These topics have been covered in previous posts on this website, especially from the RAC perspective. The most succeptible area remains establishing mecially necessary treatment.  However, though RACs can be more aggressive, there are other auditing entities for which concern is warranted.  The entities include:

Regards,

April 1, 2012 5010 Deadline

The 5010 changes are alive and well, and they now impact all HIPAA covered entities and transactions.  This major change can impact reimbursement.  According to CMS, you must be compliant by April 1, 2012 or you will be subject to fines. 

For those subscribers that emp-loy the MediGraph Billing Software, you are protected.  For those sunscribers that do not employ the MediGraph Billing Platform, please be cetain that your billing manager is ready for this change.  

Regards,

Tom Kane, PT

• As mentioned in a previous post, effective January 1, 2012, all medicare providers must use the revised ABN form for services provided in all out patient settings except for services provided by a home health agency. SNF Part A and home health agencies will continue to use their respective ABN forms. The the old ABN form will not be accepted by  Medicare contractors. For more information and to download a revised copy of the ABN form, click on the link below.

https://www.cms.gov/BNI/02_ABN.asp

Regards,

Tom Kane, PT

The House of Representatives and Senate have passed a bill that provides a two month extension on the scheduled 27.4% reduction in payment for Medicare services.   This bill also extends the therapy cap exception through February 2012. The haouse and senate will  reconvene in January and they will begin work on a compromise bill for a longer term extension on these issues.  I encourage everyone to join the PTeam of the APTA who represents pysical therapist interests in these matters. http://www.apta.org/pteam/

Regards and Happy Holidays,

Tom Kane, PT

MediGraph Software

The use of pre-established functional measurements and outcome questionnaires satisfy the objective-evidence based criteria that RACs employ to determine medically necessary.  Another important component of writing a RAC audit proof note is to include ADL functional goals. 

 Goal Statement Examples:

1. Increase patient’s independent stair ambulation to 12 steps, enabling the patient to access the second floor of his home by increasing lower extremity strength and ambulation training.
2. Increase functional range of motion of the involved shoulder to enable the patient to independently engage a seat belt while driving.
3.  Increase the patient’s lower extremity strength to enable the patient to transfer from sitting to standing safely to avoid a reoccurrence of falling during this process. 

 Methodology:

1. Measure diagnosis related impairments:  objectively measure  strength (hand held dynamometer),  ROM (bubble inclinometer), sensory deficits (Moberg, Semmes Weinstein). etc. 
2. Employ peer reviewed diagnosis related outcome questionnaires (Oswestry, Knee Outcome Survey, Shoulder Disability Scale, etc.) and functional tests (Six Minute Walk, TUG,  Box and Block. Etc.) that have pre-established norms against which the patient’s performance will be measured.
3. Employ specific goal statements that relate to these impairment measurements, questionnaires, and functional measurements as illustrated above under Goal Statement Examples.

Regards,

Tom Kane, PT

Defining “Medically Necessary” for Physical Therapy

 We at MediGraph are in a unique position.  As Physical therapy software providers, we are presented with ongoing opportunities to interact with our subscribers and receive feedback when updating our program.  However, another area of important feedback comes from potential subscribers.  We often receive calls from therapists that are looking for documentation software because of a bad experience with a RAC audit.  These therapists experience the hard way what we at MediGraph have been addressing for years; objective standards are required to satisfy the ‘medically necessary’ component of intervention.  It does not matter if your treatment was appropriate.  It does not matter if your skills enabled the patient to overcome a physical impairment.  It does not matter if you increased the patient’s functional ability.  What matters is your ability to prove that what you provide is ‘medically necessary’. 

 As previously stated for our subscribers, RAC audits resemble IRS audits.  Both of these government sponsored hunting expeditions are poorly defined.  When the unstated goal is recapturing revenue, vagueness helps the RAC auditor to establish cause for obtaining a refund of your fees, just as the ambiguity found in the thousands of pages of the IRS code helps the IRS agent to extract their pound of flesh.   

 While there is case law to establish that physical therapists’ judgments are based on their ability to evaluate the patient’s condition (not based on the referring physician), this degree of autonomy does not satisfy the medically necessary standard for CMS or for RACS.  In a recent APTA podcast, the Stanford University Center for Health Policy: Model contractual language for medical necessity was mentioned as the model for determining what is medically necessary.   Five pillars were mentioned as the basis for satisfying the necessity standard: authority, purpose, scope, evidence, and value.  While these five pillars should be the components of sound clinical decisions, it is the last two categories, evidence and value, that the RAC auditors utilize to define medically necessary and are the two areas that require the most attention.

 Evidence that intervention was necessary is easily established, yet the most susceptible area where PTs fall short in their documentation to RACs.   Value, as stated in the Stanford model, is defined as the likelihood of the intervention to “Improve function, minimize loss of function, or decrease risk of injury and disease.”  Evidence and value are easily measured.  Unfortunately, in today’s environment,  if we do not consider proper  documentation that satisfies evidence and value of our treatment  we leave ourselves vulnerable to the RAC auditors’ axe.  The best way to provide evidence and value is with peer reviewed functional tests and impairment measurements that eliminate subjectivity and doubt.  To accomplish this task, MediGraph PT Software includes more than 300 tests and measurements with references.  Are you using these tools? 

 As always, please call if I can assist you with this process.

Be well,

Tom Kane, PT

Stanford University Center for Health Policy: Model contractual language for medical

necessity. Developed at the workshop, Decreasing Variation in Medical Necessity Decision

Making. 1999 Mar 11-13; Sacramento (CA). Available at

Regards,

Tom Kane, PT

https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4170&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date 

s.

• Meet  active and ongoing therapeutic intervention standards, one of which has to be physical therapy or occupational therapy;
• Require intensive rehabilitation therapy
• At admission to the IRF must reasonably be expected to be actively participating to significantly benefit from the intensive intervention.
• Require rehabilitation physicians to conduct visits with patients at least three days per week during their stay in the IMF.
• Need intensive and coordinated interdisciplinary approach to providing rehabilitation.

For those in patient facilities that employ MediGraph, we continue to implore you to nuse the functional loss documentation as previously discussed, including outcome questionnaires and functional measurements that are the result of measured impairments.  Obviously, functional documentation standards apply to outpatient facilities as well.  As always, if there are any questions regarding the best way to use MediGraph to satisfy Medicare and the RACs, please call me.

Regrds,