Application of Billing and Reimbursement Tina Patel Gunaldo PT, PhD, DPT, MHS

Objectives  Understand the influence of national, state, and local organizations on occupational therapy documentation and practice.  Exhibit the ability to document speech language pathology services to demonstrate accountability of service provision and meet standards for reimbursement as required by the practice setting, third party payers, and regulatory agencies.  Understand the impact of current policy issues related to models of health care, education, community, and social systems within the context of occupational therapy.  Articulate the implications of federal and state regulation and legislation and how they impact speech language pathology practice.

Insurance Plans  Indemnity Plan - plan that reimburses the patient and/or provider as expenses are incurred; Fee for Service plan  Greatest freedom of patient choice  Preferred Provider Organizations (PPO) – plan with a network of providers, where patient is allowed more freedom to seek medical care without referrals from PCP (in network and out-of- network opportunities )  Point of service plans (POS) - HMO and PPO hybrid  Health Maintenance Organizations (HMO) – plan with a network of providers, where patient selects a primary care physician (PCP) and additional referrals are made through this medical office; PCP = Gatekeeper  Low premiums for patients  Exclusive provider organizations (EPO) – plan where care is restricted to in-network only, no out-of-network benefits  Most restrictive for patients

Medical Payment Systems  Fee-for-Service  Episode Payment  Single price for an entire episode of care (all services needed in inpatient and outpatient)  Comprehensive Care Payment  Condition-adjusted capitation/risk adjusted  Single price for all services needed by a group for a fixed period of time ymentSystemisBest.pdf

Medical Insurance Terminology  Copayment  A form of cost sharing where the patient pays a fixed dollar amount when a medical service is received.  Deductible  A form of cost sharing where, within a benefit period, a patient pays for medical expenses before the insurance company begins to make payments.  Coinsurance  A form of cost sharing where the patient pays a percentage of medical expenses after the deductible amount is paid.

Medical Insurance Terminology  Fee Schedule Fee Schedule  Billing a set amount based on CPT codes  Contractual Adjustment  You bill $100 but contracted amount is $55  A Contractual Adjustment is a part of a patient’s bill that a doctor or hospital must write-off (not charge for) because of billing agreements with the insurance company. Adjustments, or write- off’s, are the dollars that are adjusted off a patient account for any reason. The Contractual Adjustment is the most common type of adjustment.  An example of a Contractual Adjustment is when a provider charges a practice fee for a certain service of $100. The contracted rate between the insurance company and the provider for this service is $80, with the insurer paying $64, or 80%, and the remaining 20% of the contracted rate amount paid by the patient. The $20 difference between the $100 charged by the provider and the $80 collected is adjusted off the patient account as a contractual adjustment.  Allowable Amount  This is where we try to get that remaining $45 from the client to be fully reimbursed  Providers charge more for services than what the insurance company agrees to pay and the amount that is paid by the insurance is known as an allowable amount. The amount above what the insurance company agrees to pay is a reduction known as a contractual adjustment. Providers that participate believe the broader access to members is worth the contracted rates on services. Additionally, this is a way the providers can ensure that they are paid at least a significant portion of their fee which patients without insurance may not be able to afford.

Billing and Reimbursement  Billing  Amount billed by health care provider for services a patient has received  Reimbursement  Amount paid by an individual or organization for services Billed Amount ≠ Reimbursed Amount

CPT Codes  Time vs. Service CPT Codes  Time  Direct one-on-one patient care  minutes  Can bill more than one unit daily per discipline per patient  Service  Generally untimed  Bill one unit daily per discipline per patient  Exception  Can bill more than one unit per day if patient is seen at separate time (am/pm treatments)  Document

CPT Codes  Timed or Service?

CPT Code Application  Using a draft SOAP note, progress summary or lesson plan and the SLP Superbill with CPT codes  1) Determine whether the CPT codes are timed-based or service-based  2) Document the correct number of billing units per CPT code based on the time spent

CPT Code Application  In groups, share your note along with the suggested CPT code(s) and units for billing with a member of your group. Peer reviewers should provide feedback on agreement or suggested alternatives for CPT code units.

Medicare Part B (Time based codes)  8 minute Rule – page 37 before you can bill your first code  this 8 min will be the same code 8 minute Rule  8-22 minutes = 1 billable unit  minutes = 2 billable units  minutes = 3 billable units  minutes = 4 billable units

CPT Code Application  Using the 8 Minute Rule  1) Document the correct number of billing units per CPT code based on the time spent

CPT Code Application  In groups, share your note along with the units for billing with a member of your group. Peer reviewers should provide feedback on agreement or suggested alternatives for CPT code units based on the 8 Minute Rule.

CPT Code Application  8 Minute Rule  Additional Examples – page 39 Additional Examples

Example  Prospective Payment System (PPS) for SNF Facility Prospective Payment System (PPS)  Patient cases are categorized using the Resource Utilizations Groups (RUGs) for Medicare Part A recipients  The Minimum Data Set (MDS) is completed to determine reimbursement for CMS  RAI Manual – Resident Assessment instrument RAI Manual  ASHA Guidance ASHA Guidance

Example  Outpatient Medicare Benefit Policy Manual Outpatient Medicare Benefit Policy Manual  Page  Certification/Recertification Plan of Care - Initial Plan of Care (within 30 days), and every 90 days following  Has to be signed by referral source  Progress Note – at least once every 10 th treatment day

Components of a Bill/Claim  NPI Number (10 digit number)  The Health Insurance Portability and Accountability Act (HIPAA) required a unique national provider identifier for each health care provider (professional or supplier)  Medicare Provider Enrollment Information Medicare Provider Enrollment Information  CMS - NPI of practitioner and physician who routinely reviews plan of care

Revenue Codes  PT =42x; OT=43x; ST=44x  X=0 General  X=1 Visit  X=3 Group  X=4 Evaluation or Re-evaluation  X=9 Other  Placed on the UB92 form  NGS Revenue Codes – page 36 NGS Revenue Codes  Revenue Code must be accompanied with a therapy modifier  GO = OT; GP = PT; GN = SLP

Medicare Therapy Caps  Part B  Per beneficiary therapy cap is $1920 for physical therapy and speech language pathology services combined and $1920 for occupational therapy servicestherapy cap  Medicare pays $ (80%) and beneficiary pays $ (20%)  CMS Limits on Therapy Services Document CMS Limits on Therapy Services Document  Exceptions to Therapy Cap - application of KX Modifier on billKX Modifier

National Correct Coding Initiatives  CCI Edits  Initiative to prevent up-coding in therapy providers providing Part B therapy  Other insurance carriers may use CCI edits as well, you need to ask  Applies to private practice, hospital-based outpatient, Rehab Agencies, SNF Part B, HH and CORF under Part B  Implement to decrease fraud and abuse  Federal False Claims Act Federal False Claims Act  Office of Inspector General – OIG Workplan  Recovery Audit Contractors (RACs) CCI Edits  CCI Edits CCI Edits

Physician Quality Reporting System (PQRS)  Reporting program that uses incentive payments and payment adjustments to promote the quality of information reported Reporting program  Resource Guide Resource Guide

Documentation  Follow guidelines provided by  Board of Examiners –  National Association –  Insurance Companies/Payers  CMS - Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition. CMS  700 Form - Plan of Treatment 700 Form  701 Form - Updated Plan of Progress 701 Form

Non-Payable G-Code for Functional Limitations and Severity Modifiers  Via nonpayable G-codes and modifiers  Status  On eval  On 10 th treatment day (not less)  On discharge  Report on only 1 functional limitation at a time – primary functional limitation  If skilled services are medically necessary after primary limitation is resolved, report on second functional limitation on next date of service after primary limitation is “discharged”  G-codes and modifiers need to be documented on a claim and in the medical record

Multiple Procedure Payment Reduction (MPPR)  The Affordable Care Act of the Social Security Act  HHS to identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with a single service.  Full payment is made for the unit or procedure with the highest practice expense (PE) payment.  For subsequent units and procedures, same NPI, furnished to the same patient on the same day, full payment is made for work and malpractice and 80 percent payment for the PE for services furnished in office settings and other non-institutional settings (physician and private practice) and at 75 percent payment for the PE services furnished in institutional settings (Part B – CORF, SNF, HH OP hospital and rehabilitation agencies) % reduction in payment  For therapy services furnished by a group practice or “incident to” a physician’s service, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines (including physical therapy, occupational therapy, or speech-language pathology).

Multiple Procedure Payment Reduction (MPPR)  Codes subject to MPPR Codes subject to MPPR  Applies to therapy services provided in physician offices, private practice, SNF Part B, HH Part B, CORF, Rehab Agencies and OP Hospital-based  Reason for payment reduction – CMS notes that there is duplicate clinical labor included in the practice expense for the CPT codes noted and there is increased utilization of OP therapy services.

Multiple Procedure Payment Reduction (MPPR)  Patient receives x 2 and x 1  Before MPPR = $83.67  $28.43 x 2 = $56.86  $26.81 x 1 = $26.81  After MPPR = $79.69  $28.43 x 1 then $25.85* x1  $24.41*  * reduced payment

Reimbursement  Payer sources can have different rules/policies on billing, claims processing and reimbursement  In order to reduce the number of denials follow payer guidelines  Documentation must support medical necessity  Pre-authorization of therapy services  Ask for covered/non-covered CPT codes for discipline  Visit limitation  Time frame limitation  Dollar value limitation  Advance Beneficiary Notice of Noncoverage Form Advance Beneficiary Notice of Noncoverage Form  Medicare formform

Other  Students  Only services of a therapist can be billed and paid under Part B ; therapist has to be direct supervision of student  Conditions of Participation and Conditions for Coverage Conditions of Participation and Conditions for Coverage  Minimum Health and Safety Standards healthcare organizations must have in order to participate in Medicare and Medicaid programs