medicare

[Guest guest]

Hi to all. I have a few patients with permanent conditions that require physical

therapy in my private practice.

One patient has Parkinson's disease that despite meds, causes her upper traps to

spasm. This escalates into neck/upper back pain plus headaches.

I can successfully treat her and moderate her pain in about 6 visits, but she

needs to return every couple of months for another series of therapy.

We are already into the cap for this year. My questions " is there a cap to the

cap " .

When will I have to stop treating her?

Thanks PT, CPST, Spokane, Wa.

[Guest guest]

Mr. LePage,

Don't throw the baby out with the bath water! There's a reason your claims

are being denied by Medicare and it may have absolutely nothing to do with

Medicare and everything to do with how your practice is coding and billing

claims to Medicare.

Our company has provided practice management and AR management services for

over 50 private practice PTs, OTs and SLPs in Louisiana since 1999 and as

such, I respectfully submit the following for your review and consideration:

1. If the patient's name on the Medicare card is " " and your

staff enters his name as " Smyth " (regardless if that is the correct

spelling of the patient's last name), Medicare will deny the claim as " insured

not recognized. "

2. Keep in mind that therapists are required to include the referring MD's

NPI on the 837P and CMS-1500 and by 3/1/08, will also be required to include

the appropriate NPI number in the billing, pay-to and rendering fields. You

can obtain more information regarding this policy implementation by visiting

_http://www.cms.hhs.gov/NationalProvIdentStand/01-Overview.asp_

(http://www.cms.hhs.gov/NationalProvIdentStand/01-Overview.asp) .

3. Go to _https://nppes.cms.hhs.gov_ (https://nppes.cms.hhs.gov) to ensure

your NPI/legacy pairs are accurately linked by Medicare. We are already

seeing some claims being kicked back by Medicare (as early as December 2007)

for

therapists who when applying for their NPI provided the incorrect legacy

number on their application.

4. Reference YOUR LOCAL COVERAGE DETERMINATION POLICY (LCD). The LCD is

updated quarterly and provides policy and coverage guidelines based on CPT

codes as well as a listing of all covered ICD-9 codes. Some therapists forego

utilizing the LCD and simply bill Medicare the same ICD-9 code(s) that have

been provided to them by the referring MD, which most often are medical

diagnosis codes (i.e., CVA, Diabetes, HNP, TKR, etc.). The patient is being

referred to therapy as a result of the late effects of the medical diagnosis

and/or

as a result of lack of coordination, muscle weakness, edema, gait

abnormality, limb pain, sprains and strains, lumbago, cervicalgia, etc. By

and large,

incorrect coding accounts for the majority of Medicare denials. If you are

receiving Medicare denials based on " lack of medical necessity, " chances are

you have incorrectly coded for the procedure or modality performed.

Common Medicare billing/coding errors include: billing for more than one

unit of an un-timed procedures/modalities performed on the same DOS (i.e., IE,

RA, whirlpool, mechanical traction, vasopneumatic device, paraffin bath,

infrared); failing to append the proper HCPCS Level II modifier to indicate

outpatient PT, OT and SLP services were provided; failing to properly use 59

modifier when performing a separate and distinct service on the same DOS (i.e.,

mechanical traction and manual therapy) and over utilization or appending a 59

modifier on ALL procedures/modalities performed; failing to provide clinical

documentation to support the use of use of two heated modalities on the same

DOS; and exceeding the standard number of procedures or modalities performed

based on Medicare's guidelines for that covered diagnosis.

5. Track Medicare therapy caps daily and ensure Medicare patients have read

and signed an NEMB prior to reaching their outpatient cap.

6. Consider offering a wellness/fitness program to Medicare patients who

have reached their cap and do not have a diagnosis that falls under the therapy

cap exception rule.

7. Your practice should be filing Medicare claims electronically. There

are clearinghouses that do not charge providers to file electronic claims to

Medicare. For a nominal fee, Medicare will provide you with EDI software that

will allow you to directly file claims to them without incurring a per claim

fee.

8. You may consider streamlining the number of Medicare patients you see on

a daily or weekly basis in lieu of opting out of the Medicare program

altogether. It is my understanding that once you opt out of the Medicare

program,

you must wait 2 years before being eligible to become a par provider with

Medicare. Even if you opt out of the Medicare program and become a non par

provider, you must follow all the same Medicare guidelines that are in place

for

par providers when you treat a Medicare patient. You cannot charge the

Medicare patient more than Medicare's " limiting charge " amount, which for some

outpatient physical therapy procedures and modalities is less than $1

difference from the par fee. More importantly, Medicare pays the patient

directly if

they have been treated by a non par provider, leaving your staff with the

burden of collecting directly from the patient. Believe me when I tell you

that you are better off participating with Medicare and receiving payment

directly from Medicare than not participating with Medicare and the check going

to

the patient.

9. Keep in mind that when you file a clean claim to Medicare, you will be

paid within 14-24 days (14 days if you are set up to receive electronic

payments/direct deposit from Medicare and 24 days if you are not).

10. Before you consider opting out of Medicare, take a close look at the

contracted rates your practice is being paid by commercial, managed care and

health maintenance organizations and compare these rates to Medicare's par fee.

You may actually be surprised to learn that Medicare is paying you at a

higher rate of reimbursement as compared to commercial, MCO and HMO insurance

plans that pay you based on a per diem rate (i.e., $45-$65 per DOS); insurance

plans that limit the number of outpatient therapy visits to 20 per year;

and/or insurance plans that extremely high patient deductibles and coinsurance

amounts.

11. While it is important for you to consider how opting out of the

Medicare program will impact your MD referrals, it is more important, at least

in my

professional opinion, for you to consider how opting out of Medicare will

impact your patients and your medical community.

Hope this helps and please remember, one day, you too will be Medicare

eligible!

D. Cavitt, President

Medical Legal Alliance, L.L.C.

Lafayette, LA 70508

(cell)

**************Start the year off right. Easy ways to stay in shape.

http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489

[Guest guest]

I appreciate your very detailed response. I have done and been doing your #'2

1-7 and 9-11 for 15 years and my coder for 18. I am just now considering #8.

Every now and then my clearing house makes a " boo boo " with one of the boxes;

I'm electronic. I have talked to my intermediary several times when they tell

me that my documentation doesn't substantiate the services and on the phone they

can't give me a good reason why they denied it and just tell me to re-submit. I

think that my local Medicare review policy is to deny every 38th claim that

comes through the system. I am now trying to make the patient's prior level of

function clearer for them as this has come up on a few phone calls and when I

tell them that it is in there they seem dumb founded. My point earlier was that

I do not have time to make these phone calls, type up an appeal, which has to be

a hard copy so I end up making copies and then mailing it....this is a lot of

extra staff time. A large company probably just dedicates some staff to the

appeals process so that they are always waiting 120 days or longer for their

payment...I don't want to do that. I have talked to other clinic owners and

physicians and it appears that every one is kind of silently opting out by

limiting the number of Medicare patients they see every month...for the same

reasons I have mentions. So it appears that your #8 solution may be my option

as well. I'm going to give typing the patients PLOF in 16 size font in 4 places

on the Evaluation and see if that works first.

Jeff LePage, PT

Wasilla, Alaska

Re: Medicare

Mr. LePage,

Don't throw the baby out with the bath water! There's a reason your claims

are being denied by Medicare and it may have absolutely nothing to do with

Medicare and everything to do with how your practice is coding and billing

claims to Medicare.

Our company has provided practice management and AR management services for

over 50 private practice PTs, OTs and SLPs in Louisiana since 1999 and as

such, I respectfully submit the following for your review and consideration:

1. If the patient's name on the Medicare card is " " and your

staff enters his name as " Smyth " (regardless if that is the correct

spelling of the patient's last name), Medicare will deny the claim as " insured

not recognized. "

2. Keep in mind that therapists are required to include the referring MD's

NPI on the 837P and CMS-1500 and by 3/1/08, will also be required to include

the appropriate NPI number in the billing, pay-to and rendering fields. You

can obtain more information regarding this policy implementation by visiting

_http://www.cms.hhs.gov/NationalProvIdentStand/01-Overview.asp_

(http://www.cms.hhs.gov/NationalProvIdentStand/01-Overview.asp) .

3. Go to _https://nppes.cms.hhs.gov_ (https://nppes.cms.hhs.gov) to ensure

your NPI/legacy pairs are accurately linked by Medicare. We are already

seeing some claims being kicked back by Medicare (as early as December 2007)

for

therapists who when applying for their NPI provided the incorrect legacy

number on their application.

4. Reference YOUR LOCAL COVERAGE DETERMINATION POLICY (LCD). The LCD is

updated quarterly and provides policy and coverage guidelines based on CPT

codes as well as a listing of all covered ICD-9 codes. Some therapists forego

utilizing the LCD and simply bill Medicare the same ICD-9 code(s) that have

been provided to them by the referring MD, which most often are medical

diagnosis codes (i.e., CVA, Diabetes, HNP, TKR, etc.). The patient is being

referred to therapy as a result of the late effects of the medical diagnosis

and/or

as a result of lack of coordination, muscle weakness, edema, gait

abnormality, limb pain, sprains and strains, lumbago, cervicalgia, etc. By and

large,

incorrect coding accounts for the majority of Medicare denials. If you are

receiving Medicare denials based on " lack of medical necessity, " chances are

you have incorrectly coded for the procedure or modality performed.

Common Medicare billing/coding errors include: billing for more than one

unit of an un-timed procedures/modalities performed on the same DOS (i.e., IE,

RA, whirlpool, mechanical traction, vasopneumatic device, paraffin bath,

infrared); failing to append the proper HCPCS Level II modifier to indicate

outpatient PT, OT and SLP services were provided; failing to properly use 59

modifier when performing a separate and distinct service on the same DOS

(i.e.,

mechanical traction and manual therapy) and over utilization or appending a 59

modifier on ALL procedures/modalities performed; failing to provide clinical

documentation to support the use of use of two heated modalities on the same

DOS; and exceeding the standard number of procedures or modalities performed

based on Medicare's guidelines for that covered diagnosis.

5. Track Medicare therapy caps daily and ensure Medicare patients have read

and signed an NEMB prior to reaching their outpatient cap.

6. Consider offering a wellness/fitness program to Medicare patients who

have reached their cap and do not have a diagnosis that falls under the

therapy

cap exception rule.

7. Your practice should be filing Medicare claims electronically. There

are clearinghouses that do not charge providers to file electronic claims to

Medicare. For a nominal fee, Medicare will provide you with EDI software that

will allow you to directly file claims to them without incurring a per claim

fee.

8. You may consider streamlining the number of Medicare patients you see on

a daily or weekly basis in lieu of opting out of the Medicare program

altogether. It is my understanding that once you opt out of the Medicare

program,

you must wait 2 years before being eligible to become a par provider with

Medicare. Even if you opt out of the Medicare program and become a non par

provider, you must follow all the same Medicare guidelines that are in place

for

par providers when you treat a Medicare patient. You cannot charge the

Medicare patient more than Medicare's " limiting charge " amount, which for some

outpatient physical therapy procedures and modalities is less than $1

difference from the par fee. More importantly, Medicare pays the patient

directly if

they have been treated by a non par provider, leaving your staff with the

burden of collecting directly from the patient. Believe me when I tell you

that you are better off participating with Medicare and receiving payment

directly from Medicare than not participating with Medicare and the check

going to

the patient.

9. Keep in mind that when you file a clean claim to Medicare, you will be

paid within 14-24 days (14 days if you are set up to receive electronic

payments/direct deposit from Medicare and 24 days if you are not).

10. Before you consider opting out of Medicare, take a close look at the

contracted rates your practice is being paid by commercial, managed care and

health maintenance organizations and compare these rates to Medicare's par

fee.

You may actually be surprised to learn that Medicare is paying you at a

higher rate of reimbursement as compared to commercial, MCO and HMO insurance

plans that pay you based on a per diem rate (i.e., $45-$65 per DOS); insurance

plans that limit the number of outpatient therapy visits to 20 per year;

and/or insurance plans that extremely high patient deductibles and coinsurance

amounts.

11. While it is important for you to consider how opting out of the

Medicare program will impact your MD referrals, it is more important, at least

in my

professional opinion, for you to consider how opting out of Medicare will

impact your patients and your medical community.

Hope this helps and please remember, one day, you too will be Medicare

eligible!

D. Cavitt, President

Medical Legal Alliance, L.L.C.

Lafayette, LA 70508

(cell)

**************Start the year off right. Easy ways to stay in shape.

http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489

[Guest guest]

On Sunday Feb. 24 D. Cavitt, President of Medical Legal

Alliance, LLC posted this message

" ...if the Medicare patient you are treating has met his cap at

another outpatient facility and you are treating him for a different

diagnosis that is covered and meets the guidelines of the therapy cap

exception rule, Medicare should cover these services. "

I respectfully disagree and I would qualify this statement by saying

that you should let your physical therapy findings dictate whether or

not the patient qualifies for an exception to the physical therapy cap.

Your findings should generate a physical therapy diagnosis, which may

be sufficient to qualify for the exception.

Try not to rely on a physician's diagnosis to build a case for an

exception.

How would you phrase a Justification Statement for a cap exception

based only on the physician's diagnosis of, say, Weakness?

Try to base your case on these three criteria (for both Progress Notes

and for cap exceptions)

1) Demonstrated Medical Necessity for Physical Therapy

2) Expected Significant Improvement in a Predictable Timeframe

3) Show Skilled Therapy (in the daily note, not the Progress note)

This passage from Transmittal 63 (Medicare BPM)may help clarify...

" • While a beneficiary's particular medical condition is a valid

factor in deciding if skilled therapy services are needed, a

beneficiary's diagnosis or prognosis should never be the sole factor

in deciding that a service is or is not skilled. The key issue is

whether the skills of a therapist are needed to treat the illness or

injury, or whether the services can be carried out by nonskilled

personnel. "

Page 19

Tim , PT

timrichpt@...

[Guest guest]

There is no " specified " limit on therapy a beneficiary can receive under either

an automatic or a manual exception. The catch is that you must still be

prepared to defend your treatment as being medically necessary. Make absolutely

sure you have all your t's crossed and i's dotted or you will trigger an audit.

Also, Medicare will track how many KX modifiers you use. If your use exceeds

the national average, you may be scrutinized more closely.

Rob Jordan, PT, MPT, GCS, OCS

medicare

For Medicare patients with an 'exception' diagnosis...is there a limit (visits

or $amount) on the therapy they can receive in outpatient private practice? I

realize they need to be recertified after 90 days but is there a limit on their

therapy?

D. Moreau, PT

NC