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

Billing for self care/home management and therapeutic activities on the same day
5/24/2011 4:30:00 PM

CPT code 97535 for self care/home management is often considered a component of the more comprehensive code, therapeutic activities (CPT code 97530).  Many therapists incorrectly assume that these two activities cannot be billed on the same day.   Both interventions may be provided on the same date of service and can be billed to your Medicare contractor. To be reimbursed for CPT code 97535, you would have to append modifier-59 to CPT code 97535 on the claim form.  As always, your documentation must support the medical necessity of both interventions and that the interventions were provided at separate and distinct times from each other. 

For modifier 59 please remember that two therapy interventions may not be reported in the same 15 minute period (except for supervised modalities 97010-97028) with other services rendered.  Also recall that:

  1. Two timed procedures (i.e. group and individual) performed in separate time increments, apply Modifier 59. The time calculation rules apply.

  2. Modifier 59 is not appropriate for re-evaluation (97002, 97004) and planned therapy during the same day/encounter.

  3. Apply Modifier 59 for a change in the patient’s condition causing medical necessity
Provide and use Modifier 59 for separate time periods only.   Take extra precautions to document the time period that each service was provided. For example, 9:00AM-9:30AM theapeutic exercises of (list exercises), followed by 9:45AM-10:15AM, aquatic therapeutic exercises (list the exercises).  The words "followed by"  informs the Medicare contractor that you provided  land-based exercises followed by aquatic therapy.  Do not assume that the Medicare contractor will know or ''Figure things out."  Make it easy for them to pay you by elininating their judgement, and or creating extra work for the contractor.  


Tom Kane, PT
MediGraph Software

The Financial Costs of Appealing a RAC Audit
5/5/2011 11:34:00 AM
A recent article from the American Hospital Association (AHA) discussed the costs associated with appealing a RAC audit.  The AHA paper is quite revealing of how the RACs posses numerous advantages in extracting a refund from you (the only way a RAC get paid for their efforts).    One  of these advantages is that a RAC appeal costs between $2,000 and $7,000 dollars per claim (per individual patient audited).    The cost- benefits ratio of a RAC appeal becomes decidely less attractive for PT appeals because of  the costs.  Why?  If a RAC requests a $1,000 refund, would you be willing to spend between $2,000 to $7,000 to protest this refund?  Probably not.   Do not misinterpret my position.   I understand the arguments based on principle when a person believes thay are being penalized unjustly.   But from a business perspective, the decision to spend between $2,000 - $7,000 to prevent the RAC from capturing $1,000 is a losing proposition.

Regrettably, I must state that the RACs are not auditing records that are free from errors.  Frankly,  RACs do not have to fabricate their findings to obtain a refund.  Medical providers are creating plenty of opportunities for RACS.   When codes are not supported by proper documentation the RACs are emboldened.  There are limits to the RACs'''' authority, but these limits are primarily window dressing.  RACs are limited by the number of charts they can request per 45 day period.  For example a therapy practice with five or less therapist is limited to  auditing 10 charts every 45 days.   However, that 45 day period can be extended indefinitely.  Stated plainly, every 45 days the RAC auditor can request another 10 charts.  Unfortunately, the RACs can go back three years from the date of the audit and continuously request records.  (https://www.cms.gov/RAC/Downloads/PhyADR.pdf).

I implore my colleagues to pay attention to these warnings.  I will not repeat what we must do to prevent RAC audits.  Those suggestions have been presented on numerous occasions on this blog.  Consider this strategic view; if a RAC  reviews the claims you are now submitting, and your coding and documentation meet the current standards, the RACs are unlikely to request a 'Complex' review.  Avoiding a 'Complex' helps to deter the RAC from  reviewing your previous records because the RAC prefers to look for someone that has current documentation deficiencies.  Obviously, a person whose recent charts have deficiencies is more likely to have past discrepencies as well, which presents the RAC with the opportunity of capturing additional revenue from the fees that you were paid in the past.   Do not make yourself an easy target.  Use the MediGraph tools at your disposal to avoid the RAC trap.

Be well,
Tom Kane, PT
MediGraph Software
Documenting Functional Limitations to Avoid RACs
5/3/2011 1:35:00 PM

In 2011, Medicare will change its focus from auditing inpatient facilities to out patient providers.  Remember, RACs (Random Audit Contractors) only get paid if they obtain a refund for services that you have rendered.  RACs sift through your data to find triggers that propmt a review.  These audit triggers  include:

  1. Un-timed codes
  2. The 8 minute rule.
  3. One on one CPT codes.
  4. The 15 minute CPT codes definitions as the basis of patient encounters.
  5. Time in-time out documentation.
  6. Physician certification of the plan of care and the 90 day physician re-certification.
  7. Kx modifier use.
  8. Demonstrating that skilled therapy was required.
  9. Supervision of PTAs. 
  10. Writing a progress note every tenth visit, or, 30 days (whichever occurs first).  
  11. Not using the SOAP note format.

The above list is not new information to most MediGraph subscribers that read our blog.  However, the above list does not desribe the retrospective data mining by a RAC trigger that provokes a RAC audit.   The documentation trigger associated with a RAC complex review is the need to prove that intervention was medically necessary.   A question to consider is, "How did you come to the decision that treatment was necessary?"   Many therapists falsely assume that point 8 from the above list (Demonstrating the need for skilled care) satisfies the medically necessary requirement for providing care.  Unfortunately, demonstrating that skilled care was clinically indicated does not automatically prove that care was medically necessary according to Medicare.  Confused?  Read on.

Imagine a patient, Mr. Jones,  presented with complaints of pain in his left knee.  Examination reveals limited range of motion in the knee and strength testing reveals decreased strength when compared to the unaffected knee.   Further evaluation reveals that a contributing  cause of Mr. Jones'''''''' condition is  limited distal movement of the patella.  You appropriately suggest joint mobilization to restore patellar glide, increase ROM, and reduce pain.   To restore strength th-ex is also suggested, and more prepatory modalaties are suggested as well (US, Estim, etc.).   As sound as these clinical  decision may be,  they do not satisfy the requirement to demonstrate that intervention was medically necessary. 

 To establish that intervention was necessary we must demonstrate that Mr. Jones'' functional ability has been compromised by his impairments.  For example, if  Mr. Jones impairments do not reduce function (ambulate independently, ambulate stairs,  rise from a seated position) it will be a problem justifying the need for care (even though clinically, we all know that he needs treatment).    To provide the intervention the patient obviously needs, and satisfy the bureaucrats and RAC auditors, we must employ objective evidence based  functional assessments that have been pre-established in the literature that confirm a functional deficit.  In Mr. Jones'' case, we may want to employ the Six Minute Walk test, the Timed Up and Go, Tinetti, or any of the 14 gait and balance tests in MediGraph to demonstrate a functional deficit.  These measures wcan also be used to measure and establish progress. 

Though this approach may seem unnecessary to the purist among us, I assure that unless we recognize the documentation requirements that are employed by CMS and RACs are one of the wedges they employ to reduce our fees we will learn the hard way that clinical competence is not enough to operate a successful facility.  By employing MediGraph to satisfy the standards being demanded by Medicare and other private insurers, you can provide the level of care your patients deserve while beating the paper pushers at their own game.

Be well,
Tom Kane, PT
MediGraph Software