Eli's Rehab Report

Published on Wed Sep 26, 2007 PDF

Find out why you may want to screen a wheelchair-bound patient for falls risk

Refresher: From July 1 to Dec. 31, CMS is allowing Medicare providers to voluntarily report 74 quality measures for a 1.5 percent bonus, through the Physician

Quality Reporting Initiative (PQRI). Of those 74 measures, PTs and OTs in private practice and physician-owned therapy practices are eligible to report "screening for future falls risk." (See the related articles in Physical Medicine & Rehab Coding Alert, Vol. 8, No. 9 for more details.)

In the last issue, you read about how to screen for future falls risk, how to code the screen, and how to qualify for the bonus. But these facts have brought up even more questions among providers that you should be aware of:

Q: Do I have to register anywhere to begin reporting my screens? No, your reporting is voluntary -- CMS doesn't require registration. "You simply begin submitting claims" with the proper category II codes, said Gayle Lee, JD, director of regulatory affairs for APTA, at the course titled "Transforming Physical Therapy: Patient Assessment, Outcome, Measurement and Payment Policy," during the organization's annual conference in Denver.

Do this: Be sure to report quality codes with a $0.00 charge -- or a $0.01 charge if your billing software does not accept a $0.00 charge, Lee said.

Q: How does CMS calculate the 1.5 percent bonus, and when can we expect to receive it? If you meet CMS' requirement of screening at least 80 percent of eligible patients in the reporting period, CMS bases its bonus calculation on your total allowed charges from July 1 to Dec. 31-- for services billed under the Physician Fee Schedule, Lee said.

For instance: "Suppose you had $500,000 of allowed charges within that time period. You'd get 1.5 percent of that amount in a lump sum in mid-2008," Lee said. CMS would make payments out to the Taxpayer Identification Number (TIN) holder.

Q: I heard that there's a cap on the bonus. How is that calculated? Yes, there will be a cap, based on the amount a business or individual may receive and based on the size and volume of the clients seen, says Kate Brewer, PT, MBA, GCS, vice president of Greenfield Rehabilitation Agency Inc., in Greenfield, Wis.

The calculation: Cap = (individual's instances of reporting quality data) x (300%) x (national average amount per measure payment instances of reporting), Brewer says.

But don't worry too much about the cap. It was established so that a physician or other healthcare professional would not receive the full 1.5 percent bonus for six months worth of their claims, while reporting infrequently on the quality measures, Lee tells TCI. '"The cap won't be much of an issue for therapists because the falls screening measure would apply to most of their Medicare patients; therefore, the physical therapist would be reporting on the quality measure frequently," she says.

Q: How should I define "fall" when I screen my patients? "You should refer to the Tinetti definition when reporting this measure," said Ken Harwood, PT, PhD, CIE, APTA director of practice, at the outcome measurement course at the APTA annual conference in Denver. That is, a "sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force."

Q: What if I encounter an eligible patient who is wheelchair-bound? Should I still screen him for falls? Technically, you could report Category II code 1100F with modifier 1P to signify that you did not perform the measure for medical reasons -- which will still count toward your bonus since you reported it. But experts believe that not screening a patient simply because she's wheelchair-bound may not be the final answer.

Why: "Often, beneficiaries who utilize wheelchairs do ambulate short distances or transfer on their own, which would put them at risk for falls," Brewer says.

In addition, "if you study the Tinetti definition closely, 'fall' means a change in position to a lower level, so the patient doesn't necessarily have to be standing for a fall to occur," Harwood said.

Best bet: "I would suggest that it is appropriate to screen patients in wheelchairs who perform some mobility tasks," Brewer says.

Q: In a group practice, does CMS track the screen through the practice's NPI? "CMS tracks the 80 percent threshold requirement through individual therapists, so each PT in a group practice needs his or her own NPI," Lee said. And even if you're in a setting, such as a SNF, that's not eligible to report the falls risk screen, you should still be getting your individual NPIs in case you can report it in the future.