Understanding Medicare's requirements and ensure your practice is compliant!
Essential information, necessary actions, and steps to maintain compliance in your practice.
No one enjoys dealing with paperwork. Therapists are caring individuals who focus on their patients' needs. They love sharing in the joy when patients make progress and feel appreciated. But therapists are super busy. Whether they're in a small or large practice, they spend a lot of time with each patient and see multiple patients every day. Sadly, the job isn't over when the session ends. Therapists, like all medical professionals, are required to document each treatment encounter according to specific guidelines, and that takes time.
Documenting patient treatment encounters is crucial for therapists to track both short-term and long-term treatment progress and to inform future treatment planning. Additionally, thorough and defensible documentation is vital for justifying treatments to secure payment from payers.
As time goes on, some therapists might start cutting corners with their paperwork. I mean, time is money, right? The more patients they see, the more cash the practice pulls in. The faster the notes are written, the sooner the workday is over. And really, what's the chance of getting audited? It's not like this is life threatening surgery; it's just therapy. Who's even looking at my notes anyway?
Whether you own a private practice or work as a therapist in a small or large clinic, getting a documentation review (audit) request from a payer can catch you off guard. Think your practice can handle a claims review? Let's see!
Common Citations in Unfavorable Audit Outcomes
As a therapist practicing in the 21st century, it is highly probable that you and your practice will undergo a claims review (audit) at some point in your career. An unfavorable audit outcome is not always due to fraudulent billing practices. More frequently, a failed audit results from the submission of incomplete records, documentation that does not comply with Medicare regulations, or a treatment narrative that fails to support the medical necessity of the billed services. Below is a list of the most frequently cited reasons for an unfavorable audit outcome:
Missing certifications in a patient’s plan of care
Noncompliance with the 8-minute rule and/or CCI edits - does not support number of billed units
Failure to document time and/or duration within the treatment documentation
Illegible signatures (either physicians’ or therapists’)
Reproduced signatures (i.e., using a stamp instead of physically signing the document)
Missing physician signatures
Failure to recertify the plan of care when appropriate
Noncompliance with frequency/duration rules indicated within Local Coverage Decision (LCD)
Insufficient documentation - documentation does not include all the required elements
Post-denial modification to documentation
Failure to provide adequate PTA supervision
Failure to supply records to Medicare when requested
Ensuring Compliance and Audit Review Readiness
As a practice owner, it is crucial for you and your staff to uphold the highest standards of professional practice. Fostering a professional culture enhances every aspect of your office procedures, environment, and patient experience. Audits can make the most seasoned professionals anxious; however, there are simple steps that, when regularly implemented, can make the audit experience less stressful and; therefore, result in a positive review. The following are suggestions to guide your self-audit efforts:
Study the Medicare Local Coverage Determination (LCD) guidelines specific to your specialty
Establish policies and procedures that support compliance from the initial appointment call to the final discharge
Engage your therapy staff in educational opportunities designed to elevate their compliance in defensible documentation as dictated by the LCD of your specialty
Perform regular self-audits
to uncover treatment documentation compliance irregularities
to review front office procedures and patient account record completeness
to uncover over or under billing habits
to review patient payment expectations, policies, and outcomes
Regularly have other professionals review your documentation for compliance
Utilize self-audit resources such as the APTA Claims Audit Checklist
Reminder... Medicare is not the sole entity that might conduct a claims review. Commercial, Worker's Compensation, No-Fault, and Medicare Advantage payers may also require or randomly request claims documentation as review of your professional practice.
What is Medicare Requesting?
The Supplemental Medical Review Contractor (SMRC), who handles claim reviews for Medicare, expects providers to follow a 20-point list of Documentation Requirements for every claim they check. Here's the list straight from the SMRC Response Cover Sheet Form from a recent records review:
Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim review.
1- Physician/Non Physician Practitioner (NPP) order or evidence of intent to order
2- History and Physical reports (include medical history and current list of medication)
3- Beneficiary's medical records which may include: practitioner medical records, hospital records, nursing records, home care nursing notes, physical/occupational therapy notes that support the item(s) provided is/are reasonable and necessary
4- Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Local Coverage Article
5- Initial evaluation/re-evaluation singed by ordering physician or practitioner
6- Physical Therapy (PT)/Occupational Therapy (OT)/Speech Language Pathology (SLP) - Initial valuation/re-evaluation, plans of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
7- Physician/Non Physician Practitioner (NPP) certification of Plan of Care for Claim Period Including Justification when the Certification is Delayed More than 30 days
8- Signed and dated overall plan of care including, short and long term goals with any updates to the plan of care
9- Progress reports written by the clinician-services related to progress reports are to be furnished on or before every 10th treatment day
10- Specific Skilled Procedures and Modalities
11- For all therapy services rendered submit attendance/treatment records for the claim period - must include total treatment time and identify each specific skilled modality provided
12- Therapy logs that show services, dates and times for code billed
13- Records of aide visits, times, and dates
14- List of all personnel billing services under your NPI. List credentialing, training, licensure, etc., of all personnel
15- Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual check-in
16- Providers or suppliers are encouraged to review the documentation prior to submission, to ensure signature information is available when authenticity is not conclusively documented. Please include a signature log or signature attestation for any missing or illegible signature within the medical record.
17- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
18- Any other supporting or pertinent documentation
19- If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
20- PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.
Medicare Resources
Medicare has set forth official guidelines for each specialty, referred to as Local Coverage Determinations (LCDs). These LCDs outline the documentation requirements for each billable CPT code. It is essential for all therapists and office staff within your practice to enhance their professional practice by adhering to these guidelines. Additionally, it is advisable to regularly review the documentation guidance and conduct random assessments to ensure compliance.
Click the highlighted caption below to link to the Medicare LCD for your specialty.
Outpatient Physical and Occupational Therapy Services
Local Coverage Determination (LCD): L33631
Chiropractic Services
Local Coverage Determination (LCD): L37254
Speech-Language Pathology
Local Coverage Determination (LCD): L33580
Final Thoughts
Medicare claims reviews, or audits, can lead to significant consequences if the results are unfavorable. There are many cases where medical practices have experienced negative outcomes, requiring them to repay amounts ranging from thousands to, in some instances, hundreds of thousands of dollars. As noted earlier, not all unsuccessful audits are due to fraudulent actions; they frequently result from failing to meet the documentation standards set by the payer for professional medical providers.
The metaphor of a mirror effectively represents the process of getting ready for an audit. Looking into a mirror, we see our reflection, which might contrast with our self-image but matches how others perceive us. Regularly checking this reflection is essential to ensure that our self-perception matches our outward appearance. By engaging in professional self-reflection and ongoing improvement, your practice can be prepared to successfully tackle the challenges of a claims documentation audit.
Are you ready?
Let us provide your SOUND MEDICAL BILLING SOLUTIONS!
John Spiezio, President
Sound Medical Billing Solutions, LLC
Call, click or email for more information about this or any topic that my affect your practice. We will be happy to help!
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