Alyssa Trotsky, DPT University of Michigan Hospital.

Alyssa Trotsky, DPTUniversity of Michigan Hospital

73% report they were not adequately prepared for managed care and other reimbursement issues by their professional education programs.

71% do not think they are well informed regarding the government’s fraud and abuse investigations

31% are aware of situations where a PT was encouraged to provide or document services in an unethical, fraudulent, or illegal manner.

Patient

Treatment

Billing

Payment

Pay Day

Acute Care: DRG

Inpatient Rehab: PPS

Skilled Nursing Facilities: PPS & RUG

Home Health Care: PPS & OASIS

Outpatient: Individual insurance & Caps

DRG: diagnosis-related group Each case is classified into one of 467 groups

Specified sum of money is provided to hospital from insurance per patient diagnosis.

Patients who are uninsured will need to provide costs out of pocket.

PPS: prospective payment system Cases are grouped into Rehabilitation Impairment

Categories

Further grouped into case-mix groups (CMG)

Then grouped into Tier 1-4 within each CMG

Additional adjustments are made for interrupted stays, short stays of less than 3 days, short-stay transfers, and high cost outliers.

PPS: prospective payment system RUG: resource utilization group

creates tiers of payment based on level of nursing care, room considerations, and minutes of therapy provided

assessment review dates (ARD) 5 levels – based on number of hours of

therapy provided

PPS: prospective payment system Home health agencies are paid a pre-determined

rate.

Health condition, care needs, and geographic location are taken into consideration.

Payment is for 60 day episodes

Payment is based on case mix assignment

Nurse or therapist uses the Outcome and Assessment Information Set (OASIS) to assess patient condition.

Reimbursement specific to insurance “Therapy Caps” for patients with Medicare

Part B $1,900 for PT/SLP services in 2013

$1,900 for OT services in 2013

Manual Medical Review

KX Modifier

Medicare Medicaid BCBS Cigna Humana Highmark Workers’ Compensation Automobile Insurance Tricare & VA

Part A & B Qualifications:

a) >65 years b) Under 65 with certain diagnoses c) People with end stage renal disease

8 Minute Rule:◦ ≥ 8 to < 23 1 unit ◦ ≥ 23 to < 38 2 units◦ ≥ 38 to < 53 3 units◦ ≥ 53 to < 68 4 units ◦ ≥ 68 to < 83 5 units◦ ≥ 83 to < 98 6 units◦ ≥ 98 to < 113 7 units◦ ≥ 113 to < 128 8 units

ICD-9 Code Soon to be replaced by ICD-10 codes

More specific Ex: ICD-9 – angioplasty ICD-10 – dilation of right femoral artery with

drug-eluting intraluminal device, open approach - dilation of right femoral artery with

intraluminal device, open approach

G-Codes for patients with Medicare only in July 2013

Initial Evaluation (97001) Aquatic Therapy (97598) Orthotic Management and Training (97113) Physical Performance Test and Report

(97750) Therapeutic Activities: any activity to

imrpove function including positioning, bed mobility, tilt table, proper body mechanics in the performance of ADL’s, and transfers.

Neuromuscular Re-Education: re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception.

Prosthetic Training

Therapeutic Exercise: exercise to improve breathing, endurance, oral-motor function, posture, ROM, and/or strength, stretching/flexibility exercises, and neuromobilization.

Wheelchair Management Community Re-Entry Manual Therapy Techniques Gait Training Iontophoresis Airway Clearance Techniques Electrical Stimulation VS. Unattended

Electrical Stimulation

Smart Billing! Reimbursed different amounts for each

procedure ◦ Ex: Initial Evaluation ($224.00)

Inpatient Rehab, Skilled Nursing Facility (Part A), Acute Care:o can bill separately for the distinct services

provided at the same timeo ensure co-treatment is clinically appropriate and

provided for the sole benefit of the patient

Home Health Care:o only one therapist could billo if both patients were treated same day but

separate times, then both therapists could bill

Skilled Nursing Facility (Part B), Outpatient Hospital and Physical Therapists in Private Practice:o Cannot each bill separately for the same serviceo Cannot bill for different services provided at the

same time to the same patient o When two therapists work together, you may

split the minutes for timed codes and each bill for part of the treatment minutes, but you may not both bill timed codes for the same minutes.

Timeliness of care.

Work with utilization management or case management.

Proper utilization of support personnel.

Efficient use of resources: aware of costs

What are the payment policies of payer?

Documentation of skilled intervention.

Explanation of Benefits (EOB) Denials and appeals Write offs

◦ Related to tax laws Balance billing

◦ Provider requests more cost than what the health insurance pays

First party pay◦ Which insurance plan pays first

Ex. Coordination of benefits In Michigan – Auto pays first, then private pay

Direct contracting◦ Company cuts out the middle man of the insurance

company and draw up a contract to directly pay the health care provider

Patient: The name of the person who received the service. This may be you or one of your dependents.

Insured ID Number: The identification number assigned to you by your insurance company. This should match the number on your insurance card.

Claim Number: The number that identifies, or refers to the claim that either you or your health provider submitted to the insurance company. Along with your insurance ID number, you will need this claim number if you have any questions for your health plan.

Provider: The name of the provider who performed the services for you or your dependent. This may be the name of a doctor, a laboratory, a hospital, or other healthcare provider.

Type of Service: A code and brief description of the health-related service you received from the provider.

Date of Service: The beginning and end dates of the health-related service you received from the provider. If the claim is for a doctor visit, the beginning and end dates will be the same.

Charge (also known as Billed Charges): The amount your provider billed your insurance company for the service.

Not Covered Amount: The amount of money that your insurance company did not pay your provider. Next to this amount you may see a code that gives the reason the doctor was not paid a certain amount. A description of these codes are usually found at the bottom of the EOB, on the back of your EOB or in a note attached to your EOB.

Total Patient Cost: The amount of money you owe as your share of the bill. This amount depends on your health plan’s out-of-pocket requirements, such as an annual deductible, copayments, and coinsurance. Also, you may have received a service that is not covered by your health plan in which case you are responsible to pay the full amount.

Additional information may include the amount of payment actually made to your provider and how much of your annual deductible has been met.

Did you know your costs? Can you be more efficient? What are your outcomes relative to your

expenses? Was your patient/client satisfied? Did your patient/client meet his/her goals?

Health Care System Documentation – Justification/Reviews Contract Negotiation QI – Outcomes/Best Practice Billables for PT Basic Terms of Coding Link to Ethics/Legal Methods of Payment Link to Core Values History of Medicare/Workers Comp Justification – Denials/Appeals Advocacy – Political/Professional Business for Revenues – Self Pay/POPTS State Law Risk Management Healthcare for under insured – Pro Bono Cost Benefit Ratio Administration Peer Review Benefit Languages: Copay/ Deductibles

APTA Courses◦ Annual Conference

Coding Reversing Denied Claims Wound Management Evidence for Reimbursement Compliance for Medicare

◦ Reimbursement Seminar

APTA Website◦ CPT Coding Changes for 2005  ◦ About Reimbursement  ◦ Coding, Billing, and Payment  Information about how PTs are

reimbursed: coding, billing, fees, costs, payment by treatment setting 

◦ Regulatory Issues: Medicare, HIPAA, and Others  Medicare, Medicare fee calculator, Medicaid, HIPAA, workers' compensation, and state insurance commissions. 

◦ References & Resources for Practice  Positions on supervision, legal and ethical issues, reimbursement resources, and educational materials 

◦ Information for Payers and Employers  Payers frequently ask for assistance with CPT coding, state practice acts, direct access, CEUs, and APTA positions and policies - We provide help on these pages. Payers can also sign up to attend one of our annual Insurance Forums. 

◦ Information for Consumers  What you need to know about physical therapy.  

◦ Frequently Asked Questions  ◦ Continuing Education  APTA offers a variety of seminars,

online courses, and publications on reimbursement issues. ◦ Reimbursement Message Board  ◦ Subscribe Now to Physical Therapy Reimbursement

News  ◦ Opinions Wanted  ◦ "ASK REIMBURSEMENT"

APTA Reimbursement News◦ $79/yr

Government Websites◦ www.apta.org/govt_affairs/regulatory/medicare◦ www.apta.org/govt_affairs/regulatory/

fraud_abuse◦ www.apta.org/govt_affairs/regulatory/

regulatory_documentation

Early - Knowledge◦ Professional Orientation◦ Professional Ethics in Health Care◦ Basic Exam Skills◦ HIPAA, Documentation, Priority of Interventions

Mid – Application◦ Preferred Practice Pattern Courses◦ Clinical Education – 632 with exposure

End – Synthesis◦ Management – Knowledge through Synthesis◦ Current Issues◦ Complex Clinical Problems◦ Clinical Education III

Insurance Language/Definitions Timelines of benefits Cost of PT Services Use of Support Personnel CPT Codes and ICD9 and HCPCS Billing Principles Fee Schedules Denials

Cover services or supplies/equipment that are medical necessary ◦ Services requiring the skills of a qualified provider◦ Services are safe and effective◦ Services are consistent with the symptoms or

diagnosis◦ Services are accepted among the medical or

professional standards◦ Services are the most appropriate, safe, and

effective

Must provide support of the services or supplies/equipment

What service or procedure was rendered To what extent the service was rendered Why the service, procedure, or other item

was medically necessary

PT and OT are covered only for restorative therapy by Medicare (expectation to restore a patient’s level of function that has been lost due to injury, disease, or illness (no maintenance

Services furnished could be furnished elsewhere

Care that exceeds length of stay Services denied or bundled Physician standby services Case management services (telephone calls

to/from the beneficiary) Supplies included in the basic allowance of

the procedure

Billing for services not furnished Soliciting, offering or receiving a kickback, bribe

or rebate Violating the physician self referral Using an incorrect provider identifier Selling, sharing or purchasing Medicare health

insurance claim numbers Offering incentives to Medicare patients Falsification of any documentation or billing

statement Using inappropriate codes to get coverage

Office of Inspector General (OIG) Department of Justice (DOJ) Federal Bureau of Investigation (FBI) Medicare Administrative Contractors

(MAC) Recovery Audit Contractors (RAC) Quality Improvement Organizations (QIO) Program Safeguard Contractors (PSC) Medicare Zone Program Integrity

Contractors (ZPIC)

Coding and Documentation◦ Establish continuing ed on CPT and ICD-9 coding◦ Prepare a coding policy◦ Document services and check documentation◦ Arrange for outside consultant

Payer Correspondence◦ Read all memos and newletters◦ Keep all written correspondences

Claims Review◦ Review and learn why claims are rejected◦ If a mistake occurs, correct it immediately

CPT Symbols◦ Different symbols tell you code is new, revised, or

need an “add-on” code as it cannot stand alone (ex. Hotpack needs something else with it)

May use several CPT codes but each code cannot exceed total time spent with patient

Documentation should match CPT code used

http://www.cms.gov/manuals Intro Entitlement Benefit Policy Claims Processing Secondary Payer Manual Medicare Program Integrity Manual