I know it's late but Happy New Year and what a start to 2011. It was = the first time since who knows when that we actually knew we had an exception process till the end of the year.

I heard that there are several MACs already doing probe reviews for u= se of the KX modifier for the latter part of 2010. I haven't heard many results though. If you have experienced any reviews and would like = to share the results let me know.

We have developed new workshops seminars for 2011 and are working on changes to our website. See "What's happening = at Encompass".

News you can use provides informati= on on how you can access the fee schedule for your location throu= gh the CMS website if you are having difficulty with your Contractor website.

Medical Review looks at the findings of 2 reports published by the = OIG which will have a big impact in the coming months.

Tip of the Month provides information on "timely billing". Big changes have occurred on time of submission and holding onto claims can prove costly.

A/B MAC Tips includes a change in the LCD by NGS and an edit from Trailblazer for Therapy Services billed "incident to physician services". This wo= uld be a good edit for ALL MACS to adopt!

Please feel free to forward this Newsletter to anyone you believe would be interested in its content. Please use the link at the= end of the newsletter to forward to a friend. This way we can keep trac= k of forwards and improve our content.

What's Happening= at Encompass

Workshop/Seminars

We have designed 2 new seminars for Part B services as well as redesigning our = Skilled Nursing program.

We updated our Medicare Part B Made Easy to "Anatomy of Documentation: Putting Muscle on the Bones of Medicare Compliance&quo= t;. We had our first presentation in Jacksonville for an Outpatient Company and the reviews were great. We have it planned for April 2nd at the Good Samaritan Hospital in Los Angeles, CA.

We are following it = the next day with our brand new "Tests, Measures and Questionnaires: Making Assessments Work for YOU". This program is app= licable to both Outpatient Clinics and SNF providers as it covers a good vari= ety of functional tests. It also includes ones that can be used to support the PQIS. This course is predominantly for Physical Therapists althou= gh it may be of interest to OTs and Rehab Managers.

If you would like to host this seminar, let me know, it has not been scheduled anywhere el= se as yet. Anyone in Miami-Dade interested? You might be after you read = our "Medical Review" section.

Our other new workshop is for SNF. We have gone back to our old format of a 2 day program on Friday and Saturday. Day 1 includes all Part A regulations, including the MDS 3.0 and its assessments, RUG IV levels, and how nursing can support therapy in their documentation; we also review restorative nursing and therapies role. Day 2 is Part B a= nd is very similar to our Anatomy of Documentation Workshop. Registration can be for one day or both and hopefully = we will persuade some nurses to attend Day 1. <= /p>
Again, we are looking for host sites for this course. = Are you a Hospital based SNF with access to meeting space or know of a facility that might have meeting space? Think about our hosting options, let us know if you are interested. Our schedule for the rest of the year is still in the development mode so= now you don't even have to be on our "list".<= /span>

Website News:=

Newsletter Questions and Answers: We have moved our Q&A from= the Newsletter onto our website under the "Medicare Mentor" pag= e. We are posting questions we have received and have both SNF and Part B sections. We update the pages on a Friday and Monday.=

On the topic of questions, please remember that the company is trying to make a profit and while we are more than happy to answer your questions, free ones = may take a little longer to get back to you although I do try to respond timely. Have an ongoing need for questions being answer? Think about opening an account with us. Call for more information

Website Desig= n: We have st= arted the process of redesigning our website and hope to have a launch date for the end of March. We will have more user friendly applications and will be incorporating on-line registration for our seminars and on-line payment ability for our other products.

We will also be linking it to our Facebook page making= it easier for you to keep up to date with what's happening and what we are doin= g.

News You Can Use

CMS has redesigned the web page for accessing Medicare Coverage Databases including National Coverage Determinations (NCD) and Local Coverage Determinations (LCD). From this link you can find your LCD, obtain a PDF version or e-mail the link direc= tly to someone else.

CMS maintains all the LCDs on their website, so even if you go to your Contractors site, that will lead you here. The LCDs are updated weekly and other pages accessible from the site are updated in live time.

Remember, always have the most current copy of your LC= D at hand, it is what you will be reviewed on for your current coverage.

Under a Medical Review already? You need to make = sure that you have the LCD that was active at the time you provided those services. They are on this site as well under archived or retired LCD= s.

http://www.cms.gov/medicare-coverage-d= atabase/overview-and-quick-search.aspx

Update on Medical Review Activities

Late in December&= nbsp;the Office of the Inspector General (OIG) released two reports= on "Questionable Billing Practices", one for Medicare = Outpatient Therapy Servic= e and the other for SNF Part A Services. The findings in both of these reports was of high overutilization of services with both abuse and fraud occurring. The recommendations for both of these reports were to incr= ease scrutiny of claims submitted and institute changes to the ways that payment for these services are created.

What they found:

For outpatient therapy services, 20 counties were identified that, in 2009, had provided

1) the highest average Medicare payments per beneficiary and

2) had services that produced more than $1 million = in total Medicare payments, i.e. high utilization counties. <= /span>

For SNF, it was determined that from 2006 to 2008,

1) billing for high paying RUGs increased even though beneficiary characteristics remained generally unchanged,

2) For profit SNFs were more likely to bill higher paying RUGS than not for profit = or government SNFs,

3) Some had questionable billing practices with high RUGs and long length of stay (total of 348 of facilities in study).

4) For SNFs w= ho were purchased by a large, for-profit chain, their billing pract= ices changed soon after their purchase, i.e. higher RUG levels were billed= and length of stay was increased.

What does that mean for us?

MORE Medical Reviews!

Who needs to be concerned?

Well, for OPT, Miami-Dade was analyzed separately from all others as it has a much higher utilization of all counties. The other= 19 counties included 6 counties in Louisiana, 4 in Texas, 3 in Mississip= pi, 2 in Indiana, 2 in New York, 1 in Georgia and another in Florida.

For SNF, large companies had the highest utilization of high RUG levels, mainly RU groups, with a noticeable increase in utilization after they purchased new facilities.

What are the triggers?

For OPT, the use of = the KX modifier both during treatment and on initial therapy visit, treat= ment throughout the year as well as services by multiple providers; also included is treatment exceeding 8 hours a day.

For SNF, high= use of RUG Ultra levels along with longer than average length of stay and higher than average ADL scores. The report also identified used of IC= D-9 codes with V57, care involving use of rehab procedures, increasing 4.= 9% in 2 years and heading their list of codes.

To read more about these reports follow this= link for the OPT report and follow this= link for SNF

Not sure if your documentation would withstand review?= Plan on attending either our live workshops or one of our webinars in 2011.

<= b>Tip of the Month

As a result of PPACA, all claims for services furnished after January 1st 2010 MUST be file= s with the Medicare Contractor no later than one calendar year (12 months) f= rom the date of service - or Medicare will deny them.

For cla= ims submitted by Therapists in Private Practice, the "From" date determines the timeliness of the claim. For institutional claims that span dates of service ("From" date and "Through" date), the "Through" date determines timeliness.=

I had mentioned this at the end of last year on our "What's News" page on the Encompass website. I am reminding everyone again here as = all of the Contractors as well as CMS are sending out reminders of this n= ew law.

This is probably more relevant to the SNF providers as claims are not routine= ly sent for the immediate prior month. In my travels I have come across = some therapists that have been holding onto claims, so, as always be aware= .

<= b>A/B MAC Tips

Trailblazer: Jurisdiction 4

Trailblazer issued an edit= for claims submitted "Incident to Physician Services" after July 1st 2010. This edit requires that the claim form identifies the person providing the services when not provided personally by the physician. They want to know the name and therapy degree of the performing thera= py professional; the name of the academic institution having conferred t= he therapy degree; the date of their graduation and finally the name and professional degree of the supervising physician/NPP.

This edit was put in place to ensure that physicians w= ere billing appropriately and not utilizing personnel not authorized to b= ill therapy services to Medicare as "incident to" services. Such personnel include, but are not limited to: Therap= ist Assistants, Massage therapists, Exercise physiologists, Athletic trai= ners and aides or techs.

The information is added to the electronic claim or as= an addition to the paper claim.

It would be nice to see other contractors adopt the sa= me position as we know that there is still a lot of fraudulent billing occurring.

<= span style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif";color:#39= 5D87'>

National Government Services (NG= S): <= /span>

<= span style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif";color:#39= 5D87'>In our last Newsletter, we identified that NGS had updated their therapy LCDs and were indicating that they were requiring the V-codes for the= rapy services to be the primary billing code. They have since rescinded th= is policy and updated the LCDs once more. Now = iat is the responsibility of the provider that the ICD-9 code identified = on the claim is coded to the highest level specified in the ICD-9-CM (e.g., to the fourth or f= ifth digit) and supports the Medical Necessity of services. For example; a patient with Diabetes that has had an amputation and is receiving gait training would have the ICD-9 code of abnormality of gait which actua= lly reflects the treatment being provided. The LCD also states that "= ;The correct use of an ICD-9-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination."<= o:p>

<= span style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif";color:#39= 5D87'>

<= strong>Jurisdiction 15: Ohio and Kentucky

<= strong>CIGNA Government Services announced that it has been given the contract for Jurisdiction 15; Ohio and Kentucky and would start transitioning those States over onto their system. Part B Kentucky has a transfer date of April 30th; Part B Ohio June 18th and Part A both states by October 1= 7th. The LCDs should be available 45 days before the takeover which would = mean sometime the middle of March for Kentucky. As soon as these are publi= shed we will announce it on our website.

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&nb= sp;

Medicare News and Rules for therapists is brought to y= ou by Encompass Consulting & Education, LLC. A therapist owned compa= ny specializing in Consulting & Educational services for therapists = and other professionals providing Medicare services in SNF, Rehab Agencie= s, Private Practice and Hospital Outpatient clinics.

Pauline M. Franko, PT, MCSP is owner and CEO of the company and is also known as the "Medicare Advisor" columni= st for the "Advance for" family of News Magazine providing ans= wers to Medicare questions for over 10 years. She also acts a resource for= the respected Eli Reports and matters concerning rehab services and Medic= are.

&nb= sp;

Thank you so much for subscribing to our Newsletter. Please feel free to forward this to anyone you believe would be interested in receiving news about Medicare. Please use the link belo= w, as this way we are able to track how many of you are forwarding it to your friends and associates.

Sincerely

Pauline

Pauline Franko
Encompass Consulting & Education, LLC

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