Share

Medicare rejected my claimSo, you submitted a claim lacking functional limitation reporting to Medicare after July 1. Uh oh. By now, you’ve probably received a polite rejection letter telling you that Medicare will not be providing you with reimbursement for your services—and neither will the beneficiary.

What’s a PT, OT, or SLP to do? Well, unless you actually completed a full functional limitation assessment during your patient’s evaluative visit and simply forgot to include the corresponding G-codes and severity modifiers, the answer is: nothing. Unfortunately, going back now and changing anything on your documentation to ensure payment is a very, very bad idea. Just ask compliance expert Tom Ambury, who points out that the Federal Government has won several recent court cases against providers who created inaccurate or unjustifiable documentation—even on accident. Here’s what Ambury has to say about one such case in his latest Compliance Chat:

“A U.S. Court of Appeals decision recently upheld the conviction of a provider who had documented inaccurately in the medical record. The provider was found guilty of making false statements relating to health care matters, even though Medicare never reviewed the documentation. The provider testified that they were extremely busy and sometimes waited weeks or even months to complete the documentation, which ended up containing inaccurate information.”

Ambury also writes: “It appears from the decision that the False Medical Record statute does not require for there to be a specific intent on the part of the creator of the medical record to deceive or mislead. The information in the medical record just needs to be inaccurate. Conviction under the False Medical Record Statute carries penalties of up to five years in prison”—with substantial fines on top of that.

Let’s face it: There’s no way that going back and changing your documentation is worth the risk. Instead, on your patient’s next visit—regardless of the visit type—complete and submit functional limitation reporting, and you’ll be back on track—albeit a little short on overall reimbursements. This might feel like a hard pill to swallow, but it certainly beats facing an audit, trial, and possible jail time. “Let’s learn our lessons as we go, lick our wounds as we need to, and keep moving forward. After all,” Ambury says. “Our industry is constantly changing and these are life-long learning lessons.”

Now, if you did in fact identify your patient’s primary functional limitation, complete an outcome measurement tool, and document appropriately during the episode of care, you can create an addendum containing the missing G-codes and severity modifiers and resubmit. However, adding an addendum could create red flags for Medicare—so be very sure that your documentation is in tip-top, super-defensible shape. If you're not confident in adding an addendum, inquire with your local MAC or a compliance consultant on what steps you should take from here.

In the spirit of moving forward, I’ll leave you with a few more pieces of advice from WebPT and Tom Ambury. To ensure you always receive appropriate reimbursement:

  1. Document well during the episode of care.
  2. Complete periodic internal documentation audits to ensure defensibility.
  3. File your claims in a timely manner.
  4. Stay up to date on the latest in reporting regulations and legislation.
  5. Seek out a reputable source for compliance information and ask a lot of questions.

Have you received a rejection letter? How did you handle it? What advice do you have for fellow therapists? Leave your thoughts in the comment section below.

ICD-10 Checklist - Regular Banner

article Mar 20, 2013

“What Box Does my G-Code Go Into?”: Responding to Outdated Questions Related to Paper Billing Claims

Today’s blog comes from WebPT’s Billing Onboarding & Operations Manager Stacey Abelman. Thanks Stacey!   Members often ask: where does my G-code go? Or what box does my NPI go into? Additionally, we—as the WebPT Billing Service—receive such requests as “I need my facility address changed in Box 32” or “I need to use my Tax ID instead of my SSN in box 24j.” But these “boxes” that Members sometimes refer to don't exist anymore in modern …

Why You Must Code for Medical Necessity with ICD-10 Image

article Apr 8, 2014

Why You Must Code for Medical Necessity with ICD-10

In order to successfully transition to ICD-10, healthcare providers will need to change more than the actual codes they use; they’ll also have to change the way they think about coding. Because in addition to choosing the right code from a list of 68, 000 possibilities, providers must ensure that the code they choose most accurately reflects the specific condition they’re treating so it supports the medical necessity of their services. As this article points out, “Medical …

The 8-Minute Rule: What it is and How it Works in WebPT Image

article Feb 27, 2014

The 8-Minute Rule: What it is and How it Works in WebPT

With most buyer-seller transactions, calculating the cost of a product or service is fairly simple. There are no complicated formulas for determining the monetary value of a pizza or a movie ticket; you simply pay the business’s advertised price. When it comes to Medicare’s payment for rehab therapy services, however, things aren’t always so simple. Yes, I’m talking about the dreaded 8-Minute Rule (a.k.a. the Rule of Eights). The Basics The 8-Minute Rule governs the process by …

webinar May 21, 2013

Get Ready for Functional Limitation Reporting

Beginning July 1, 2013, CMS is requiring that you complete functional limitation reporting (FLR) on all Medicare patients in order to receive reimbursement for your services. We know you want to get paid. That’s why it’s crucial you have functional limitation reporting down pat. With that in mind, WebPT will host a special webinar on May 20 to help you get fully prepared for FLR. In this 60-minute session, hosts Heidi Jannenga and Mike Manheimer will explain …

Most Frequently Asked Questions From Our Functional Limitation Reporting Webinars Image

article May 22, 2013

Most Frequently Asked Questions From Our Functional Limitation Reporting Webinars

Today's blog post comes from WebPT Senior Writer Charlotte Bohnett, contributing writer Erica Cohen, and WebPT Co-Founder Heidi Jannenga, PT. Monday and Tuesday we hosted webinars on functional limitation reporting. We got tons of great questions. Here are the most frequently asked ones: The Basics What is functional limitation reporting? Beginning July 1, 2013, CMS is requiring that you complete functional limitation reporting (FLR) on all Medicare part B patients in order to receive reimbursement for your …

article May 23, 2013

Gaming the System and Other FLR No-Nos

We all know that functional limitation reporting (FLR)  means (a little) more work for (basically) the same reward. And that can be a hard pill to swallow for many therapists who are already stretched thin as a result of increasing caseloads and increasingly stringent documentation requirements. Even so, taking the easy road—the low road—and gaming the system—and thus, this profession—is not the answer. It never is. This—just like everything else you do for your patients, your practice, …

Ain’t Nothin’ But a G-Code, Baby. What You Need to Know About the New G-Codes. Image

article Nov 19, 2012

Ain’t Nothin’ But a G-Code, Baby. What You Need to Know About the New G-Codes.

Today's blog post comes from WebPT Senior Copywriters Erica Cohen and Charlotte Bohnett. Like the 90s hip-hop-themed title of this blog post implies, G-codes may be new, but they’re nothing to fret over. Essentially, effective July 1, 2013, CMS will require therapists to report new G-codes, moving us closer to incorporating function and functional progress within our treatment. But the good news is that you should already be checking (and documenting) functional progress through your short- and …

article May 30, 2013

Managing MPPR: A Response to Chuck Felder’s Post from WebPT Co-Founder and PT Heidi Jannenga

Thank you, Chuck, for presenting such detailed information on the Multiple Procedure Payment Reduction (MPPR) changes. My biggest takeaway from Chuck’s post is that, now more than ever, clinic owners must focus on practice management and truly pay attention to their business. Understanding the metrics of your practice is crucial in this age of declining reimbursements and frequent regulatory changes. There are three crucial metrics that I think come into play when assessing MPPR’s impact on your …

How to Complete Functional Limitation Reporting in WebPT Image

article Feb 19, 2014

How to Complete Functional Limitation Reporting in WebPT

As of July 1, 2013, the Centers for Medicare and Medicaid Services (CMS) requires that therapists complete functional limitation reporting (FLR)—through the use of  G-codes and severity modifiers —on all eligible Medicare Part B patients at the initial evaluation, re-evaluation if applicable, every progress note (minimum of every ten visits), and discharge in order to receive reimbursement for their services. Today, several other private insurance companies also require FLR data as a condition of reimbursement. Good thing …

Get exclusive content delivered right to your inbox.