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Clinical and Compliance Bulletin

877.799.9595 | www.evergreenrehab.com
2012 Quarter 2

Coding Corner
FAQ
1. Do I have to complete a recertification if I change the treatment frequency for a Medicare Part B patient?

No. CMS Medicare Benefit Policy Manual, 100-02, Chapter 15, Section 220.1.2 states that while the therapist may not significantly alter a plan of treatment established or certified by a physician/NPP without their documented written or verbal approval, a change in By appending the KX modifier, the provider is attesting that the frequency, duration, short term goals to adjust for improvements services billed: made toward a corresponding long term goal, or to procedures/ modalities are insignificant alterations in the plan of care and do not Are reasonable and necessary services that require the skills of a therapist; (See Pub. 100-02, chapter 15, section 220.2); and require a recertification. Are justified by appropriate documentation in the medical record, (See Pub. 100-02, chapter 15, section 220.3); and A change in long-term goals (for example if a new condition was to be treated) would be a significant change requiring a recertification Qualify for an exception using the automatic process exception. containing a dated physician/NPP signature. It should be noted that a recertification is also required if a short term goal is added to an updated plan of care that does not correspond to a goal on the initial certified plan of care. For example if the initial plan of care did not contain a goal that addressed dressing and bathing and later these goals are added, a recertification is required. 2. Is there a specific CPT code to bill for administration of the RIPA? Yes. CPT code 96125, Standardized Cognitive Testing (e.g. Ross Information Processing Assessment) per hour of a qualified health care professionals time, both face to face time administering the tests to the patient and time to interpret and prepare the report, is the appropriate CPT code to bill for administration of the RIPA. This code is time based; however, it is based on per hour. In addition, this is a rare code that allows for not only the administration of the test but also the documentation time to interpret and prepare the written report. 4. What is the 59 modifier The -59 modifier is used to indicate that a procedure or service was distinct or independent from other services.

3. What is the KX modifier? The Deficit Reduction Act of 2005 directed CMS to develop exceptions to therapy caps for calendar year 2006. In 2006, the Exception Processes fell into two categories, Automatic Process Exceptions, and Manual Process Exceptions. Beginning January 1, 2007, all services that require exceptions to caps have been processed using the automatic process in which all requests for exception are in the form of a KX modifier added to claim lines.

Decoding CPT Codes


Each quarter we focus on decoding the mystery of a specific CPT code. This quarter we will focus on CPT code 97116Gait Training. CPT code 97116 is the appropriate code to bill for training patients and instructing caregivers in ambulating patients whose walking abilities (including stair climbing) have been impaired by neurological, muscular, skeletal abnormalities or trauma. It is important to note that multiple FI/MAC Local Coverage Determinations (LCDs) state that repetitive walk-strengthening exercise (such as for feeble patients or to increase endurance or gait distance) does not require the skills of the therapist and is considered not reasonable and necessary and is noncovered.

Documentation must support that the skills of the therapist are required to provide gait training. Examples: Caregiver instruction Pre gait weight shifting activities Pre gait training prep for swing phase Skilled Gait Training to decrease backward/forward/lateral lean during weight acceptance on Right/Left Skilled gait training to correct Trendelenberg deviation Skilled gait training to normalize hip ROM during weight acceptance Skilled gait training to decrease excessive knee flexion during weight acceptance Skilled gait training to eliminate knee hyperextension during weight acceptance Skilled gait training to normalize heel strike to foot flat during weight acceptance Skilled gait training to normalize foot clearance during swing phase Skilled gait training in use of assistive device Skilled gait training instruction/progression in gait pattern (2 point, 3 point, 4 point, limited weight bearing) Skilled gait training focusing on speed required for community ambulation (speed to cross street during light) Skilled gait training to address higher level activities such as: opening doors, over thresholds, elevators, walking in a busy/crowded environment, direction change/obstacle negotiation, uneven surface, stairs, ramps, curbs, turning, sidestepping, backward walking

Overall patient case mix is not significantly different from that observed in FY 2011--there have been small decreases in both the Rehabilitation and Rehabilitation Plus Extensive Services categories and increases in some of the medically-based RUG categories, most notably Special Care. FY 2011 FY 2012 Rehabilitation Plus Extensive Services Rehabilitation Extensive Services Special Care Clinically Complex Behavioral Symptoms and Cognitive Performance Reduced Physical Function 2.38% 89.5% 0.6% 4.0% 2.1% 0.3% 1.2% 1.78% 88.9% 0.6% 4.7% 2.2% 0.3% 1.4%

The percentage of residents in Ultra-High Rehabilitation has increased from FY 2011 and although there have been decreases in the High and Medium therapy RUG-IV categories, CMS stated that some of the decrease may be due to index maximization into the Special Care category. FY 2011 FY 2012 Ultra-High Rehabilitation ( 720 minutes of therapy per week) Very-High Rehabilitation (500 719 minutes of therapy per week) High Rehabilitation (325 499 minutes of therapy per week) Medium Rehabilitation (150 324 minutes of therapy per week) Low Rehabilitation (45 149 minutes of therapy per week) 46.2% 27.3% 10.9% 7.4% 0.1% 46.7% 27.3% 10.4% 6.3% 0.1%

Keeping Straight on the Regulation Road:

CMS Released FY 2012 SNF PPS Monitoring Activities Report CMS released a report detailing the FY 2012 SNF PPS Monitoring Activities which presents an initial look at the first quarter impact Initial FY 2012 data indicate that after the allocation of group therapy of the FY 2012 policy changes including the recalibration of the facilities are providing individual therapy almost exclusively. parity adjustment, allocation of group therapy and changes to the MDS including the introduction of the Change-of-Therapy (COT) STRIVE FY 2011 FY 2012 Other Medicare Required Assessment (OMRA). Below are some of the highlights. Individual 74% 91% 99% Concurrent Group 25% <1% 1% 8% 1% 0%

In the FY 2012 SNF PPS final rule, CMS estimated that approximately 884,492 COT OMRAs would be submitted during FY 2012, based on an estimate of 62 COT OMRAs per facility per year for 14,266 SNF facilities (76 FR 49534). CMS stated in this report that assuming that the number of COT OMRAs per quarter remains constant, the total number of COT OMRAs that will be necessary in a given year was overestimated. However, it was also noted that the first part of FY 2012 quarter one included a transition period for the new policies, and therefore may not be entirely representative of all of FY 2012. FY 2011 Scheduled PPS assessment Start-of-Therapy (SOT) assessment End-of-Therapy (EOT) assessment (w/o Resumption) Combined SOT/EOT End-of-Therapy assessment (w/ Resumption) (EOT-R) Combined SOT/EOT-R 95% 2% 3% 0% N/A N/A FY 2012 85% 2% 3% 0% 0% 0% 10%

FAQ:
1. What happens if I do not combine them as I should? CMS provided the following answer If a scheduled assessment ARD is set for a day that is after the ARD set for an unscheduled assessment, and the ARD for the unscheduled assessment is set for a day within the scheduled assessment window, then the scheduled assessment is not used for payment purposes. It is important to remember that the scheduled assessment still needs to be completed. Example #1: Resident last received therapy on day 11 EOT OMRA completed with an ARD of day 14 Scheduled 14 day assessment ARD set for day 15 In this scenario, the 14 day is not used for payment because the assessments were not combined; therefore, the EOT OMRA would pay beginning on day 12 and continue until the next scheduled or unscheduled assessment used for payment. 2. What happens if day 7 of the COT observation period falls within the ARD window of an EOT? The answer is dependent on the ARD of the EOT OMRA. For example, if day 7 of the COT observation period falls on days 1 or 2 of the EOT ARD window and the EOT ARD is set for day 3 then the COT must be completed. However, if the ARD of the EOT and the COT are the same, then the decision to complete the COT may be made by the provider just as with a scheduled PPS assessment. 3. What is the relevance of used for payment? The statement used for payment is key to understanding the impact of a PPS assessment on the COT ARD calendar and ensuring that the correct calendar is used for ARD compliance in order to avoid late, missed or early assessment penalties. If an assessment has an ARD set for on or prior to day 7 of the COT observation period, but this assessment is not used for payment, then completing this assessment does not impact the COT calendar. Example #1: COT OMRA completed with ARD of day 13 Scheduled 14 day assessment ARD set for day 15 In this scenario, the 14 day is not used for payment because the assessments were not combined; therefore the COT OMRA would pay beginning on day 7 (day 1 of the COT observation period) and continue until the next scheduled or unscheduled assessment used for payment. It is important to note that because the 14 day was not used for payment, it has no impact on the COT calendar and the next COT observation period day 7 is day 20.

Change-of-Therapy (COT) assessment N/A

CMS Hosted the MDS 3.0 National Conference in St Louis in March At the MDS 3.0 National Conference, CMS provided education on the FY2012 Updates and Clarifications and the MDS Item Set Changes that will be effective April 1, 2012. FAQs and CMS clarifications provided at the conference are detailed below: Assessment Combination: CMS reiterated that if the ARD for an unscheduled assessment falls within the ARD window (including grace days) of a scheduled PPS assessment, and the ARD for the scheduled assessment would be set for a day after that of the unscheduled assessment , then the assessments must be combined. For example, if the ARD for an EOT OMRA is day 14 and the 14 day scheduled PPS assessment is not set for prior to day 14, the assessments must be combined. CMS also clarified that, although not in the manual updates yet, if the ARD of a PPS assessment used for payment is set for on or prior to day 7 of the COT observation period, then no COT would be required but a provider may choose to complete the COT.

Example #2: Day 7 of the COT observation period and the ARD of the 30 day assessment are set for day 27. The SNF chose not to complete the COT The patient discharged on day 30 In this scenario, the 30 day was not used for payment. The COT was not done and is now considered a missed assessment resulting in all days that would have been paid by the missed assessment as provider liable. ARD setting for unscheduled assessments CMS announced that effective April 1, 2012, facilities are permitted to set the ARD for unscheduled PPS assessments for a day within the allowable ARD window for that assessment no more than 2 days after the window has passed. For example, day 7 of the COT observation period is day 37. The ARD may be set for days 37 on days 37-39. If the ARD is not set for day 37 by day 39 it is considered late. Unscheduled Assessment ARD Compliance (Late, Missed, and Early) Policies CMS provided clarifications on the policies for late, missed, and early ARDs for unscheduled assessments: Early Unscheduled Assessment Policy: If the ARD for a COT OMRA is set for prior to day 7 of the COT observation period, the facility must bill the default rate the total number of days the assessment is out of compliance (the number of days by which the assessment is early). The default rate is effective from day 1 of the COT observation period and is billed for the number of days that the assessment is out of compliance. The facility may then bill the RUG from the COT OMRA for the remainder of the COT observation period until the next scheduled or unscheduled assessment used for payment. An early COT does reset the COT calendar.

Example: The 30 day assessment ARD is day 30 Day 7 of the COT observation period is day 37 The ARD for the COT is set two days early on day 35 In this scenario the facility is two days out of compliance resulting in the default rate on days 29 and 30. The COT OMRA RUG would be billed beginning day 31 and continue until the next scheduled or unscheduled assessment used for payment. The next COT observation period day 7 would be day 42 (seven days from day 35, remember the early COT does reset the COT calendar)

Late Unscheduled Assessment Policy: If the SNF fails to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident being assessed is still on part A, the ARD cannot be set for any earlier than the day the omission was identified. The total number of days the assessment is out of compliance, including the late ARD, must be billed default beginning on the day the assessment would have controlled payment until another intervening assessment would control payment. A late COT does reset the COT calendar. Example #1: The 30 day assessment ARD is day 30 Day 7 of the COT observation period is day 37 The ARD for the COT is set two days late on day 39 In this scenario the facility is two days out of compliance resulting in the default rate for two days on days 31 and 32. The COT OMRA RUG would be billed beginning day 33 and continue until the next scheduled or unscheduled assessment used for payment. The next COT observation period day 7 would be day 46 (seven days from day 39, remember the late COT resets the COT calendar) Example #2: The 30 day assessment ARD is day 30 Day 7 of the COT observation period is day 37 The ARD for the COT is set 15 days late on day 52 Resident last received therapy on day 39 EOT OMRA is completed timely with an ARD of day 42 In this scenario, the EOT is the intervening assessment so the facility would bill the default rate for day 31-39 and the EOT OMRA RUG from day 40 until the next scheduled or unscheduled assessment used for payment.

Missed Unscheduled Assessment Policy: If the SNF fails to set the ARD for an unscheduled assessment within the defined ARD window for that assessment, and the patient has been discharged from Part A, the assessment cannot be completed. All days which would have been paid by the missed assessment are billed as provider liable (the provider receives no payment but the days count against the 100 day benefit period) until the point when an intervening assessment would control payment. Example #1: The 30 day assessment ARD is day 30 Day 7 of the COT observation period is day 37 The COT OMRA is not completed The patient is discharged from part A on day 40 The missed COT OMRA is identified two weeks after the part A discharge In this scenario the facility must bill provider liable for days 31-40 and receives no payment. Example #2: The 30 day assessment ARD is day 30 Day 7 of the COT observation period is day 37 The COT OMRA is not completed Last day of therapy is day 39 EOT OMRA is completed timely with an ARD of day 42 The patient is discharged from part A on day 45 The missed COT OMRA is identified two weeks after the part A discharge In this scenario the facility must bill provider liable for days 31-39 and receives no payment. The facility then bills the EOT OMRA from day 40 until d/c. Inactivating Assessments CMS stressed a procedure they stated has been effective since MDS 2.0. that a Data Modification cannot be done for an error in ARD, Discharge or Entry dates, or Reason for Assessment. These must be inactivated and a new MDS created. If an assessment is inactivated for this or any reason, any replacement assessment must have a current ARD and completion dates. If the inactivation results in SNF PPS assessments being late, the late or missed assessment policy, depending on the situation, applies.

Unscheduled Assessment Interviews Effective April 1, 2012, when coding a standalone unscheduled PPS assessment (COT, EOT, SOT) the interview items (must be resident interview and not staff assessment) may be coded using responses provided by the resident on a previous scheduled or unscheduled assessment if the interview responses were obtained within a 14-day time frame from the ARD of the unscheduled assessment on which those responses will be used. This new policy does not apply if the unscheduled assessment is combined with a non-PPS assessment or scheduled PPS assessment. It is the discretion of the provider to determine if a change is observed during the assessment period and if so, the responses should not be carried forward from a prior assessment. Therapy Cap Exceptions Process Extended Through December 31, 2012 Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, which added 1834(k)(5) to the Act, required payment under a prospective payment system (PPS) for outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). Section 4541(c) of the BBA required application of financial limitations to all outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). Since the creation of therapy caps, Congress has enacted several moratoria. The Deficit Reduction Act of 2005 directed CMS to develop exceptions to therapy caps for calendar year 2006 and the exceptions have been extended periodically. Exceptions to caps based on the medical necessity of the service are in effect only when Congress legislates the exceptions. In 2006, the Exception Processes fell into two categories, Automatic Process Exceptions, and Manual Process Exceptions. Beginning January 1, 2007, there is no manual process for exceptions. All services that require exceptions to caps shall be processed using the automatic process. All requests for exception are in the form of a KX modifier added to claim lines. The KX modifier is added to claim lines to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record.

On February 22, 2012, President Obama signed into law the Middle Class Tax Relief and Jobs Creation Act of 2012 extending the Therapy Cap Exception Process through December 31, 2012. Details related to the Therapy Cap Exception Process include the following: Automatic exception process using the -KX modifier continues for patients who exceed the Therapy Cap of $1,880 for PT/SLP combined and OT services separately Now includes outpatient hospital providers in the cap and exception process Beginning with services received on or after October 1, 2012, claims that exceed $3,700 annually for PT/SLP combined and OT services separately will be subject to a manual review process to be defined by CMS. CMS Delays ICD10 Implementation Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 a delay of two years from the compliance date initially specified in the 2008 proposed rule. HHS will announce a new compliance date moving forward. Occurrence Code 16 Discontinued CR 7717 released on 1/26/2012 discontinued the requirement for SNF providers to report Occurrence Code 16 indicating the last day of therapy services on claims. CMS Issues a New Combined Notice of Medicare Non-Coverage CMS issued a new combined Notice of Medicare Non-Coverage (NOMNC). This notice will replace the CMS 10123 (Original Medicare notice) and the CMS 10095 (Medicare Advantage notice). The requirements for issuing these notices have not changed. This combined notice retains the form number of the current Original Medicare Notice (CMS 10123) and the name of the Medicare Advantage notice (Notice of Medicare Non-Coverage, or NOMNC). Highmark Medicare Services Becoming Novitas Solutions Effective Jan 1, 2012, Diversified Service Options, Inc, a whollyowned subsidiary of Blue Cross and Blue Shield of Florida Inc, acquired Highmark Medicare Services from its parent company,

Highmark Inc. As a result, Highmark Medicare Services changed its name to Novitas Solutions, Inc. Novitas will continue to be the Medicare Administrative Contractor (MAC) for J12 and the Section 1011 Administrative Contractor. In the near future, the website will be changing to www.Novitas-Solutions.com. RAC Collections Update The Recovery Audit Program (October 1, 2011 December 31, 2011) Quarterly Newsletter details the total RAC overpayments collected, underpayments returned and total corrections. In FY 2012 Quarter 1, the RAC National Program has already collected 45% of the total collections reported in FY 2011. Overpayment Collected FY 2010 $75.4M FY 2011 FY 2012 Qtr. 1 $797.4M $397.8M $141.9M $24.9M $939.3M $422.7M

Underpayments Collected $16.9M Total Corrections $92.3M

CMS Updates RAC Additional Documentation Limits for Providers On March 13, 2012 CMS announced that the RAC Additional Documentation Limits for Providers has been increased effective March 15, 2012. The percentage of requests increases from 1% to 2%. In addition the maximum number of requests per 45 days increases to 400. Each limit is based on the providers prior calendar year Medicare claims volume. The limit is equal to 2% of all claims submitted for the previous calendar year divided by 8. The Recovery Auditors may go more than 45 days between record requests but may not make requests more frequently than every 45 days. A providers limit will be applied across all claim types, including professional services. For Skilled Nursing Facility (SNF) claims, one additional documentation request represents a beneficiarys entire episode of care. This includes medical records for all services rendered from the date of admission to the final date of discharge. CMS may give the Recovery Auditors permission to exceed the limit. Permission to exceed the limit may occur by CMS own initiative or from the Recovery Auditor requesting permission. CMS or the Recovery Auditor will notify affected providers in writing.

RAC Region D Contractor, HealthDataInsights, Reviewing SNF Claims RAC Region D Contractor, HealthDataInsights, is reviewing Skilled Nursing Facility (SNF) documentation to determine if the stays are medically reasonable and necessary. HealthDataInsights Region D consists of 17 states and 3 territories: Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam, American Samoa, and Northern Marianas.

Therapy Whistleblower Suit Allowed to Proceed in MN The Minneapolis Star Tribune reported on February 24, 2012 that an occupational therapy assistant will be able to move forward with a lawsuit against her former employer, Aegis Therapies and Golden Gate National Senior Care LLC, doing business as Golden Living, over what she says were fraudulent therapy claims. According to court documents, Johnson said she oversaw the length of time clients were on exercise machines in a wellness center, without supervision, and that those records were used by Aegis to bill Golden Living for occupational therapy and physical therapy services. Golden Living then would bill Medicare or Medicaid, according to the lawsuit. The suit alleges that eight other facilities in Minnesota and some Golden facilities in other states followed similar billing practices, the Minneapolis Star-Tribune reported. If the case stays limited to Hillcrest, the damages could be hundreds of thousands of dollars, but more widespread errors could cost the company significantly more, the paper reported.

All Eyes on Therapy


Therapy remains the focus of many Medicare Administrative Contractors (MACs)/Fiscal Intermediaries (FIs) as well as the Regulatory and Law Enforcement Agencies of the Federal Government as the commitment to deterring fraud, waste and abuse in the Medicare and Medicaid systems has increased.

Contact Information:
Liz Barlow Vice-President of Clinical Services 502.400.1619 liz@evergreenrehab.com Shawn Halcsik Director of Compliance 414.791.9122 shalcsik@evergreenrehab.com