Eli's Rehab Report

Overcome errors with clear, legible notes to avoid big financial losses.

Do you know what makes the grade as medically reasonable and necessary? If you don’t have the requirements for Medicare Part B Outpatient Physical Therapy Services down pat, you could be putting your practice at risk.

Background: The U.S. HHS Office of the Inspector General (OIG) published a report recently about a Vero Beach, Fla. physical therapy practice that inappropriately collected $52,000 in Medicare reimbursement in 2012 and 2013 from incorrectly billed claims. Of the 100 beneficiary claims audited, 86 were accepted. However, the remaining 14 were found by OIG auditors to be arbitrary for different reasons that were dependent on the details of each particular claim.

The report specifics overwhelmingly showed that a stronger grasp of Medicare semantics combined with more thorough diagnosis and treatment documentation would have helped the practice overcome their claims’ errors. Of the 14 disputable claims, four were deemed “medically unnecessary,” eight lacked proper documentation, and ten contained coding errors.

Deciphering Defensible Documentation

As the investigation suggests, there really isn’t anything more crucial than clear and legible notes on what services and treatments should be rendered to the patient. Not only are your medically scripted records important evidence should an audit be performed, but their clarity is essential for your practice coders to properly bill the claims to Medicare.

In light of the recent news about the MACRA payment initiatives, being medically articulate can only help in a system based on merit, value, and quality of care.

“It’s crucial for therapists to document defensibly. Because — at the very least — proper documentation justifies payment. Furthermore, as we move toward a pay-for-performance model, defensible documentation will be necessary to prove your value,” writes Courtney Lefferts of WebPT in a Nov. 23, 2015 blog post. “If your documentation doesn’t stand up to scrutiny, you’re losing more than payments: you’re limiting the value of your profession.”

Is This Treatment Necessary?

The American Physical Therapy Association’s (APTA) Center for Integrity in Practice suggests that a physical therapist should make decisions about care based on their “clinical judgement.” In coordination with the American Occupational Therapy Association, (AOTA) and the American Speech-Language-Hearing Association (ASHA), the APTA has published a Consensus Statement on Clinical Judgment in Health Care Settings, providing a framework for physical therapists to work from when administering care.

In short, the primary points of the comprehensive statement encourage providers to consider the following before suggesting, coding, and billing treatment:

• Use clinical ethics and knowledge as a standard when devising care.
• Follow federal policies and procedures closely.
• Make clear the proper “evaluation and treatment.”
• Provide clear and concise documentation.
• Advocate for your practice’s medical integrity.
• “Take action if there is a problem.”

For the complete draft of the APTA Consensus Statement on Clinical Judgment in Health Care Settings, visit integrity.apta.org/ClinicalJudgment/.