Blog Post

The PT’s Guide to Surviving a Medicare Audit

Medicare audits might be unavoidable, but they're completely survivable—if you follow this advice. Read on to learn how.

Tom Ambury
5 min read
May 30, 2016
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“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.


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