Following the Rules of the Therapy CapIf you’re like most rehab therapists, finding a letter from Medicare in your mailbox is enough to make your brow sweat and your heart skip a beat. With all of the regulations we have to follow—and the potential penalties associated with noncompliance—it’s no surprise that we have grown to fear Medicare. We’re afraid of doing something wrong. Or in some cases, we’re afraid of not getting paid. Thus, rather than defend our decisions, our expertise, and our treatment plans, some of us look for ways to “game the system.” One way therapists are doing this is working around the therapy cap to avoid having their exceptions rejected.

In a recent article on RAC Monitor, compliance expert Nancy Beckley explains that there is yet another Centers for Medicare & Medicaid Services (CMS) review contractor scrutinizing outpatient therapy—specifically, in instances where treatment stopped “at or near the cap” and then started up again at the beginning of a new benefit period. This looks suspicious to CMS, and understandably so. In their eyes, stopping treatment means therapy is no longer “medically necessary.” So why would it suddenly become necessary again after the cap resets? To an auditor, the therapist in this type of scenario would appear to be working around the system. Medicare has rules, and those rules are there to protect the beneficiary and to ensure we give the proper justification for our services and the costs incurred. Sure, we didn’t create them. In fact, we didn’t even have much say in the matter (partly due to our industry’s historical lack of a strong, unified voice). Even so, we must follow them—no matter how inconvenient they may be.

As I’ve stated in previous blog posts, we as therapists have something to prove. We’re the musculoskeletal experts, and we deserve the same respect, autonomy, direct access, trust, and reimbursements as other medical professionals. But gaming the system proves the exact opposite of all of that. What a monumental disservice not only to yourself, but also to your patients and the entire therapy profession.

Now, you may argue that stopping therapy at or near the cap is a good idea because waiting to roll over to a new benefit period might save the beneficiary out-of-pocket money—and ensure that you, as the therapist, get reimbursed. However, this is exactly the kind of mindset that got us into this predicament in the first place. I admit that early in my career, I felt the same way. But after learning more about the insurance landscape and becoming a clinic director, I realized that lack of business-mindedness is a detriment to what we are ultimately trying to achieve. Our job is not to cower in the face of Medicare and its regulations or to adjust treatment to work around them. Our job is to provide exemplary patient care. If our clinical judgment tells us that a patient needs treatment and we believe it is “medically necessary,” then it’s up to us to show that through documentation—and not doing this well has been our downfall. When our documentation is sub-par, we do not objectively show Medicare the value we provide every day in our clinics. This, in turn, leads them to more severely scrutinize our plans of care. Therefore, some of us fearfully (or lazily) resort to shortcuts rather than standing up for what we know to be correct based on our clinical judgement. In short, we have not properly and definitively articulated whether or not it’s appropriate to continue treatment beyond the therapy cap.

If you’re nervous about exceeding the cap, you should question why. Any reluctance to proceed with treatment is likely a sign that therapy may not be totally necessary. Are the services you’re providing crucial to the patient’s ability to function adequately in his or her daily life? Has the patient reached his or her prior level of function? If the answer is yes, then it’s time to discharge the patient or possibly provide post-care services on a cash payment basis through the proper use of an ABN. If the answer is no, then you should have nothing to worry about: continue treatment; provide documentation that is clear, correct, consistent, and detailed; and play by Medicare’s therapy cap rules. Remember, there is no “approval” process to go over the cap. If you use your clinical judgment and document appropriately, apply the KX modifier and continue to see the patient. If and when you reach the $3,700 threshold, understand that it then becomes more complicated. Still, though, it all boils down to good documentation that proves medical necessity.

Note my above emphasis on documentation. Herein lies what I believe to be the key when it comes to exceeding the cap. Documentation is a story; we as therapists have to present an honest and detailed case for every patient. And like a story, there needs to be a beginning, middle, and end. Proper documentation starts from the very first visit. You must paint a clear picture of who the patient was before he or she needed therapy and who he or she is at the outset of treatment. In short, clearly document both prior and current levels of function. Then, continue the patient’s case using objective measures as the story unfolds. Document progress—or lack thereof. That way, if you exceed the therapy cap, the patient care you’ve chronicled will demonstrate the medical necessity of your actions. Of course, if you finish treatment (i.e., get the patient to the projected goal status) before he or she reaches the cap, then that’s great, too. Complete your documentation accordingly and discharge.

Ultimately, your documentation validates your actions, your decisions, and your services to everyone, including Medicare. So, don’t ever slack in that area. Of course, don’t muddy your documentation with lengthy, flowery prose. Instead, use clear, concise, and objective language.

The therapy cap is a pain—we all know this—but we’re never going to raise it, let alone eliminate it, if we don’t justify our reasons for exceeding it. Data doesn’t lie, and that’s what CMS uses to develop their rules. Furthermore, if we continue to game the system, Medicare will 1.) most likely conduct an audit,  2.) have one more reason to not raise the cap, and 3.) continue to resist giving therapists the autonomy and direct access we deserve. And we will only have ourselves to blame for that.

This is a very pressing issue as these audits are already happening. According to Beckley, the contractor conducting the audits (Strategic Health Solutions) sent letters to more than 350 therapy providers requesting they submit specific claims for post-payment review. Claims submitted August 2012 through March 2013 are subject to review, and for this round of audits, “therapy providers have 45 days from the date of [the] letter to submit documentation in support of the identified claims. The supplemental review contractor [then] has 60 days from the receipt of the medical records to provide a response.”

If you receive one of these letters, don’t panic, but understand the implications you face. I recommend you refer to Beckley’s advice. And going forward, I hope you consider mine: do your job honestly, correctly, and genuinely. You owe this to both your patients and your peers in the therapy industry. Document well, do what’s right for your patients, and follow Medicare’s rules. (If you’re not clear on the regulations surrounding the therapy cap, visit this CMS page.) Furthermore, make a concerted effort to stay abreast of current issues and changes that affect the rehab therapy industry. That way, we can have a strong and informed voice to champion our causes when necessary. Remember, we have something to prove. It may not be fair, but this is the only way to achieve our professional goals. So, no workarounds; no hacks; no cheats. And definitely no sticking our heads in the sand and hoping it all goes away.

The PT’s Guide to Billing - Regular BannerThe PT’s Guide to Billing - Small Banner
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