Physical Medicine and Rehabilitation 97000 Series CPT Codes

CRT Clinical Service: Challenges and Strategies
February 27, 2015
ISS 2015
CRT Clinical Service:
Challenges and Strategies of
Operating a Seating Clinic
Laura Cohen,PhD, PT, ATP/SMS
Barbara Crume, PT, ATP
• Laura Cohen, PhD, PT, ATP/SMS
– Principal, Rehabilitation & Technology
Consultants, LLC- Arlington, VA
– Executive Director, Clinician Task Force (CTF)
• Barbara Crume, PT, ATP
– Seating and Mobility Specialist with CarePartners
Health Services- Asheville, NC
– Member CTF, Ex-Officio Executive Board Member
Objectives
• Explain 3 threats to sustainability of Seating and
Wheeled Mobility (SWM) Clinics
• Describe 3 strategies to improve seating clinic
quality and efficiency
• Identify therapy payment issues driving SWM
clinic practices
• Describe how to advocate to ensure clinical CRT
services are incorporated into CRT legislative
and regulatory initiatives
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
CRT Team Approach Critical
to Service Delivery Process
Trends Influencing CRT Team
Approach
• Supplier Trends
– Mergers/acquisitions
– Negative impact of policy trends resulting in shrinking
margins
– Redesigning services
• Availability/participation in SWM clinics
• Availability of loaner/trial equipment
– In Clinic
– In Home
• Dedicated rotating schedule based on location
• Patient’s responsible for bringing equipment to supplier or
waiting until service tech will be in area
Trends Influencing CRT Team
Approach
• Therapist Trends
– Negative impact of policy trends resulting in shrinking margins
• Therapy cap and other payment regulations
• Unsustainable contracts (e.g. Medicaid, private payers)
• Consolidated billing/Capitated service agreements
– Mergers/acquisitions
• Non-profit hospitals converting to for-profit
• Shift in mission/purpose/priorities to serve the community
– Diminishing research funds
• Increased competition and fewer awards for Model System Centers
of Excellence and related services
– Redesigning services to align with ACA and new models of care
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Building Capacity
• Threats to SWM clinics directly impact supplier
access to qualified LCMP’s
– Jeopardize access to complete medical documentation
required to justify patients’ need for CRT
• Need to engage/educate therapists beyond
specialty SWM clinics to meet public need
–
–
–
–
Home Health Care (HHC)
Extended Care Facilities (ECF)
Assisted Living
IP Rehab
Challenges to Building Capacity
• Difficult to identify therapists (e.g rural areas)
– Critical mass
– Due to low reimbursement
– Medicare Cap limiting access
• Extensive paperwork- time consuming/redundant
processes
– PT/OT LCD documentation requirements PLUS
– DME LCD documentation requirements
• Therapists/MDs are not interested in learning for
occasional/infrequent referral
– do not know how to document, OR
– do not want to provide documentation
Poll for Suppliers
• Where do you obtain most of your clinical
documentation for CRT requests?
A.
B.
C.
D.
E.
F.
G.
H.
Physician only
Specialty SWM clinic
Other specialty clinic (ALS, MS, CP, etc.)
Physician plus OP clinician
Physician plus Home Health clinician
Inpatient rehab team
Inpatient acute care team
Other
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Internal Supplier Study
• Results
– 90% denial rate for PMD requests with no therapy
evaluation provided
– Only 10% of referrals had ‘complete’ physician
documentation
Dedicated SWM Clinics
SWM Locations
•
•
•
•
•
University/Medical Centers
Regional Referral Centers (e.g. Mayo Clinic)
Dedicated Model Centers
Regional and Local Rehab Centers
Specialty Clinics
– ALS, MD, MS, Spina Bifida, Pediatric clinics
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
SWM Clinics
• Viewed as service to community
– not money makers, usually lose money or
break even
• Increasing trend in facility acquisitions
converting non-profit to for-profit centers
– Several clinics have been downsized or
eliminated around the country
• Schwab Rehab, Braintree Rehab
Survey Monkey
• How is your wheelchair seating and
mobility clinic funded ? (13 responds)
– Medical insurance payments -8
• Medicare, Medicaid and private health insurance
– Facility/school, unable to bill for services -2
– Pro bono clinic-1
– Funded by business owner -1
– Grant – 1 (10% funding from grant)
CarePartners (CP) Report Card
• Salary and overhead cost = >150% productivity
• CP considers SWM services to be a ‘value
added’ service to community
• Contractual adjustments average 60% of UCC
• Payor mix - 36% Medicare, 32% Medicaid, 34%
other
• Example:
–
–
–
–
Charge for evaluation is $215.00, our cost is $248.00
Medicare allowable is $ 70.82
Medicaid reimbursement is $61.83
BCBS reimbursement is $182.75
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Reimbursement Data
• Few clinics have access to payment data
to identify problems and errors
• Survey Monkey (14 respondents)
– “Do you at least break even after contractual
adjustments?”
•
•
•
•
Yes – 4
No – 2
Don’t know or unsure – 5
N/A - 2
Clinic Referral Management
Referrals
• Ideally support staff manages referrals
– Receive phone calls/faxes/emails from doctors,
patients, caregivers, therapists, case managers,
suppliers
– When a supplier refers to SWM
• helpful if supplier obtains MD order for PT/OT to evaluate
and treat
• obtain copy of MD medical records – H&P, annual exam,
admit/dc notes, test results, last 2 progress notes
– Obtains demographic & insurance information
– Schedules evaluation with therapist
– Inquires about Home Health services
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Education of Referral Sources
• Should begin upon referral
• Explain process to complete CRT
recommendations
• Physician role with F2F requirements
– Dear Physician Letter
– DMAC Education Tools
– http://www.cgsmedicare.com/jc/claims/denial_
help_aid.html
Consolidated Billing
Home Health Agencies (HHA)
• Paid under prospective payment system
– Consolidated Billing
– Per patient/episode of care
• Specialty Clinic OP Facility
– may contract with HHA provide services
– facility cannot bill Medicare directly if under HHA
episode
– HHA episode of care may not appear for 30 days in
system (Medicare Database verification)
• HHA not permitted to discharge patient to
receive OP SWM services
CarePartners Home Health
• CarePartners has a HH agency
– HH therapists contact HH Case Manager for
approval of referral to seating clinic
– SC Patient Access contacts HH Case
Manager for approval when referrals received
direct from doctors
– Procedures billed are transferred to HH cost
center
– Therapist time is transferred to HH cost center
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Other HH Agencies
• Other HHAs contract with CP and are
billed Medicare allowable rate
• Companies without contract are billed
usual and customary rate
• Access staff obtain signed approval for
payment of services stating expected CPT
codes and cost per code
Acute Care Hospitals
Skilled Nursing Facilities (SNFs)
• Consolidated Billing applies for IP Acute
Care Hospitals and SNF (under Part A)
• OP SC cannot bill Medicare for an OP visit
when patient is an IP at another facility
• CP does have a contract with acute care
hospital. Access Staff obtains signed
agreement for payment of services.
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Prior Authorization
• Access staff contacts private insurance
prior to initial evaluation
• Insurance Verification Form
– Preferred provider
– Amount of deductible
– Co-insurance
– Out Of Pocket- met for year
– Visit limitations, visits used
Access Staff
• Obtain PA for evaluation and therapy visits
• Confirm if time limitation per visit
– Many Insurance companies only pay for 1
hour of therapy per visit
• Confirm CPT codes covered
– NC Medicaid does not cover 97755
– Some plans may not cover 97542 or 97760
• Alert therapist to obtain Medicaid PA
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Access Staff
• Completion of
insurance forms
• Signatures
• Copy cards for our
records and supplier
• Collect co-pay
• Medical Intake Form
Medical Intake form
• Diagnoses, impairments, medications,
surgeries past and future, pain, skin condition,
current equip receipt date/supplier, problems,
goals
• Send form to patient to complete and return
prior to appointment- often forget to bring with
them
• Complete over the phone – very time
consuming for access staff
• Complete upon arrival in clinic- time
consuming, therefore request they arrive early
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Intake Information
• Supplier assistance necessary for
– Information on current equipment, age,
condition, repair history, cost to repair
– Home assessment when already completed
(or if completed following evaluation), provide
your documentation to therapist!
– Functional issues observed during home
assessment
Coding & Payment
• Viable SWM outpatient clinics use
appropriate CPT coding to maximize
payment
– Multiple visits
– Time limited appointments
– Proper utilization of codes and modifiers on
same date of service
Codes primarily used for
Evaluation, Fitting and Training
• 97001or 97003 Evaluation PT or OT
• 97542 Wheelchair management
• 97750 Physical Performance Test or
Measurement
• 97755 AT Assessment
• 97760 Orthotics Fitting & Training
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
CPT Codes
• Reference your PT/OT LCD criteria
– Each Fiscal Intermediary has different LCD
• Locate an LCD:
http://www.cms.gov/medicare-coveragedatabase/overview-and-quick-search.aspx
Payment Policies
Medicare Fee Schedule
• Fee Schedule: allowed charge, the lower of
the actual charge or fee schedule amount.
• Medicare Payment is 80% of allowed charge
after deductible met.
• Medicare patients must meet annual
deductible ($147) and pay 20%, or their
secondary insurance pays 20%
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Threat # 1 Medicare Cap
• Therapy cap amount $1940 for OT and $1940
for PT and Speech therapy combined
• Recipients still pay $147 deductible and 20% of
the $1940 ($388)
• Evaluation to determine need for therapy is
covered even if patient has exceeded therapy
cap
• Therapy Cap Exceptions Process($1940-$3700)
– when medially necessary and documented
– Provider must use KX Modifier with codes billed
Medicare Cap
• Manual medical review
– When the $3,700 threshold is exceeded
– No pre approval process
• Collecting Out of Pocket
–
–
–
–
Patient doesn’t qualify for exception
Obtain signed Advanced Beneficiary Notice (ABN)
Collect from beneficiary &/or bill secondary insurance
Insurance may require denial from Medicare
SGR Legislation
• Long Term Fix for SGR Therapy Cap
– Senate Finance Committee Proposal
• Repeals SGR
• Freezes Medicare Fee Schedule for 10 years
• Provisions for payment incentives above base rate
– Value based quality performance incentive programs
– Alternative payment methods
• New medical review & PA program in 2015
• New data collection system for functional reporting
– House Ways & Means Proposal
• Repeals SGR
• Allows .5% payment increase/year until 2017
• 2017 payment system based on quality/performance
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Threat # 2 Sequestration
• 2% payment cut for all Medicare providers
• Began April 1, 2013
• Applies to the Medicare payment, not
beneficiary copayment
Threat # 3 Multiple Procedure
Payment Reduction (MPPR)
• Originally went into effect January 1, 2011 with 25%
reduction
• Applies to Practice Expense (PE) portion of each code
• 50% reduction began April 1, 2013
• Example – 4 units 97542 billed in NC would normally be
$118.66, with MPPR and Sequestration, payment is now
$97.13 ($21.53 less)
• MPPR Adoption by private payers (UHC, BCBS, Aetna,
Humana, Worker’s Comp)
(APTA Fee Calculator)
Functional Limitation Reporting
• Medicare requirement beginning July 1, 2013
• Condition for payment
• Submit Functional G code and modifier on the
claim forms
– At time of evaluation, re-evaluation, minimum of 10th
visit, changing of primary limitation and at time of
discharge
• Documentation in the medical record must
include the G-code and modifier, and state how
the modifier was selected
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Functional Limitation Reporting
• Medicare will automatically discharge the functional
episode after 60 days of inactivity (no claims submissions)
• APTA recommends submitting 3 G codes for each visit
• The goal of the functional limitation reporting is data
collection only, but in the future may be used for outcome
based payment.
• Modifier selected based on
– objective, measurable standardized test or
– by the therapist based on clinical judgment using multiple tools
during evaluation process
– CTF working on recommendations for SWM measures for
therapists providing wheelchair seating services
Strategy to Maximize
Efficiency and Payment
Pre-appointment Paperwork
• Schedule 90 min. PT only
• Intake
– Register, complete medical history form,
functional reporting form
• Options
– Preadmission process
– Telephone interview process
– Pt instructed to arrive 30 minutes prior to appt
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Evaluation
• Only perform evaluation at first appointment
without supplier
•
•
•
•
Obtain medical and functional status
Equipment status and posture
Pressure map if needed
Mat assessment
• Establishing a plan of care for future appts
• Identifying necessary trial equipment
• Communicating with supplier
Second visit
• Supplier responsible for preparing equipment for
assessment
– Configuring based on eval notes
• Equipment trials, simulation, and problem solving
• Order forms completed
• Documentation completed with patient present
Poll for Suppliers
• Do you obtain detailed clinical information
specifying configuration of trial equipment
needed for clinic visit?
– What % of therapists that you work with
provide this detailed information?
A.
B.
C.
D.
0-25%
26-50%
51-75%
76-100%
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Paperwork
• Therapist forwards all documentation to supplier
• Supplier responsible to send all documents to
physician for concurrence & signature (except
the POC)
SWM Clinic Constraints
• Excessive UOS may be denied
– May not be billed to the beneficiary
– Cannot be waived or subject to ABN.
• Maximum time/eval limited to 1-1.25 hours
– Business decision
• Collect co-pay at time of visit!
– Necessary to provide charges before end of visit
Documentation
• Meditech EHR system with custom SWM template
– Leverages efficiencies for documentation
– Checklists, comment boxes and text boxes.
• EHR environment changing
–
–
–
–
Administrative decisions often without clinical input
Interfacing systems challenging
International EHR standards constantly changing
Tension between requirements & functionality
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
CarePartners Productivity
• 1993 productivity target = 50%, actual = 34%
– Reasons
• labor intensive service
• handwritten notes
• complete evaluation/trials/recommendations in one visit
– Improvements
• Computer documentation (Meditech, Redoc)
• 2014 productivity target = 75% (24 UOS), actual = 60%
(19 UOS)
– Target 5 patients/day
– Strategies
• Minimize cancellation/no show rate to <10%
• Utilize nonbillable time for case management, communications,
PAs, inventory maintenance, calibrating FSA, etc
Survey Monkey
• What is your SWM clinic productivity
expectation?
– Not sure, encouraged to meet 75%
– 60%
– 5 appts per day
– 3-4 visits per day for 90 mins each
– Unknown, not sure, no idea, don’t have one,
trying to figure that out, too difficult to
ascertain,
Appeals
• Critical to work with business office to identify
denials for clinical services
– Few clinics are notified of denials in clinical services
– Must appeal denials in a timely manner
– A facility may submit an appeal to insurance as
the patient’s representative
– Sustainable SWM clinics seek access to this info
• Support staff can obtain PA and restrictions in
coverage prior to provision of clinical services
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Ideas and Strategies
• Need models that support sustainability
– Efficient & productive systems/operations
• Administrative system design to eliminate
redundancies
• Adoption of program efficiencies
–
–
–
–
–
Administrative program support
Scheduling
Confirming appointments/ “no-show” policies
Cancellation call lists
Pre-appointment intake forms
Ideas and Strategies
• Need models that support sustainability (cont)
• Adoption of EHR systems
– Auto-population of redundant information (pt identifiers, ICD-9, PMH)
– Development/implementation of custom templates for SWM
• esMD S&I Framework Initiative
–
–
CTF participating as industry dedicated member
Pilot projects for PMD Clinical Template underway
Ideas and Strategies
• Need models that support sustainability (cont.)
– Access to data about fiscal health of clinic
– Reasonable payment for services
• access to codes, coverage and payment
• multitude of fiscal intermediaries with dissimilar coverage policies
– Contracts with payers for ‘niche’ services
• SWM evaluation services (HHA, SNFs, ACOs, Medical Homes)
• Wheelchair skills training clinics/camps
– Public Relations Opportunities
• Wheelchair “wash” clinic
• Wheelchair maintenance clinics
• Donations, grants, foundation support, fundraising
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
Ideas and Strategies
– Compliance with infection control & other
requirements
•
•
•
•
•
Cleaning/sanitizing products for trials
Charging schedule for PWCs
Stocking linen
Inventory management
Cleaning tools, mat, FSA etc.
Strategies to Stay Alive
•
•
•
•
Templates for evaluations, interventions and LMNs
Reminder calls to pts to reduce no show/cx
Flexibility to schedule another pt when cx occurs
Review plan with supplier prior to appt to make
sure equipment is ready
• Consider double booking patients for fitting appts
Questions/Discussion
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CRT Clinical Service: Challenges and Strategies
February 27, 2015
References
• Medicare Therapy Services:
– http://www.cms.gov/Medicare/Billing/TherapyServices
/index.html?redirect=/TherapyServices/
– http://www.cms.gov/outreach-andeducation/medicare-learning-networkmln/mlnmattersarticles/downloads/MM8206.pdf
• To locate an LCD:
– http://www.cms.gov/medicare-coveragedatabase/overview-and-quick-search.aspx
• Mobility Device Clinical Documentation Guide
http://www.apta.org/SeatingWheeledMobility
Contact Information
Laura J. Cohen PhD, PT, ATP/SMS
Rehabilitation & Technology Consultants, LLC
Arlington, VA
Laura@rehabtechconsultants.com
404-370-6172
Barbara Crume, PT, ATP
CarePartners Health Services
Asheville, NC
bcrume@carepartners.org
828-274-9567 ext. 4151
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