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.

Blog Subscription - Regular Banner
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 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 …

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 …

article Oct 3, 2013

ICD-10 Questions and Answers

So, you’ve got some questions about ICD-10. We don’t blame you. There’s a lot going on with the transition to these new diagnostic codes―which will occur October 1, 2015―and it’s best to be on your toes. That’s why we put together this handy-dandy list of questions―and, more importantly, answers―to help you stay on pointe. What’s ICD-10? ICD-10 is the tenth revision to the International Classification of Diseases. Check out this World Health Organization article for a complete …

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 Feb 5, 2013

Embracing Functional Limitation Reporting

Today's blog post comes from WebPT Co-Founder Heidi Jannenga, PT, MPT, ATC/L. By now, I’m sure you’ve heard about functional limitation reporting—also known as claims-based outcome reporting (CBOR) and G-code reporting. Regardless of what your clinic calls it, functional limitation reporting is coming quickly. In fact, as of July 1, 2013, CMS is making it mandatory. That means they won’t pay you for your services if you don’t properly report functional limitations via specific G-codes on the …

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 …

webinar Mar 4, 2013

Better Navigate the Murky Waters of Medicare

Between PQRS, Functional Limitation Reporting, and the updated Therapy Cap, there’s a lot going on with Medicare in 2013. Not to fret, though, WebPT’s got your back—and your life preserver. In this month’s webinar, hosts Heidi Jannenga and Mike Manheimer will provide you with everything you need to know to successfully navigate the murky waters of Medicare, including a special section on three functional limitation reporting pitfalls to avoid.

article Mar 11, 2013

February Medicare Webinar Q&A

Today's blogs post comes from WebPT Co-Founder and PT Heidi Jannenga, Marketing Manager Mike Manheimer, and Senior Writers Erica Cohen and Charlotte Bohnett.   Last month’s webinar on Medicare was our most highly attended webinar to date. And that’s really not surprising, because wherever Medicare goes, questions follow. But unfortunately, we couldn’t get to them all live. So we thought we’d put together a blog post will all the great questions you asked and our answers. That …

Get exclusive content delivered right to your inbox.