Eli's Rehab Report

Published on Fri Oct 28, 2011 PDF

Get to know these two issues that will impact therapists next year under the OIG's 'Work Plan.'

This month, check out the following areas that the OIG intends to scrutinize next year for therapy services as revealed in the 2012 OIG Work Plan.

Independent Therapists, Beware

The OIG will be taking aim at "physical therapy services provided by independent therapists," and will seek to determine whether the services complied with Medicare's reimbursement rules. In the past, the OIG found that independent PTs collected Medicare payment for services later determined to not be reasonable, medically necessary, or properly documented.

Best practice: Ensure that all PT services are medically necessary, and link the appropriate ICD-9 codes to these services to demonstrate the medical necessity for the procedures performed. In addition, maintain thorough documentation to provide a clear picture of why the services were performed.

For instance: Coding for patients with pain can be hairy, but if you are able to nail down a specific diagnosis, your claims will be more accurate. If the patient has an identifiable problem such as sciatica (724.3) or fibromyalgia (729.1), be sure to list that specific diagnosis rather than a generalized pain ICD-9 code (such as 780.96). Generalized pain is often not included on local coverage decisions (LCDs) for therapy procedures, and many practices that offer these services to patients try to alter the diagnoses on their claims to Medicare to ensure payment, which is never appropriate.

The bottom line? Code a specific diagnosis code if it's in the documentation, but choose a "symptoms" code if it isn't.

Big Bills Might Get Attention

The OIG also intends to look at "high cumulative Part B payments" in 2012, which refers to a particularly high payment made to a practitioner or supplier on behalf of one beneficiary over a specified period. "Prior OIG work has shown that unusually high Medicare payments may indicate incorrect billing or fraud and abuse," the Work Plan notes.

Best practice: Make sure your documentation is thorough enough to back up any auditors' record requests for claims resulting in high reimbursement amounts.

If you customarily bill higher amounts than a typical therapist, that doesn't mean the OIG is going to demand a refund from you. In fact, many high payments are made for legitimate reasons -- for instance, if you exclusively treat patients recovering from traumatic brain injuries with paralysis, you will likely be submitting higher bills than a therapist with a broader practice population. Therefore, even the OIG's record request shouldn't be a source of concern if you know you've documented and billed appropriately for your services.

To read the complete 2012 OIG Work Plan, visit http://go.usa.gov/93X.