Medicare Questions

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 way, you can access it wherever, whenever you want. Ready to jump in? Here’s your Medicare Q&A. 

 (P.S. Are you a first timer to thiswebinar or looking for a refresher? Click here to rewatch the webinar.)

PQRS

Q. Are PQRS and functional limitation reporting the same thing?
A. No. While both PQRS and functional limitation reporting are reporting requirements, they are completely separate.

Q. How often do we need to report PQRS?
A. It depends on the measures you choose; some measures require you to report at the initial examination (97001, 97003) and at the reexamination (97002, 97004), while others only require you to report at the initial exam.

Q. I actually work in a SNF (skilled nursing facility) setting. Are all the functional limitations and PRQS reporting requirements the same? Are they both required in a SNF setting?
A. Yes for functional limitations; no for PQRS.

Q. If I choose WebPT’s registry-based PQRS reporting option, will you submit my PQRS data quarterly?
Initially, CMS was going to allow registries to report PQRS data quarterly. However, we have recently learned that registries will not be able to report quarterly and will remain on the annual reporting schedule. This means that WebPT will report all the registry data we collect from 2013 to CMS in early 2014.

Q. Does WebPT have a screen setup for submitting PQRS codes? I know they differ from the functional limitation reporting codes, but I didn’t hear your explanation regarding how the clinician would document them in WebPT so that the codes would appear on the 1500.
A. WebPT is a  CMS certified registry for PQRS. As such, if you decide to report PQRS with WebPT (as it is an add-on feature), you can choose one of two submission options: claims- or registry-based. If you select registry-based PQRS reporting, you don’t need to include the PQRS codes on your 1500 form. Instead, we submit them on your behalf. However, if you choose the claims-based option, you will need to include the PQRS codes on your 1500 form. To make things easier, though, we will include these codes on the billing report and on your daily notes showing both the  CPT and PQRS codes.

Q. Our clinic doesn’t report PQRS at this time because we only have 1%–5% Medicare clients. Will this be an issue later on? I don't mind getting penalized since it’s a small percentage of our patient base. Any suggestions?
A. You can choose not to participate in PQRS. However, if your payer mix ever changes, you’ll never be able to go back and recoup that 1.5% penalty. Plus, if you’re a WebPT Member, PQRS is so easy that it might be worth it to complete (especially since this is the last year with an incentive). Also, because this is the first year that CMS is rolling out this penalty, you can avoid it altogether by successfully documenting and reporting on at least one patient. However, the minimum one patient rule will not be the case in 2014.

Q. Which of WebPT’s PQRS reporting methods should we use: claims or registry?
A. We recommend registry-based reporting. However, please note that you only have until the end of March to sign up for registry. But we make both methods very easy to implement so ultimately it is a clinic decision based on the bandwidth of your front office staff.  Claims reporting can be more time consuming with regard to auditing and making sure the codes are attached to claims.

Q. How do we see how we are doing on PQRS within WebPT?
A. Clinic administrators can view the PQRS compliance report within WebPT. If your clinic is using our registry service, the administrators can also access a dashboard that graphically displays progress by clinic and therapist.

Q. Does PQRS apply to rehab agencies and skilled nursing facilities or just to private practice?
A. PQRS only applies to private practices.

Q. We use an outsourced billing company that does not use WebPT as their software. Would registry-based PQRS reporting work for us?
A. Yes, you may use WebPT’s registry-based PQRS reporting option regardless of your billing provider.

Q. Do we have to use WebPT’s Billing Service to benefit from the registry-based PQRS reporting option?
A. No, you may use WebPT’s registry-based PQRS reporting option regardless of your billing provider.

Q. Will commercial carriers start using PQRS or functional reporting soon?
A. Most likely as we are moving to a pay for performance model. However, there hasn’t been any legislation to date that documents support of this movement for commercial carriers.

Q. Is PQRS reporting included in our current WebPT services or is it an additional service we need to sign up for?
A. PQRS reporting is an additional service. Please click here for more information about our registry- and claims-based reporting options.

Functional Limitation Reporting

Q. Are PQRS and functional limitation reporting the same thing?
A. No. While both PQRS and functional limitation reporting are reporting requirements, they are completely separate requirements mandatory this year for Medicare providers.

Q. Is functional limitations reporting going to be available within WebPT prior to July 1, 2013, so that we can get acquainted with it?
A. Yes, functional limitation reporting will be available within WebPT by mid spring.

Q. How often do we need to complete functional limitation reporting?
You must report (G-codes and corresponding severity modifiers) on the initial examination, at minimum every ten visits (progress notes), and at discharge.

Q. If my patient has Medicare as a secondary insurance, do I still need to complete functional limitation reporting?  
A. Yes, you must complete functional limitation reporting for any patient who uses Medicare insurance to cover their treatment.

Q. To successfully complete functional limitation reporting, can I treat more than one body part at the same time?
A. You can treat as many body parts as you want; you just have to identify a primary functional limitation.

Q. How do I complete functional limitation reporting if I do an initial evaluation and it’s a one-time visit?
A. You will submit three codes on that day: initial status, goal status, and discharge status G codes along with severity modifiers for all three. (WebPT will offer this functionality.)

Q. My CHT attended a CEU course and was told medicare was only accepting FOTO functional outcome questionnaire for occupation therapist. Is that true?
A. This is a common question because CMS initially listed FOTO as an example of a functional outcome tool. However, CMS has since decided not to name any specific tools for PTs and OTs. You can use any functional outcome tool—like the Oswestry, DASH, or TUG—that you deem relevant and appropriate to the functional limitation you select based on your clinical judgement. Note that Medicare continues to list NOMS for SLPs as a suggested tool.

Q. For therapy visits other than initial exams, progress notes, and discharge notes, are any codes necessary for functional reporting (e.g., G8942, which indicates that the visit occurred within 30 days of a previously documented functional outcome measurement)?
A. There are only certain G-codes that apply to functional limitation reporting; this particular code you mention does not apply. For a complete list, check out this blog post.

Q. Could I use the same measure for functional reporting and falls risk assessment (e.g.,Timed up and Go) and count for each one?
A. Yes, we encourage you (when appropriate) to choose outcome tools that overlap so you don’t have to perform excessive tests.

Q. Do I need to include the G-code and severity modifier on each claim or just the exam, 10th visit note, and discharge?
A. For functional limitation reporting, you must include the G-code and modifier on the exam, at minimum every ten visits (progress notes), and at discharge. You are not required to complete functional limitation reporting during any other visits.

Q. Is there any cost for Members to complete functional limitation reporting?
A. No, functional limitation reporting is completely free for WebPT Members.

Q. Will WebPT prompt on each patient when they are hitting the 10th visit since the last functional reporting visit? That way we know when reporting is needed.
A. Yes, WebPT will provide an alert system that will notify you when your patient is nearing his or her 10th visit since his or her last functional limitation report.

Q. If we see the patient for less than 10 visits, do we still need to report G-codes and the severity modifiers three times?
A. No, but you will need to report G-codes and severity modifiers at the initial exam and at discharge.

Q. What about Medicare Advantage Plans?
A. Typically, functional limitation reporting does not apply to Medicare Advantage Plans. However, we always encourage you to check with your plan administrator to be 100% sure.

Q. Will commercial carriers start using PQRS or functional reporting soon?
A. Most likely as we are moving to a pay for performance model. However, there hasn’t been any legislation to date that documents support of this movement for commercial carriers.

Therapy Cap

Q. Does WebPT automatically take 80% of the fee schedule when tracking the medicare therapy cap?
A. No, the Medicare therapy cap is based on total allowable charges—not what Medicare pays. Even though Medicare pays 80% (because they are an 80/20 plan), the total allowable charge (and what will go towards the cap) is 100% of the cost.

Q. You stated that the exam and reexam wouldn’t count towards the Medicare Cap. If the patient receives treatment that day does that go towards the cap?
If you perform an exam or a reexam on a patient who has exceeded the $1,900 cap to establish the medical necessity of continuing treatment, then it does not count toward the cap. However, if you perform treatment on the same date of service, the entire visit will apply to the cap.

Q. From what I read on Palmetto’s website, it doesn't seem like CMS will accept advanced approval requests for manual medical review anymore in 2013. My concern is that now we can't get pre-approval for 20 more treatments within ten days of sending in the required documentation. We have to actually wait months for them to reimburse us after going through a lengthy ADR process?

A. Here’s the latest from the APTA:
“For 2013, CMS has replaced the prior approval process with prepayment review, at least for the interim. Under prepayment review, when the patient reaches $3,700 in outpatient therapy services, the MAC will send the provider an additional development request (ADR) asking him or her to submit documentation so that the MAC can determine whether the services are medically necessary. Typically under Medicare, MACs have 60 days to make a determination. However, CMS has requested that with regard to the therapy cap manual medical review process, MACs decide within 10 days of receipt of the documentation whether the services exceeding $3,700 will be paid.

“CMS currently is working on a long-term strategy for the manual medical review process.

“Physical therapists should consult their MACs' websites for specific information about submitting documentation in response to an ADR.”  

Q. Does the cap apply if Medicare is a secondary insurance?
A. Anything that Medicare pays will count toward the therapy cap.

Q. If a Medicare patient has a secondary insurance, does that insurance take over when the patient reaches the cap?
A. Only if Medicare has already denied all payment. Then, the secondary insurance will take over but may not pay due to Medicare’s denial. Medicare supplemental insurance is very different from a commercial secondary plan. Supplemental plans pay what Medicare doesn’t whereas secondary insurances may not depending on your contracted rates and any outstanding deductibles.

Q. I thought Medicare only had 14 days to respond to our request over the $3,700, and if we didn't get anything back, it would be automatically approved for 10 more visits.

A. Here’s the latest from the APTA:
“For 2013, CMS has replaced the prior approval process with prepayment review, at least for the interim. Under prepayment review, when the patient reaches $3,700 in outpatient therapy services, the MAC will send the provider an additional development request (ADR) asking him or her to submit documentation so that the MAC can determine whether the services are medically necessary. Typically under Medicare, MACs have 60 days to make a determination. However, CMS has requested that with regard to the therapy cap manual medical review process, MACs decide within 10 days of receipt of the documentation whether the services exceeding $3,700 will be paid.

“CMS currently is working on a long-term strategy for the manual medical review process.

“Physical therapists should consult their MACs' websites for specific information about submitting documentation in response to an ADR.”  

Q. Should I apply a KX modifier before and after my patient exceeds the $1,900 cap?
A. You must apply the KX modifier to the visit that will exceed the cap. So, for example, if a patient has currently used $1,870 of their cap and has an appointment with you today, it’s likely this visit will push him or her over the cap. Thus, you should complete a progress note for today’s visit to document why the patient requires more therapy and therefore why your use of the KX modifier (on all charges for today’s visit) is appropriate. In WebPT, once you apply the KX modifier to the case, we will automatically apply the KX modifier to all subsequent visits.

Q. I thought that KX modifiers were to justify why a patient needs to continue treatment beyond the $1,900 cap. Before, we used the KX modifier to justify that our patients qualified for an "exception." But you said today that there are no exceptions this year. If that’s the case, why are we using the KX modifier?
A. You are correct. To clarify, there is still an exception process. However, this year, it is an automatic exemption process with the KX modifier.
Per the APTA: “The exceptions process is applicable for therapy services in excess of the cap amount delivered any time during the 2013 calendar year. In 2013 there are two exceptions processes: an automatic exception process and a manual medical review exception process. The manual medical review exceptions process applies to patients who meet or exceed $3,700 in therapy expenditures for PT/SLP combined and a separate $3,700 in occupational therapy expenditures.”

Q. Just to clarify: We do not submit for approval from Medicare after the patient reaches $1,900. We only have to do this at the $3,700 threshold, correct?
A. Correct,  and the submission for approval is no longer in effect for most local MACs. Please check with your local MAC for specific information.

Q. Is there a way to enter the dollar amounts our patients have accrued from previous therapy services at other facilities into their cap calculator?
A. Yes. Here’s a screenshot from the WebPT application:

therapy cap screen shot

Billing

Q. Regarding WebPT’s billing, is there a way that we can collect the patient payment portion in our office (e.g. 20% if it’s an 80/20 plan)? Can we collect the 20% rather than WebPT sending patients bill statements? This would help our patients avoid the shock of an unexpected bill and help us appropriately distribute our financial hardship discount.
A. We recommend that you collect the patient’s payment portion upfront for the services you provide because it’s always easier to collect while the patient is in your office. Within WebPT, our Billing Service Members will find a payment/copay log where they can track their over-the-counter collections. We ask that you submit this log to us daily so we can post it to the patient’s account. This way, if your patients pay their full share, they won’t receive a statement.

Also, a note regarding financial hardship discounts: Please make sure you are completing the proper paperwork to verify that your patients meet the financial hardship discount requirements. Otherwise, you run the risk of an audit.

Q. In my clinic, everyone except workers comp pays out of pocket. We submit Medicare bills for our patients and Medicare reimburses the patient. All of these rules still apply for the patient to get reimbursed, correct?
A. If you’re referring to functional limitation reporting, yes, you must still comply to ensure your patients receive reimbursement.

Q. You mentioned, while speaking on iontophoresis, that because it is not covered by Medicare, the PT must fill out an ABN form. Can you describe what this is?
A. An ABN form is an advanced beneficiary form. You can find the most updated ABN form here.

Q. Medicare will only pay for reexams every 30 days, right? So, if I reexam in six visits, they won’t reimburse?
A. There is no specific timeframe to perform a reexam. You may be referring to the progress note requirement, but routine progress notes do not need rexams. You should only charge for reexaminations for circumstances in which the patient experiences a significant change. You should not use this code to submit only to complete functional limitation reporting.

Here’s what Medicare has to say:
“Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient's condition or functional status that was not anticipated in the plan of care.”

Q. Is there an effective date for non-payment of iontophoresis? We are still getting reimbursed, and it is on our MCR fee schedule.
A. The majority of Medicare contractors (MACs) will not reimburse for iontophoresis because most view it as investigational. However, some still pay. Please check with your local contractor for their local coverage determination (LCD) to see if this applies. You may be one of the lucky ones.

Q. Do patients have to fill out an ABN so we can charge the deductible/co-pay (if they do not have supplemental)?
A. No, you should only use an ABN form when you genuinely doubt that Medicare will pay for a particular service. You should avoid routine use of ABNs.

Q. How will you incorporate the upcoming 50% fee reduction within WebPT?
A. The 50% fee reduction is with regard to multiple procedure payment reduction (MPPR). We’re currently building functionality to adjust for the MPPR, and we’ll notify Members as soon as it’s ready. Currently, the adjustment is only 20% if you are in an outpatient setting and 25% if you are facility-based. It’s set to move to a 50% fee reduction beginning April 1st, depending on congress voting differently at the end of March.

Miscellaneous

Q. What impact do you think the MPPR changes taking effect in April will have?
A. Per the APTA, allowing MPPR to take effect will result in a 6–7% payment cut for outpatient therapy providers in addition to 2011’s 6–7% cut. The combination of sequestration and MPPR could result in at least a 9% cut for therapy providers under Medicare in 2013.

Q. So, if I do a progress note at visit five, is the next progress note due at visit 15 or visit 20?
A. Your next progress report is due on the 15th visit—ten visits from your last progress note.

Q. Please explain documentation requirement at discharge. So many patients will quit therapy without a specific discharge visit, so how legit is quick discharge in the eyes of Medicare for these patients?
A. A quick discharge is absolutely appropriate if a patient discontinues therapy without a specific visit to reassess for discharge. In your notes, document why the patient did not return if you spoke on the phone and refer to the last Progress Note you completed for more recent objective measures. If you do complete a full discharge (when the patient is present), it is absolutely appropriate to bill (and receive reimbursement for) a reexam (97002).

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