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With Payment Changes and Medicare Audits, Therapy Services Are Ripe for Monitoring

Because Medicare significantly increased payment for CPT code 97530 (therapeutic activity) in January, it’s ripe for monitoring as part of an internal audit plan at organizations that provide rehabilitation. Therapists tend to bill CPT 97530 and 97110 (therapeutic exercises) incorrectly or are confused about how to bill them, and auditors have taken notice. The codes are the focus of at least one Medicare administrative contractor (MAC) under Targeted Probe and Educate (TPE), and they’re an example of why rehab providers should track utilization, experts say.

It’s hard for therapists to demonstrate their clinical judgment and support the medical necessity of CPT 97110 visit after visit because the patient performs therapeutic exercises every time and it can become repetitive, said Holly Hester, senior vice president of compliance and quality at Casamba. “If all your treatments look the same from a billing perspective, it could be a little red flag you’re waving to your MAC, saying ‘I am doing something out of the ordinary,’” she said. “CMS has told us over and over, shame on you if you change your practice based on reimbursement.”

Monitoring utilization trends in rehab is an important part of compliance oversight, especially with auditors looking over their shoulder and new therapies gaining currency and codes, Hester said at the Health Care Compliance Association’s Compliance Institute in April. Because of the potential for errors with the billing and documentation of physical, occupational and speech therapy—and the licensure and credentialing of therapists—organizations may want to include them in their annual Work Plans, said Yolunda Dockett, corporate compliance officer at Lorien Health Services, who also spoke at the conference.

External auditors certainly have their eye on rehab. Part B therapies in a hospital setting are on the list of approved issues in all states for recovery audit contractors (RACs), and they’re a focus of TPE. For example, Novitas added physical therapy to TPE reviews in May. Inpatient rehabilitation facilities and skilled nursing facilities also are on TPE and RAC audit lists, and therapy drives a lot of their reimbursement. Auditors may zero in on suspiciously consistent billing for units of therapy, which are 15 minutes each, and rounding of therapy minutes. “Medicare expects the actual treatment time to be delivered, not to the nearest rounded minutes,” Hester said. “If every treatment is 45 minutes on the dot, it’s a problem. Therapists are good, but they are not that good at starting and stopping treatment. If every treatment is 38 minutes so you have just enough minutes to bill a third 15-minutes unit of therapy, that’s a problem.”

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