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
- Un-timed codes
- The 8 minute rule.
- One on one CPT codes.
- The 15 minute CPT codes definitions as the basis of patient encounters.
- Time in-time out documentation.
- Physician certification of the plan of care and the 90 day physician
- Kx modifier use.
- Demonstrating that skilled therapy was required.
- Supervision of PTAs.
- Writing a progress note every tenth visit, or, 30 days (whichever occurs
- 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
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.
Tom Kane, PT