Trailblazer (the fiscal intermediary for Part A and carrier for Part B in the states of Colorado, New Mexico, Oklahoma, Texas, and the Indian Health Service) conducted a “Probe” of billed SNF payments.  They focused on the highest paying RUG groups (what else would we expect), selecting “a random sample of 100 claims from 15 of the top billing providers of SNF services with dates of service July 2007 through December 2007.”

The results?

“Medical Review denied or partially denied services on 34 percent of the total claims reviewed. The error rate for this widespread sample was 13.5 percent.”

As a therapist who has practiced in the SNF setting for several years, I’m disturbed by their findings.  Here are the reasons for denial — in Trailblazer’s own words. . .with my comments thrown in for good measure.

“Based on the results of the probe review, Medical Review identified the following problem areas:

• Utilization of higher levels of intensity of rehabilitation than were medically necessary.

What medical condition ISN’T worthy of the highest levels of therapy the patient can tolerate?!?  After all, they are in a SNF to get the maximum level of therapy possible in order to send them home as quickly as possible.  If a patient can tolerate three hours of therapy, then by golly give him three hours of therapy!

• Patients reached their functional potential without being turned over to restorative care in a reasonable time frame.

This one I’ve got to agree with, and I’ve seen it myself.  Get them healthy, get them safe, and then let them practice with the RNA or, better yet, send them home for more training with home health.

• Therapies were continued past the restoration of the patient’s prior level of functioning.

This denial I find rather disturbing.  I can’t tell you the number of times a patient has said to me, “You know, I used to ___[walk, go grocery shopping, enjoy an evening out with my family, ride my bike, get out of my own bed]___ but I haven’t been able to for so long because ___[my knees hurt too bad, my back was causing so much pain, I was afraid of falling]___ and now that I have ___[my knee replaced, my back surgery, better pain medicine management, this new walker]___ I’d like to get back to the way I was.”

Well, not according to Medicare.  According to Medicare I can only give you enough therapy to get you back into a wheelchair because that’s what you used in the customary span of time before you went to the hospital.  Sure, you COULD walk again, you COULD return to a better quality of life, but not on MEDICARE’s dime.

ALL YOU PEOPLE OUT THERE CONSIDERING A NATIONALIZED HEALTHCARE SYSTEM - REMEMBER THIS DENIAL!!

• Therapies were provided to individuals who were not reasonably capable of participation or of making/sustaining gains.

“Sustaining” gains — tell that to the Parkinson’s patient who needs intense therapy just to maintain their present levels. . .or the CVA who shows potential, but since you aren’t God and really aren’t sure what the outcome could be. . .or . . .or. . .or

• Documentation did not support the need for continued care in an SNF:
  • Patients had reached their potential and were medically stable.
  • Documentation did not indicate participation of medically stable patients in ordered therapies.
  • No gains were accomplished due to declining physical health issues.
• Utilization of higher RUG codes than medically necessary:
  • Documentation did not support the intense levels of skilled therapy.
  • Speech-language pathology was ordered for cognitive deficits when documentation indicated there were no deficits.
  • Patients were not capable of participating in high levels of intense therapy.
• Documentation received was incomplete:
  • Minimum Data Set (MDS) was not in the National Repository.
  • Medical records did not contain one or a combination of the following documents:
    • Physician orders for SNF services.
    • Certification/recertification for SNF services. “

Do you know how ICD-9 codes relate to the exceptions process?

The Medicare Claims Processing Manual, Chapter 5 has all the guidelines.  Now, if you don’t relish digging through all the documentation, here’s a cheat sheet to help.  I keep one in my clipboard as a reminder.

REMEMBER:  This document is an EXCERPT only.  Please read all applicable documentation for guidelines.

 Therapy Cap ICD-9 Exception List: Download

One of the most difficult aspects of trying to read and learn about Medicare, or anything government for that matter, is getting through their TLAs.  That’s right — the miriad of Three Letter Acronyms (TLA).

It’s like swimming in alphabet soup.

So, here it is.  The ultimate acronym guide, straight from the Centers for Medicare & Medicaid — every TLA and FLA (four letter acronym) you’ve ever struggled to find.

This document is not for the faint of heart.  The bloomin’ thing is 112 pages!

Enjoy!

 The Complete List of CMS Acronyms: Download

Did you know that a new ABN form will be implemented on March 1st?

According to the Center for Medicare & Medicaid Services (CMS), “An ABN is a written notice that a provider/supplier gives to a Medicare patient before items or services are rendered when the provider/supplier believes Medicare probably/certainly will not pay for some or all of the items or services.”

The new ABN replaces the previous ABN-G, ABN-L and NEMB forms.

Trailblazer Health Enterprises, the Medicare Administrative Contractor (MAC) for Colorado, New Mexico, Oklahoma, Texas, and the Indian Health Service, is offering training on the new ABN.  This is web-based training, available to anyone with a Windows 98, 2000, or XP system (Vista systems don’t work with their teleconference provider).  The training is FREE, on March 4, 11:00am-1:00pm CT, noon-2:00pm ET.  You must register for the training.

Register at TrailblazerHealth Part B Revised ABN of Non-Coverage Web-Based Training

To access the CMS information on this topic, see CMS FFS ABN-G and ABN-L

The Centers for Medicare and Medicaid Services have published eleven (11) Part B scenarios for physical and occupational therapists.  The scenarios include:

1. Billing - CPT Codes:  Not Permitted
2. Billing - CPT Codes:  Permitted
3. Group Therapy -vs- Individual Therapy (I found this particularly interesting)
4. Team Therapy
5. Counting Minutes of Service Units
6. Group and Individual CPT Codes Billed on Same Day
7. Supervision
8. Qualified Personnel
9. Group Frequency
10. Documentation
11. SNF Part B Billing

There is a brief explanation of the difference between group therapy for Part A versus group therapy for Part B at the bottom of the article.

The document is well written, with easy-to-follow explanations.  It might save you some lost billing to read through it.  Check it out at Centers for Medicare and Medicaid Services - 11 Part B Billing Scenarios for PTs and OTs