Clinical and Compliance Bulletin

877.799.9595 | www.evergreenrehab.com
2011 Quarter 3

Coding Corner
FAQ 1. How do I bill for group speech therapy treatment?
There are two group therapy CPT codes that are applicable to speech therapy skilled group treatment. The appropriate CPT code for treatment of speech, language, voice, communication, and/or auditory processing provided to a group of 2 or more individuals is CPT code 92508. CPT code 92508 is an untimed code and only one unit may be billed per day. The appropriate CPT code for treatment of dysphagia is dependent on each FI/MACs Local Coverage Determination (LCD). The majority of the LCDs state the appropriate CPT code for group swallow treatment is CPT code 97150. However, the LCDs for Cahaba and WPS MAC Jurisdiction 5 (Iowa, Kansas, Missouri, and Nebraska) do not follow the CPT code definitions and instead instruct providers to use CPT code 92508 for group swallow treatment. Both CPT codes 97150 and 92508 are untimed codes and only one unit may be billed per day.

LCD
NGS LCD for Swallow Evaluation and Dysphagia Treatment (L27364) NGS LCD for SpeechLanguage Pathology (L27404)

Codes that Support Medical Necessity

438.82, 464.01, 464.51, 478.30478.34, 478.6, 507.0, 787.20-787.24, 787.29 307.0, 315.00 - 315.02, 315.09, 315.1, 315.2, 315.31, 315.32, 315.34, 315.35, 315.39, 315.5, 315.8, 352.1 - 352.6, 356.8, 389.00, 389.01 - 389.06, 389.08, 389.10 - 389.18, 389.20 - 389.22, 438.0, 438.10 - 438.14, 438.19, 438.6, 438.83, 478.30 - 478.34, 478.5, 784.3, 784.40 - 784.42, 784.51, 784.52, 784.59, 784.61, 784.69, 799.51-799.55, 799.59, 996.79, V40.1, V41.2, V41.3, V41.4, V43.81, V52.8, V72.83 146.0 - 146.9, 148.0 - 148.9, 149.0 - 149.9, 161.0 - 161.9, 212.1, 235.6, 307.0, 307.23, 315.00 - 315.02, 315.09, 315.1, 315.2, 315.31, 315.32, 315.34, 315.35, 315.39, 315.5, 315.8, 332.0 - 332.1, 333.0, 333.2, 333.5, 333.6, 333.81 - 333.89, 333.90 - 333.99, 335.20, 341.0 341.9, 342.00 - 342.92, 352.1 352.6, 356.8, 388.40, 388.43, 388.45, 389.00 - 389.06, 389.08, 389.10 - 389.14, 389.17, 389.18, 389.20 - 389.22, 438.10 - 438.14, 438.19, 438.81, 438.83, 464.00 466.19, 470 - 473.9, 476.0 476.1, 478.30 - 478.34, 478.4, 478.5, 478.6, 478.70 - 478.79, 478.9, 524.50 - 524.59, 528.00 528.9, 740.0 - 748.1, 748.2 748.3, 749.00 - 749.04, 749.10, 749.20, 750.0, 750.10 - 750.19, 758.0, 781.8, 783.42, 784.3, 784.40 -784.44, 784.49, 784.51, 784.52, 784.59, 784.60, 784.61, 784.69, 850.0 - 850.9, 851.00 851.99, 854.00 - 854.15, 873.70 873.79, 874.10 - 874.11, 874.5, 905.0, 907.0 - 907.1, 908.3, 996.79, V10.21, V10.85, V40.1, V41.2, V43.81, V52.8

2. My facility has had some speech therapy denials due to ICD-9 codes. How can I be sure I am using the correct codes?
The best way to be sure you are using the correct ICD-9 codes is to refer to the Local Coverage Determination (LCD) for your FI/ MAC. The LCDs often have a list of ICD-9 codes that support medical necessity at the end of the LCD and an ICD-9 code from this list must be on your claim or the claim will be denied. When using the LCDs to determine the most relevant ICD-9 codes, it is important to note that often the FI/MACs have two LCDs one that addresses dysphagia evaluation and treatment and one that addresses communication related speech therapy. For example if your FI/MAC is NGS and you are seeing a patient for swallow deficits and billing 92526, the ICD-9 codes that support medical necessity are in NGS LCD for Swallow Evaluation and Dysphagia Treatment (L27364). If during that patients treatment you want to bill 92507 on a day and it is supported as medically necessary in your documentation, you will have to consult NGS LCD for Speech-Language Pathology (L27404) for the ICD-9 codes that support the medical necessity of 92507. Here are some examples of LCDs and the codes that support medical necessity:

Highmark LCD L27531 - SpeechLanguage Pathology (SLP) Services: Communication Disorders

LCD
Cahaba LCD for Medicine: Dysphagia/Swallowing Therapy (L30005)

Codes that Support Medical Necessity

141.0 - 141.8, 144.0 - 144.8, 145.2 - 145.3, 150.0, 150.3, 161.0 - 161.9, 240.9, 300.11, 438.82, 478.30 - 478.34, 507.0, 530.0, 530.3, 530.5, 530.6, 530.81, 530.85 - 530.87, 783.3, 787.20 - 787.24, V41.6, V43.81, V44.0 307.0, 310.2, 310.8, 315.01, 315.02, 315.09, 315.1, 315.2, 315.31, 315.32, 315.35, 315.39, 315.5, 315.8, 352.1 - 352.6, 356.8, 388.40, 388.43, 389.01 389.08, 389.11 - 389.22, 438.0, 438.11 - 438.19, 438.81 438.83, 478.30 - 478.34, 478.75, 784.3, 784.40 - 784.49, 784.51, 784.52, 784.59, 784.61, 784.69, 799.51 - 799.55, 799.59, 905.0, 907.0, 996.79, V40.1, V41.2 - V41.6, V43.81, V52.8, V72.83 342.00 - 342.92, 434.00 - 434.91, 438.82, 478.30 - 478.34, 507.0, 530.0, 530.3, 530.6, 530.81, 783.3, 784.2, 786.2, 787.20787.24, 787.29, 793.1, 933.1, 934.0, 934.1, V41.6, V48.3

LCD
First Coast Local Coverage Determination (LCD) for Dysphagia/Swallowing Diagnosis and Therapy (L28831) Palmetto Local Coverage Determination (LCD) for Outpatient Speech Language Pathology (L31603)

Codes that Support Medical Necessity

N/A

Cahaba LCD for Medicine: Speech Language Pathology Outpatient (L30010)

WPS Dysphagia (L2603)

WPS J5 MAC (MO, KS, IA, NE) 141.0 - 141.8, 144.0 - 144.8, Dysphagia/Swallowing Therapy 145.2 - 145.3, 150.0, 150.3, 161.0 (L26565) - 161.9, 240.9, 300.11, 438.82, 478.30 - 478.34, 507.0, 530.0, 530.3, 530.5, 530.6, 530.81, 530.85 - 530.87, 783.3, 784.52, 787.20 - 787.24, V41.6, V43.81, V44.0 Trailblazer

294.11, 307.0, 307.23, 307.50, 307.59, 307.9, 310.1, 315.00 315.09, 315.31, 315.32, 315.34, 315.35, 315.39, 315.4, 315.5, 315.8, 331.0, 333.71, 333.79, 333.82, 341.0 - 341.9, 342.00 342.92, 343.0 - 343.9, 344.81 344.89, 344.9, 351.0 - 351.9, 352.1 - 352.2, 358.00, 358.01, 358.2 - 358.9, 359.21 - 359.24, 359.29, 359.3, 359.4, 388.40, 388.41, 388.43, 388.45, 389.00 389.04, 389.05, 389.06, 389.08, 389.10 - 389.18, 389.20 389.22, 389.7, 438.10 - 438.14, 438.19, 438.81 - 438.83, 476.0 476.1, 478.20 - 478.29, 478.30 478.34, 478.4, 478.5, 478.6, 478.70 - 478.79, 507.0, 524.20, 524.21 - 524.29, 524.50, 529.8, 530.0, 530.3, 530.6, 530.81, 748.3, 749.00 - 749.04, 749.10 749.14, 749.20 - 749.25, 750.0, 750.10 - 750.19, 780.99, 781.8, 783.3, 783.42, 784.3, 784.40, 784.41, 784.42, 784.49, 784.51, 784.52, 784.59, 784.60 - 784.69, 784.99, 786.1, 786.2, 787.20 787.24, 787.29, 799.52, 807.5 807.6, 873.70 - 873.72, 873.74 873.79, 874.10 - 874.11, 874.5, 933.1, 934.0, 934.1, V10.21, V40.1, V41.2, V41.4, V41.6, V43.81, V48.2 - V48.7, V52.8, V55.0 N/A

3. With the October 1, 2010 Medicare changes, is it possible to have productivity above 100%?
If only individual treatment is being performed and documented with no unattended modalities, it is not possible to have productivity above 100%. If a therapist provides and documents group or several unattended modalities in a day, it is possible that the productivity for that day may be over 100%.

Keeping Straight on the Regulation Road:

CMS Released the Proposed Rule for Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for Fiscal Year (FY) 2012 on April 29, 2011
Significant changes were proposed for the Skilled Nursing Facility Prospective Payment System (SNF PPS) in FY 2012 in the Proposed Rule issued by the Centers for Medicare & Medicaid Services (CMS) in April. The proposed rule includes: new SNF PPS assessments, clarifications regarding some current assessments, new PPS assessment schedule, revised definition of group therapy, change to student supervision requirements, and two very different payment rate options. Again, these are proposed changes, it is expected that the final rule will be available at the end of July. Once the final rule is published training will be scheduled. Details of some of changes in the proposed rule are discussed below. FY 2012 SNF PPS payment rates: CMS is looking at two different options for SNF PPS payment rates in FY 2012. The first option would adjust for a spike in nursing home payments identified by CMS since the new RUG-IV payment classifications were put into effect October 1, 2010. CMS has stated that since the October 1, 2010 changes, providers filed for reimbursement in the highest rehab classifications at more than four times the expected rate thus triggering Medicare payments far in excess of the original projections. This first option would result in an 11.3% cut in the SNF prospective payment system and would amount to about $3.94 billion less going to providers than in the current fiscal year. The second option would be to apply the standard payment update methodology, which would provide an increase of $530 million, or 1.5 percent to the FY 2012 payment rates. Proposed Changes to MDS 3.0 SNF PPS Assessment Schedule: CMS proposes to modify the current assessment schedule by shortening the Assessment Reference Date (ARD) window and grace days in order to address concerns that the combination of current grace period allowance and observation period could cause MDS assessments to be performed in such a way that some of the information coded on a subsequent assessment is duplicative of the previous assessment. The new proposed schedule is: Assessment Reference Date Grace Days Days 6-8 Days 15-18 Days 30-33 Days 60-63 Days 90-93 Applicable Medicare Payment Days Days 1-14 Days 15-30 Days 31-60 Days 61-90 Days 91-100

Decoding CPT Codes

Each quarter we focus on decoding the mystery of a specific CPT code. This month we will focus on CPT codes 92610 and 92506. The definition for CPT code 92610 is evaluation of oral and pharyngeal swallowing function. It is an untimed code allowing only one unit of billing per day. The code is also used to bill for re-evaluations of oral and pharyngeal swallowing function. The definition for CPT code 92506 is evaluation of speech, language, voice, communication, and/or auditory processing. It is an untimed code allowing one unit of billing per day. The code is also used to bill for re-evaluations of speech, language, voice, communication, and/or auditory processing. It is important to note that if both types of evaluations are performed and documented on the same day, you should bill both CPT codes. In addition, if you are seeing a patient under a plan of care for speech, language, voice, communication, and/or auditory processing and later evaluate swallow you must bill 92610 for the swallow evaluation, document the plan of care for swallow, and get the new plan of care certified by the physician if the patients payor source is Medicare Part B. The same logic applies if the opposite occurs and you are seeing a patient for swallow and later evaluate speech. You must bill 92506 for the speech evaluation, document the plan of care for speech, and get the new plan of care certified by the physician if the patients payor source is Medicare Part B.

Medicare MDS Assessment Type 5 Day 14 Day 30 Day 60 Day 90 Day

Assessment Reference Date Window Days 1-5 Days 13-14 Days 27-29 Days 57-59 Days 87-89

The proposed new Change of Therapy OMRA (COT OMRA) would be required if the patient is in a therapy RUG and the number of therapy minutes changes to such a degree that the RUG from the last assessment no longer accurately reflects the intensity of therapy. This new assessment will require weekly monitoring beginning on day seven after the ARD and then a rolling seven days after. For example, a patients 5 day assessment ARD was Friday 6/10/2011 and the patient was placed in an ultra high therapy RUG. The rolling seven day window for weekly monitoring begins on 6/11/2011 and the minutes received from Saturday 6/11/2011 through Friday 6/17/2011 are evaluated on Friday 6/17/2011. In this example the minutes of therapy fell below the ultra high therapy RUG requiring a COT OMRA and the assignment of a lower therapy RUG. The patient continues to receive therapy and on 6/24/2011 the minutes are evaluated again and the minutes of therapy increased back to an ultra high therapy RUG requiring a COT OMRA and the assignment of the higher therapy RUG. CMS proposes to require that an EOT OMRA be completed once all therapy services cease for three consecutive days, regardless of the reason whether planned or temporarily due to illness, patient refusal or visits to the doctors office. Under the proposed rule all facilities will be considered seven day a week facilities and all days of the week will count toward the three consecutive days whether therapy was scheduled or not. For example if a patient was not seen on Saturday or Sunday and misses all therapy on Monday, an EOT OMRA is required. If therapy resumes within 5 days at the same RUG level, the facility will have three options to obtain a therapy RUG again: 1. Complete the new end of therapy resumption assessment (EOT-R) which requires a resumption date on the EOT. Using the new EOT-R OMRA does not require the completion of a SOT OMRA and does not require a new therapy evaluation when therapy resumes. 2. Complete a SOT OMRA 3. Wait until the next scheduled assessment If therapy does not resume within 5 days or resumes within 5 days but at a different therapy RUG level, the facility will have to complete the EOT OMRA, complete a SOT OMRA or wait until the next scheduled assessment, complete a new therapy evaluation, and complete a new care plan.

CMS indicated concerns that the current therapy reporting methods have created an inappropriate payment incentive to replace concurrent therapy with group therapy, so the agency proposes to apply to group therapy the same methodology now being used to count minutes under concurrent therapy. CMS also proposes to modify its definition of group therapy to therapy provided simultaneously to four patients performing similar activities. Under the CMS proposal, SNFs would continue to report the total group therapy minutes on the MDS 3.0 for each patient, but the MDS software will only allocate 25% of the group minutes to the minutes counting toward the RUG classification. For example, four patients seen in a group session for 60 minutes would each have 60 group minutes entered on the group line in section O of the MDS. The software would divide the 60 minutes by 4 and only 15 minutes would count toward the RUG. CMS proposes to revise current policy regarding the supervision of therapy students so that a therapy student working in an SNF would no longer be required to be in the supervising therapists line of sight. According to CMS National Coverage Determination 270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds, the use of ES and electromagnetic therapy for the treatment of wounds are considered adjunctive therapies, and will only be covered for chronic (have not healed within 30 days of occurrence) Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers only after appropriate standard wound therapy has been tried for at least 30 days and there are no measurable signs of improved healing. If ES or electromagnetic therapy is being used, wounds must be evaluated at least monthly by the treating physician. ES and electromagnetic therapy will not be covered as an initial treatment modality and continued treatment with ES or electromagnetic therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Therapy remains the focus of many Fiscal Intermediaries (FIs) as well as the Regulatory and Law Enforcement Agencies of the Federal Government as the commitment to deterring fraud, waste and abuse in the Medicare and Medicaid systems has increased.

The OIG issued a report on 5/6/2011 entitled Review of Physician Therapy Services Provided During Home Health Episodes in Calendar Year 2008. The Medicare home health prospective payment system (HH PPS) requires consolidated billing of home health services; however, in May 2003, the Centers for Medicare & Medicaid Services (CMS) instructed Medicare contractors to allow Part B payments for therapy services furnished during home health episodes whenever those services were billed with a physician specialty code. The OIG sought to determine whether the HH PPS base rate includes reimbursement for physician-provided therapy services that are also separately billable by physicians and are not subject to the consolidated billing requirement. The OIG found that although CMS has allowed Part B payments to physicians for therapy services furnished during home health episodes since 2003, the home health base rate was not adjusted because CMS officials believed that the effort to determine the extent of physician-provided therapy included in the base rate did not justify the perceived benefit in improved payment accuracy. As a result, when a physician bills Part B for therapy provided to a beneficiary during a home health episode, Medicare pays twice for the same service: once to the physician under Part B and again to the home health agency under the HH PPS. The OIG recommended that CMS eliminate any duplicate payments when rebasing home health payments by adjusting the HH PPS rate to exclude physicianprovided therapy services or by making physician therapy services subject to the consolidated billing requirement again. In its written comments, CMS agreed with the OIGs recommendation and provided information on action that it planned to take to address the recommendation.

If convicted on all counts, Crisler faces a maximum penalty of 10 years in federal prison on the healthcare fraud charge, a fine of $250,000, or twice the gross gain/loss caused by the offense, whichever is greater, and a term of supervised release of not more than three years. He faces a consecutive mandatory minimum of two years in federal prison on the aggravated identity theft counts. The indictment also notifies Crisler that the United States intends to seek a money judgment or forfeit any assets which are alleged to be traceable to proceeds of the offense

Sault Saint Marie Physical Therapist and Wife Sentenced to Jail for Health Care Fraud
A press release issued on April 13, 2011 by the Western District of MI US Attorneys Office announced that Aaron Clark, a physical therapist, and his wife, Michelle Clark, both of Sault Ste. Marie, Michigan, were sentenced to jail on criminal charges related to their operation of Superior Physical Therapy in Sault Ste. Marie. The allegations in the Indictment alleged that the Clarks defrauded BCBSM and Medicare using a variety of schemes to obtain payment for services that were not provided or did not qualify as physical therapy. U.S. District Court Judge Robert Holmes Bell sentenced Aaron Clark to two years federal imprisonment, three years of supervised release following prison, and restitution to Blue Cross Blue Shield of Michigan (BCBSM) and Medicare totaling $345,000.00. During the same hearing, Judge Bell sentenced Michelle Clark to 90 days imprisonment, one year of supervised release, and the same $345,000.00 in restitution.

Occupational Therapy Assistant Charged with Healthcare Fraud and Identity Theft in Connection with Medicaid
On May 17, 2011 the United States Attorney Robert E. ONeill announced in a press release the return by a grand jury of an indictment charging Patrick Crisler (45, Inverness) with six counts of health care fraud and six counts of aggravated identity theft. According to the indictment, Crisler, an occupational therapy assistant and owner of Active Life Rehab, Inc., was charged with health care fraud and aggravated identity theft for submitting fraudulent claims of more than $1 million to the Medicaid program for occupational therapy services that were either not provided at all, or not provided as billed to Medicaid.

Brooklyn Physical Therapist Pleads Guilty to Fraud Scheme Involving False Billings to Medicare
The Department of Justice issued a press release on 5/13/2011 announcing that a Brooklyn physical therapist pleaded guilty for his role in submitting false and fraudulent claims to Medicare for physical therapy services that were medically unnecessary and never provided. According to the indictment, between January 2005 and July 2010, Kharkover caused the submission of approximately $11.9 million in false and fraudulent claims to Medicare for physical therapy services that were not performed and were not medically necessary. According to the indictment, Kharkover hired individuals who were not certified as physical therapy assistants to purportedly provide physical therapy to Medicare beneficiaries. Kharkover faces a maximum of 10 years in prison for each count of health care fraud. His sentencing has not yet been scheduled.

Contact Information:
Liz Barlow, Vice-President of Clinical Services 502.400.1619 liz@evergreenrehab.com Shawn Halcsik, Director of Compliance 414.791.9122 shalcsik@evergreenrehab.com