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Hiding in Plain Sight


Therapy Coding Billing and Compliance Risk

By Nancy J. Beckley, MS, MBA, CHC
September 2016

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.

Next Steps
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:

  1. 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.

  2. 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 nancy@nancybeckley.com.

Low Arrival Rate Is Lost Revenue

By Michelle Collie, PT, DPT, MS, OCS

Most practices spend resources, time, and money on marketing to referral sources. The planned result is the physician, dentist, or office, referring patients to your practice. But how many of these referred patients actually arrive for their initial evaluation and become real, revenue-producing patients? This variable is most commonly referred to as arrival rate. And a low arrival rate is simply lost revenue and an added expense.

The goal of most practices’ marketing and public relations campaigns is to get new patients. This goal can be further defined and categorized based on the types of new patients; returning or new to the practice, payer type, referred or through direct access, social media, website, or word of mouth—the list goes on. The Healthcare Financial Management Association (HFMA) defines revenue cycle as “All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.” Before any revenue can be captured, managed, or collected, these new patients must arrive for their first visit.

What is your practice’s arrival rate for patients scheduled for an initial evaluation that do not show? How many referrals does your practice receive via fax or electronically, but is unable to make contact with? Alternatively, after contact is made, how many patients decide not to come to physical therapy due to financial barriers, or they decide to go to another practice or seek an alternative type of provider? How many patients are referred but never contact a practice to make an appointment? All of these patients simply add to your marketing, administrative, and clinical expenses and result in lost revenue.

Establish best practices that ensure patients arrive for their first visit. There is a lot more to scheduling a patient than having a pleasant person offering convenient days and times for appointments. Scheduling staff need to understand their goal is not only to schedule a patient but also to ensure they arrive for the initial evaluation. The appropriate verbiage is required to proactively address any barriers or reasons why this patient may not arrive for their first appointment. For example: “Have you been to physical therapy before? Do you know what to expect? Would you like me to provide directions? Are there any reasons why you may not be able to come to your first appointment?” The scheduler is often the first person the new patient comes into contact with, so it is essential to have a person in this role who represents your practice well and has impeccable customer service. The scheduler must also be able to explain to the patient the value of physical therapy and address challenges from the patient who does not want to come to physical therapy despite being referred. Consider offering a free consult to the skeptical patient, or the opportunity to speak with a physical therapist. Be aware of the scheduler who describes physical therapy when asked as “exercise, massage, and dry needling.” This will drive away any patient who asks what physical therapy is! Equip schedulers with answers to questions on cost, what treatment will consist of, frequency and duration. Consider how the scheduler explains the cancellation policy. Finally, the scheduler can tell the patient who their physical therapist is and any additional information, establishing a personal connection between the patient and clinician before the first visit.

When appointments are made days in advance, consider additional reminders the day before the scheduled appointment; a text message, email reminder, or another phone call. There are many automated systems available that are separate or integrated into many EHRs (electronic health records). Alternatively, a welcome email that introduces the patient to the practice and the physical therapist they will see.

Establish what “unable to reach patient” means for your practice. One unanswered phone call to a referred patient should not result in a note being sent to the referral source stating “unable to reach patient.” What time are phone calls made and to which number? Can the referral source provide multiple ways to reach the patients? If contact cannot be made via a phone call, consider sending emails, postcards, or letters to patients’ homes.

How many patients receive a referral for physical therapy and never actually call to make an appointment? Or how often does a physician inform you they referred “lots of patients,” yet your records show one or two. Assess how every office makes their referrals and find solutions to the patient who leaves with a referral in hand but who never follows through with making an appointment. Online referral systems, faxes, and phone calls are all options to be considered. Additionally, consider the information the referral source gives to the patient. A professional and informative brochure representing your practice is more likely to result in a patient calling to schedule their initial evaluation.

Arrival rate is important to track as part of any practice’s revenue cycle management. Ongoing refinement in your practice’s processes including analyzing the data, training in best practices, and the communication of clear expectations and goals will ensure as many referrals as possible turn into real, revenue-generating patients.


Michelle Collie, PT, DPT, MS, OCS, is the chair of the PPS PR and Marketing Committee and chief executive officer of Performance Physical Therapy in Rhode Island. She can be reached at mcollie@performanceptri.com.

PPS Announces 2016 Awards

PPS is pleased to present the recipients of the Section’s 2016 awards. Awards Committee Chair Drew Bossen, PT, MBA along with committee members Patrick Graham, PT, MBA; Curt DeWeese, PT; Kelly McFarland, PT, DPT; Carl DeRosa, PT, DPT, PhD, FAPTA; and Andrew Clarke, PT, presented this slate of award recommendations to the PPS Board of Directors. Please join the Private Practice Section in congratulating our award recipients at the opening keynote session and reception Wednesday evening, October 19th in Las Vegas.

2016 Robert G. Dicus Award


David Qualls, PT

Owner, Qualls & Co

The Private Practice Section’s (PPS) Board of Directors is very pleased to announce that the 2016 Robert G. Dicus Award winner is David Qualls, PT. For the last four decades, David has exemplified the highest level of servant leadership, in both his professional and personal communities. As a PT, he has been actively involved in advocacy of this profession at the state and national levels through his ongoing participation in both the Louisiana Physical Therapy Association and the APTA. David has served in various capacities with both organizations, including as president and chief delegate of the LPTA and as a member of the PPS Board of Directors. He has indeed mastered the art of balancing patient care while advocating and protecting our profession.

Moreover, his role as a servant leader has extended beyond the bounds of our professional arena and into David’s own personal community. If you know David, you are aware that his community involvement lights up his face; it is simply an extension of all that he sees as his responsibility to give back from what he calls his treasure trove of experiences. He inspires others by his quiet demeanor, steadfast faith in his abilities and those of others, and a sense of humor that keeps everyone reminded that life is good.

Indeed, David is the definition of a “Southern Gentleman.” Yet, he is also a sharp and cunning PT who has stood firm in representing both the profession and our patients. In light of his many years of humble leadership and his continued advocacy of our profession, it is an honor of this organization to bestow the 2016 Robert G. Dicus Award to David Qualls.

Jayne L. Snyder Practice Award


Daniel Rootenberg, PT, DPT, CSCS

President, SPEAR Physical Therapy Centers of New York City

The Private Practice Section’s (PPS) Board of Directors is very happy to announce Daniel Rootenberg, PT, DPT, CSCS, and SPEAR Physical Therapy Centers of New York City as the recipient of the 2016 Jayne L. Snyder Practice Award. SPEAR PT has made a uniquely positive impact on the profession of physical therapy. They have elevated the reputation and exposure of the private practice physical therapist on a state, regional, and national level. SPEAR was the first physical therapy private practice to ring the bell at the New York Stock Exchange when on May 4, 2016, during small business week, they were featured live on MSNBC. This nationally covered event put private PT practice in the spotlight.

In addition to leadership, SPEAR PT also has a very intense clinical focus and is a leader in the field. In 2013, Columbia University presented SPEAR with the Leadership in Clinical Education award. SPEAR prides itself on their clinical mentoring program, as well as their monthly manual therapy workshops. These group sessions allow therapists to hone their clinical skills through a collaborative learning approach, with an emphasis on striving toward growth and clinical excellence.

Every team member at SPEAR lives and breathes their SPEAR-IT values and strives to provide a personalized experience with clinical excellence and 5-star customer service. As a group, they have been able to impact the lives of over 10,000 New Yorkers this year across their 9 Manhattan locations. Since its founding in 1999 by Dan Rootenberg and David Endres, SPEAR Physical Therapy has become one of the faster growing outpatient physical therapy providers in New York City. Our collective congratulations to Dan and the entire team at Spear PT.

Friend of Private Practice Award


James C. Hall

Owner and General Manager, Rehab Management Services, LLC

The PPS Board of Directors is pleased to honor James Hall of Cedar Rapids, Iowa, as the recipient of the section’s 2016 Friend of Private Practice Award. Jim truly exemplifies advocacy and support of private practice across this country. Though an accountant by trade, Jim has supported our collective mission and vision for years. Jim first started contributing to the PT community on a national level through frequent postings on PT Manager.com, a website that began in 1998 and continues to be considered a “go to” resource for private practitioners. Through this contribution he began to develop relationships with clinicians, business owners, and other experts in the national physical therapy private practice arena. Jim’s contributions include serving on the PPS payment policy committee from 2012 until present. He is also the payment policy committee liaison to the PPS administrator counsel.

This past spring, Jim joined the Iowa delegation at the APTA Government Affairs Forum in Washington, D.C., advocating for our causes to members of Congress. Despite the fact that Jim is not a physical therapist, he passionately advocates for the profession as though he is. His dedication to our profession has been demonstrated time and time again by the countless hours spent working to improve our future as private practice business owners. If you know Jim, you also know that he does this not to advance himself or his business but rather he does this because of the passion that he has for our profession.

On behalf of our profession, thank you for your contribution.

Service Award


Jim Morgan

Owner/President, Let’s Meet, Inc

The PPS Board of Directors is pleased to present the 2016 Board Service Award to Jim Morgan. This award was established by the PPS Board of Directors to honor an individual who has made extraordinary contributions above and beyond the duties of their position. Jim’s service to the section over the past 15 years as our conference planner and director exemplifies the intent of this award.

As the Owner/President of Let’s Meet, Inc., Jim and his Let’s Meet family are a staple of the PPS Annual Conference and have provided the foresight and leadership to make the meeting not only the best meeting in physical therapy but one of the finest professional meetings in the country. Under Jim’s stewardship, attendance at the PPS annual conference has grown 225%. He has endured three different PPS presidents and worked with multiple program chairs, driving us to always provide the best possible product. What comes off as a polished final product is largely due to Jim’s tireless behind-the-scenes manipulations. Jim’s professional expertise is unequaled, but it is his humor, compassion, and love for the section that makes him extraordinary.

Jim’s career has spanned many fields—none of which included being a physical therapist—but over the years the knowledge he has gained about issues that face the successful physical therapist in private practice that have been useful in his own entrepreneurial career. Having worked with PPS is one of his proudest engagements. Jim is grateful to have had the opportunity to work with the very talented and dedicated PPS members and staff whose commitment to the section has shaped PPS and who continue to strive to make PPS viable and set the standard for all physical therapists, especially those in private practice. The Private Practice Section is honored to have Jim as our friend and colleague.

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