September 27, 2018 | Net Health

5 min read

Audit Trends That Can Impact Your Outpatient Therapy Practice

Therapists in outpatient clinics need to be aware of audit trends that could impact their practice. From documentation to billing and coding, Medicare Part B auditors are paying attention.

In our recent webinar on how to keep outpatient therapy clinics healthy, Ellen Strunk, owner of Rehab Resources & Consulting, Inc., shared a few of the issues that are driving both Medicare and commercial auditors to focus on therapists.

Here are three common areas where therapists need to be especially vigilant.

Non-covered services

As long as a patient’s treatment meets the definition of a medically necessary service and is covered by the patient’s benefit—and clearly documented in the patient record—Medicare and other payers consider it a ‘covered service.’ Non-covered services, however, are where things can get sticky. You can still get paid, but you will need to have the patient sign an advance beneficiary notice (ABN) form for Medicare beneficiaries. Medicare will also require you to submit a claim for those services with the appropriate GA, GX, GY or GZ modifier. In general, commercial payers don’t require you to report non-covered services, but it’s a good idea to verify that.

The ABN gives the patient the opportunity to choose whether or not to receive the non-covered service.  If the patient chooses to receive it, and signs the form, then he/she is effectively stating an understanding that the treatment may not be covered and, when the claim is denied by Medicare, agrees to be financially responsible. Alternatively, the patient may choose the option to pay for the service and release you from submitting a claim.

Keep in mind that services that are medically necessary at the beginning of treatment may not be covered later as the patient recovers. It’s important to communicate these changes with patients and back them up with documentation. Commercial payers will likely have their own forms, so make sure to understand the various requirements or you could find yourself dealing with unhappy patients, unpaid bills and scrutiny from regulators.

Services that aren’t correctly coded

Coding therapy services with the appropriate therapy modifier is also key to reimbursement.  There are possibly only a few short months left of submitting functional limitation G-codes[1], but they must still be added to the claim in order to be paid. And as mentioned above, if you have the patient sign an ABN form, you will need to submit the appropriate G modifier. Lastly, when therapy services go beyond the $2,010[2] threshold, you will need to add a KX modifier attesting to the medical necessity of services.

Many of the therapy codes are ‘paired’ with other codes as a result of the Correct Coding Initiative (CCI), which can cause confusion and frustration. When codes are paired, you will only receive payment for one of the codes unless you can specify the services were distinct and separate using a 59 modifier or one of the X modifiers. When the X modifiers were introduced in 2015, physical therapists weren’t required to use them. But movement toward the use of these modifiers—with greater scrutiny of claims with the 59 modifier—is happening. Some commercial payers have begun to require therapy claims to use the X modifiers because they provide greater clarity for certain situations. For instance, you’ll want to add an XE modifier to indicate a service is distinct because it occurred as a separate encounter—which could happen if you saw a patient more than once in the same day.  Otherwise, payers might think that you are billing two codes for the exact same thing.

Low-value or grey area services

Unlike other Part B services where CPT codes are paid at $100 or more, many therapy CPT codes are in the range of $20 and $30, and are billed in multiple increments in one visit. These low-value/high-volume services post a unique risk and are often targets of medical review.

Here are examples of common CPT codes that are currently targeted for medical review by both Medicare and commercial payers:

97110 – Therapeutic Exercise

97140 – Manual Therapy

97530 – Therapeutic Activities

97112 – Neuro-muscular re-education

There are other gray areas that present opportunities for people to blur the lines even more, particularly as you go across settings—from the skilled nursing facility to home health care to outpatient therapy. As a therapist providing care in these different environments, you need to understand the specific guidelines of each and variations in coverage.

When auditors look at the data to uncover abuse or fraud, they are generally looking for patterns that signal there may be a problem. To minimize risk, it would be useful to do a quick self-audit to see if there are any patterns in your practice that could be considered suspect. Ask yourself:

  • Are you overutilizing new codes?
  • When codes change in value from year to year, do your utilization patterns change? For example, when codes decrease in value, do you decrease your use of them? Or increase your use of codes that go up in value?
  • Are there other practices that might be perceived as a tactic to inappropriately maximize reimbursement?

While it can be tedious to ensure you’re taking the steps to document, code and bill correctly, at the end of the day you will protect yourself and your practice.

To learn more about audit trends, and how you can use this information to keep your outpatient clinic healthy, watch our webinar: Tips for Keeping Your Outpatient Therapy Clinic Healthy.

[1] In the CY 2019 Medicare Physician Fee Schedule final rule (announced on Nov. 1, 2018), CMS discontinued functional status reporting requirements for Part B therapy services. This will eliminate the need to append outpatient therapy claims with functional limitation G-codes (G8978-G8999 and G9158-G9186) and severity modifiers (CH-CN) starting on or after January 1, 2019. While this will significantly ease the burden on outpatient therapy providers, the correct coding of services remains a key area of concern impacting reimbursement.

[2] Starting in 2019, the threshold is set at $2,040 for PT/SLP combined and OT separately.

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