Outpatient Rehab Facility (ORF) Physical Therapy - Service Specific Post-Payment Final Findings - JE Part A
Outpatient Rehab Facility (ORF) Physical Therapy - Service Specific Post-Payment Final Findings
CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian’s priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis.
This is to update providers of the claim review findings and closure of the file of outpatient physical therapy services for JE.
Summary of Findings
Since the initiation of the review, 398 claims were reviewed from October 5, 2020 through October 28, 2021 with an overall claim error rate of 27.4% and payment error rate of 12.6%. The breakdown of those findings are as follows:
- 289 claims were accepted
- 2 claims received correction for the following reason:
- Documentation did not support correct CPT® code for services
- 55 claims were partially denied for the following reasons:
- Documentation did not support the number of units billed for time-based codes.
- Documentation did not support all services billed were medically necessary resulting in partial denial.
- 52 claims were denied in full for the following reasons:
- Documentation was not received timely in response to additional documentation request (ADR).
- Documentation did not support physician certification/re-certification of the plan of care.
- Documentation did not support medical necessity of the services billed.
- Documentation did not support services were rendered as billed.
- Documentation did not support medical necessity for re-evaluation to be billed
If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.
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|Certification/Recertification/Plan of Care Requirements||
The certification requires a qualified physician or nonphysician practitioner (NPP) signature and date on the plan of care or some other document to indicate approval of the plan of care. A plan of care outlines the treatment plan after an evaluation of a patient’s condition and is considered to be established when it is developed, e.g. written or dictated. The signature and professional credentials of the person who established the plan and the date must be supported in the documentation. The plan of care may only be developed by a practitioner or a licensed therapist specific to their specialty, e.g. a physical therapist would complete a plan of care specific for physical therapy services. At a minimum, the plan of care must include the following:
Certification requirements are met when the practitioner certifies the minimum required plan of care elements with a legible dated signature on the plan of care or some other document that indicates approval of the plan of care. If the order contains all the required elements of the plan of care and is legibly dated and signed by the practitioner, then no further certification is required.
Initial evaluation services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants. These services can only be provided by qualified clinicians, i.e. a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP). Therapy evaluation codes can only be billed when the medical record supports a completed comprehensive evaluation with sufficient data to support development of a thorough plan of care, including goals and intervention selection. Documentation must support that the evaluative service was medically necessary based on the patient’s current status and medical/functional history. Medicare does not reimburse for services related solely to workplace skills and activities. Treatment codes should not be billed for time spent providing initial evaluative services.
Providers may simultaneously receive multiple physician referrals for multiple medical conditions for one patient. When this occurs, it is expected that one qualified clinician from each appropriate discipline, i.e. physical therapist (PT) and/or occupational therapist (OT), and/or speech language pathologist (SLP) will complete a thorough initial evaluation that encompasses each of the identified medical conditions. Following completion of the initial evaluation, other staff therapists specializing in specific medical conditions may treat the patient as needed. When medical necessity is supported, an initial evaluation is appropriate for:
For example: A patient is currently receiving therapy services following a total knee arthroplasty (TKA). During the therapy episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines that the rotator cuff injury is not related to the TKA. Therefore, it is reasonable for the clinician to provide and code for a new evaluation of the rotator cuff injury since it is a newly identified diagnosis for an unrelated condition.
To support medical necessity of therapy services, documentation must support the patient required skilled care. Skilled care would include:
As per the progress report requirements, documentation to support medical necessity for services is minimally required to be documented every 10 treatment days. Without the elements of the progress report documented, medical necessity is difficult to establish. Documentation must also support that the benefits from any prior therapy services for the same condition were sustainable following discharge for a reasonable amount of time.
For additional information, reference: Noridian Coverage Article, “Medical Necessity of Therapy Services A53304 (JE), IOM, Publication 100-02, MBPM, Chapter 15, Section 220-230
|Re-evaluations||Therapy re-evaluation services involve clinical judgement and decision-making which is not within the scope of practice for a therapy assistant. These services can only be provided by a qualified clinician, i.e. a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP). Therapy re-evaluation codes can only be billed when the medical record supports a completed comprehensive re-evaluation with sufficient data to support development of a thorough plan of care, including goals and intervention selection.
Documentation must support that the re-evaluative service was medically necessary based on the patient’s current status and medical/functional history. Medicare does not reimburse for services related solely to workplace skills and activities. Additional re-evaluative services may be necessary when an episode of care is interrupted by a short-stay inpatient hospitalization or outpatient surgery that could reasonably impact the patient’s therapy progress. Treatment codes should not be billed for time spent providing evaluative services.
Time spent completing tests and gathering data for mandatory progress reports (due a minimum of every 10 treatment visits throughout the episode of care) does not typically meet Medicare’s medical necessity standards and as a result these minutes are not appropriately coded as re-evaluation service. Routine re-evaluations of the patient’s expected progression in accordance with the plan of care, during the episode of care or upon discharge, are not considered to be medically necessary separately billable services. Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation.
When medical necessity is supported, a re-evaluation is appropriate for these types of scenarios:
A patient who is currently receiving therapy services and develops a newly diagnosed related condition, e.g., a patient this is currently receiving therapy treatment to TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of the walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition.
A patient is currently receiving therapy services and demonstrates a significant improvement, decline or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.
For additional information, reference the Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220(A), 220.3(C), 230.1.
|Repetitive Billing Requirements||
Physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services that are furnished to a single individual must meet monthly repetitive billing requirements. PT, OT, SLP services need to be billed on a single monthly claim (or at the conclusion of treatment), whichever comes first. For example, when a patient comes to therapy during the month of July and participates in PT, OT and SLP then all the therapy services need to be billed on a single monthly claim for July. A single monthly billing is required for a patient that is:
For additional information, reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 1, Section 50.2.2.
|Timed Code Units||
When billing timed codes for outpatient therapy, billing should be based solely on the total timed code treatment minutes provided. If only one timed code service is provided for less than 8 minutes during a single therapy visit, then the service should not be billed. However, if during a single therapy visit 8 minutes of a timed code service is provided in addition to another timed code service, then the total combined minutes for all of the timed code services is used to determine accurate billing of the total timed code unit(s). Additionally, if 2 timed code services are performed, each individually spending 1 unit worth of time, but the total timed code minutes allows 3 units to be billed, then it would be appropriate to bill 3 units based on the total timed code minutes, assigning the additional unit to the service that took the most amount of time.
Example 2 - The treatment encounter note supports:
Example 3 - The treatment encounter note supports:
Example 4 - The treatment encounter note supports:
Example 5 - The treatment encounter note supports:
Example 6 - The treatment encounter note supports:
For additional information, reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 5, Section 20.2.
View references used in review. Further educational opportunities may be found under Education and Outreach. If you are in need of an individualized education training event, contact the POE Department at email@example.com. If you need coding assistance, please check your CPT®, HCPCS, ICD-10 books and your specific association.
Provider Action Required
File results and trending errors are being shared with all providers to assess compliance and billing practices if the service is provided within your facility. If your facility had claim documentation requested for this review, please refer to the individual result letter you received. You can also access individual determinations for claims that were requested from your facility by reviewing comments in either DDE or on the Noridian Medicare Portal (NMP).
Further provider action recommended includes:
- Provide education regarding errors noted to applicable staff members.
- Verify documentation supports medical necessity of outpatient physical therapy services.
This service specific post-payment file is now closed for JE and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices.
If you have any other questions, contact the JE Provider Contact Center at 1-855-609-9960.
Last Updated Wed, 10 Nov 2021 14:45:05 +0000