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
A recent bill introduced to Congress under the name of the "Strengthening
Medicare Anti-Fraud Measures Act of 2011 (the "Act"), increases DHHS'' existing
powers. (Reminder; coding errors can be treated the same as fraud). Instead
of paying a fine (prior restitution for fraud), the bill allows DHHS to exclude
owners, officers, and mangers of companies that are convicted of health care
fraud from participating in federal healthcare programs. According to the DOJ
(Department of Justice) and HHS, new aggressive initiatives to combat health
care fraud also allows for the criminal prosecution of owners and executives.
According to the Act, the exclusion and/or prosecution may proceed even
if the owners and executives were not complicit in the fraud, but
could have stopped the fraud if they had known
that fraud was occurring. Stated more colloquially, if you did not know that
fraud was occurring, but you were in a position to stop the fraud if you did
know, you will be prosecuted as though you committed the fraud. To avoid
criminal prosecution (and the legal costs to defend yourself), you could just
surrender your ability to accept Federal insurance, and agree not to work in a
facility that accepts federal insurance. (Where could you work?). You may be
thinking, "Are we talking about the USA?" Sadly, our run amok government
considers us criminals even if we did not commit the fraud, but would have
prevented the fraud if we did know about it. (Sounds like ''''Minority
Report'''' starring Tom Cruise!). Therefore, if your billing clerk or agency
submits an improper code by mistake (and this code is repeated multiple times),
you committed Medicare Fraud. If your documentation clearly identifies the
content and context of your treatment, your documentation may serve as
mitigating factors that weigh in your favor. However, improper documentation
could be used against you to substantiate the fraudulent intent (though none
existed). Please understand that having proper documentation is not a guarantee
that your error will be dismissed. But having improper documentation almost
guaranties that you will be prey for a government bureaucrat that understands
you can be excluded from all Federal healthcare programs or undergo prosecution.
As mentioned previously on this blog, CMS has re-characterized physical
therapists in the Moderate risk category for fraud. Has fraud occurred? Yes
it has. Are the vast majority of our colleagues honest? Yes they are. These
overreaching rules and classification of PT in the Moderate fraud risk
categories should serve as a warning. Everyone is vulnerable.
Tom Kane, PT
The April 1, 2011 post on this blog presented a preview of things to come from
Medicare. That post addressed the prospect of unannounced on site visits
from Medicare. Final rules regarding eligible enrollment of PT have been
established by CMS.
Physical therapists that were enrolled in the Medicare prior to March 25, 2011
must revalidate their enrollment as required by the Affordable Care Act (ACA,
commonly referred to as Obamacare). Part of the reason for this new enrollment
is the classification of the new risk (fraud) screening criteria. As was
addressed in the aforementioned April 1, 20111 blog post, PT has been assigned
to the Moderate risk category for fraud. The risk categories (low, moderate,
high) determine the degree of screening that will be performed by MACs (Medicare
Administrative Contractors). As stated in the April posting, the moderate
risk classification means that PTs are subject to unannounced on site
inspections from Medicare Administrative Contractors.
Starting from today through March 2013, MACs will be notifying practitioners of
the need to re-enroll in Medicare. CMS has advised providers to begin
the revalidation process as soon as they hear from their MACs.
You only have 60 days from the date of the letter to submit complete enrollment
forms. Failure to submit the enrollment forms as requested may result in
the deactivation of your Medicare billing privileges.
Tom Kane, PT
New MediGraph subscribers
often ask questions that are related to Medicare standards and the legality of
specific functions that relate to documentation. Three of the most frequently
asked questions are presented below.
Question: Can I edit my notes after the day of treatment?
Answer: Section 220.3 states, “Dictated Documentation. For
Medicare purposes, dictated therapy documentation is considered completed on the
day it was dictated. The qualified professional may edit and electronically sign
the documentation at a later date.
Question: Is it legal to write a progress note at a later date?
Answer: Section 220.3 states, “Dates for Documentation. The date
the documentation was made is important only to establish the date of the
initial plan of care because therapy cannot begin until the plan is established
unless treatment is performed or supervised by the same clinician who
establishes the plan. However, contractors may require that treatment notes and
progress reports be entered into the record within 1 week of the last date to
which the Progress Report or Treatment Note refers.”
Question: How do I prove that a skilled professional care was required?
Answer: "To determine whether a service is skilled, and therefore
coverable, the new regulations direct decision-makers to review accepted
standards of clinical practice and to consider whether a professional is needed
for the service to be safe and effective for the particular beneficiary.”
If we interpret this last answer with a most literal perspective, the ability to
improve the patient’s condition becomes secondary to proving that skilled care
was required. If we are honest, we will admit that these perfunctory tasks are
not designed to improve patient care or outcomes. They are designed to reduce
the care rendered in an attempt to save money. A few software vendors present
the documentation changes that are taking place in Medicare as though they are
desirable. If we were accountants, not therapist, I would agree. We at
MediGraph choose not to
sugar coat this issue. We comply with the documentation standards because we
are forced to comply. We address this matter openly, with the direct attention
that it deserves. In the near future, an upgrade of the program will take
evidence based medicine to the next level, automatically providing intervention
references that are diagnosis specific. For example, if you choose to provide
transverse friction massage for lateral epicondylitis, a peer reviewed reference
will accompany the intervention. We will guide through the Medicare requirement
maze so that you can do what you do best; treat the patient.
Tom Kane, PT
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:
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.
Tom Kane, PT
financial climate is causing more Medicare beneficiaries to remain employed.
A major motivation for not retiring is because pension plans and home values
(typical retirement nest eggs) have been eroded. As the
level of economic uncertainty continues, the number of Medicare beneficiaries
that remain employed is growing. Therefore, we PTs must
recognize that our payment may depend on the collection and coordination of
health insurance coverage from the patient. Medicare can be a
secondary payer when beneficiaries are covered by other insurance, including
group health plans offered by employers (GHP). Physical
therapists must be certain to obtain all of the patients’ insurance information
instead of assuming that Medicare is always primary. If the primary payer
is not Medicare, physical therapist must bill
the primary payer before billing Medicare as required
by the Social Security Act.
are those that are responsible for the first payment of a claim. Examples are
unending but include the aforementioned group health plan (GHP) provided by the
employer of a Medicare beneficiary. Medicare remains
the primary payer for beneficiaries who are not
covered by other types of health insurance or coverage. Medicare may also be the
primary payer in some other instances. For additional
information, CMS provides guidance at
http://www.cms.gov/MLNProducts/downloads/MSP_Fact_Sheet.pdf. You may also
verify Medicare's primary/secondary status by contacting the COBC at 800-999-1118.
Important Points of Interest
Medicare sometimes pays for benefits that GHP denies or if the GHP has been exhausted.
- A signed plan of care remains a requirement if Medicare is not the primary.
- Medicare documentation requirements are required when Medicare is not the primary.
- The therapy cap remains in place. If PT services exceed the cap, an exception
must be obtained.
- When Medicare is not the primary your records remain vulnerable to RAC audits.
Tom Kane, PT
Ben Franklin stated, “An ounce of prevention is better than a pound of cure.”
This universal principle applies to everything from diet to automobile
maintenance. Medicare audits are no exception to this rule. With forethought
(prevention), the new Medicare RAC audit system can work for you instead of
The new RAC (random audit contracting) auditing methods have totally changed
Medicare audit methodology. The prior auditing system permitted the auditor to
be paid to review records regardless of the outcome. For example, if your
documentation was acceptable, and there was no demand for refunds of previous
payments, the auditor got paid. In the new RAC system auditors
only get paid if they obtain a refund from you. Those that
have endured the RAC audit have described the experience with colorful
adjectives and adverbs. However, as with most crises, opportunity may lie
We PTs are patient driven. Our instincts are to provide documentation that is
employed to advance the goal of patient recovery. Unfortuntely a
"patient only" approach to documentation will not satisfy a RAC.
Preventing RAC audits must also become one of our documentation goals or we
may shoot ourselves in the foot. Medical documentation is the primary
leverage employed by auditors to reduce fees for services. Documentation must
now satisfy our clinical needs while simultaneous serving as a document that
facilitates reimbursement by preventing a RAC audit. If we do not act
proactively reimbursement for services rendered can be denied, or we can be
forced to surrender a refund of prior reimbursements.
Auditors are paper pushers with limited knowledge of physical therapy. To the
hired-gun RAQ auditor patient strength improvement is meaningless unless we can
demonstrate increased functional ability. A functional increase must be
displayed in an easy to understand format that does not require PT knowledge.
This approach to documentation prevents an audit. When documentation is more
function oriented, and standardized test are employed to reveal functional
improvement, the RAC auditor''''s thinking changes to, “These records are
not worth reviewing. If I audit this facility and do not obtain a refund, I
won’t be paid.” As sad as this state of affairs may be, it is reality.
Recent RAC audits of PT facilities in the NJ, NY, PA garnished $9 billion
dollars in refunds. Despite our best clinical intentions, we must learn to
produce documentation that prevents our being mugged by RAC reality. Many of us
are unwilling to discuss this topic openly fearing that such a discussion is
unprofessional Nothing could be further from the truth than such shallow of a
perspective. Future blog postings will continue to offer more insight into this
Tom Kane, PT