Let's Help Each Other

Physical therapy is changing rapidly. As a PT with more than thirty years of experience, the changes observed in the last ten years triple those of the first twenty years. The pace of change is not slowing down. The Medigraph Blog will serve as a forum that will enable us to exchange ideas and assist each other. This blog will be used to share billing, documentation, and any other ideas to improve any aspects of our profession. If we share what we have learned, we can develop a resource that enables our collective understanding to advance our careers.

As profit margins grow smaller and expenses grow larger, we need to assist each other to survive and prosper. If we share our experiences we can help each other to grow professionally, administratively, and financially. Our professional lives, our livelihood, and our personal lives are intertwined. Our resources individually are limited. Together we can accomplish more than we can individually. Let's help each other


Tom Kane, PT
MediGraph Software

MediGraph Appointment Manager Makes $ense
4/21/2011 12:38:00 PM

The response to the automated appointment manager has been extremely positive.  Reminding patients’ of their next appointment via an automated telephone call, email, and text message dramatically reduces missed visits.  The financial gain afforded by this service adds significantly to the bottom line with no effort.  For example:  if the appointment manager reminder prevents only two-missed appointments per week that generate $50 per visit, the yearly gain in revenue is $5,000.00 (2 visits x $50 x 50 weeks = $5,000.)  Clinically, patients maintain consistency of their treatment program assuring continued progress.   The automated appointment manager provides better service, increases revenue, and provides a level of sophistication that increases the viability of your facility.  We are pleased that this addition has satisfied our subscribers.


Tom Kane, PT
MediGraph Software

Demand Letter from a RAC Auditor
4/19/2011 5:12:00 PM


The above link is to an example of the demand letter sent by a RAC auditor to health care providers, including physical therapists.  Let us hope you never receive one of these. Use MediGraph documentation properly (outcome instruments, objective testing, time in-time out, etc.) to help avoid getting one of these letters.  


Tom Kane, PT

MediGraph Software

Timed Codes and Audit Triggers
4/17/2011 6:18:00 PM

A frequent trigger for  RAC audits are time code violations, especially un-timed codes.  CMS documentation requirements call for a daily therapy note to include the recording of minutes in timed codes as well as total minutes of therapy.  Unfortunately, many private insurance providers are beginning to employ the same standards.  To avoid triggering an audit your billing minutes and your documentation minutes must coincide, which will prevent  RAC computer data mining triggers.  When performing your documentation, use the time recorder “Time in Time Out” utility in MediGraph to document and collaborate your intervention and charges.  The following information is an example of how to coordinate your clinical and administrative efforts to maximize revenue while simultaneously providing quality treatment.

Counting Minutes for Timed Codes in 15 Minute Units and the Eight Minute RuleTimed codes are subject to the Medicare "Eight-minute rule," and the total number of billed units is limited by the total minutes in timed codes.  These confusing standards often trigger RAC audits because of conflicts between documentation and billing.The eight-minute rule applies to any timed CPT code, which is  measured as a 15 minute unit.   Therapists can bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be billed. Time intervals for 1 through 8 units are as follows:

1 unit: ≥ 8 minutes through 22 minutes
2 units: ≥ 23 minutes through 37 minutes
3 units: ≥ 38 minutes through 52 minutes
4 units: ≥ 53 minutes through 67 minutes
5 units: ≥ 68 minutes through 82 minutes
6 units: ≥ 83 minutes through 97 minutes
7 units: ≥ 98 minutes through 112 minutes
8 units:≥ 113 minutes through 127 minutes

An example of  timed code confusion is billing for ultrasound.  If an ultrasound procedure is less than eight minutes, it is not billed directly.  Instead, because those minutes are rolled into the total minutes in timed codes, the result is an additional unit of another code being billed.   It may be simpler to bill for 8 minutes of ultrasound, which can easily be accomplished by providing 5 minutes of continuous ultrasound to elevate tissue temperature, followed by three minutes of pulsed ultrasound to gain the benefits of the mechanical effects of ultrasound.  CMS provides guidance on the "eight-minute rule" in Chapter 5 of the Medicare Claims Processing Manual.  http://www.cms.gov/manuals/downloads/clm104c05.pdf, pg. 24.

Un-timed Codes Un-timed codes are a favorite target of RACs and are responsible for a large number of audits.  It is important to understand that un-timed codes can only be billed for one (1) unit of service regardless of the actual time spent on a therapy encounter. For example, a therapy evaluation that takes 15, 30, or 60 minutes may be billed for one unit.  There is no prohibition  (CMS Transmittal 1019, which since has been incorporated into the Medicare Claims Processing Manual) against billing two separate and distinct un-timed codes; for example a physical therapy evaluation on the same day as a speech-language pathology evaluation.  For more info on untimed codes see Page 13 at:



Tom Kane, PT
MediGraph Software

New RAC "Semi-automated" Reviews
4/7/2011 5:51:00 PM

Recovery Audit Contractors  (RACs) now employ automated claims reviews and complex claims reviews with the goal of obtaining a refund of fees that physical therapists have received for services rendered.  A new form of audit has been introduced to assist the RAC bounty hunter goal of obtaining a refund from providers (they are reimbursed when they obtain a refund).  The new method is known as overpayment identification: “Semi-automated” claims review.

A Semi-automated review is slightly different than the automated and complex methods of overpayment identification used in the RAC method.  It is essentially a hybrid of the automated and complex reviews.  The changes divide this new review process into two parts. 

  1. The first part of the two-part review process involves an automated review of claims data to identify billings that are associated with a high suspicion of improper payment.  The automated  RAC review occurs when a determination is made at the computerized system level without a person.   Software reviews are often referred to as “Data mining,” where the software to process large numbers of claims combs the data.  It is essentially unchanged from prior RAC reviews.  The minor difference from the regular automated RAC is claims that are identified as only containing possible errors, rather than assumed errors, are identified.
  2. The second part has a notification letter sent to the therapist explaining the potential billing error.  The PT is given 45 days to submit documentation to support the original billing(45 days is also given to providers to submit documentation for a claim that has been selected for complex review).

“Semi-automated” reviews will lead to additional burdens for physical therapists.   It is no secret that automated reviews can result into a complex review. The semi-automated review has established the process that emphasizes the risks of automated review, making it easier for the RACs to request records for review! .  The RACs can now scan unknown numbers of records for issues,  ‘mining’ for unlimited vulnerabilities.

I know the overwhelming majority of therapist are unaware of or ignoring the impact of the documentation tsunami that approaches.  I know because I speak with MediGraph subscribers regularly.   I also speak with therapists that are interested in becoming MediGraph subscribers, and most of them are clueless.  Increasingly, new callers are aware of what approaches, which is their reason for seeking electronic documentation.  

For subscribers, I understand that my good intentions are becoming a bore.  I realize that I am the bearer of bad news that many would prefer to ignore, pretending that that are immune.  If you are already a subscriber, it should be apparent that there are no ulterior motives to my posts that implore you to use MediGraph to its complete ability.  MediGraph does not gain any income when you use the tools that we have provided.  Please document need, proof, meaningful intervention, and use objective tools in MediGraph to accomplish these tasks.  All these tools required to satisfy the Medicare bounty hunters and bean counters are at your disposal.  Start using these tools today.  The RACs are using their software to the fullest capacity to snag you.  Use MediGraph to beat them at their own game.

Tom Kane, PT
MediGraph Software

CPT Codes and Equipment Purchases. Costs vs. Benefits
4/5/2011 6:08:00 PM
I received a call from a  MediGraph subscriber that may be of  benefit to other subscribers.  The MediGraph subscriber with whom I spoke was discussing purchasing an expensive piece of equipment to perform therapeutic exercise, and asked if I had ever used this type of tool.   I had experience with the equipment and did not recommend the purchase.  Allow me to explain.
CPT codes help to identify the interventions that we provide to our patients,   standardizing and facilitating the billing process for insurance providers.    A fact that often goes unrecognized is that CPT codes also control costs.  Despite the use of modifiers and other administrative-billing adjustments, there is  limited reimbursement  that one will receive for a specific CPT code.  This fact should influence your equipment purchasing decisions, because CPT codes restrict  reimbursement,  regardless of the equipment employed.    For example, let us assume that CPT 97110  (therapeutic exercise) receives a hypothetical maximum reimbursement of $35.   If we employ a piece  that costs $35,000, a therapist would have to perform 1,000 visits on that piece of equipment prior to breaking even on this expenditure.   I understand that the long view would suggest that the equipment would supposedly be adding to the revenue stream after 1,000 patients have use that item but one must ask if there are effective alternatives.  For example,  an entire circuit of Nautilus or Keiser, etc. can be purchased for the cost of one piece of exotic equipment ($35,000),  If code 97110 does not distinguish payment between the exotic and the less esoteric, and the benefits to the exotic are , at best marginal (if any), the cost benefit, return on investment that is restricted by CPT coded payment must be a consideration when purchasing equipment.
Tom Kane, PT
MediGraph Software 
Unannounced Medicare On Site Visits Effective March 25, 2011
4/1/2011 3:24:00 PM

CMS (The Centers for Medicare and Medicaid Services released information on  new provider enrollment screening regulations.   In these new regulations physical therapists in private practice are not required to undergo site visits before they enroll in  Medicare.  However, PTs are subject to unannounced  on-site visits after they are enrolled.  Theses new measures are intended to curb fraud and abuse.  Physical therapy practices are characterized as moderate risks for fraud (the other categories are Limited and High Risk).  However, physical therapist that bill for DME will be placed in the High Risk category, and will be subject to the on site unnanounced visit standards in this category.

An unannounced site visit will include the date and time of the visit,  observations made at the facility,  and photographs will be taken of the therapists.  Obviously, unannounced visit contractors must enter the office or facility.  If any of the basic elements are not met, the provider's Medicare billing privileges can be revoked.  The changes can be viewed at: http://www.cms.gov/transmittals/downloads/R371PI.pdf.

The long term effect of these Draconian government actions are undetermined.  As overreaching these rules may be, my greater concerns are those that involve human behavior.  Medicare and RAC contractors are subject to the human frailties that unbridled authority can have on behavior, where ordinary people can become monsters because of they are placed in an authoritative position.  Bullying by government officials is not an unusual occurrence, and at the first sign of weakness, many government enforcers will jump at the opportunity to wield their prowess.   Is there fraud in PT?  Of course there is.  Is it rampant?  I do not believe fraud is rampant within our ranks.  I do believe that the incidents of fraud that are severe become sensationalized and ridiculous regulations to address the few inconvenience the rest of us. 

Personal feelings aside, the best defense in these situations are a good offense.  Are you using MediGraph in a way that helps to serve you in these uncertain times?   Are you employing the objective outcome based documentation that defeats audits and prevents them from occurring?  I have sent emails and provided many posts on the importance of objective documentation and outcomes.  Both impairment measurement and functional outcomes tests (including OPTIMAL) are in MediGraph.  Please use them.  Also, prior to this recent CMS ruling, we at MediGraph were working on an electronic Medicare Manual.  We should have this product completed in a few weeks.  When the unannounced on site Medicare examiner visits your facility and asks for your Medicare Manual, you will be able to produce an up to date document at the click of a button.  

Our desire and actions that demonstrate our clinical competence and concern for our patients is not a defense against RACs and unannounced agency examiners.   The auditors’ job has nothing to do with quality care.  Use MediGraph to beat them at their own game while simultaneously elevating your clinical intervention.

Best regards,

Tom Kane, PT
MediGraph Software