Share

[Want to run a more profitable practice? Attend Ascend, the ultimate business summit for rehab therapists, on September 18-19 in Chicago. Enter code "WebPTblog" to score $100 off signup.]


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.

Webinar: February 2015 - Regular BannerWebinar: February 2015 - Small Banner
  • Can You Ace Our 8-Minute Rule Quiz? Image

    articleJul 21, 2015

    Can You Ace Our 8-Minute Rule Quiz?

    Maybe you thought your days of grinding through word problems ended when you sold that college algebra textbook back to the university bookstore (for less than half of its original price). But if you’re a rehab therapist who treats Medicare patients, you probably have to call upon your math skills—and maybe even the ol’ TI-83 Plus—fairly often, because sometimes Medicare’s 8-minute rule seems more like a complex trigonometric function than a seemingly straightforward billing formula. Think you’ve …

  • articleMar 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 …

  • A Tale of Two Billing Blunders: Overbilling and Misbilling Image

    articleJul 23, 2015

    A Tale of Two Billing Blunders: Overbilling and Misbilling

    Billing for physical therapy services is tricky, time-consuming, and nerve-wracking. After all, there are so many rules to follow, and it seems like those rules are constantly changing. That makes mistakes tough to avoid. And in many cases, you might not even know you’re making them. And while an occasional billing error probably isn’t a huge deal, if you’re unknowingly messing up left and right, you could end up in hot water. And if you’re purposely messing …

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

    articleApr 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 …

  • Technical Diligence: The Key to Stopping Claim Denials Dead in their Tracks Image

    articleJul 9, 2015

    Technical Diligence: The Key to Stopping Claim Denials Dead in their Tracks

    Hello, readers. Over the past several weeks, I’ve enjoyed answering a number of your questions regarding billing for PT services, so I’m excited to address the topic right here on the WebPT Blog. On June 19, 2015, the Office of the Inspector General (OIG) released a report involving an outpatient private practice physical therapy provider. In case you weren’t aware, the OIG—which is part of the US Department of Health and Human Services (HHS)—is basically the CMS …

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

    articleJul 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 …

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

    articleJul 30, 2014

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

    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 sure to inquire directly with the carrier. If I did not submit …

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

    articleFeb 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 …

  • Pro-Bono Work: The Good, The Bad, and The Billing Image

    articleJul 20, 2015

    Pro-Bono Work: The Good, The Bad, and The Billing

    We’re all taught at a young age that it’s better to give than to receive. This saying helps children develop perspective, and even as adults, few people would argue against the moral truth of this simple axiom. In fact, I’m betting this statement really speaks to the empathetic nature of rehab therapists. Unfortunately, though, when you’re running a business (for the purposes of this blog, I’m referring to a private practice outpatient therapy clinic), you really need …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.