Eli's Rehab Report

Take steps now to ensure your claims are medically necessary

This year you'll want to make sure you cross all your t's and dot all your i's, because the Office of Inspector General (OIG) has released its 2005 Work Plan - which includes plans for reviewing Medicare claims for physical and occupational therapies as well as wound care services.
 
What the Work Plan is: The OIG Work Plan details aspects that the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General will address during the fiscal year.
 
The Work Plan may indicate focus areas for future audits. "When the OIG targets a specific area in the Work Plan, it means that the OIG is turning its attention to that specialty," says Joanne Byron, LPN, BSNH, CPC, CHA, President of Health Care Consulting Services Inc. in Hickory, N.C.

Check for the 5 Elements
 
 
If your practice employs a physical and/or occupational therapist(s), you'll want to pay special attention to your Medicare claims for therapy services. The OIG says it will review them to determine if the services were "reasonable and medically necessary, adequately documented, and certified by physician certification statements."
 
This means you should review and code the plan of treatment and compare it to local coverage determinations. Check for the five main elements of medical necessity: 1.  rehabilitation potential 2. need for "skilled" therapy 3.  frequency 4. duration and 5. the ICD9 code that ensures all these elements satisfy the guidelines, Byron says.

Wound Care Also Watched

Similarly, the OIG Work Plan will be reviewing claims for wound care services. If you're the coder responsible for these claims, be certain you meet medical- necessity guidelines and report these codes in accordance with Medicare requirements. Medicare paid approximately $98 million for these services in 1998 - an amount that leapt to $147 million in 2002, according to the OIG Work Plan. 
 
The OIG will focus on the high number of physical/occupational therapy and wound care services with poor level of supporting documentation in all levels of care - but especially in Part B services provided by SNFs, outpatient clinics, and agencies, says Pauline Franko, PT, MCSP, president of Encompass Consulting & Education LLC in Tamarac, Fla.
 
"The ability to perform post-pay audits has increased with authorization of the Program Safeguard Contractors as well as the information obtained from the CERT contractor whose 2004 report is due at any time," Franko says.
 
What this means to you: Therapy and wound care services are similar in that the OIG plans to pore over documentation to make sure that the services were medically necessary and reasonable. "The implication for coders is that medical record documentation needs to be accurate and thorough in demonstrating a medical need for the services provided and billed," says Allison Waxler, policy analyst for the American Academy of Physical Medicine and Rehabilitation (AAPM&R) in Chicago.
 
"Don't get caught taking shortcuts with documentation, coding, and/or determining medical necessity," Byron says.

3 Action Steps to Take Now 
 
By following the three steps listed below, you can withstand scrutiny and combat the prospect of a future audit.  First, make sure you obtain accurate information from the therapists in terms of actual reportable time and its conversion to units, Franko says.
 
For example, a stroke patient sees an occupational therapist to help prepare her to move back into her apartment. The OT documents work on upper-body exercises for 18 minutes, lower-body exercises for 13 minutes, and activities of daily living (ADL) training for 39 minutes.
 
In this case, you would report two units of 97110 (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) to account for both the upper-extremity and lower-extremity exercises, and three units of 97535 (Self-care/home management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment] direct one-on-one contact by provider, each 15 minutes).
 
Second, urge your therapist to provide a good description of the treatment diagnosis and not just the ICD-9 code. "Sometimes therapists are so used to 'quoting' the same ICD-9 codes that they're not aware that there are much better codes that describe the condition they're treating," Franko adds.
 
Last, you may want to review the CMS Web site (www.cms.hhs.gov/medlearn) and print out advance beneficiary notice (ABN) forms as well as the instruction booklet that tells you how to administer an ABN when services are not medically necessary, Byron says.