cms benefit policy manual chapter 15

cms benefit policy manual chapter 15

You may also be using compatibility mode. Our site was not designed to run in IE 7 or below but you can still continue to use it. To disable compatibility mode - View our Instructions. Physicians and non-physician practitioners need to identify the correct date of service for the services they provide to a Medicare patient. This article will discuss some of the situations where there have been questions from the provider community. This information concentrates on the date(s) of service to submit when billing for these services. If you are providing these services, please take advantage of the information available on the CMS website in addition to your Medicare Administrative Contractor’s web portals. Generally, expenses are considered to have been incurred on the date the beneficiary received the item or service, regardless of when it was paid for or ordered. Any exceptions are discussed below. The technical component is billed on the date the patient had the test performed. This will allow ease of processing for both Medicare and the supplemental payers. If the provider did not perform a global service and instead performed only one component, the date of service for the technical component would the date the patient received the service and the date of service for the professional component would be the date the review and interpretation is completed. The technical component is billed on the date the specimen was collected. This would be the surgery date. When billing a global service, the provider can submit the professional component with a date of service reflecting when the review and interpretation is completed or can submit the date of service as the date the technical component was performed. This will allow ease of processing for both Medicare and the supplemental payers. The non-complex service can be billed to Medicare when the time threshold for the procedure code has been met and documented in the patient’s records.http://www.ventnortowncouncil.org.uk/userfiles/52lg70yd-manual.xml

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Services would continue as medically necessary throughout the month. The date of the time completion is the date of the service. For complex CCM, once the requirements are met, the date of service is the end of the calendar month. CCM time requirements would begin at the start of the next month. The claim for CPO must not include any other services and is only billed after the end of the month in which CPO was provided. The date of service can be the last date of the month or the date in which at least 30 minutes of time is completed. The date of service for a patient beginning dialysis is the date of their first dialysis through the last date of the calendar month. For continuing patients, the date of service is the first through the last date of the calendar month. The date of service is the date of responsibility for the patient by the billing physician. This would also include when a patient dies during the calendar month.The date of service is the date the practitioner completes the required face-to-face service. If the specimen is collected over a period that spans two calendar dates, then the date of service must be the date the collection ended.The date must be the date performed if: The date of service is the date of the face-to-face meeting. The date of service is the date the items are provided to the patient. This service is payable only once every four weeks. The date of service is the date of the fourth test interpretation. The appropriate date of service is the date of the review. These can be identified as professional components, technical components, or a combination of the two. Some of these monitoring services may take place at a single point in time, others over 24 or 48 hours, or over a 30-day period. If the service is a technical service, the date of service is the date the monitoring concludes based on the description of the service.http://www.textmakareknutsson.se/upload/image/52lx177-manual.xml

For example, if the description of the procedure code includes 30 days of monitoring and a physician interpretation and report, then the date of service will be no earlier than the 30th day of monitoring and will be the date the physician completed the professional component of the service. Documentation should reflect that the service began on one day and concluded on another day (the date of service reported on the claim.) If documentation is requested, medical records for both days should be submitted. All services considered to be part of the global package including follow up visits are considered to have occurred on the same day as the surgical service and are not submitted separately. Surgeons who perform the surgery and then transfer post-operative care to another practitioner will submit their claims using the date of the surgery as the date of service along with Modifier 54. If the practitioner receives the patient on a date other than the discharge date from an inpatient stay, Item 19 or the electronic equivalent will include the date care began. The most common example of services performed on a separate date is when the resident sees the patient late on the first date and the teaching physician sees them the following calendar date. The service would be started on one day and concluded the following day. The service cannot be submitted to Medicare until completed. Unless otherwise notated, the billing entity can utilize either the date the service began or the following day when the service concluded. Please let us know if this article was helpful. When you rate our articles as most helpful, we know that we are on the right track for providing you with important news and information. We'll use your feedback to review this article to try to revise or expand it. Contact us with more feedback or a question on this topic. Click HERE for further details and to register.

In general, these instructions have been found in Chapter II of the Carriers Manual, Intermediary Manual, and the various provider manuals, and in Program Memoranda. Material from the Coverage Issues Manual is in the National Coverage Determinations Manual (Pub. 100-3). Please log in above or Register. Table of Contents (Rev. 241, 02-02-18) Transmittals for Chapter 15 Appendix PP - Guidance to Surveyors for Long Term Care Facilities. Table of Contents (Rev. 173, 11-22-17) Transmittals for Appendix PP None of the guidance to surveyors should be construed as evaluating the practice of medicine. Surveyors are instructed to evaluate the process of care. INTRODUCTION. Most physicians strive to work ethically, provide high-quality medical care to their patients, and submit Table of Contents (Rev. 3971, 06-13-18) Transmittals for Chapter 12 Chapter 14 - Reserved for Future Use. Table of Contents (Rev. 491, 11-22-13) Transmittals for Chapter 14 The notice provides this guidance in the form of answers to frequently. CDC twenty four seven. Saving Lives, Protecting People The rules are very detailed and have been modified several times over the years; they may or may not change in the future. In addition, the provider should verify that the patient has Medicare Part B insurance before furnishing the benefit and submitting a claim. The table is provided courtesy of Mary Ann Hodorowicz Consulting, LLC. A properly executed written or e-referral from the beneficiary’s treating diabetes provider (physician or qualified non-physician practitioner, such as a nurse practitioner, who is medically managing the beneficiary’s diabetes) is required. This is because once the initial benefit is started, the 10 hours must be furnished within 12 consecutive months starting with the first date of service; after this time, any hours not furnished cannot be billed for Medicare payment.

These conditions are: If the beneficiary does not receive the entire 10 hours in the first 12 consecutive months, the balance of the 10 hours is forfeited. For beneficiaries who start the initial DSMT in one year, and complete it in the following year, the follow-up may start in the month after the initial intervention is completed. For beneficiaries who start and complete the initial DSMT in one year, the follow-up may start in January of the following year. Any unused follow-up hours will be forfeited. Meeting a specific condition for furnishing individual follow-up is not required. DSMT is not payable if furnished at alternate non-hospital, off-site locations. It is best to first verify this with the regional MAC. It is best to first verify this with the regional MAC. Rounding of time furnished is not allowed for 30-minute time-based codes. The treating provider (who must also be an active Medicare provider or in opt out status) is the physician or qualified non-physician practitioner (nurse practitioner, physician assistant, clinical nurse specialist) who is managing the beneficiary’s diabetes. The provider must maintain a plan of diabetes care in the beneficiary’s medical record, and submit a referral documenting: A condition is not needed for FQHCs or RHCs, as only individual DSMT is payable. Visit the new DSMT Accreditation Program external icon webpage for information on the certification process and accrediting organizations.The table is provided courtesy of Mary Ann Hodorowicz Consulting, LLC. To find out more visit our privacy policy. The 2013 Jimmo vs. Sebelius settlement sought to dispel this fallacy and provide clarifications to safeguard against unfair denials by Medicare contractors for skilled therapy services that aid in maintaining a patient's current condition or to prevent or slow decline.

In addition to supervising the services provided by the PTA or OTA, the qualified therapist is still responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days. See more on Medicare payment for home health. No, it is not a requirement for maintenance therapy coverage that the patient have a certain diagnosis. Coverage is based on individualized assessment of the patient's condition and the need for skilled care to carry out a safe and effective maintenance program. Skilled maintenance therapy is covered in cases in which needed therapeutic interventions require a high level of complexity. The services can be rehabilitative, maintenance, or slowing of decline based on the physical therapist's ability to justify they are reasonable and necessary and require the skills of the physical therapist. It is considered skilled to instruct caregivers and to periodically determine if they are carrying out an unskilled service. The PTA could treat for both rehabilitative and maintenance therapy under Medicare Part A. What about the assistant. Yes, physical and occupational therapists who meet the Medicare definition for qualified personnel can provide skilled maintenance therapy. Beginning in 2020, therapist assistants are allowed to perform maintenance therapy services under a maintenance program established by a qualified therapist under the home health benefit (Medicare Part A), if acting within the therapy scope of practice defined by state licensure laws. The therapist continues to be responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days, in addition to supervising the services provided by the therapist assistant. These services are billed by the supervising physical therapist.

PTAs may not provide evaluative or assessment services, make clinical judgments or decisions, develop, manage, or furnish skilled maintenance program services, or take responsibility for the service. Read on to learn about this heavily regulated US social insurance program. In 1996, this number was only 19.1 million. According to this report published by The Commonwealth Fund, on the whole, Medicare covers about 75% of its beneficiaries’ healthcare costs and about 70% of beneficiaries are between the ages of 65 and 85. To view Medicare eligibility requirements for enrollees, click here. Here’s what you need to know about each of Medicare’s parts: Together, they form what is referred to as “Original Medicare.” While Part A covers inpatient hospital and skilled nursing facility care, home health care, and hospice care, Part B covers doctor’s services, rehab therapy services, and other outpatient care and supplies not covered under Part A. If you’re in private practice—and you accept Medicare beneficiaries—then you most likely provide services that fall under Medicare Part B. It’s important to note that Medicare does not cover Medicare Part B services for patients who are receiving Part A services. Thus, be sure to ask all patients about concurrent care. Most patients don’t pay a premium for Part A; however, they do pay a premium for Part B (based on income level and Social Security benefits). And patients usually pay a deductible and coinsurance when they access both Part A and B services. Prescription drug coverage also is usually bundled in Part C plans—and many Part C plans offer additional coverage beyond what original Medicare provides, including dental and vision. For some patients, MA plans may be more cost-effective than Original Medicare. While MA plans are funded by Medicare, questions about coverage, out-of-pocket costs, billing, and referrals should be directed to the providing company.

Patients with Original Medicare may pay a monthly premium for a Medicare prescription drug plan provided by a private company. However, Medicare Advantage beneficiaries with plans that offer prescription coverage are usually required to obtain prescription drugs through the MA company. Premiums for Part D vary and are usually weighted so that beneficiaries with higher income pay more. The definition of “reasonable and necessary” varies based on both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Each provider is responsible for knowing the current NCDs and LCDs governing his or her practice. However, in most cases, the medical necessity of services is determined based on: As part of this settlement, CMS also had to create and distribute new educational materials to correct long-standing and widespread misunderstandings about the Improvement Standard. While the settlement went into effect immediately for Medicare and Medicare Advantage plans, CMS had until January 2014 to comply with this order. Furthermore, per Chapter 15, Section 40.4 of the Medicare Benefit Policy Manual, physical and occupational therapists in private practice cannot “opt-out” of Medicare and therefore may not enter into private contracts with Medicare beneficiaries. In other words, rehab therapists can’t accept cash outright from Medicare patients for medically necessary physical therapy services. That being said, there are successful outpatient clinics that are 100% cash-based. For more information on how one Austin clinic successfully—and legally—navigates Medicare and cash-pay physical therapy, click here. You’ll then receive a Certification Statement. Your effective date of filing is the date the Medicare contractor receives the Certification Statement. Please note that a Medicare contractor will not process the online application without a signed and dated Certification Statement.

So, in addition to being legible and relevant, documentation must defend the services a therapist bills. Furthermore, documentation must comply with all applicable Medicare regulations and support included CPT codes. This evaluation should include:At minimum, Medicare requires the POC to include:Descriptions of skilled interventions should be included in the plan or progress note and are allowed, but not required daily.” When this occurs, therapists must document it and complete a recertification. Medicare may require some additional documentation to verify that the patient truly needs the additional therapy. Medicare also requires recertification after 90 days of treatment. Click here to learn more about documentation requirements for speech language pathology. For details on Medicare Part A therapy documentation requirements, click here. Authorization from a licensed physician must include the physician’s full name, location, and contact phone number as well as his or her signature on the plan of care that explains the diagnosis and level of treatment intensity. This authorization certifies that only a physical therapist can offer the type of care the patient needs. If the patient can do exercises at home on his or her own at no cost, Medicare will not cover physical therapy services. You can learn more about the direct access laws in your state here. That means that a therapist may perform—and bill for—an evaluation to determine whether therapy is medically necessary for that patient without involving a physician or other approved non-physician provider (NPP). However, once a therapist determines that therapy is, in fact, necessary, then that patient must be under the care of a physician or NPP. As such, the therapist must obtain a signed POC certification within 30 days of a patient’s first visit. While Medicare doesn’t require that patients visit their physician, some physicians may require an office visit prior to signing a POC.

However, therapists should do so only if they are extremely confident that they can secure the necessary certification within the month. Otherwise, the POC is considered “delayed,” which means the provider will have to complete additional work in order to remain compliant. If you’re a WebPT Member, keep in mind that WebPT’s Plan of Care Report shows you which plans of care are still pending certification. It will also remind you to complete your recerts before time runs out. Talk about a POC easy button. Read on to learn about the most asked-about Medicare regulations. Per the APTA, “as licensed providers, the state practice act governs supervision requirements. Some state practice acts mandate more stringent supervision standards than Medicare laws and regulations. In those cases, the physical therapist and physical therapist assistants must comply with their state practice act.” CMS generally defines “direct supervision” as a situation in which the supervising private practice therapist is physically present in the office suite at the time the PTA performs the service. To learn more about Medicare’s supervision levels, check out this blog post. For guidance on the use of PTAs in other settings, please refer to this APTA page. That means that if a PTA provides at least 10% of a given service, you must affix the CQ modifier to the claim—along with the GP therapy modifier—which will trigger Medicare to reduce its reimbursement rate. Providers must begin using the new modifier on January 1, 2020; however, as mentioned above, the payment reduction will not begin until January 1, 2022. Therapy techs may assist the professional therapist or therapist assistant in performing a specific therapy service; however, the tech can never provide the service. Thus, even if the therapist is in the treatment room with the student while the student is treating a patient, only the services provided by the therapist are billable.

To learn more about the exceptions to this rule as well as the APTA’s recommended considerations with regard to billing for student-assisted services, click here. But, when bringing in another therapist to treat patients, many practices face the “bill as” problem: to receive reimbursement from insurance companies, hired contractors must be fully credentialed with the same insurance companies whose beneficiaries the hiring practice treats. This may be a slightly more costly way of doing things compared to simply hiring a friend or associate, but in order to “bill as” correctly, you’re better off hiring a fully credentialed contractor. This is important for all insurance companies, especially Medicare. The contractor stepping in for an on-vacation therapist who treats Medicare patients must also be Medicare-credentialed. It refers to a person who temporarily fulfills the duties of another. While physicians have the luxury of simply adding a Q6 modifier to the treatment claim to indicate that a replacement physician provided the services on a particular day, most PTs, OTs, and SLPs do not. For Medicare, as long as the practice has sent in that therapist’s paperwork and that paperwork is pending CMS approval, the therapist can begin to treat patients. However, your practice must hold all claims for that new therapist (up to one year from the visit date of service, based on timely filing rules) until he or she receives credentialing approval. Medicare does not allow a co-signer on claims for non-Medicare credentialed contractors or employees. The uncredentialed therapist would need to reassign his or her individual Provider Transaction Access Number (PTAN) to your group, and you would then hold the claims until he or she receives approval. In fact, you should only ever bill for a re-evaluation if one of the following situations applies: Regarding copayment, the patient pays 20% of the Medicare-approved amounts.

Medicare and Medicaid view waiving copays or deductibles as a misrepresentation of the true charge for your services. Although Medicare may permit waiving copays in very select circumstances, you should never assume that this will be the case. Click here for greater detail on copayment collection for Medicare and third-party insurance beneficiaries. With the proliferation of high-deductible health plans, patients are shouldering more of the financial burden associated with their care. Watch this complimentary webinar to learn how best to communicate with patients about their insurance—and the value of your services—so there are no surprises when it’s time to bill. One such circumstance is financial hardship. However, waiving under the claim of financial hardship is easier said than done. First, a practice should rarely extend such waivers. Second, the practice must apply the same hardship criteria to all financial hardship cases. Practices should establish a financial hardship policy, which details the type of documentation a patient must supply (e.g., tax returns or unemployment compensation information) for the practice to consider the patient for financial hardship. Third, financial hardship is a last resort, and therapists should make all attempts to collect copayment or deductibles at the time of service. Ultimately, if a Medicare patient asks about waiving copayments or deductibles, the therapist should inform the patient that such a practice is illegal. Learn more about financial hardship here. In this blog post, Meredith Castin, PT, provides the following example: “If an OT and a PT co-treat from 10:30 AM to 11:30 AM, and the OT works on toileting strategies while the PT simultaneously addresses safe transfers, both clinicians could bill for that entire hour, provided they show proof of providing separate treatments with separate end goals.

” For home care or care provided in a skilled nursing facility that bills under Part A, therapists can bill for co-treatment services as long as the plan of care and documentation support that decision. That said, the therapists must follow all policies regarding mode, modalities, and student supervision as well as all other federal, state, practice, and facility policies. Essentially, therapists must limit total billing time to the exact length of the session, so a therapist of one discipline may bill for the entire service or co-treating therapists of different disciplines may divide the service units.Each therapist should document co-treatment sessions as such, specifically detailing which goals the team of therapists addressed and how the patient progresses. Lastly, therapists should limit therapy services performed during one treatment session to two disciplines. According to Castin, while modifier XP would be appropriate if, say, “an OT takes over treatment in the middle of a PT session,” 59 would be appropriate if the payer doesn’t yet recognize X modifiers or there is another reason you need to “identify otherwise linked services that should, given the circumstances, be reimbursed separately.” For example, you would affix modifier 59 to the 97116 charge if, say, a PT provides gait training (97116) and an OT provides therapeutic activity (97530). Doing so notifies Medicare that the services were performed separately and distinctly from one another and thus should both be paid. This means that giving gifts to patients can even be tricky, especially if they’ve referred patients to you and those patients happen to be Medicare beneficiaries. To learn more about AKS rules in your state, click here. As it stands now, therapists who perform more than one “always therapy” service on a patient during the same visit see a 50% reduction in practice expense (PE) billed to Medicare (the reduction was 20% from Jan 1, 2011 to March 31, 2013).

MPPR also extends across disciplines, which means that when two or more rehab therapists of different disciplines treat the same patient during the same date of service, CMS only pays the highest procedure value in full. CMS then reduces all subsequent procedures performed that day by half. According to the APTA, MPPR averages a 6 to 7% reduction in provider reimbursements (based on an average of 3.7 billed units per visit). That’s a lot. Apparently, part of the reason was to reduce the amount of money the Center was spending on rehab therapy prep time when more than one procedure was performed for the same patient on the same day. Remember that MPPR only affects practice expenses; however, each therapy service also includes work expenses and malpractice expenses. Thus, before MPPR, if more than one therapy service was billed at a time, CMS was paying more than once for pre and post-service activities—in addition to the actual service being provided. Since the beginning, the APTA has asserted that MPPR is flawed—mostly because provider PE rates have already been reduced to avoid duplication. According to the APTA, “The fact that certain efficiencies exist when multiple therapy services are provided in a single session was explicitly taken into account when relative values were established for these codes. Therefore, an additional cut to the practice expense of therapy service codes is arbitrary and likely to restrict patient access to vital physical therapy services.” As a result, the APTA has advised providers to vary their payer mixes and review their contracts closely to ensure they know the terms they’re agreeing to. These regulations include the therapy soft cap, the 8-minute rule, and MPPR. Failure to comply with Medicare regulations can result in penalties, denied reimbursements for provided services, and audits. Modifying documentation following a denial or not supplying documentation when Medicare requests it.

Additionally, take advantage of any CEU opportunities regarding Medicare, and get acquainted with Medicare’s website to learn how to access key Medicare reference documents, like the program’s Claims Processing Manual.We recommend conducting a self-audit and appointing at least one dedicated compliance officer within your practice who will implement a compliance plan. This plan should encourage therapists and staff to report any and all potential compliance issues, provide procedures for prompt and thorough investigation of possible misconduct, and detail appropriate responses to non-compliance scenarios. Compliance plans typically include the following: According to the CMS website, CMS instituted the CERT program to produce a national Medicare fee-for-service (FFS) error rate compliant with the Improper Payments Information Act. “CERT randomly selects a sample of Medicare FFS claims, requests medical records from providers who submitted the claims, and reviews the claims and medical records for compliance with Medicare coverage, coding, and billing rules. The results of the reviews are published in an annual report.” If any claims are denied, the MAC will invite you to attend a one-on-one education session before providing you with 45 days to improve your billing processes and claim submissions. If three rounds occur without improvement, then you’ll be referred to CMS for further inquiry. The act brings both pressures and incentives into play in its mandate to convert PHI to electronic health records (EHR), and puts teeth into the enforcement of the privacy and security rules of the Health Insurance Portability and Accountability Act (HIPAA).”. Essentially, to qualify for the incentive, these practitioners had to implement a certified electronic health record —that is, one that “offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria.