Hiding in Plain Sight
Therapy Coding Billing and Compliance Risk
By Nancy J. Beckley, MS, MBA, CHC
It all started out with a call from a health law attorney. He represented a small private practice that was under investigation. The therapy practice was in receipt of a civil investigative demand (CID); the U.S. Attorney’s office was involved as well as investigators representing federal health care programs. Is therapeutic exercise a one-on-one code? mused the attorney. If it is, how can a small practice stay in business if they have to treat patients individually? was the follow-up question.
Unfortunately, I have received many similar calls in the past year. Whistleblower cases, audits under the Office of Inspector General (OIG) Work Plan (Physical Therapists in Private Practice), Medicare Administrative Contractor (MAC) widespread probes and provider-specific probes, and unannounced visits by Zone Program Integrity Contractors (ZPICs). Outpatient physical therapy has been on the review radar with the OIG for over six years.
Reports under the OIG Work Plan are routinely published to the OIG’s website, and if nothing else they should serve as learning tools for all outpatient therapy providers, not just those in private practice. There have also been several settlement agreements and/or integrity agreements for small therapy providers in just the past several months. We have come a long way since the original OIG reports on Gem Physical Therapy and World Gym (both in South Florida) issued 16 years ago, and a long way from the “big news” corporate integrity agreements of 10 years ago with HealthSouth and Physio. All of these reports, Department of Justice (DOJ) press releases, corporate integrity agreements, and self-disclosures to the OIG all make for great case studies in compliance training and education. They make for even better case studies if you know both sides of the story.
So what do you need to do to mitigate compliance risk at your practice, and how can you use the posted settlement agreements, integrity agreements, DOJ press releases, OIG audit reports and crafting training programs, lunch and learns to mitigate compliance risk? A caveat: Just because your practice has been paid for submitted claims does not mean the claims would be considered payable if they were reviewed by a Centers for Medicare & Medicaid (CMS) contractor.
Group Code (CPT©97150) Let’s start with the obvious. This is a current code that is valued and listed in the Medicare Physician Fee Schedule. CMS even provides alternative scenarios in using the group versus individual treatment codes. Do you use the group code at your practice? Should you use the group code at your practice? Do your groups have more than one patient? Do you bill the Medicare beneficiary for group, but other patients being treated at the same time for a 1:1 code? Would it surprise you to know that it doesn’t matter if the “other” patient is covered by commercial insurance?
The code descriptor for group is “therapeutic procedures(s), group (two or more individuals).” Group therapy procedures involve constant attendance, but by definition do not require one-on-one patient contact. So the definition of group includes more than two individuals. How is that to be documented in order to demonstrate that you complied with coding? A good example of documentation requirement for those providers with National Government Services (NGS) as their Medicare Administrative Contractor (MAC) is:
“The purpose of the group and the number of participants in the group. Description of the skilled activity provided in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual.”
If you are using the group code, do you have more than one person in your group? Are you meeting the documentation requirements to support the use of the code?
Aquatic Therapy Code (CPT©97113) Medicare coverage of aquatic therapy, as noted in the local coverage determinations (LCDs) of many CMS MACs, is contingent on demonstrating the need for aquatic-based exercises, including a transition to land-based exercises and therapy. Over the years there have been a number of cases involving aquatic therapy. In one case the therapy provider billed the state’s Medicare program for therapeutic exercise because aquatic therapy was not a covered service. In another case the practice owner instructed staff to conduct “group” aquatic therapy classes and bill as if individual aquatic therapy was provided.
First Coast Services (FCSO), the Florida MAC, indicates that aquatic therapy may be considered medically necessary if at least one of the following conditions is present and documented if the patient:
“has rheumatoid arthritis; has had a cast removed and requiring mobilization of limbs; has paraparesis or hemiparesis; has had a recent amputation; recovering from a paralytic condition; requires limb mobilization after a head trauma; or is unable to tolerate exercise for rehabilitation under gravity based weight bearing.” So if the patient is unable to tolerate exercise under gravity, is this documented in your evaluation and/or ongoing assessment?
Do you provide aquatic therapy at your clinic? Is the pool on site in the clinic? If the pool is not on site at your clinic, and you provide aquatic therapy at a community pool, do your policies conform to CMS requirements for the use of a community pool? (CMS policy differs for private practice and rehab agencies on the use of community pools.) Does your documentation include the medical necessity of aquatic-based exercises?
Self-Care Home Management Training Code (CPT©97535) When you are developing a home exercise program (HEP) for a patient, how are you documenting the time, and ultimately coding and billing for the time spent in developing and progressing the HEP? If you are using the self-care management training code to instruct your patient and progress your patient in their HEP, you should review the code description to ensure meeting the code’s descriptor. Looking again to guidance from the NGS’s LCD:
“This code should not be used globally for all home instructions. When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity. For example, if the instruction given is for exercises to be done at home to improve ROM or strength, use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if instructing the patient on using a sock aide for dressing, use 97535; if teaching the patient aquatic exercises to use as an independent program in the community pool, use 97113.”
Vasopneumatic Devices (CPT©97016)
If you are treating patients with lymphedema, you are most likely familiar with the vasopneumatic code.
There seems to be a trend with therapists using this code to describe (and bill for) the use of ice and compression. Some commercial payers have reportedly approved the use of this code to reduce swelling. With respect to Medicare, are you documenting the area of the body being treated, the location of edema along with objective edema measurements (1+, 2+ pitting, girth, etc.) and doing a comparison with the uninvolved side? Does your evaluation document the effects of edema on function? Do you describe the type of device used? This is what is expected in lymphedema treatment. In the absence of a lymphedema diagnosis, the use of this code for compression and ice may be considered upcoming.
If you are billing Medicare for this code, your documentation should include all the aforementioned details.
A few high-risk codes have been identified from recent audits and reviews. But any code can turn out to be a high-risk code depending on the circumstances and your MAC. For example, NGS continues to conduct a widespread probe review in Illinois on the use of whirlpool (97022) for all provider types including physician therapists. Hand therapists using this code to report and bill for fluidotherapy are finding that their claims are subject to review and often not paid, even if documented in accordance with the LCD.
Providers are reporting that Wisconsin Physicians Service (WPS) is requesting Additional Documentation Request ADRs on the use of group therapy code. The providers report little success in getting paid, even upon appeal.
To keep you on track and help mitigate compliance risk, two items move to the top of the list and should be considered a minimum starting point for your practice:
- Exclusions Monitoring and Sanctions Check. There is an expectation that your practice does not employ individuals who have been excluded from participation in federal health care programs. The OIG maintains a list of excluded individuals and entities that is updated monthly. Although not a requirement, it is an essential underlying element of compliance commitment.
In addition to querying all your employees (https://exclusions.oig.hhs.gov/), you should check Medicare exclusions lists, keeping in mind that 37 states maintain their own exclusions list and at this time do not report to the OIG. The most frequent reason for exclusion? According to the folks at Provider Trust (http://providertrust.com), it is license infractions.
- Compliance Plan & Program. Compliance plans are required under the Affordable Care Act, but they are only applicable to skilled nursing facilities until CMS publishes further guidance. In light of that the OIG has suggested that providers use the OIG compliance guidances that are provided at their website (http://oig.hhs.gov/compliance/compliance-guidance/). The OIG guidance for individual and small-group physician practices specifically mentions the applicability to physical therapists in private practice and indicates that compliance plans can be scalable to the practice.
Please join me at the Private Practice Section’s annual conference in Las Vegas for my session on “Audits and Investigations: The True Hollywood Story.”
Nancy J. Beckley, MS, MBA, CHC, is certified in health care compliance by the Compliance Certification Board and is a frequent speaker and author on outpatient therapy compliance topics. She advises practices on compliance plan development and audit response. Questions and comments can be directed to firstname.lastname@example.org.