Both professions have difficulty showing need for their services.
- Exercise by physical therapists.
- Facet joint injections by anesthesiologists and other physicians.
This report by the Office of the Inspector Generals' (OIG) indicates physicians have difficulty showing medical necessity for spinal facet joint injections.
Eight percent of the claims were paid despite no evidence (x-ray fluoroscopy) that the services were medically necessary. The overall paid claims error rate for facet joint injections was 63%.
Physicians use fluoroscopic imaging to demonstrate pathology necessary for medical diagnosis and treatment by facet joint injection.
"...lack of consensus in the medical community about appropriate frequency of injectionsThirteen of the 15 Medicare Carriers have Local Coverage Determinations that set forth medical necessity requirements for facet joint injections.
is a barrier to creating frequency limits in Local Coverage Determinations."
"Carriers are also responsible for implementing program safeguards to reduce payment errors. To accomplish this, carriers create local coverage determinations (LCD), issue instructional articles implement claims processing edits. Carriers also analyze data, conduct provider education, and conduct medical reviews."An uncertain environment
Physical therapy medical necessity is even more ambiguous - for instance, there are no National or Local Coverage Determinations (LCD) that determine the criteria for physical therapy services like the following"
- Therapeutic Exercise (97110)
- Manual Therapy (97140)
- Neuromuscular Reeducation (97112)
The 'expert' reviews your written notes to see if the exercise codes you billed Medicare are necessary.
"It is encouraged but not required that narratives that specifically justify the medical necessity of services be included in order to support approval when those services are reviewed." (Transmittal 88)Can't physical therapy reporting get more transparent, less hazardous or both?
Why, when our focus is patient treatment, should we be forced to spend valuable patient time on lengthy notes and charts?