1. February 2014 Jean C. Russell, MS, RHIT jrussell@epochhealth.comjrussell@epochhealth.com Richard Cooley, BA, CCS rcooley@epochhealth.comrcooley@epochhealth.com Matthew H. Lawney, MSPT, MBA, CHC mlawney@epochhealth.com 518-430-1144

2. 2 Agenda Payment Basics 2014 PT / OT / SP Codes Deleted Codes New Codes Significant Changes Therapy Cap Claims-based data collection for therapy services Modifiers

3. 3 Payment Medicare Majority of codes are paid off the Physician Fee Schedule Some APC Services Majority of codes are “timed codes” Services must be performed under a “plan of care” New to hospitals Payment Caps Outcome reporting

4. 4 Payment Medicaid Either paid under APGs or off Fee Schedule depending if facility has a “clinic rate” APG reimbursement higher than Fee schedule reinbursment

5. 5 Payment Medicaid Units impact reimbursement for many therapy procedures Discounted, not consolidated E/M will not be packaged when reported with the therapies – that is, both will be paid

6. 6 Payment Medicaid Each visit should be separately reported Do not bill recurring therapies on different dates of service on separate claims Beginning July 1, 2010, therapies performed in hospital outpatient departments (even those that are referred amb) will be reimbursed under APGs Translation – Bill the therapies with a rate code (e.g., 1432)

7. 7 Deleted Codes 92506 – Evaluation of speech, ;language, voice, communication, and/or auditory processing disorder

8. 8 New Codes 92521 - Evaluation of speech fluency (eg, stuttering, cluttering) 92522 – Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) 92523 - Evaluation of speech sound production; with evaluation of language comprehension and expression (eg, receptive and expressive language) 92524 – Behavioral and qualitative analysis of voice and resonance

9. 9 Why New Speech Codes? The four new evaluation codes were developed by ASHA in collaboration with experts in the field from ASHA's Special Interest Groups. AMA's Relative Value Update Committee re-evaluated speech- language pathology codes to include "professional work" value (one of three components of a code's value that reflects the amount of time, technical skill, physical effort, stress, and judgment required to provide the service. Developed specific evaluation procedure codes to replace 92506 to more accurately and appropriately value the professional work performed.

10. 10 Can They be Billed Together? Neither the CPT Handbook or the National Correct Coding Initiatives (CCI) edits restrict an SLP's ability to bill the new codes together. There are circumstances when it is appropriate for a patient to be evaluated for multiple disorders on the same day. The exception is the same-day billing of the combination of 92522 and 92523, which is restricted by both the CPT Handbook and CCI edits. In cases when multiple evaluations may be appropriate, documentation should clearly reflect a complete and distinct evaluation for each disorder. Evaluation codes should not be billed for brief assessments that could be considered screenings.

11. 11 92523 - What if Language Evaluation is Only Performed? If a patient is evaluated only for language, SLPs should bill 92523 with the -52 modifier -52 is used when the services provided are reduced in comparison with the full description of the service There is also an aphasia assessment code (CPT 96105) that may be appropriate for some patients

12. 12 Non-speech Generating Device Evaluation Medicare Part B instructs SLPs to use the deleted code CPT 92506 to bill for a non-speech generating device evaluation ASHA recommends billing CPT 92523 until a better replacement is developed.

13. 13 Therapy Cap In 2014, the annual per beneficiary therapy cap amounts are: $1,920 for physical therapy and speech language pathology services combined There is a separate $1,920 amount allotted for occupational therapy services.

14. 14 Therapy Cap In 2014, the therapy caps with an exceptions process applies to services furnished in the following outpatient therapy settings: Physical, Occupational and Speech Therapists in private practice, physician offices, skilled nursing facilities (Part B), rehabilitation agencies (or ORFs), and comprehensive outpatient rehabilitation facilities (CORFs), and outpatient hospital departments. Application of the therapy cap in critical access hospitals (CAHs) for 2014

15. 15 Therapy Cap Exception Exceptions applicable for therapy services in excess of the cap amount delivered any time during the 2013 calendar year. The 2 exceptions processes are: An automatic exception process A manual medical review exception process Applies to patients who meet or exceed $3,700 in therapy expenditures for PT/SLP combined and A separate $3,700 in occupational therapy expenditures.

16. 16 Automatic Exceptions May be made when the patient's condition is justified by documentation that indicates the beneficiary requires continued skilled therapy to achieve their prior functional status or maximum expected functional status within a reasonable amount of time. Can be used for any diagnosis for which they can justify services exceeding the cap.

17. 17 Automatic Exceptions The automatic exception can be used for claims that are between $1,900 and $3,700 Claims exceeding $3,700 will be subject to manual medical review in order to be paid

18. 18 Submitting a Request for an Automatic Exception When the beneficiary qualifies for a therapy cap exception, the provider should apply the KX modifier to the therapy procedure code subject to the cap limits Codes subject to the therapy cap tracking requirements are listed in a table in the Medicare Claims Processing Manual, Chapter 5, Section 20(B)

19. 19 Using the KX Modifier The KX modifier attests that the services billed: Qualified for the cap exception; Are reasonable and necessary services that require the skills of a therapist; and Are justified by appropriate documentation in the medical record. It should not be routinely applied

20. 20 Additional Documentation Providers do not need to submit additional documentation for automatic exceptions Documentation justifying the services are necessary in response to any Additional Documentation Request (ADR) for claims that are selected for medical review.

21. 21 Manual Medical Review Claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to a manual medical review. Criteria for medical review is based on current medical review standards. Medicare Administrative Contractors (MAC) have 10 business days to make decisions regarding whether services will be approved over the $3,700 threshold

22. 22 Manual Medical Review If a decision is not made by the MAC within 10 business days, the MAC should notify the provider that they did not review the request and that claims beyond the $3,700 threshold will be approved. Advanced approval will allow an additional 20 treatment days beyond the $3,700 amount. Does not guarantee payment. May still be reviewed retrospectively When more than 20 days are required the provider must submit an additional request for more service.

23. 23 Manual Medical Review Advanced approval should be requested before providing the service. When a provider did not request advanced approval prior to providing services over $3,700 Payment for the claims will stop Request for medical records will be sent to the provider Provider will be subject to prepayment review for those claims (approximately 60 day review period)

24. 24 Manual Medical Review Refer to the MAC website for information on what is required for advanced approval Providers may and should submit the request to the MAC when the patient is close to exceeding the $3,700 if additional services are medically necessary. Submit the KX modifier on the claim form when therapy services exceed $3,700, the MACs will also give the provider a tracking number that should be placed on the claim

25. 25 Identifying Cap Dollars The cap is an annual cap It does not reset with a change in diagnosis Providers may access the accrued amount of therapy services from the ELGA screen inquiries into CWF Providers may access the remaining therapy services limitation dollar amount through the 270/271 eligibility inquiry and response transaction Providers who bill to FIs will find the amount a beneficiary has accrued toward the financial limitations on the HIQA

26. 26 Not Qualifying for Exception If the patient does not qualify for an exception to the cap, they can continue to receive services and pay for these services out of pocket The provider must obtain a signed Advanced Beneficiary Notice (CMS-R-131) (ABN) from the patient

27. 27 Not Qualifying for Exception Providers should continue to submit the claim to Medicare with the modifier for a denial: GA (Waiver of Liability Statement Issued as Required by Payer Policy) GY (Notice of Liability Not Issued, Not Required Under Payer Policy) GX (Notice of Liability Issued, Voluntary Under Payer Policy) codes Can bill a secondary insurance

28. 28 Functional Reporting Beginning July 1, 2013, practice settings that provide outpatient therapy services had to include on claim forms information regarding the beneficiary’s function and condition, therapy services furnished, and outcomes achieved. Failure to do so results in payment penalties

29. 29 Functional Reporting Apply to PT, OT and SP services furnished in: Skilled Nursing Facilities (Part B stay) Rehabilitation Agencies Home Health Agencies (for beneficiaries who are not under a Home Health plan of care, are not homebound, and whose therapy or other services are not paid under the Home Health prospective payment system) CORFs (PT, OT, and SLP services) Hospitals, including beneficiaries in Outpatient and Emergency Departments, and inpatients paid under Part B Critical Access Hospitals Therapists in Private Practice Physicians: Medical Doctors (MDs), Doctors of Osteopathy (DOs), Doctors of Podiatric Medicine (DPMs), and Doctors of Optometry (ODs) NPPs: Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs ).

30. 30 Purpose of Functional Reporting Medicare uses this information to reform future payment structure for outpatient therapy services Moving towards a bundled payment system Through data collection of beneficiary function CMS hopes to: Understand who uses therapy services Understand how a patient’s functional limitations change over time as a result of the therapy

31. 31 Functional Reporting CMS is not currently changing how therapy claims are paid. The rules governing therapy documentation and reimbursement and coverage requirements all remain the unchanged

32. 32 The G-Codes CMS will require providers to report G-codes to collect information on beneficiaries’ function and condition on claims forms 42 G-codes were established to describe the patient’s functional limitation that is the primary reason for the therapy services

33. 33 Review of G Codes CPT/HCPCSDescription CPT/HCPCSDescription G0456Neg pre wound <50 sq cm G8998Swallow D/C status G0457Neg pres wound >50 sq cm G8999Motor speech current status G8978Mobility current status G9158Motor speech D/C status G8979Mobility goal status G9159Lang comp current status G8980Mobility D/C status G9160Lang comp goal status G8981Body pos current status G9161Lang comp D/C status G8982Body pos goal status G9162Lang express current status G8983Body pos D/C status G9163Lang express goal status G8984Carry current status G9164Lang express D/C status G8985Carry goal status G9165Atten current status G8986Carry D/C status G9166Atten goal status G8987Self care current status G9167Atten D/C status G8988Self care goal status G9168Memory current status G8989Self care D/C status G9169Memory goal status G8990Other PT/OT current status G9170Memory D/C status G8991Other PT/OT goal status G9171Voice current status G8992Other PT/OT D/C status G9172Voice goal status G8993Sub PT/OT current status G9173Voice D/C status G8994Sub PT/OT goal status G9174Speech lang current status G8995Sub PT/OT D/C status G9175Speech lang goal status G8996Swallow current status G9176Speech lang D/C status G8997Swallow goal status G9186Motor speech goal status

34. 34 G-Code Examples Mobility: Walking & Moving Around G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset and at reporting intervals. G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. Swallowing G8996 Swallowing functional limitation, current status, at time of initial therapy treatment/episode outset and reporting intervals. G8998 Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation

35. 35 G- Codes Therapists should familiarize themselves with all 42 of the new G- codes. Required for PT, OT and SP services

36. 36 G-Code Modifiers With each G-code, a modifier must be reported to demonstrate the severity and complexity of the functional limitation. There are seven modifiers which could be selected (a seven point scale) The therapist bases the assessment on the score of an outcome measurement tool as well as their skilled clinical knowledge In addition to reporting G-codes and modifiers, the therapists must continue to report the GO, GP, and GN modifiers as appropriate

37. 37 G-Code Modifiers

38. 38 HCPCS codes should be accompanied by the following modifiers in FL 44. The modifiers are: GN: Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care GO: Service delivered personally by an outpatient occupational therapist or under an occupational therapy plan or care GP: Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care Other Relevant Modifiers

39. 39 Always and Sometimes Therapy Codes The following codes are “always therapy” services. These codes always require therapy modifiers (GP, GO, GN): 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92607, 92608, 92609, 96125, 97001, 97002, 97003, 97004, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762, 97799, G0281, G0283, G0329.

40. 40 Continued… “ Sometimes Therapy” No modifier is required if not performed by a therapist under a therapy plan of care. However, these codes when performed by a therapist require the use of a therapy modifier: 90901, 92610, 92611, 92612, 92614, 92616, 95831, 95832, 95833, 95834, 95851, 95852, 96105, 96110, 96111, 97532, 97597, 97598, 97602, 97605, 97606, 0019T, 0029T

41. 41 Initial Evaluation Codes 97001 and 97003 o Include all components necessary to evaluate the patient; all tests and measurements performed during the initial evaluation are inclusive of the code and should not be separately reported. o Only one unit of an initial evaluation should be billed regardless of the time spent with the patient. o Treatments performed in addition to the initial evaluation can be separately reported as long as Medicare requirements are met.

42. 42 Billing Units Constant attendance" services require direct one-on-one provider-patient contact and generally fall within the 97032-97762 HCPCS ranges. The CDM Description should indicate these codes as timed codes When performed, medically necessary and documented, the therapist may bill for multiple units 42

43. 43 Patient Contact Time Time Interval Units Billed 8 – 22 Minutes1 23 – 37 Minutes2 38 –52 Minutes3 53 – 67 Minutes4 68 – 82 Minutes5 83 – 97 Minutes6 98 – 112 Minutes7* *The time interval / units billed follow the same pattern should greater than 7 units be performed

44. 44 Timed Codes (CPT Rules) The expected average time spent for these codes is 15 minutes Providers should not bill for services performed for less than 8 minutes If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time 44

45. 45 Example 24 minutes of code 97112 and 23 minutes of code 97110 were furnished Total treatment time was 47 minutes; 3 units can be billed for this encounter. The correct coding is: 2 units of code 97112 1 unit of code 97110 Assign more units to the service that took the most time. 45

46. 46 Specific Limits for HCPCS 46

47. 47 Questions and Discussion

48. 48 Contact Us Jean Russell Phone: 845-642-6462 Email: mlawney@EpochHealth.Com@EpochHealth.Com Richard Cooley Phone: 518-430-1144 Email: RCooley@EpochHealth.ComRCooley@EpochHealth.Com Jean Russell Phone: 518-369-4986 Email: JRussell@EpochHealth.ComJRussell@EpochHealth.Com

49. 49 http://www.EpochHealth.com/

50. 50 CPT ® Current Procedural Terminology (CPT®) Copyright 2012 American Medical Association All Rights Reserved Registered trademark of the AMA

51. 51 Disclaimer Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.