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.

Are you looking for an EMR? - 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 …

Common Questions from our G-Code Denials Webinar: Part 2 Image

article Jul 30, 2014

Common Questions from our G-Code Denials Webinar: Part 2

Today’s blog post comes from WebPT writers Brooke Andrus and Erica Cohen. I heard that some private insurance carriers are now requiring functional limitation reporting. Is this true? Some non-Medicare insurers do require functional limitation reporting (e.g., Texas Workers' Compensation). Check out this blog post to see a list of the ones we know about right now. Keep in mind, however, that this list is ever-changing—so if you’re unsure of whether a particular plan requires FLR, be …

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 …

Common Questions from our G-Code Denials Webinar: Part 1 Image

article Jul 29, 2014

Common Questions from our G-Code Denials Webinar: Part 1

Today’s blog post comes from WebPT writers Brooke Andrus and Erica Cohen. If a patient has more than one functional limitation associated with a single diagnosis, should I report G-codes and severity modifiers for all of them? No. Medicare will only accept functional limitation reporting (FLR) data for one primary functional limitation per case. Therefore, if the patient has multiple functional limitations associated with a single diagnosis, you'll need to determine which one represents the patient's primary …

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 …

article Jan 3, 2013

Now That I Know G-Codes Ain’t No Thang, How Do I Implement ‘Em?

Last month, we discussed CMS’s new G-codes in a cleverly titled post, “ Ain’t Nothin’ But a G-Code, Baby. ” As the name implies, this new functional limitation reporting mandate is not nearly as daunting as you may think. In fact, if you use WebPT, it’s going to be as easy as pie—cherry pie, or maybe apple. Regardless, I digress. Here, we’ll discuss how with just a few clicks, and some clinical judgment, you can easily implement …

Founder Letter: Happy One-Year FLR Anniversary Image

article Jul 1, 2014

Founder Letter: Happy One-Year FLR Anniversary

Today marks the one-year anniversary of the mandatory implementation of functional limitation reporting (FLR). While it might not be an occasion worthy of streamers, cake, and noisemakers, this anniversary definitely warrants a moment of reflection. Despite the months-long FLR testing period, July 1, 2013, still hit our industry like a punch to the gut. Assuming you’re a medical professional who provides outpatient therapy services to Medicare patients, you may have experienced this FLR gut punch, too. Since …

Back to Basics: Functional Limitation Reporting G-Codes Image

article Feb 11, 2013

Back to Basics: Functional Limitation Reporting G-Codes

We’ve covered the ins and outs of G-codes as well as how it easy it will be to implement them successfully within WebPT —and why an integrated functional limitation reporting solution is the best solution . Today let’s go back to the G-code basics. What’s a G-code? Effective July 1, 2013, CMS will require therapists to complete functional limitation reporting through the use of new G-codes and corresponding severity modifiers for all eligible Medicare patients at the …

Common Questions from our Modifier Open Forum Image

article Jul 7, 2014

Common Questions from our Modifier Open Forum

Today’s blog post comes from WebPT writers Brooke Andrus, Charlotte Bohnett, and Erica Cohen. Should I have my patients sign an advance beneficiary notice of noncoverage (ABN) just in case Medicare doesn’t pay? No, by having your patient sign an ABN, you are acknowledging that you do not believe that the services you are providing are either medically necessary or covered by Medicare. If you have an ABN on file, you should include a modifier GA or …

Get exclusive content delivered right to your inbox.