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3D"Encompass

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Medicare News and Rules for Therapists

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Encompass Consulting & Education, LLC E-Newsletter

October/November 2010 = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; Vol 5, Issue 6

In This Issue <= /p>

News You Can Use

Update on Medical Review Activities

Tip of the Month

A/B MAC Tips

SNF Q&A: I'm confused about the timing of our evaluation

Part B Q&A: What's yo= ur opinion about company mandate therapy Part B percentage?

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Quick Links

Encompass= Website

Previo= us Newsletters

What's= News In the Medicare World

Compan= y News

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Dear Pauline,

3D"Pauline

Where has this year gone? I cannot believe we are in November. Last Month was a very busy month for Encompass as I know = it was for all of you in Skilled Nursing.
Our workshops are completed for this year and we are beginning to p= lan our 2011 schedule. This will be a combination of live workshops and webinars. We will keep you posted as we finalize the programs.=

News you can

use <= /o:p>

provides information on the Fee Schedule changes that will come into effect January 1st for Part B services. Consisting of "Good News" and "Bad News" for therapists, unfortunately, mostly the latter.

Medical Re= view is what's happening along with the OIG's plan for 2011. NHIC recently performed a pre-payment probe on Part B SNF. See what they found.

Tip of the= Month leads you to a cheat sheet we have developed to ease the losses of 2011 in Part B.

A/B MAC Tips is new, in it we will identify items of note enacted by the various MACs. This time it is Trailblazer and NGS.

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In our = Q&A sec= tion we address areas of interest to both SNF and Outpatient providers. =

Encompass Seminars: As always, we are looking for host sites or even other locations to sponsor the programs if we're not in your area. We are presently working with a location in LA and one in Dayton Ohio.

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 track of forwards and improve our content.

News You C= an Use

It's official, therapists are in for a decrease in reimbursement starting January 1s= t. CMS released the Final Rule for 2011 effecting reimbursement for Part B services. The regulations will be published in the Federal Register on November

Good news: the Therapy Cap has increased a whopping $10 to 1870 per cap, =

Bad News: We still have the caps in place and no exception process for 2011 unl= ess addressed by Congress.

Good News, well according to CMS: The cap will go father enabling the beneficiary to have more therapy before the cap is met!!= !!

Bad News: CMS is implementing the multiple procedure reduction policy (MPPR),

Good News: it's 25% of the practice expense RVU of the fee schedule, not the 50% init= ially proposed. CMS indicated that it has estimated that this will result i= n a 7% to 9% reduction in payments, not the 11% to 13% in the proposed rule!!!

Really Bad News: The MPPR applies to all "always therapy codes" provided by the provider/supp= lier to the beneficiary per day. This means that for institutional provide= rs it applies to all therapy services performed that day, just like the = CCI edits. It is provider specific policy, not discipline specific, there= fore if a combination of PT, OT and SLP services are provided on the same = day, the CPT code with the highest Practice Expense Relative Value (PE RV) billed by any of the disciplines will be paid in full while = rest of the claim will be subject to the MPPR reduction. It also applies to BID treatments as it is day specific not treatment session or visit.<= /span>

Also in the FR, CMS continues to address the options for reimbursement of therapy Part B services.

To learn more about how these changes will affect you.

Read our ar= ticle "Medicare Part B Therapy Reimbursement"=

Update on Medical Review Activities

The Office of the Inspector General (OIG) published its Work Book for Fiscal Year 2011 which started October 1^{st 2010.
The major areas of concern for therapists are in 2 main provider
settings, SNF Part A and PTs in Private Practice.}

For Part A SN= F, the OIG will perform medical reviews for payments during calendar year 2009. They performe= d a similar study for 2002 in which they identified that 26% of the claims had RUGs that were not supported by the Medical Record; this produced= an estimated $542 million in overpayments for that year. The Medical Rev= iew will determine "whether claims were medically necessary, sufficiently documented, and coded correctly." The report, OEI; = 02-09-00200; is expected to be published in FY 2012.

For Outpatient Physi= cal Therapy Services Provided by Independent Therapists, the OIG will review = if the therapy services provided were in compliance with Medicare's Regulations for Medically Necessary Services.

"claims for therapy services provided by independ= ent physical therapists that were not reasonable, medically necessary, or properly documented." The Medical Review will focus on Physical Therapy Practices that have a high utilization rate for outpatient physical therapy services and whether or not those services were in a= ccordance with Medicare Guidelines published in CMS's "IOM Medicare Benefit Policy Manual, Pub. No. 100 The OIG has investigated this concern previously and noted that -02, ch. 15, § 220.3, Documentation Requirements for Therapy Services=

NHIC, the J14 A/B Mac published the resul= ts of a pre-payment probe it has completed on the billing of 97004, Occupational Therapy Re-evaluations performed on both the 22X bill ty= pe, Inpatients Part B and 23x bill type Outpatient Part B. The findings w= ere not good!

Denial were very similar to those identified by the CE= RT contractor and included

Rec= ords not received timely
Doc= umentation did not support Medical Necessity of services<= /span>
Ser= vices not documented
Mis= sing or incomplete documentation
Phy= sician order for services not present

The last one is actually not a valid reason as, in the Benefit Manual, CMS states that "Payment is dependent on the certification of the pl= an of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan."

For more information on the NHIC probe, follow this= link

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

We have created a list of the Practice Expense Relative Values based on the information in the Final Rule for Part B 2011. You can access this through the link below. As with all our products, it is intended for informational use only and is based on national levels.

PE RV List<= /a>

<= b>A/B MAC Tips

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<= strong>Trailblazer: Jurisdiction 4

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

<= span style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif";color:bla= ck'>Trailblazer has limited the number of units of therapy it will pay for either per= day or per month. The maximum per day is 5 direct one-on-one units or 60 direct units per month.
Find their notice through the following link. Trailblazer= limits units of therapy

National Government Services (NGS):

NGS recently updated it's LCD for PArt B therapy service= s by indicating that it wanted the primary diagnosis on the claim to ibe a V-code. The LCD identifies that

"When coding for therapy services, the primary diagnosis codes should indicate the reason for the encounter, and the specific condition for which therapy services are provided MUST also = be included as secondary and subsequent diagnoses. Claims without secondary diagnoses may be denied."

The V-codes identified were

V57.1	CARE INVOLVING OTHER PHYSICAL THERAPY
V57.21	CARE INVOLVING OCCUPATIONAL THERAPY<= o:p>
V57.3	CARE INVOLVING SPEECH-LANGUAGE THERAPY
V57.81	CARE INVOLVING ORTHOTIC TRAINING
V57.89	CARE INVOLVING OTHER SPECIFIED REHABILITATI= ON PROCEDURE

<= b>Q&A for SNF

Question: =

I am confused about the timing of our evaluation and treatment under the new MDS guidelines. If we don't see the patient on the day of admissi= on, will we be losing money? I have been told that we must see the patien= t on the day of admission otherwise we will be paid at a nursing level unt= il therapy does an evaluation. Our company is asking us to "volunteer" to be available late in the day for patients who are not admitted until the evening, and also on the weekend so that we can get 5 consecutive days and therefore not lose money. This is not necessarily a good thing for the patients as they are not ready to be evaluated late in the evening.

Answer: =

This is a BIG Rumor that is just not true! Nothing has changed in the rules concerning creating the RUG for the 5-day PPS assessment. What is cau= sing the "panic" and therefore misunderstanding, is that, under = the MDS 3.0, you cannot project a patient into a RUG level as one could d= o in the MDS 2.0. The inability to do this will only cause problems if the patient is unexpectedly discharged before the 8^th day and = has not been able to obtain the 5 days of therapy.

The 3 grace days are still available to the facility and will probably be used in almost 100% of the Rehab RUGs, making the ARD either day 6, 7= or 8. CMS has always stated that the use of grace days for the Rehab pat= ient is perfectly acceptable as it prevents therapy being delivered = before the patient has stabilized and the therapist can perform the evaluation that produces an appropriate plan of care. S= o, forget the late night evaluation or the 5 consecutive days as that can get you into trouble.=

If the patient is not ready to participate in therapy due to medical complications or complexities, then you can hold off seeing the patie= nt and use a SOT OMRA when they are appropriate to start. This way, the clinical RUG will cover day one through the day before the start of therapy, and then the therapy RUG will cover the rest of the time till the next scheduled PPS assessment.

The facility needs to be aware of the Case Mixed Index, as there may be occasions when the clinical RUG will reimburse at a higher level that= the therapy RUG, especially when it comes to the lower ADL scores.=

<= strong>Q&A for Outpatient Part B

Question:&nbs= p;

What is your opinion o= n a company mandate that states 20% of all eligible Part B patients = in a long term care facility should be on therapy caseload at all times? Obviously I have issues with this. Also, how many times c= an you pick up the same person over and over again when the reason they have declined is because post therapy instructions have not been followed ( restoratve not done, walk to dine/bathroom not done = by nursing staff). It seems wrong to continue to pick people up for this reason, however they have a real decline so I am unsure of= the "right" thing to do. Thank you so much for your services, those of us in the field must have some hard facts to back us up sometimes when we are asked to do things we know are not right.

Answer:

My opinion is that you cannot mandate your residents to require therapy services on a regula= ted schedule! Should there be patient's on Part B, absolutely. Can you ha= ve a mandated number, Absolutely NOT. In working out budget requirements, there are a number of patients that can be factored in, but it depend= s on your patient mix.

To keep picking patients up for therapy because the faci= lity is not doing its job is not what Medicare is for. To keep picking a patient up because of a decline that could have been preventive throu= gh the facility doing what they are getting paid for (maintaining or preventing decline) is Medicare Abuse and something that should / wou= ld certainly be identified during State Survey.

As therapist, we know we can help, but the "person" who should be paying for your services is the administrator. If there are no restorative programs or any follow thr= ough by the facility, then the administrator can have the therapy departme= nt follow through, pay for those services (through the therapist saleries and c= ost reporting) and count as Restorative nursing on the MDS.=

You have to be knowledgeable of Medicare compliance and = to pick up patients who do not meet their requirements can affect your l= icense. If you pick a patient up who has used their cap up and use the KX modifier for billing those services, the facility opens itself up to accusation of abuse and maybe fraud on a Medical Review.

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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.

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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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