PURPOSE: 

The purpose of this notice is to update the provider community of issues surrounding the service wide review for Outpatient Rehabilitation Therapy Services conducted by Highmark Medicare Services and to remind providers of the indications and limitations of coverage and/or medical necessity guidelines for Outpatient Rehabilitation Therapy Services.  This notice is also intended to assist in decreasing the claims error rate and to avoid provider denials of the above listed service. 

BACKGROUND:

Local Coverage Determination (LCD) Y-1FF

Physical medicine and rehabilitative services are designed to improve or restore physical functioning following disease, injury or loss of a body part and are covered when performed with the expectation of restoring the patient’s level of function which has been lost or reduced by injury or illness.  Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction of function (e.g., temporary weakness which may follow a brief period of bed rest following abdominal surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities.  Also, therapy performed repetitively to maintain a level of function is not eligible for reimbursement. 

A maintenance program consists of activities that preserve the patient’s present level of function and prevent regression of that function.  It may be reasonable and medically necessary for the clinician to develop a maintenance program, and instruct the patient, family member(s) or caregiver(s) in carrying out the maintenance program.    

REVIEW SUMMARY: 

As stated in the Provider Information section of the Highmark Medicare Services website, “What’s New”, a service wide review of all providers billing physical therapy services was initiated on 09/25/2007.  The information provided below is based on the review of submitted claims from 09/25/2007 through 03/31/2008:  

Medical review of claims for Outpatient Rehabilitation Therapy Services for the above mentioned dates shows an overall error rate of  58%.  The majority of the denials were related to information either not being provided or insufficient information to validate that services were rendered as billed or were medically reasonable and necessary.  Specific issues identified through the review of Outpatient Rehabilitation Therapy Services claims are as follows and are brought to your attention for educational purposes: 

Per CMS IOM Pub 100-02, Chapter 15, Section 220.3, therapy services are payable when the medical record and the information on the claim form consistently and accurately report covered therapy services.  Documentation must be legible, relevant and sufficient to justify the services billed.  The documentation in many cases was missing the initial evaluation and/or physician certification/recertification of the plan of care.  Some medical records did not reflect that the service that was billed was performed per the CPT description or did not include the timed code treatment minutes or the total treatment time in minutes.  Claims billed for re-evaluation services in many cases did not include documentation to support a significant improvement or decline or change in the patient’s condition or functional status that was not anticipated in the plan of care for that interval.  Although some regulations and state practice acts require re-evaluation at specific intervals, for Medicare payment, re-evaluations must meet Medicare coverage guidelines. 

A thorough review of submitted claims found that the documentation did not always support the need for continued skilled therapy services.  Documentation was insufficient regarding the patient’s prior level of function and often did not include a time frame where a prior level of function was noted.  The documentation in many claims did not support that significant progress was made from the start of care,  and support that the patient had reached a functional level, had reached a plateau level or support services that were repetitive in nature.  Documentation did not indicate the cause for decline in function or reason for debility or if applicable, the cause for a decline while on a Restorative Nursing Program.  Justification for services more extensive than is typical for the condition treated was often not provided. 

Additionally, specific information for lymphedema treatment is required per the Local Coverage Determination and was not consistently provided for review.  It should be noted that this type of therapy is designed to transfer the responsibility of the care from the clinic, hospital, or doctor, to home care by the patient, patient family or patient caregiver. It is very important that providers contact third parties such as physicians or other providers, health care facilities, or suppliers and request a copy of the medical documentation necessary to fully support the services billed to Medicare.  It is the responsibility of the provider submitting the claim for payment to obtain all the requested documentation, regardless of where the records are kept. 

Physical medicine and rehabilitative services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by Section 1862 (a)(1)(A) of the Social Security Act. 

The ADR generated for Outpatient Rehabilitation Therapy Services is specific to the documentation required for the review.  Listed below is a sample of the documentation requested: 

• Physician’s order for evaluation services, initial evaluation and date.
• Physician’s order for therapeutic services (include type, amount, duration and frequency of services).
• Physician’s initial certification, signed and dated.
• Physician’s recertification, if applicable, to cover billing period, dated and signed.  Results of any/all testing for services billed.
• Clinical documentation of diagnosis for which each therapy is rendered.
• Individualized, dated treatment plan (include long and short term goals, estimated length of services, expected outcome, modalities).
• Treatment log of services (include units and minutes or start and end times, description of specific modalities, region of body being treated, signature and title of individual providing services).
• If indicated, justification /reasoning for services that are more extensive than is typical for the condition treated.
• Progress notes to support medical necessity of services including how the patient is progressing toward meeting goals.
• Itemized bill.  

When you receive a request for additional information (ADR) please read the ADR letter carefully and submit the necessary documentation for review. 

Again, the purpose of this notice is to update the provider community of issues surrounding the service wide review for Outpatient Rehabilitation Therapy Services conducted by Highmark Medicare Services.  We want providers to be aware of the review results so that issues may be addressed and any necessary corrections can be made.  The goal of Highmark Medicare Services is to process and appropriately pay correctly submitted claims for Medicare beneficiaries and to decrease the error rate for individual providers. 

The Highmark Medicare Services website offers an efficient method for providers to make comments and suggestions for improving the educational process.  To take advantage of this opportunity, visit the Highmark Medicare Services website. 

If you have any questions regarding this bulletin, please contact our Customer Contact Center at 1-866-488-0545. 

REFERENCES: 

Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220 and 230- Coverage of Outpatient Rehabilitation Therapy Services.  

Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 10.2- The Financial Limitation.  

Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 20- HCPC Coding Requirements.   

Local Coverage Determination (LCD) Y-1FF: Physical Medicine and Rehabilitation Services, PT and OT.  

Local Coverage Determination (LCD) Y-13D: Speech-Language Pathology (SLP) Services.  

Local Coverage Determination (LCD) Y-14: Treatment of Dysphagia (Swallowing Disorders), General; Includes VitalStim® Therapy. 

Clinical Coverage Topics: Outpatient Rehabilitation- Documentation.    

Clinical Coverage Topics: Lymphedema.