Clinical and Compliance Bulletin

877.799.9595 | www.evergreenrehab.com
2013 Quarter 2

Coding Corner
FAQ
1. I have multiple patients who are currently on a ventilator due to a prior acute respiratory failure. I know I shouldnt code the

Decoding CPT Codes

Each quarter we focus on decoding the mystery of a specific CPT code. This quarter we will focus on CPT code 92507, treatment of

acute respiratory failure because they are beyond the acute phase speech, language, voice, communication, and/or auditory processing disorder. This can include the following skilled interventions: but want to capture the complexity of the ventilator. Is there a code that I can use to report the ventilator? Yes, you can add ICD-9 V46.11, dependence on respirator status, BUT THIS CAN NEVER BE CODED AS A PRINCIPAL DIAGNSOSIS. 2. Is there a code for tremors? Yes, 781.0, abnormal involuntary movements. 3. Is there a code for neurological neglect? Yes, 781.8, neurological neglect syndrome. 4. What is the difference between the three symbolic dysfunction codes? The description of the three codes are as follows and the correct code should be chosen based on highest level of specificity: Code 784.60 784.61 784.69 Description Symbolic dysfunction, unspecified. Many Local Coverage Determinations (LCDs) do not include this in the list of codes that support medical necessity. Alexia and dyslexia Other symbolic dysfunction Includes: acalculia, agnosia, agraphia, apraxia Skilled interventions aimed at increasing expressive language skills including ability to communicate wants and needs and treatments to address appropriate syntax and morphology. Skilled interventions to increase receptive language skills for comprehension of spoken and written language impacting ability to respond to questions, follow directions, and comprehend structured and spontaneous interactions with others. Skilled interventions aimed at increasing speech intelligibility skills including interventions aimed at improving articulatory patterns and addressing motor speech impairments such as apraxia of speech and dysarthria. Skilled interventions aimed at improving pragmatic language skills related to social aspects of communication including adequate knowledge and use of rules for conversation and story- telling and appropriate adaptations of language based on setting and conversational partner. Skilled interventions to increase vocal function related to respiration, phonation, resonance, and pitch. Skilled interventions for aural rehabilitation including provision of speech reading. Skilled interventions aimed at training and use of non-speech generating augmentative and alternative communication (AAC). Skilled interventions for training and modification in the use of a voice prosthetic.

Keeping Straight on the Regulation Road

Impact of the American Taxpayer Relief Act of 2012 (ATRA) on Therapy
The American Taxpayer Relief Act of 2012 (ATRA) was signed into law by President Obama on January 2, 2013. The law extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013, prevented a scheduled 26.5% payment cut to the physician fee schedule from taking effect on January 1, 2013, and increased the MPPR rate to 50%. Exceptions process extended through December 31, 2013 Section 603 of ATRA extends the exceptions process for outpatient therapy caps through December 31, 2013. Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims when an exception to the cap is requested for medically necessary services furnished through December 31, 2013. Section 603 also extends the mandate that Medicare perform manual medical review of therapy services furnished January 1, 2013 through December 31, 2013, for which an exception was requested when the beneficiary has reached a dollar aggregate threshold amount of $3,700 for therapy services. There are two separate $3,700 aggregate annual thresholds: (1) physical therapy and speech-language pathology services and (2) occupational therapy services. CMS announced on March 21, 2013 that Medicare Administrative Contractors (MACs) will conduct prepayment review on the claims reaching the $3700 threshold until March 31, 2013 and beginning April 1, 2013 the Recovery Audit Contractors (RACs) will take over the manual medical review process. RACs will conduct two types of review: (1) prepayment review in demonstration states and (2) postpayment review in non-demonstration states. Claims submitted in the Recovery Audit Prepayment Review Demonstration states will be reviewed on a prepayment basis. These states are Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri. In these states, the MAC will send an ADR to the provider requesting the additional documentation be sent to the RAC (unless another process is used by the MAC and the RAC). The RAC will conduct prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision. In the remaining states, the RACs will conduct immediate postpayment review. In these states, the MAC will flag the claims that meet the criteria, request additional documentation and pay the claim. The MAC will send an ADR to the provider requesting

the additional documentation be sent to the RAC. The RAC will conduct postpayment review and will notify the MAC of the payment decision. Physician fee schedule ATRA froze the conversion factor for 2013 at the 2012 level, averting a 26.5% cut to physical therapists and other providers under the physician fee schedule and continues the 1.0 GPCI work value floor through 2013. MPPR update Congress included a provision in the American Taxpayer Relief Act of 2012 that applies a 50% multiple procedure payment reduction (MPPR) to outpatient therapy services effective April 1, 2013. The multiple procedure payment reduction that applies to the practice expense will increase from the 20% (office) or 25% (institutional) to 50% for all outpatient therapy settings. The MPPR applies to the PE payment when more than one unit or procedure is provided to the same patient on the same day. The MPPR applies to multiple units as well as multiple procedures and disciplines. The code with the most expensive practice expense will be paid at the full physician fee schedule. For the second and each subsequent code, the practice expense value will be reduced. This means that the code with the highest practice expense value that day will be reimbursed at 100% and the practice expense values for the second and subsequent codes will be reduced when multiple therapy services are billed on the same date by the same practitioner or facility under the same NPI, regardless of whether those therapy services are furnished in separate sessions or by multiple disciplines. For example: A patient is seen on the same day for a speech-language evaluation (92506) and a physical therapy evaluation (97001). 92506 97001 Total Payment Total Payment w/o MPPR w/MPPR No Reduction = $50.83 $97.45 + (50% x $22.45) = $108.68 No Reduction = $2.46 $50.83 + $108.68 + $2.46 = $161.97

Work $21.22 $29.61 $50.83 Practice $97.45 $22.45 $119.90 Expense Malpractice $1.23 $1.23 $2.46 Total $119.90 $53.29 $173.19

Legislation Introduced in House and Senate to Repeal Therapy Cap Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA), and Senators Ben Cardin (D-MD) and Susan Collins (R-ME) introduced the Medicare Access to Rehabilitation Services Act (HR 713/S 367) in both chambers on February 14, 2013. HR 713 and S 367 would permanently repeal the therapy cap imposed on physical therapy, occupational therapy, and speech-language pathology services. S 367 is currently in the Senate Finance Committee. HR 713 is currently in the House Energy and Commerce and House Ways and Means Committees. House and Senate Lawmakers Officially Introduce Observation Stay Legislation Lawmakers in the House and Senate formally introduced the Improving Access to Medicare Coverage Act of 2013 to close the socalled observation stay loophole. The bill would change a Medicare rule to broaden coverage. Currently, therapy in skilled nursing facilities is only covered by Medicare Part A after a three-day stay as an inpatient. Days spent in the hospital under observation status do not count toward this three-day minimum. The Improving Access to Medicare Coverage Act of 2013 would change this, save seniors money, and reduce administrative burdens on providers. S 818 is currently in the Senate Finance Committee. HR 1543 is currently in the House Energy and Commerce and House Ways and Means Committees. Federal Judge Grants Final Approval of Jimmo Settlement A federal judge approved the October 2012 settlement agreement in Jimmo v. Sebelius marking another step toward guaranteeing Medicare coverage for therapy patients needing skilled services. As a result of the settlement with the Department of Health and Human Services, individuals who need maintenance care for conditions that are not improving can no longer be denied Medicare coverage under an improvement standard. The Centers for Medicare & Medicaid Services will have to update its policy manual and undertake an education campaign to increase awareness of the policy according to the settlement agreement. Fraud Prevention System (FPS) Update The First Implementation Year Report on the Fraud Prevention System that was due to Congress on September 30, 2012 was finally submitted to Congress by CMS on December 14, 2012. CMS reported an estimated savings of $115.4 million, estimated costs of

$34.7 million and estimated Return on Investment of 3.3 to 1. However, the OIG report The Department of Health and Human Services Has Implemented Predictive Analytics Technologies But Can Improve on Related Savings and Return on Investment issued September 2012 found that these numbers were not accurate. In addition, the GAO issued CMS Has Implemented a Predictive Analytics System, but Needs to Define Measures to Determine Its Effectiveness in October 2012. The OIG and GAO reports related to the first year of the program found that: CMS did not fully comply with the requirements for reporting actual and projected improper payments recovered and avoided in the Medicare Fee for Service program and its return on investment Methodology for savings calculations included some invalid assumptions that may have affected the accuracy of reported amounts (100% fraud) CMS has not defined or measured quantifiable benefits or established appropriate performance goals Has integrated the FPS into its overall fraud-prevention strategy but not the payment processing system In addition, the GAO Report reported on ZPIC Feedback regarding the technology. ZPICs reported: FPS has not fundamentally changed the way in which they investigate fraud FPS has not significantly sped up investigations or enabled quicker administrative actions FPS provides broad indicators that may include false positives and often require additional investigative steps Provides data to support analysis of leads including near real-time claims data allowing for time sensitive interviews and verification of tips and complaints

RAC Update
CMS issues FY 2011 Medicare RAC report to Congress The Centers for Medicare and Medicaid Services (CMS) issued its annual Medicare Recovery Auditor report to Congress confirming that recovery audit contractors collected $797.4 million in overpayments from hospitals and other providers and repaid $141.9 million in underpayments in fiscal year 2011. CMS concluded that after accounting for RAC contingency fees, appeals, and other RAC-related costs the RAC program saved Medicare more than $488 million in 2011.

Skilled nursing facilities accounted for miniscule portion of 2011 Medicare overpayments Skilled nursing facilities accounted for only about $200,000 of $797 million (.3%) in collected Medicare overpayments in 2011 identified by Recovery Audit Contractors. Inpatient claims accounted for the majority of collected overpayments, at more than $677 million, according to the Centers for Medicare & Medicaid Services report. Physician, Durable Medical Equipment and other claim types each accounted for between roughly $33 million and $35 million in overpayments. Outpatient claims represented more than $17 million. Region B Medicare RAC, CGI, adds two skilled nursing facility audit issues CGI, the Medicare RAC for Region B, has added two skilled nursing facility issues to its audit list recently. The complex reviews will look at: Skilled Nursing Facility (SNF) Psychiatric Condition--Patients with only a psychiatric condition who are transferred from a psychiatric hospital to a participating SNF are likely to receive only non-covered care. Skilled Nursing Facility (SNF) Unrelated to Terminal Condition--A hospice beneficiary certified as having a terminal illness with a life expectancy of 6 months or less waives all rights to Medicare payment for services related to the terminal condition. Services unrelated to the terminal condition may still be payable and are designated by the presence of condition code 07. SNF Part A claims with a condition code 07 will be reviewed to validate that the services did not relate to the patients terminal condition and met SNF coverage criteria. Government Teams Recovered $4.2 Billion in FY 2012 On February 11, 2013 Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius released a new report showing that for every dollar spent on health carerelated fraud and abuse investigations in the last three years, the government recovered $7.90. This is the highest three-year average return on investment in the 16-year history of the Health Care Fraud and Abuse (HCFAC) Program. The governments health care fraud prevention and enforcement efforts recovered a record $4.2 billion in taxpayer dollars in Fiscal Year (FY) 2012, up from nearly $4.1 billion in FY 2011, from individuals and companies

who attempted to defraud federal health programs serving seniors and taxpayers or who sought payments to which they were not entitled. Over the last four years, the administrations enforcement efforts have recovered $14.9 billion, up from $6.7 billion over the prior four-year period. Since 1997, the HCFAC Program has returned more than $23 billion to the Medicare Trust Funds. In FY 2012, the Justice Department opened 1,131 new criminal health care fraud investigations involving 2,148 potential defendants, and a total of 826 defendants were convicted of health care fraud-related crimes during the year. The department also opened 885 new civil investigations. Strike force operations in the nine cities where teams are based resulted in 117 indictments and information and complaints involving charges against 278 defendants who allegedly billed Medicare more than $1.5 billion in fraudulent schemes. In FY 2012, 251 guilty pleas and 13 jury trials were litigated, with guilty verdicts against 29 defendants, in strike force cases. The average prison sentence in these cases was more than 48 months. The new authorities under the Affordable Care Act granted to HHS and the Centers for Medicare & Medicaid Services (CMS) were instrumental in clamping down on fraudulent activity in health care. In FY 2012, CMS began the process of screening all 1.5 million Medicareenrolled providers through the new Automated Provider Screening system that quickly identifies ineligible and potentially fraudulent providers and suppliers prior to enrollment or revalidation to verify the data. As a result, nearly 150,000 ineligible providers have already been eliminated from Medicares billing system. CMS also established the Command Center to improve health carerelated fraud detection and investigation, drive innovation and help reduce fraud and improper payments in Medicare and Medicaid. The Department of Justice and HHS also continued their successes in civil health care fraud enforcement during FY 2012. The Justice Departments Civil Division Fraud Section, with their colleagues in U.S. Attorneys offices throughout the country, obtained settlements and judgments of more than $3 billion in FY 2012 under the False Claims Act (FCA). These matters included unlawful pricing by pharmaceutical manufacturers, illegal marketing of medical devices and pharmaceutical products for uses not approved by the Food and Drug Administration, Medicare fraud by hospitals and other institutional providers, and violations of laws against self-referrals and kickbacks. This marked the third year in a row that more than $2

billion has been recovered in FCA health care matters. Additionally, the Civil Divisions Consumer Protection Branch, working with U.S. Attorneys offices, obtained nearly $1.5 billion in fines and forfeitures, and obtained 14 convictions in matters pursued under the Federal Food, Drug and Cosmetic Act. Statute of Limitations for Medicare Overpayment Recovery Extended The Centers for Medicare & Medicaid Services (CMS) now has five years instead of three to recover non-fraudulent Medicare overpayments. The longer time frame could result in the collection of $500 million from providers and others by some estimates. The change reflects a recommendation made in May by the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services in its report Obstacles to Collection of Millions in Medicare Overpayments which stated the three-year statute of limitations prevented CMS from collecting more than $332 million in overpayments identified in 154 audit reports examined as of Oct. 8, 2010. OIG Report: The Centers for Medicare & Medicaid Services Collected the Majority of Medicaid Overpayments but Millions Remain Uncollected (A-05-11-00071) The OIG report found that as of December 2012, CMS reported collecting $987.5 million of the $1.2 billion in Medicaid overpayments that it had sustained in the 147 audit reports covered by the OIG review. However, CMS had not collected the remaining $225.6 million. CMS had not collected the $225.6 million in overpayments because it had not always proceeded with the collection process in a timely manner. Also, CMS could not document that $7.2 million it reported as collected had been collected because it did not maintain adequate supporting documentation. Additionally, CMS did not ensure that the States reported Medicaid overpayments on the correct lines of the Form CMS-64 to facilitate CMS tracking of recoveries. The OIG recommended that CMS: (1) Collect the remaining $225.6 million that is due the Federal Government, (2) Review and address delays in resolving OIG audit recommendations and promptly pursue corrective actions, (3) Maintain adequate documentation to support the collection of overpayments in accordance with OMB Circular A-50 and CMS Standard Operating Procedures, and

(4) Educate the States about their responsibility to report overpayments on the correct line of the CMS-64 to improve oversight of the reporting process. CMS concurred with the second, third, and fourth recommendations and provided information on actions that it had taken or planned to take to address them. CMS partially concurred with the first recommendation. OIG Report: Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI 02 09 00201) Skilled nursing facilities (SNF) are required to develop a care plan for each beneficiary and provide services in accordance with the care plan, as well as to plan for each beneficiarys discharge. In fiscal year 2012, Medicare paid $32.2 billion for SNF services. This study is part of a larger body of work about SNF payments and quality of care. The results are based on a medical record review of a stratified simple random sample of SNF stays from 2009. The reviewers determined: For 37 percent of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans. For 31 percent of stays, SNFs did not meet discharge planning requirements. Medicare paid approximately $5.1 billion for stays in which SNFs did not meet these quality-of-care requirements. Additionally, reviewers found examples of poor quality care related to wound care, medication management, and therapy. As a result the OIG recommended that CMS: (1) Strengthen the regulations on care planning and discharge planning, (2) Provide guidance to SNFs to improve care planning and discharge planning, (3) Increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and to hold these SNFs accountable, (4) Link payments to meeting quality-of-care requirements, and (5) Follow up on the SNFs that failed to meet care planning and discharge planning requirements or that provided poor quality care. CMS concurred with all five of OIGs recommendations.

All Eyes on Therapy

Therapy remains the focus of many Medicare Administrative Contractors (MACs)/Fiscal Intermediaries (FIs) as well as the Regulatory and Law Enforcement Agencies of the Federal Government as the commitment to deterring fraud, waste and abuse in the Medicare and Medicaid systems has increased. CGS Probe Medical Review for KY: Resource Utilization Group (RUG) Code RUB10 The J15 Part A Medical Review department will implement a service specific probe edit for type of bill (TOB) 21X for RUG code RUB10. Approximately 100 claims will be reviewed as part of this probe review. RUB10 represents ultra high therapy (720+ minutes) with an ADL score of 6-10 for the 5 day scheduled PPS assessment. Nursing Home Company Reaches $2.7 million Settlement in Therapy Billing Case Tennessee-based nursing home operator Grace Healthcare LLC will pay the federal government more than $2.7 million and enter into a Corporate Integrity Agreement (CIA), settling charges that Grace violated the False Claims Act by billing Medicare for unnecessary rehabilitation therapy. A former Grace employee alleged that 10 Grace-operated skilled nursing facilities billed for unnecessary and unreasonable physical, occupational and speech therapy to meet the corporations reimbursement goals from 2007 to 2011. The company did not admit to wrongdoing as part of the agreement, and said the governments investigation was not related to quality of care issues. Grace said it settled to avoid an expensive suit that would distract from its operations.

Contact Information:
Liz Barlow Vice-President of Clinical Services 502.400.1619 liz@evergreenrehab.com Shawn Halcsik Director of Compliance 414.791.9122 shalcsik@evergreenrehab.com