Why Rehab Therapists Need to Be Prepared for an Audit FAQ

I recently hosted a webinar discussing the recent rise in audits from both commercial payers and Medicare. (If you missed it, you can watch the recording here.) I wasn’t able to get to every question during our Q&A session at the end, so I’ve taken those questions and answered them here. 

Is the procedure area in Clinicient enough for the audit, or do we still need to send in a flow sheet? 

You need to send everything that establishes Medical Necessity: an Eval, POC, at-least-10-visit progress notes, HEP instructions, exercise flowsheets, and outcome measure results.

For Clinicient users, what is the best way to add an Addendum? 

Assuming the note is completed and signed, you would need to unsign the note, make the changes, and resign the note.  If you need to know what was changed or when on the note, you can go into Insight EMR, Chart F4, under Client, pick the patient and the case, and click on the note.  If the note is signed, an extra tab labeled 'Revision History' will appear.  Click on revision history.  It will have the note, as well as the sign and unsign history and what was changed with each revision. If you need more help with this, reach out to Insught Support.

Are you seeing audits on maintenance therapy patients due to a lack of adequate documentation? 

Yes, but those audits fall under the $3000 Medical Review Threshold rules.

Can you give me the CPT code or codes that are most audited? 

The most audited codes are 97110, 97112, and 97530.

Are flow sheets mandatory for Medicare, or is it acceptable to list exercises under each specific CPT code? 

If you adequately document your movement interventions within the context of the daily notes, you do not need a flowsheet.

UHC gave us an audit response of “no timed documentation.” We use WebPT, which requires including the time to close a note, and we document time for interventions in the box provided.  We sent an appeal letter with clear documentation of time used, and yet our appeal still gets denied. How can this be prevented? 

You need to provide the minutes for each CPT code in situations like this. If you did that, you should ask for a clarification.

If a patient transitions to maintenance therapy, is it best to continue to document in the same case as the rehabilitative care, or should a new case be created?

In this instance, you should continue to document in the same case. 

We are currently under a Targeted Probe and Educate (TPE) audit with Medicare. They requested 20+ notes to audit code 97110 for our OT. We fixed them, sent them, and they denied a few, saying we didn't send POC/progress notes, even though we did. We resent the POCs and notes and haven't heard anything else for a month. What should we expect next? 

Sometimes the note types are not obvious to the reviewer. In an appeal, you should number all the pages sent so you can refer to the exact location of the documents they claim you left out.

What are your thoughts on acute care patients in observation status? Is it a problem if the actual treatment frequency deviates from the plan of care? 

Yes, it is. In that instance, you should revise the POC.

Are they auditing the use of the CQ modifier? 

I have personally not seen any audits where the CQ modifier was applied. However, I have seen audit findings when the use of an assistant can be determined by the notes but no CQ modifier was used.

What about the use of the ABN form and the Medicare threshold? How are providers utilizing them? 

If the therapist bills the KX modifier, an ABN is never used for those services.

When it comes to re-education exercise, is it your opinion that it’s the "changing" of the exercise that makes the PT "needed" for the exercise, or the complexity of it? Also, how long into the exercise before you need to make changes? 

When the activity is no longer “skilled”, it should be replaced or upgraded to make it skilled. “Skilled” is evidenced by exercise progress, noting the patient’s response and improved function as a result of the exercises, and the clinical reasoning noted in the “A” section of the notes.

Isn’t a prescription for a Medicare patient sufficient in lieu of a POC in New Jersey? 

No, you still have to produce a POC, the therapist needs to sign it, and it needs to be forwarded to the physician within 30 days so they can make changes, if they want.