“How can I avoid being audited by Medicare?” This is one of the compliance questions I hear most frequently, and the honest answer is, quite simply, that you can’t. Just because CMS or one of its auditing entities hasn’t come knocking on your door doesn’t mean you’re not being audited. In fact, every claim you submit undergoes statistical analysis, and Medicare compares your claims data to the data for all other claims submitted. Furthermore, Medicare now analyzes that data in real time.

So, not to sound all doom and gloom, but the idea of avoiding an audit is very unrealistic.  A better approach to protecting yourself and your practice from costly Medicare penalties—and one that goes hand-in-hand with this month’s WebPT Blog theme—is ensuring that all claims you submit for payment are accurate and supported by your documentation.

Just last month, an Office of Inspector General (OIG) finding regarding an outpatient PT provider in Florida identified a documentation error rate of 14%. And actually, that’s pretty good compared to some other findings I’ve seen. For context, a 14% error rate means that OIG looked at 100 random claims and found only 14 that did not meet Medicare billing and documentation requirements. As for the penalty, OIG applied the 14% over the two-year period covering the audit, and as a result, the practice has been asked to return roughly $52,000.  

Again, 14% isn’t bad unless it’s 14% of a large sum. But honestly, we can—and should—do better than that. We work very hard for what we get paid, and we should do our best to make sure we get to keep every dollar we earn. Is it possible to have a documentation error rate of 0%? Probably not; we are human, after all. But reducing our error rate to less than 10% is very realistic.

So, how do we do that?

Fortunately, WebPT provides a lot of built-in compliance functionality to help Members meet all of Medicare’s documentation and billing requirements. Aside from arming yourself with an EMR that has Medicare compliance on lock, here are some key tips to follow:

  • Get certified. I’m talking about plan of care certification. In the land of Medicare, certified POCs are golden. Plus, it’s a condition of payment: no certified POC, no payment. It’s pretty much that simple.
  • Follow the appropriate billing guidelines. For Medicare—and any other insurances that follow Medicare rules—you should use the 8-minute rule to determine how many units to bill for each service. (WebPT helps with this requirement.)
  • Complete your documentation in a timely fashion. Remember, you can’t bill for any services provided until you’ve completed the required documentation for that date of service. So, if you’re a practice owner or manager looking for a quick and easy way to improve your practice’s cash flow, focus on getting therapists to complete their notes promptly.
  • Make sure your documentation accurately reflects the skill you as a therapist demonstrate when providing treatment.
  • Be sure to identify and objectively measure all impairments treated.
  • Explain how the patient’s impairments relate to his or her decline in function.
  • Create goals that are specific to the patient’s functional limitations.
  • Avoid “cookie-cutter” documentation, treatments, and billing.

To further explain that last bullet, I would emphasize that all insurances expect the treatment provided to be specific to the needs of the patient. But, if your billing and documentation appear to be the same—or nearly the same—for every patient you treat, it would suggest that all of your patients are the same, which would be a red flag to the payer. For example, if you document and bill for 40 minutes of therapeutic exercise (97110) for every single patient—and you never bill any other codes—it’s going to look pretty suspicious to the payer. Essentially, you would be indicating that none of your patients ever needed manual therapy (97140) or neuromuscular re-education (97112)—or any other commonly used codes in the PT space. And to a payer, that looks pretty fishy. I’m hoping you can see what I mean.

Sometimes, we get into a documentation rut where it seems like we’re writing the same things all the time. Often, we intentionally use the same phrases over and over in our documentation.  While this doesn’t necessarily mean you are documenting poorly, it can appear questionable to use the same catchphrases in note after note, patient after patient.

My last bit of advice would be to periodically review local coverage determinations (LCDs) and medical policies, as they can change. For example, Novitas—the MAC for 11 states—recently revised LCD L35036 for PT/OT Services. By reviewing LCDs, you’ll gain additional information about what the MAC will—and will not—pay for.


Craving additional guidance on documentation and billing best practices? Check out the WebPT Marketplace to access PT Compliance Group’s most recent training courses on these subjects. Have a question? Leave it in the comment section below.

Unwrapping MIPS and the Final Rule: How to Prepare for 2019 - Regular BannerUnwrapping MIPS and the Final Rule: How to Prepare for 2019 - Small Banner
  • Common Questions from Our PT Billing Open Forum Image

    articleAug 18, 2018 | 34 min. read

    Common Questions from Our PT Billing Open Forum

    Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing . Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • Who You Gonna Call? Which Compliance Resource to Contact and When Image

    articleOct 10, 2016 | 6 min. read

    Who You Gonna Call? Which Compliance Resource to Contact and When

    As is the case for healthcare professionals across the care spectrum, compliance resources for physical therapists are constantly evolving—forcing you, the rehab and remediation specialist, to wear many hats. Not only are you treating patient impairment and injury on a day-to-day basis, but you’re also responsible for ensuring that you and your practice meet a slew of ever-changing regulatory requirements . Man—and you thought finding treatment slots for your growing Rolodex of patients was a challenge. Don’t …

  • The PT's Guide to Billing Image

    downloadJun 7, 2016

    The PT's Guide to Billing

    When it comes to physical therapy billing, you have to know your stuff—because even the simplest mistakes can cause denials. Of course, knowing billing backwards and forwards doesn’t have to be complicated. That’s why we created a comprehensive billing resource specifically for PTs. Take the guesswork out of billing. Enter your email address below, and we’ll send your free guide.

  • The Ultimate ICD-10 FAQ: Part Deux Image

    articleSep 24, 2015 | 16 min. read

    The Ultimate ICD-10 FAQ: Part Deux

    Just when we thought we’d gotten every ICD-10 question under the sun, we got, well, more questions. Like, a lot more. But, we take that as a good sign, because like a scrappy reporter trying to get to the bottom of a big story, our audience of blog readers and webinar attendees aren’t afraid to ask the tough questions—which means they’re serious about preparing themselves for the changes ahead. And we’re equally serious about providing them with …

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum . As expected, we received more questions than our Medicare experts could answer during the live session, so we've provided the answers to the most frequently asked ones below. Don't see the answer you're looking for? Post your question in the comment section at the end of this …

  • The 8-Minute Rule Showdown: Medicare vs. AMA Image

    articleNov 25, 2015 | 5 min. read

    The 8-Minute Rule Showdown: Medicare vs. AMA

    The guidelines for using the 8-Minute Rule are kind of like the instructions for building a piece of furniture from IKEA: they appear simple at first, but before you know it, you’ve been struggling for hours, you’ve got a lopsided futon, and there are seven leftover screws of various shapes and sizes scattered around your living room floor (maybe they’re just extras, right?). To make matters even more confusing, not all payers adhere to the same set …

  • Double Duty: How to Bill for PT and OT on the Same Day Image

    articleNov 12, 2018 | 6 min. read

    Double Duty: How to Bill for PT and OT on the Same Day

    In many cases, physical therapy and occupational therapy go together like peanut butter and jelly. PTs and OTs often share similar goals and interventions, treat the same types of patients in the same settings, and get confused by the billing rules that apply to our respective specialties. This confusion leads to quite a few questions, including this head-scratcher: how does one bill for OT and PT provided to a single patient on the same day? While the …

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