Medical Review - JF Part B

Q1 What are the supervision requirements for a therapy assistant and does the PT need to cosign the therapy assistant notes each time?
A1: Physical therapy assistants (PTA) and Occupational therapy assistants (OTA) can provide treatment to Medicare patients only when they are appropriately supervised by a qualified therapist from each respective discipline. Assistants are licensed, registered, certified (in most states). General supervision is required for PTA/OTAs in all settings except private practice. General supervision means that when a PTA/OTA provides services on or off the organization’s premises, those services must be supervised by a qualified PT/OT who makes an onsite supervisory visit at least once every 30 days or more frequently if required by state/local laws or regulations. This requirement is assumed to be met unless the medical record documentation indicates otherwise.

Direct supervision is required for private practice locations, unless state practice requirements are more stringent, in which case state or local requirements must be followed. Private practice locations include physician/NPP offices/clinics and therapists in private practice (TPP) clinics. Direct supervision means that when a PTA/OTA provides services the qualified therapist must be present and available within the office suite at the time the service is performed. Note that a physician/NPP cannot meet the supervision requirement for a PTA/OTA. The supervision requirement is assumed to be met unless the medical record documentation indicates otherwise.

Therapy assistants cannot provide evaluation services, make clinical judgments and/or decisions or take responsibility for the service. Therapy assistants can complete medical record documentation without the need for therapist co-signature.
Refer to: MBPM, Chapter 15, Sections 230.1.C, 230.2.C, 230.3.C, and 230.4-230.5

Q2: The Additional Documentation Request (ADR) letters often include an extensive list of information for submission. Do we need to submit everything that is listed? Should we send the chart so that we do not miss anything?
A2: No. Do not send the entire chart. It is unnecessary to submit hundreds of pages for review. The ADRs list items that MAY be needed to support the billed service. If the item is not relevant to the billed service for the specified patient, it shouldn’t be submitted. The items listed on the ADR are not all inclusive. Submit documentation to support the medical necessity of the service, whether or not, it is specifically identified on the ADR.

Refer to: Documentation Requirements

Q3: When is it acceptable to rebill a claim?
A3: It is an inappropriate billing practice to rebill claims. Claims should only be rebilled if the claim is denied for a processable error, which is when a claim rejects for missing, invalid, or incomplete information. If the provider has made an error when submitting the claim or disagrees with the claim decision, a provider should follow the self-service reopening or appeals process to make corrections to the claim or appeal the decision. If a claim is rebilled as a duplicate, it will be denied. Providers who are found to be billing duplicate claims during the review will be educated on the error. If providers continue to submit duplicate claims despite education, program integrity action may be taken.

Refer to: 120 - Detection of Duplicate Claims General Billing Requirements