED
Source: CMS‐1590‐P
9
Severity Modifiers PROPOSED
• “For each functional G‐code used on a claim, a modifier would be required to report the severity/complexity for that functional limitation • We propose to adopt a 12‐
point scale to report the severity or complexity of the functional limitation involved.”
Source: CMS‐1590‐P 10
Caps: Full Implementation in 2006
Automatic Exception
• Automatic
– Patients may be “expected” to exceed the cap in certain circumstances:
• Originally by specified ICD‐9 codes and/or Identified complexities or co‐morbidities
• Now any code may be used as long as it is medically necessary
• Must be medically necessary to exceed the cap and so documented
Manual Exception
• Manual (2006 only)
• Patients not qualifying for automatic exception may qualify if PT/OT has case “manually” reviewed
• Fax forms and records prior to hitting the cap, request additional visits based on medical necessity
• Contractor approves, modifies or denies request
• Back again 10/1/2012
– New implementation rules
– “Threshold” level at $3700
11
Therapy Cap vs. Threshold
• Therapy caps for PT/SLP (combined) and OT
– $1880 for 2012
• Therapy cap accrues/attaches to the beneficiary
• Therapy cap is calendar year
– Exceptions process in place by legislation (ends 12/31/12)
– All therapy at HOPD (previously exempt) from 1/1/12 counts
• Threshold is set at $3700 for each cap (PT/SLP and OT)
– Manual medical review (pre‐authorization) of claims to exceed $3700
– Threshold is implemented by NPI‐based Phases (10/1, 11/1, 12/1)
• Private practice by individual therapist NPI, not group NPI
• Part A providers by institutional NPI (not individual therapists, even if they have NPI)
12
Manual Medical Review Process
Previous Therapy Cap
• $1880 through October, 1 2012
• Included Outpatient care only
$1880
Outpatient Care Only
Jan 1, 2012
Oct 1, 2012
13
Manual Medical Review Process
Therapy Cap After Oct 1, 2012, Now!
• $3700 retroactive therapy cap threshold
• Now extends to hospital outpatient depts.
• Manual medical review for services beyond threshold
• Justified by documentation • Process / Paperwork unique to MAC
• Claims exceeding $3700 threshold will be denied without approved exception
• Cap is applied to first claims received, not by DOS
• Denied services beyond cap are beneficiary liable
~ Approaching $3700
Apply for Exception
> $1,800 Cap: Apply KX Modifier
Shared Cap with Hospital Outpatient Services (Retroactively applied)
Jan 1, 2012
$3700
Dec 31, 2012
14
KX & Attestation
15
When the beneficiary qualifies for a therapy cap exception, add the KX modifier to the therapy procedure code subject to the cap limits
• The condition or complexity that caused treatment to exceed caps must be related to the therapy goals
• Must either be the condition that is being treated or a complexity that directly and significantly impacts the rate of recovery of the condition being treated such that it is appropriate to exceed the caps • Documentation for an exception should indicate how the complexity (or combination of complexities) directly and significantly affects treatment for a therapy condition
15
CMS Letter to Beneficiaries
• All beneficiaries at $1700 therapy per cap this year
• Explains the process – financial responsibility, even years from now patient may be responsible
• Excerpt from letter…..
16
APTA Provides Resource
• 550,000 beneficiary letters mailed in August
• Additional letter mailed: confusing regarding home health benefit
• APTA provides notice letter to supplement CMS letter 17
Voluntary Use of ABN
• When using the ABN form as a voluntary notice, the form requirements specified for its mandatory use do not apply – The beneficiary should not be asked to choose an option or sign the form – Beneficiary’s name and the reason Medicare may not pay should be noted
• After the cap is exceeded, voluntary notice via a provider’s own form or the ABN is appropriate, even when services are excepted from the cap
– A cost estimate is suggested, but not required
– Insertion of the following reason is suggested: “Services do not qualify for exception to therapy caps. Medicare will not pay for physical therapy and speech‐language pathology services over $1880 in 2012 unless the beneficiary qualifies for a cap exception.” CMS: Advance Beneficiary Notice of Non‐coverage (Form CMS R‐131 and Instructions)
18
Mandatory Use of ABN
• The ABN is also used before the cap is exceeded when notice about non‐
covered services is mandatory
– For example, whenever the treating clinician determines that the services being provided are no longer expected to be covered because they do not satisfy Medicare’s medical necessity requirements, an ABN must be issued before the beneficiary receives that service 1.
2.
3.
skilled services are not medically necessary, clinical goals have been met, or
no longer potential for the rehabilitation of health and/or function in a reasonable time
– If the beneficiary requests further services, beneficiaries should be informed that Medicare most likely will not provide additional coverage, and the ABN should be issued prior to delivering any services
• The ABN informs the beneficiary of his potential financial obligation to the provider and provides guidance regarding appeal rights – When the ABN is used as a mandatory notice, providers must adhere to the form requirements
CMS: Advance Beneficiary Notice of Non‐coverage (Form CMS R‐131 and Instructions)
19
New Therapy? More Therapy?
• Evaluation codes exempt from the cap ($1880) after the cap is reached
– PT & OT
• 97001, 97002, 97003, 97004
– Speech‐language Pathology
• 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105
• New diagnosis
– Concurrent
– Subsequent
20
Codes, Caps & Quirks
• “Always” therapy codes always subject to the cap regardless of who performs them
• “Sometimes” therapy codes subject to the cap when billed by a therapist, or other provider under a “therapy plan of care”
– Example
– Rules applicable to hospitals OPPS
• Other Hospital/SNF services subject to the cap
– Observation – Part A to Part B rebilling demo
– Part A benefits exhausted/Part B only beneficiaries
Reference: CMS 2012 Therapy Code List
Spread Sheet ‐ Attached
21
Manual Medical Review Process ‐ Phases
• CMS provider notification letter mailed
• CMS posted database
– https://data.cms.gov/dataset/Therapy‐Provider‐Phase‐
Information/ucun‐6i4t
22
Manual Medical Review Process
• “Threshold” of $3700 aligns with PT/SLP cap and OT cap
• Request manual review for up to additional 20 visits
– MACs have posted forms and generally want (verify)
• Order, Plan of Care, Documentation
• MBPM (Ch. 15, Sec. 220+) and LCD will be utilized
– Contractor has 10 business days, if no reply, “approved”, buyer beware!
• WPS will not accept fax requests, but will fax back if you identify request (15‐20 days)
– Can request unlimited number of exceptions
– Some MACs requiring approval code to be entered on the claim
– Approval of request does not guarantee payment
• Records subject to MR process, as is all other claims
• If you do not request review at $3700 – Submit claims and be subject to prepayment review (up to 60 days)
23
Manual Medical Review Process ‐ 2
• If not approved: – Come back with more info or
– Submit claim and be subject to pre‐payment review
• CMS expects detailed response letter by contractor for non‐approved
• Appeal rights are in place
• Options:
– Don’t request manual review, submit claim: subject to prepayment review (45 ‐ 60 days)
• KX modifier on all claims over $1880 (statutory exclusion)
• CMS: Special Open Door Forums (3)
– Review and explain process, instructions to contractors
– Slide presentation and sample documentation
24
MMR Documentation Elements
•
•
•
•
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Initial
Beneficiary Medicare Claim Number (HICN)
• Beneficiary Date of Birth
• Beneficiary Address and Telephone Number
• Provider Number (National Provider Identifier (NPI)) of Physician/NPP Certifying Plan of Care
• Name of Provider Certifying Plan of Care
• Address of Provider Certifying Plan of Care
• Telephone and Fax Number of Provider Certifying Plan of Care
• Number of Treatment Days Requested
• Expected Date Range of Services
• Date of Submission
•
•
•
•
Name of Performing Provider
Address of Performing Provider
Performing Provider Number (NPI)
Telephone and Fax Number of Performing Provider
Source: CMS MM 8086
25
MMR Cover Sheet Requirements
•
•
•
•
•
•
•
•
•
Cover Page
Justification
Evaluation or reevaluation(s) for Plan(s) of Care
Certification(s) of the plan(s) of care, where available
Objectives and measurable goals and any other documentation requirements of the Local Coverage Determinations (LCDs)
Progress reports
Treatment notes
Any orders, if applicable, for the additional therapy services and
Any additional information requested by the Medicare contractor
Source: CMS MM 8086
26
Sample Form for CGS
27
Sample Documentation
CMS example of “good documentation”
Source: CMS Open Door Forum Slide Show 9/5/12
28
CMS Example – Not Skilled…
Source: CMS Open Door Forum Slide Show 9/5/12
29
CMS – Documentation Needed
• Previous medical history including diagnosis, premorbid conditions, and recent hospitalizations impacting functional abilities
• Patient’s prior level of functional abilities, i.e. able to ambulate functional distance in recent past
• Timely physician certification/involvement with clear frequency/duration and certification date range parameters on plan of care
• Medical necessity supported ‐ patient would benefit from the development of an effective home strengthening program to:
– Regain ability to safely ambulate to/from bathroom to ensure appropriate pericare, etc.
– Facilitate the patient’s ability to maintain strength and prevent further functional decline with other functional skills, i.e. transfers/bed mobility.
Source: CMS Open Door Forum Slide Show 9/5/12
30
Reasonable and Necessary
Treatment should be consistent with the nature/ severity of illness / injury
• Is this a new or acute problem?
– May need intensive focused care
– E.g. reduce pain and/or work on a specific impairment or functional loss
• Is this an old or chronic condition that needs retraining, or has had a change in condition?
– May need to update or modify program
• Is this an exacerbation of a condition?
– May have to modify treatment, change assistive devices as the condition deteriorates
– Are there other conditions (e.g. medical diagnosis) that are the underlying problem?
• Cognitive performance can impact care
– What is the beneficiary’s ability to retain newly learned information (cognitive function)?
– What is the beneficiary's ability to participate and benefit from rehabilitative services?
Source: CMS Open Door Forum Slide Show 9/5/12
31
MMR Denial Letters
Examples from Noridian
• There are both
partial approvals:
• And total denials:
• There are categories for the denial:
MMR Denial Letters
And specific language justifying the denial (though the responses are canned.)
Reasonable & Necessary
• Assessing Objective Measurable Gains for Rehabilitation Therapy
• Look at:
– Changes in the level of assistance required to perform functional tasks
– Changes in the types of functional activities/ tasks
– Changes in the types of assistive devices
– Improvement in rating of reported pain levels and changes in the ability to perform tasks given the reduction of pain
• (E.g. ‐ Ability to sit for a duration of time as a result of pain reduction)
Source: CMS Open Door Forum Slide Show 9/5/12
34
Reasonable & Necessary
Considerations:
• Did the therapist consider the beneficiary’s goals?
• Were the therapist’s and beneficiary’s goals realistic based on the beneficiaries condition and,
• For rehabilitation therapy did the therapist change goals/ treatment plan in response to improvement or lack of improvement in the beneficiary’s condition?
• Were there objective, measurable changes using standard scales and assessment tools?
• What was the beneficiary’s response to treatment?
– Did this change over time?
– Was it sustained?
Source: CMS Open Door Forum Slide Show 9/5/12
35
Follow Your MAC’s Instructions
• Website Links For MAC Manual Medical Review –
–
–
–
–
–
–
–
–
CGS Medicare
NGS Medicare
WPS Medicare: J5, J8, Legacy
Noridian
Palmetto
Novitas Solutions
Cahaba
First Coast Service Options
NHIC
36
Assessing Therapy Utilization
• 10/1/2012 – System reframed to report therapy utilization “up” (vs. “down” or “cap amount remaining”)
– System will take until 10/8/2012 to populate with historical data and hospital utilization – Information is good only as of the time you look at it
– HIPAA Eligibility Transaction System (HETS)
– Common Working file (CWF) Part A Eligibility System (ELGA)
– IVR system, DDE portal
– Many MACs have their own portals/phone to access
• CMS will not strictly apply sequential billing rule
37
Critical Action
• Current patients – What therapy has a patient received since 1/1/2012?
– Must know prior to your phase
• Find internally for your own patients
• CMS not able to post correct historical until 10/8…..problem
– What is your billing cycle?
• Referred patients
– Identify CY 2012 therapy counting toward the cap received elsewhere
– Evaluation to determine therapy needs?
• If over $1880, eval codes are exempt
• The “Phase” Quagmire in Private Practice
– May have therapists in each Phase
– Impacts coverage for Phase II‐III therapist’s patient by a Phase I therapist
38
Medical Review Issues
• CERT reports specific to your contractor
– Paid error rate
– Specific therapy claims “paid in error”
• Comparative Billing Reports (CBR)
– Project awarded to Safeguard Services LLC
– Profiling PT in Private Practice
• High KX modifier utilization
• Reports in 2010, 2011 profiling top 5000 physical therapist on KX utilization – 5 codes (10,000 total PTs)
• 2012 re‐profiles those identified in 2010
• OIG 2013 Work Plan – physical therapy in private practice
• RAC rumors
39
Physical Therapy Practice Risks
• Insufficient documentation
• Coding & Billing
• Licensed/non‐licensed providers
• Excessive # of visits
• Employee’s understanding
• Patient’s understanding
40
Risks & Interdependencies
• Medical Necessity
– Treatment
– Documentation
– Coding
– Billing – KX Modifier Therapy Evaluation
Daily Treatment
Plan of Care
Document
Coding ‐
ICD
Coding
Procedures
41
How an EMR and Practice Management System Can Minimize Your Audit Risks
Critical Actions
Requirements:
How Clinicient Helps:
1
Track the Phase of Treating Therapist, According to NPI#
Automated therapist phase tracking and alerts
2
Re‐Verify the Therapy Cap of Each Patient
Automated therapy cap tracking, single form for all Medicare patients
3
Accurately track the Cap and the Exceptions Threshold Automated and accurate tracking of caps with alerts and KX modifier applications
4
Follow the Exceptions Process
Alerts for exceptions process and ABNs
5
Document Defensibly, Demonstrate Medical Necessity
Goal tracking, required elements, plan of care
certification tracking, progress note tracking
6
Ensure Documentation Always Supports Claim
Therapist time from documentation is accurately converted to units following CMS guidelines
Critical Action #1:
Track the Phase of Treating Therapist
OCT 1
Phase 1
|
NOV 1
|
DEC 1
Phase 2 Phase 3 Automated report that shows the phase of each therapist in your organization, according to NPI #
Critical Action #2:
Re‐Verify the Therapy Cap
X
(9th)
• Prioritize by patient and therapist phase
• Track starting amount used
• Record the date you verified the information
• Automatically tracks toward KX cap and MMR threshold
Critical Action #3:
Track the Cap and MMR Threshold
• Automated front desk alerts
• Therapist alerts
• Management alerts and reports
• Authorized visit tracking for MMR exceptions Critical Action #4:
Follow the Exceptions Process
• Alerts when approaching $3700 MMR threshold
• Visit authorization tracking for exceptions granted
• Task Management for authorization tracking
• ABN alerts, automated ABN creation
Critical Action #5:
Document Defensibly
• Required fields in documentation templates
• Tag items as goals to automate progress tracking
–
–
–
–
Time dated
Initial measure Progress ratings/ completion dates
Track progress on functional goals and outcomes measures
• Plan of Care and Progress Report requirement tracking
• System generated reports with all required elements
• Plan of Care physician certification tracking
Critical Action #6:
Ensure Documentation Supports Claim
• Charges flow from therapist documentation of procedures
• Time accurately converted to units, applying CMS rounding rules
– Total treatment minutes and timed minutes automatically included
– Apply 8 minute rule & unit caps per CMS
– Trim codes per CMS guidelines
• Built‐in CCI edits
• Alert to apply KX modifier when necessary
– Constant reminder to document medical necessity
• Fax evals and progress reports directly to referring physician
In Summary
Requirements:
How Clinicient Helps:
1
Track the Phase of Treating Therapist, According to NPI#
Automated therapist phase tracking and alerts
2
Re‐Verify the Therapy Cap of Each Patient
Automated therapy cap tracking, single form for all Medicare patients
3
Accurately track the Cap and the Exceptions Threshold Automated and accurate tracking of caps with alerts and KX modifier applications
4
Document Defensibly, Demonstrate Medical Necessity
Goal tracking, required elements
5
Ensure Documentation Always Supports Claim
Therapist time from documentation is accurately converted to units following CMS guidelines
6
Follow the Exceptions Process
Alerts for exceptions process; easy‐to‐produce reporting
Resources and Questions
NEW LinkedIn Group: Twitter: “PT and Rehab Compliance Group”
Community group for sharing discussions and questions surrounding Medicare and compliance regulations
#therapycap
@nancybeckley
@clinicient
New Resource Page:
APTA PPS SHOW: www.Clinicient.com/mmr‐resources/
Clinicient Booth: #226 & 127
Therapy Provider Phase Information
Manual Medical Review Forms
Therapy Codes per CMS
LinkedIn Group: PT and Rehab Compliance Group
Therapy Cap FAQ from CMS
APTA FAQ: 2012 Medicare Therapy Cap
CMS Guidelines on Therapy Services and Documentation
Nancy Beckley:
“Compliance Hot Topics”
Roundtable Session: Friday 8:30 –
9:30am
“Profiling Your Organization: Where is Your Risk?”
Saturday, 10:30am – 12:00pm
Contact Info
Nancy J. Beckley, MS, MBA, CHC
President
Nancy Beckley & Associates LLC
nancy@nancybeckley.com
414‐748‐4376
1‐877‐312‐6494
www.Clinicient.com
Visit our website to • Learn More
• Schedule a Demo
• Get a Price Quote
Visit us at APTA PPS Show: Booth #
@nancybeckley
@clinicient
http://www.linkedin.com/in/nancybeckley
http://www.linkedin.com/company/clinicient