SNF Therapy Audit help! Level 3 dispute!

bundydelly

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This is going to be long, and I apologize. I need some help from anyone with SNF experience, especially with billing of CPT codes. Here goes....

The first denial came back stating:

"The 5 day assessment, ARD 8/3/17 pays for 8/1-8/3/17 and the 14 day/COT assessment ARD 8/10/2017 pays for 8/4-8/12-17. Billed RVB x 3 days and RUB x 9 days, validated RHB x 3days and RUB x 9days. The CMS RAI manual requires clinical documentation of daily therapy minutes provided. The ST minutes are incorrectly coded on the 5 day assessment compared to documentation received. Evaluation minutes are not to be included on the MDS."

On 8/1 this is what was done- 92507 (47 minutes) 92523 (55 minutes) and 96125 -59 (60 minutes). 8/2 92507 (36 minutes) and 8/3 92507 (31 minutes)

We had a total of 174 minutes of ST on the MDS. My interpretation of what they said was that they thought we were including the 55 minutes for the 92523 - Evaluation of Speech Sound Production. We did not, it was the 96125 with -59 Standardized Cognitive testing which includes face-to-face time administration and interpretation and report.

I sent that in over 2 months ago and we got yet another denial/upholding of the Level 1 stating:

This is what they state in a letter we received on 7/20/18.

Per CMS guidelines, CPT code 96125 is a billable code if face-to-face tested is completed and the interpretation is not completed by a technician or coputer. The treatment code completed for CPT code 96125 does not indicate how the testing and interpretation of testing were completed. Unable to determine if all time billed for CPT code 96125 was billable minutes. The eval is digitally signed by the ST, that' show it reads and it's our Speech Therapist. Are they reading that as Tech?!



In a letter we received 7/18 they state:

Per CMS guidelines, CPT code 96125 is a timed code and evaluation time cannot be billed on the MDS, only time for interpretation of the evaluation and preparation of the report are billable. Documentation provided does not distinguish between evaluation minutes and interpretation minutes.

So they have 2 letters stating 2 different reasons for denial. I'm not even the biller here, I'm the coder, I do diagnosis coding for my facility. And I'm the only one so it's frustrating at this point. This is the first time I've worked in LTC/SNF so I need all the help I can get with this one.

Thank you for taking your time to read this!
 

cgaston

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This is going to be long, and I apologize. I need some help from anyone with SNF experience, especially with billing of CPT codes. Here goes....

The first denial came back stating:

"The 5 day assessment, ARD 8/3/17 pays for 8/1-8/3/17 and the 14 day/COT assessment ARD 8/10/2017 pays for 8/4-8/12-17. Billed RVB x 3 days and RUB x 9 days, validated RHB x 3days and RUB x 9days. The CMS RAI manual requires clinical documentation of daily therapy minutes provided. The ST minutes are incorrectly coded on the 5 day assessment compared to documentation received. Evaluation minutes are not to be included on the MDS."

On 8/1 this is what was done- 92507 (47 minutes) 92523 (55 minutes) and 96125 -59 (60 minutes). 8/2 92507 (36 minutes) and 8/3 92507 (31 minutes)

We had a total of 174 minutes of ST on the MDS. My interpretation of what they said was that they thought we were including the 55 minutes for the 92523 - Evaluation of Speech Sound Production. We did not, it was the 96125 with -59 Standardized Cognitive testing which includes face-to-face time administration and interpretation and report.

I sent that in over 2 months ago and we got yet another denial/upholding of the Level 1 stating:

This is what they state in a letter we received on 7/20/18.

Per CMS guidelines, CPT code 96125 is a billable code if face-to-face tested is completed and the interpretation is not completed by a technician or coputer. The treatment code completed for CPT code 96125 does not indicate how the testing and interpretation of testing were completed. Unable to determine if all time billed for CPT code 96125 was billable minutes. The eval is digitally signed by the ST, that' show it reads and it's our Speech Therapist. Are they reading that as Tech?!



In a letter we received 7/18 they state:

Per CMS guidelines, CPT code 96125 is a timed code and evaluation time cannot be billed on the MDS, only time for interpretation of the evaluation and preparation of the report are billable. Documentation provided does not distinguish between evaluation minutes and interpretation minutes.

So they have 2 letters stating 2 different reasons for denial. I'm not even the biller here, I'm the coder, I do diagnosis coding for my facility. And I'm the only one so it's frustrating at this point. This is the first time I've worked in LTC/SNF so I need all the help I can get with this one.

Thank you for taking your time to read this!


They keep stating that the documentation does not support the code billed. They must not see the report the same way you do.
 

bundydelly

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Horton, MI
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I wrote a letter and sent with the Level 2 dispute, I broke it down for them. And their reasoning for the upholding of the 2nd level is different from the level 1 dispute. :confused:

The ST Daily Treatment Note does in fact include CPT code 92525, Evalutaion of speech sound production; etc. for 55 minutes. These minutes were not included on the MDS as stated above.

It also includes CPT code 96125, Standard Cognitive Testing/Interpretation, one hour. With that our Speech Therapist as included modifier -59, “Distinct Procedural Service” – Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. These are the minutes that our facility has included on the MDS for payment for date of service 8/1/2017, ARD 8/3/2017.

DOS 8/1/2017
92507-Speech Therapy-- 47 minutes
96125-Standard Cognitive Testing-- 60 minutes with modifier -59 present
107 minutes

DOS 8/2/2017
92507-Speech Therapy-- 36 minutes

DOS 8/3/2017
92507-Speech Therapy--- 31 minutes

174 total minutes included on MDS
 
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