12 weeks of Physical Therapy Required By New Medicare Guidelines Prior to Joint Replacement in Florida

Medicare has begun to deny hospital charges for total joint replacement surgery IF the surgeon has failed to implement up to 12 weeks of pre-operative PT and/or bracing, according to Vincent Hudson, CEO of the medical consulting practice PMC, Inc.

"Medicare A has denied payment to hospitals, and I am sure will trickle over to physicians.  

This new standard should be increasing the numbers of referrals we see from Medicare.  

As in most cases, I expect to see other commercial insurances to follow shortly.  

Make your referring physicians aware of this, as hospitals have already begun to do so..."

Vincent made his comments on March 20th on LinkedIn in the Physical Therapists in Private Practice group.

This agressive new program in Medicare Audits is threatening physician and hospital reimbursement for total joint replacements and lumbar spine fusion in many states across the country.

The expanded use of Medicare Administrator Contractor (MAC) pre-payment audits has placed a premium on documentation in the hospital record and may threaten reimbursement for physicians with poor documentation skills.

On November 15, 2011, CMS announced three new 3-year demonstration projects (reported here by PTD). The Recovery Audit Prepayment Review Demonstration is designed to help curb improper Medicare and Medicaid payments.

As proposed, the demonstration would allow Medicare recovery auditors to review claims after services are provided but before the claims are paid to ensure that the provider complied with all Medicare payment rules. This would prevent improper payments before they are made.

Seven states with high populations of fraud- and error-prone providers are targeted

1. Florida
2. California
3. Michigan
4. Texas
5. New York
6. Louisiana
7. Illinois

...and four states with high claims volumes of short inpatient hospital stays are targeted.

1. Pennsylvania
2. Ohio
3. North Carolina
4. Missouri

As designed, this program would affect almost half of the Medicare population.

The contractor for MAC jurisdiction 9 is First Coast Service Options (FCSO), which includes Florida, Puerto Rico, and the Virgin Islands. FCSO developed a local coverage determination (LCD) on total joint replacements.

The original draft LCD included a requirement that multiple 12-week nonsurgical interventions, such as physical therapy, be documented prior to surgical total joint replacement.

Revisions to the LCD now require only one non-surgical intervention, such as 12 weeks of physical therapy.

Weeks later, the MAC announced a new prepayment audit of 15 specific DRGs, 4 of which are orthopaedic codes, including those that cover total joint replacements.

"As with the Total Knee replacement, the medical record documentation must indicate continued symptoms following medication ....there also must be documentation of a trial of physical therapy and/or external joint support provided equal to or greater than 12 weeks..."

I agree with Vincent.

Get out there and educate your physicians, especially your family practice docs and your unaffiliated orthopedic surgeons who will want to avoid denials.

They'll appreciate the heads-up.