Medical Review

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.

Education

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 3.2.3.8, 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:
  • Services provided which are individualized and rendered for treatment of a medical condition that require the skills and knowledge of a therapist
  • Services that meet acceptable standards of medical practice to effectively treat the patient's condition
  • Services that are complex and sophisticated such that they require the judgement and skills of a qualified therapist to be completed safely and effectively
  • Rehabilitation services provided should be of a reasonable duration as evidenced by the patient continuing to significantly and objectively benefit from ongoing skilled therapy services
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.

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:
  • Rehabilitative Therapy: "the patient's condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time"
  • Maintenance Therapy: "treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient's functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel"
For additional information, reference: Noridian Coverage Article, "Medical Necessity of Therapy Services (A52775), IOM, Publication 100-02, MBPM, Chapter 15, Section 220-230
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:
  • Diagnosis
  • Long term treatment goals
  • Type, amount, frequency and duration of therapy services
  • Frequency of therapy refers to "the number of times in a week the type of treatment is provided" which can be tapered as necessary. Long term treatment goals should be measurable and related to the patient's impairments.
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.

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:

 

  • 30 minutes initial evaluation, Current Procedural Terminology (CPT®) 97162
  • 5 minutes therapeutic exercises, CPT® 97110
  • When the visit includes both untimed and timed-based services, the documentation needs to clearly indicate that the total time of the visit was 35 total visit minutes. This documentation supports coding of 1 unit for CPT® 97162 and no coding for CPT® 97110 since the required minimum 8 minute threshold is not met.
Example 2 - The treatment encounter note supports:
  • 20 minutes of manual therapy, CPT® 97140
  • 20 minutes of therapeutic exercises, CPT® 97110
  • The total timed code treatment time is 40 minutes, which allows 3 units to be billed (3 units = 38-52 minutes). Even though each service is performed for only 1 unit of time individually, the total time allows for 3 units. Since both services are performed for the same amount of time, choose 1 service to bill 2 units and the other service is billed for 1 unit.
Example 3 - The treatment encounter note supports:
  • 35 minutes of manual therapy, CPT® 97140
  • 7 minutes of gait training, CPT® 97116
  • Total time-based treatment time is 42 minutes, which allows for 3 units to be billed. The first 30 minutes counted towards CPT® 97140 which supports 2 full units (per the 15 minute relative work value for each unit). The remaining time spent on CPT® 97140 (5 minutes) compared to the time spent on CPT® 97116 (7 minutes) and the service that took more time is the service that should receive the remaining 1 unit. The documentation supports 2 units of CPT® 97140 and 1 unit of CPT® 97116
Example 4 - The treatment encounter note supports:
  • 25 minutes of therapeutic exercises, CPT® 97110
  • 24 minutes of therapeutic activities, CPT® 97530
  • Total timed-based treatment time is 49 minutes, which allows for 3 units to be billed. Therefore, even though each individual service is performed for 2 units worth of time, the total time allows for only 3 units. The documentation supports 2 units of CPT® 97110 and 1 unit of CPT® 97530, billing more timed units to the service that took the most time.
Example 5 - The treatment encounter note supports:
  • 20 minutes of manual therapy, CPT® 97140
  • 10 minutes of therapeutic exercises, CPT® 97110
  • 10 minutes of gait training, CPT® 97116
  • 8 minutes of ultrasound, CPT® 97035
  • Total time-based treatment time is 48 minutes, which allows for 3 units to be billed. Therefore, even though each individual service is performed for 1 unit worth of time, the total time allows for only 3 units. This documentation supports 1 unit each of CPT® 97140, 97110, 97116. The ultrasound is not able to be billed, as the total units that can be billed are constrained by the total timed code treatment minutes. (In order to bill 4 units, there must be 53-67 total time-based treatment minutes).
Example 6 - The treatment encounter note supports:
  • 10 minutes of vasopneumatic device, CPT® 97016
  • 21 minutes of therapeutic exercises, CPT® 97110
  • 9 minutes of manual therapy, CPT® 97140
  • The total treatment time is 40 minutes and the total time-based treatment is 30 minutes. This documentation supports 1 unit of CPT® 97016, 1 unit of CPT® 97110 and 1 unit of CPT® 97140.
For additional information, reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 5, Section 20.2.
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:
  • Date of treatment
  • Identification of each specific intervention/modality to support billing
  • Legible signatures with professional credential of qualified staff
  • Total treatment minutes for the session, including minutes for timed and untimed code services
Total treatment minutes for the session do not include time for services that are not billable (e.g., rest periods, independent gym activities, patient changing clothing, waiting for/set-up of equipment).

The following are examples to help clarify appropriate documentation requirements:
  • Example 1: A patient is seen and treated for 50 minutes. Services completed included therapeutic exercises for 40 minutes and a cold pack for 10 minutes. The total treatment time should be documented as 50 minutes and the total timed code treatment should be documented as 40 minutes supporting the billing for 3 units for Current Procedural Terminology (CPT®) code 97110.
  • Example 2: A patient is seen and treated for 45 minutes. Services completed include an evaluation for 30 minutes and therapeutic exercises for 15 minutes. The total treatment time should be documented as 45 minutes and the total timed code treatment should be documented as 15 minutes, which would support billing of CPT® 97162 for 1 unit and CPT® 97110-1 unit.
  • Example 3: A patient is seen and treated for 40 minutes. Services completed included therapeutic exercises for 22 minutes, manual therapy for 8 minutes and ultrasound for 10 minutes. The total treatment time should be documented as 40 minutes and the total timed code treatment should be documented as 40 minutes, which would support billing of CPT® 97110-1 unit and 97035-1 unit.
For additional information, reference the Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3(E).

 

References

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 mac@noridian.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.

Summary

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