Outpatient Rehab Facility (ORF) Physical Therapy - JF Service Specific Post-Payment Final Findings - JF Part A
Outpatient Rehab Facility (ORF) Physical Therapy - JF 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 ORF physical therapy services for Jurisdiction F.
Summary of Findings
Since the initiation of the review, 300 claims were reviewed from October 5, 2020 through September 2, 2021 with an overall claim error rate of 37.7% and payment error rate of 29.1%. The breakdown of those findings are as follows:
- 186 claims were accepted
- 3 claims received correction for the following reasons:
- Documentation did not support CPT® Manual code descriptor requirements.
- Documentation did not support accurate coding of units for time-based codes.
- 32 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 minutes of therapy(ies) provided were skilled resulting in partial denial of units billed.
- Documentation did not support plan of care was certified/re-certified for all dates of service billed.
- Documentation did not support CPT® Manual code descriptor requirements.
- Documentation did not support all services billed were medically necessary resulting in partial denial.
- 79 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.
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.
|Paragraph Name||Paragraph Details|
|Timely Submission of Documentation and 569PPs||It is the responsibility of Medicare providers to submit all documentation requested on the additional documentation requests (ADR) within the allotted time frame. Noridian allows 45 calendar days for the medical records to be received per the ADR request for post-payment reviews. On day 46, if the medical records have not been received, the claim will be denied provider liable with reason code 569PP. If there is no documentation to complete the medical review (MR), services billed on the claim cannot be supported.
A redetermination request should be submitted to Noridian within 120 days from the date of the 569PP denial. Contractors shall reopen the claim for review as long as all conditions are met. The determination made on the reopening claim has the potential to reverse non-covered dollars.
For additional information, refer to Internet-only Manual Pub 100-08, Chapter 3, Section 188.8.131.52, 42 CFR 424.5(a)(6), and Social Security Act sections 1815(a), 1833(e) and 1862(a)(1)(A).
|Documentation Requirements for Therapy Services||In order for a claim for Medicare benefits to be paid, there must be sufficient documentation to verify the services were performed and also at the level of care that was required. If there is no documentation or insufficient documentation, then there is no justification for the services or the level of care billed. Services that are denied based on no documentation are reflected as billing errors.
For additional information, reference the Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3(E).
|Documentation to Support Billing||In order for a claim for Medicare benefits to be paid, there must be sufficient documentation in the patient's records to verify the services were performed. If there is no documentation supporting the service was completed, then Medicare considers the service was not rendered resulting in denial.
For additional information, reference the Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Sections 220 & 230.
|Medical Necessity||To support medical necessity of therapy services, documentation must support the patient required skilled care. Skilled care would include:
Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3 outlines requirements for rehabilitative and maintenance therapy as follows:
|Progress Report||The progress report(s) must provide justification of medical necessity for continued treatment and supports that required therapy services are complex and sophisticated such that they can only be safely and effectively provided by or under the supervision of a qualified therapist. The minimum progress report period shall be at least once every 10 treatment days which includes assessment of the patient's response to therapy services, plans for continued treatment or treatment revisions, updates to short or long term goals and objective functional assessment. If each element required in a progress report is included in the treatment encounter notes, at least once during the progress reporting period, then a separate progress report is not required. Without the elements of the progress report documented in the medical record, medical necessity is difficult to establish.
Physical therapy assistants (PTAs) or occupational therapy assistants (OTAs) may write elements of the progress report dated between qualified therapist reports. Reports written by assistants are not complete progress reports. The qualified therapist must write a progress report during each progress report period regardless of when the assistant writes other reports.
For additional information, reference: Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3(D), 220-230, Noridian Coverage Article, "Medical Necessity of Therapy Services (A52775).
|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.
|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:
Timeliness is met when the initial certification is signed within 30 days of the initial treatment under that plan. Recertification of the minimum required plan of care elements must be legibly signed and dated by the practitioner during the duration of the prior plan of care or within 90 days, whichever is less. For example, if frequency and duration on the prior certified plan of care is documented as 2 times a week for 4 weeks, then that certification is valid for 4 weeks and the recertification must be completed by the practitioner within that 4 week time frame to meet the timeliness standard.
Delayed certification/recertification is acceptable without justification for an additional 30 day grace period after they are due. If the plan of care has not been legibly signed and dated within 60 days, the practitioner must also provide a rationale for the delay.
For additional information, reference Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Sections 220(A), 220.1.2 - 220.1.3.
|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.
The expectation remains, however, that a provider's direct treatment time for each timed code unit will average 15 minutes. If a provider is consistently billing less than 15 minutes for a unit, this may be highlighted for review.
The following are examples to help clarify appropriate billing practices based on total timed code treatment minutes for therapy services:
Example 1 - The treatment encounter note supports:
|Treatment Encounter Note Documentation||A treatment encounter note is required to include two time elements: the total time-based treatment minutes and the total treatment minutes. The total treatment minutes includes both time spent providing time based and untimed code services. The total treatment minutes do not include time for services that are not billed. For Medicare purposes it is not required that the unbilled services that are not part of the total treatment minutes be recorded, although they may be included voluntarily to provide an accurate description of the treatment. The specific amount of time for each intervention and/or procedure provided may also be recorded, but it is not required.
Additionally, the number of minutes spent on non-covered versus covered services should be clearly differentiated for each treatment encounter note to support accurate coding and billing.
Treatment encounter notes must include:
The following are examples to help clarify appropriate documentation requirements:
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 errrors 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 physical therapy services.
This service specific post-payment file is now closed for JF 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 JF Provider Contact Center at 1-877-908-8431.
Last Updated Tue, 14 Sep 2021 16:55:19 +0000