Physical medicine and rehabilitation physicians targeted in probe of therapy services

First Coast Service Options Inc. (FCSO) conducted a widespread probe (WSP) review in response to an aberrant billing pattern for CPT codes and posted this notice June 12th, 2012.

Here are the codes with high error rates:

1. 97032 (Application of a modality to one or more areas; electrical stimulation [manual], each 15 minutes);
2. 97035 (Application of a modality to one or more areas; ultrasound, each 15 minutes)
3. 97124 (Therapeutic procedure, one or more areas, each 15 minutes; massage including effleurage, petrissage and/or tapotement [stroking, compression, percussion]) billed by specialty 25 (physical medicine and rehabilitation).

The results of the widespread probe yielded a 62 percent claim error rate.

The most common reason for an error to be assigned was insufficient documentation including failure to meet Medicare’s documentation requirements specific to therapy services.

As a result of the widespread probe findings, FCSO will implement a prepayment medical review edit for therapy services billed by physical medicine and rehabilitation physicians.

The following is a brief summary of Medicare requirements for therapy services:

1. Therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services.
2. Documentation must be legible, relevant, and sufficient to justify the services billed.
3. The patient receiving outpatient therapy services must be under the care of a physician/nonphysician practitioner (NPP). NPP signifies a physician assistant, clinical nurse specialist or nurse practitioner, who may, if state and local law permit it, and when appropriate rules are followed, provide, certify, or supervise therapy services.
4. Therapy services must relate directly and specifically to a written treatment plan.
5. The plan (also known as a plan of care or plan of treatment) must be established before treatment is started. The plan is established when it is developed (e.g., written or dictated).
6. The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded within the plan.
7. The Plan of Care shall contain, at minimum, the following information as required by regulation (42 CFR 424.24 and 410.61) See Pub. 100-02, Chapter 15, section 220.3 for further documentation requirements).
• Diagnosis
• Long Term treatment goals
• Type, amount, duration and frequency of therapy services
8. The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan.
9. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources.
10. Long Term treatment goals should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care in the current setting.
11. When the episode of care is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified.
12. Goals should be measurable and pertain to identified functional impairments.
13. When episodes in the setting are short, measurable goals may not be achievable; documentation should state the clinical reasons progress cannot be shown.
14. The type of treatment may be PT, OT, or SLP, or, where appropriate, the type may be a description of a specific treatment or intervention.
15. Where a physician/NPP establishes a plan, the plan must specify the type (PT, OT, SLP) of therapy planned.

Various entities may request documentation to support services billed to the Medicare program (e.g., Medicare administrative contractor [MAC], comprehensive error rate testing [CERT], recovery audit contractor [RAC], zone program integrity contractors [ZPIC], or the office of inspector general [OIG]).

Documentation in the Patient's Chart
The following documentation must be submitted in response to a request for documentation, unless the requesting contractor specifies otherwise.

1. Evaluation and plan of care (POC) (may be one or two documents). Include the initial evaluation and any reevaluations relevant to the episode being reviewed; Certification (physician/NPP approval of the plan) and recertification when records are requested after the certification/recertification is due;
2. Progress reports (including discharge notes, if applicable) when records are requested after the reports are due;
3. Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes). Daily treatment notes must indicate the individual modalities performed that day. Minutes must be documented for each modality that represents a time-based code and the total time in treatment must be documented.
4. A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands the reasoning for services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation. If the patient is expected to exceed the therapy cap, the record must clearly indicate the medical necessity for the patient to receive covered services above the cap. Note: The excessive use of modifier KX (Requirements specified in the medical policy have been met) may indicate abusive billing.

Therapy services have their own benefit under section 1861 of the Social Security Act (“the Act”) and shall be covered when provided according to the standards and conditions of the benefit described in Medicare manuals. Statute 1862 (a) (20) of the Act requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions -- other than licensing -- that would apply to a therapist.

Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology.

That means that the services of athletic trainers, massage therapists, recreational therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as covered therapy services.

In addition, there is no coverage for services provided “incident to” the service of a therapist. Although physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) work under the supervision of a therapist and their services may be billed by the therapist, their services are covered under the benefit for therapy services and not by the benefit for services “incident to” a physician/NPP. The services furnished by PTAs and OTAs are not incident to the therapist’s services. A physical therapist must supervise PTAs and an occupational therapist must supervise OTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless state practice requirements are more stringent, in which case state or local requirements must be followed. The service of a PTA and OTA shall not be billed as services “incident to” a physician/NPP’s service, because they do not meet the qualifications of a therapist. Only services provided by a licensed therapist or an individual who has completed an accredited PT or OT curriculum and are qualified for licensure may provide services “incident to” the physician/NPP.

Providers are encouraged to review the complete requirements for billing rehabilitation services found on FCSO’s Therapy and Rehabilitation Services local coverage determination L29399 (Puerto Rico and the U.S. Virgin Islands) as well as the requirements found in the Internet-only manual (IOM), Pub. 100-02 , Medicare Benefit Policy Manual, Chapter 15, Sections 220-230 .