Reimbur$ement: Show Me the Money! Carolyn A. Dobson, MT-BC AMTA Reimbursement Committee Representative WRAMTA Conference - Long Beach, CA April 1, 2011

Reimbursement Sources Medicare Medicare –Partial Hospitalization (PHP) Healthcare Common Procedure Coding System (HCPCS) Healthcare Common Procedure Coding System (HCPCS) Activity Therapy Code: G0176 Activity Therapy Code: G0176

Reimbursement Sources Medicare Medicare –Prospective Payment System (PPS) In-Patient Rehab & Psychiatry In-Patient Rehab & Psychiatry Hospice Hospice Skilled Nursing Facilities (SNFs) Skilled Nursing Facilities (SNFs)

Reimbursement Sources Medicare Medicare –Minimum Data Set (MDS) Restorative Care Restorative Care Section O: Special Treatments, Section O: Special Treatments, Programs, And Procedures Programs, And Procedures O0400: Therapies

MDS 3.0 Section O Importance of O Item Rationale –Health-related Quality of Life Maintaining as much independence as possible in activities of daily living, mobility, and communication is critically important to most people. Functional decline can lead to depression, withdrawal, social isolation, breathing problems, and complications of immobility, such as incontinence and pressure ulcers, which contribute to diminished quality of life. The qualified therapist, in conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents. Maintaining as much independence as possible in activities of daily living, mobility, and communication is critically important to most people. Functional decline can lead to depression, withdrawal, social isolation, breathing problems, and complications of immobility, such as incontinence and pressure ulcers, which contribute to diminished quality of life. The qualified therapist, in conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents. Rehabilitation (i.e., via Speech-Language Pathology Services and Occupational and Physical Therapies) and respiratory, psychological, and recreational therapy can help residents to attain or maintain their highest level of well-being and improve their quality of life. Rehabilitation (i.e., via Speech-Language Pathology Services and Occupational and Physical Therapies) and respiratory, psychological, and recreational therapy can help residents to attain or maintain their highest level of well-being and improve their quality of life.

MDS 3.0 Section O Criteria for Applicable Treatments, Procedures, & Programs Applicable treatments/ procedures include: Services provided by or under the direction of a qualified occupational or physical therapist Services provided by or under the direction of a qualified occupational or physical therapist Skilled therapy services only Skilled therapy services only Respiratory, psychological, and recreational therapy that meet specific criteria only Respiratory, psychological, and recreational therapy that meet specific criteria only Applicable treatments/ procedures do not include: Services provided solely in conjunction with surgical services and diagnostic services Services provided solely in conjunction with surgical services and diagnostic services Non-skilled services Non-skilled services Minimum Data Set (MDS) 3.0 Section O August 2010

Purpose of O0400 Therapies Conduct the Assessment Determine : Therapy(ies) the resident received Therapy(ies) the resident received Mode for each therapy received Mode for each therapy received How many minutes the resident spent in each mode of therapy during the look-back period How many minutes the resident spent in each mode of therapy during the look-back period Number of days of therapy during the look-back period Number of days of therapy during the look-back period Document the start and end date of each therapy. Document the start and end date of each therapy. Review the resident’s medical record. Review the resident’s medical record. Rehabilitation therapy evaluation Rehabilitation therapy evaluation Treatment records Treatment records Recreation therapy notes Recreation therapy notes Mental health professional progress notes Mental health professional progress notes Consult with each of the qualified care providers. Consult with each of the qualified care providers.

The RAI Version 3.0 Manual states that Recreation Therapy is NOT a skilled service according to the Security Act however, for purposes of the MDS, providers should record services for recreational therapy when the conditions for the provision of recreation therapy are as follows: The physician orders Recreation Therapy that provides therapeutic stimulation beyond the general activity program; The physician orders Recreation Therapy that provides therapeutic stimulation beyond the general activity program; The physicians order must include a statement of frequency, duration, and scope of treatment; The physicians order must include a statement of frequency, duration, and scope of treatment; The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a therapeutic recreation specialist; The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a therapeutic recreation specialist; The services are required and provided by a state licensed or nationally certified therapeutic recreation specialist or therapeutic recreation assistant who is under the direct supervision of a therapeutic recreation specialist; and The services are required and provided by a state licensed or nationally certified therapeutic recreation specialist or therapeutic recreation assistant who is under the direct supervision of a therapeutic recreation specialist; and The services must be reasonable and necessary for the resident’s condition. The services must be reasonable and necessary for the resident’s condition. Special Treatments and Therapies: Section O Special Treatments and Therapies: Section O

Remember………Remember……… The assessor records the number of days and the minutes that recreation therapy was administered over the 7 day look back period. Sessions must be at least 15 minutes in length. The RAI Version 3.0 Manual states that therapy logs are not a MDS requirement but is standard of good clinical practice by all therapy professionals. The assessor records the number of days and the minutes that recreation therapy was administered over the 7 day look back period. Sessions must be at least 15 minutes in length. The RAI Version 3.0 Manual states that therapy logs are not a MDS requirement but is standard of good clinical practice by all therapy professionals. It’s also important to note that when two clinicians work together, which may be common with a recreational therapist and an occupational therapist, the clinicians must split the time between the two disciplines. It’s also important to note that when two clinicians work together, which may be common with a recreational therapist and an occupational therapist, the clinicians must split the time between the two disciplines. Music Therapy is included under Recreational Therapy as well. Music Therapy is included under Recreational Therapy as well.

Reimbursement Sources Medicaid Medicaid –Approved Providers –Waiver Programs

Reimbursement Sources Private Insurance Private Insurance –Indemnity –Preferred Provider Organization (PPO) –Health Maintenance Organization (HMO) –Point of Service (POS)

Reimbursement Sources Workers’ Compensation Workers’ Compensation TRICARE TRICARE Automobile Insurance Automobile Insurance

Reimbursement Sources Adoption Subsidy Adoption Subsidy State and County Boards/Departments State and County Boards/Departments –Health –Social Services –Developmental Disabilities

Reimbursement Terminology Diagnostic Codes Diagnostic Codes –ICD 9 (CM) Procedural Coding Procedural Coding –CPT  2011 –HCPCS Revenue Codes Revenue Codes

Reimbursement Process Step One: Obtain your National Provider Identifier Number (NPI) Step One: Obtain your National Provider Identifier Number (NPI) –“Respiratory, Developmental, Rehabilitative and Restorative Service Providers”

Reimbursement Process Step Two: Seek Referrals Step Two: Seek Referrals Physicians, Psychologists, Social Workers, Case Managers, Parents, Clients, Allied Healthcare Providers Step Three: Collect Insurance Information Step Three: Collect Insurance Information –Music Therapy Pre-Approval Form –Assignment of Benefits Form –HIPAA Notice

Reimbursement Process Step Four: Determine Client Needs Step Four: Determine Client Needs –Initial Assessment: Brief or Full –Define the scope, duration, and frequency of music therapy treatment –Determine Medical/Behavioral Necessity

Reimbursement Process Step Five: Prepare Marketing Materials Step Five: Prepare Marketing Materials –Music Therapy Definition –Supportive Research –Health Care Industry Recognition –Qualifications

Reimbursement Process Step Six: Contact Primary Care Physician Step Six: Contact Primary Care Physician –Provide MT information –Seek Written Referral –Request Diagnostic Codes International Classification of Diseases- International Classification of Diseases- 9 th Revision (ICD-9)

Reimbursement Process Step Seven: Select Procedure Codes that best describe Step Seven: Select Procedure Codes that best describe MT interventions –Current Procedural Terminology (CPT) –Determine Rates/Fees Per Code

Reimbursement Process Step Eight: Call the Insurance Company Step Eight: Call the Insurance Company –Request Case Manager Review –Present Diagnostic (ICD-9) and Procedure Codes (CPT) –Review Pre-Approval Process –Negotiate Rates –Request Reporting Requirements

Reimbursement Process Step Nine: Provide MT Interventions Step Nine: Provide MT Interventions –Document all elements of treatment Assessment Assessment Treatment Descriptions Treatment Descriptions Potential Cost Savings Potential Cost Savings Client Response to Treatment Client Response to Treatment Functional Outcomes Achieved Functional Outcomes Achieved

Reimbursement Process Step Ten: Complete Claim Forms Step Ten: Complete Claim Forms –CMS 1500 – clm104c26.pdf Step Eleven: Submit Claim Step Eleven: Submit Claim –Include Required Attachments

Reimbursement Process Step Twelve: Follow-up with Payer Step Twelve: Follow-up with Payer –Appealing an Adverse Decision What was the reason for denial? What was the reason for denial? Who made the initial decision? Who made the initial decision? What is the appeals process? What is the appeals process? What additional information is needed to review the appealed case? What additional information is needed to review the appealed case? Involve the referring physician Involve the referring physician Involve the patient/family Involve the patient/family

Reimbursement Tips –Don’t Stop at “NO” –Develop Relationships with Insurance Company Case Managers –Present Clear and Accurate Information –Respond to All Communication in a Timely and Professional Manner

Resources

AMTA Reimbursement Committee Representative Carolyn A. Dobson, MT-BC