Physical, Occupational and Speech and Language Pathology Therapy Services: Prevent Easily Avoidable Errors

Evaluation/Plan of Care Documentation Elements

The POC must contain, at a minimum, the following required elements:

Diagnoses
Long-term treatment goals and
Type, amount, duration and frequency of therapy services

The POC must be certified by a physician or NPP within 30 days or proof of attempts at obtaining signature needs to be provided.

The evaluation/reevaluation needs to contain all of the following required elements:

Diagnosis
Objective, measurable physical function
An assessment- the clinical judgments and/or subjective impressions that describe the current functional status of the condition being evaluated
A plan stating treatment is needed or not needed

The evaluation may serve as the POC if it contains all of the POC elements and is signed by the physician/NPP.

Rehabilitative Therapy versus Maintenance Therapy

Rehabilitative therapy may be needed, and improvement in a patient’s condition may occur, even when a chronic, progressive, degenerative or terminal condition exists.

Rehabilitative therapy requires the skills of a therapist to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation.

Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.

For information regarding Jimmo v. Sebelius Settlement, please view the Jimmo v. Sebelius Settlement Agreement Fact Sheet.

KX Modifier

Section 50202 of the Bipartisan Budget Act of 2018 repeals application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold of incurred expenses above which claims must include a modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record. This is termed the KX modifier threshold.

Along with this KX modifier threshold, the new law retains the targeted medical review process but at a lower threshold amount of $3,000.

The beneficiary may qualify for use of the cap exceptions process at any time during the episode when documented medically necessary services exceed caps. All covered and medically necessary services qualify for exceptions to caps. All requests for exception are in the form of a KX modifier added to claim lines.

An exception may be made when the patient’s condition is justified by documentation indicating that the beneficiary requires continued skilled therapy, i.e., therapy beyond the amount payable under the therapy cap, to achieve their prior functional status or maximum expected functional status within a reasonable amount of time. View the Centers for Medicare & Medicaid Services (CMS) Internet-Only-Manual (IOM), Publication 100-04, Medicare Claims Processing Manual for more information.

Common Findings

Missing or incomplete documentation submissions
Missing elements in the evaluation, plan of care or other additional documentation
Missing or illegible provider signatures
Lack of medical necessity
Billing errors related to therapy minutes or CPT codes

Recommendations

If selected for a targeted probe and educate review, refer to the ADR and the local coverage determination for all required documentation needed for submission.
- Send all supportive documentation through NGSConnex for ease and timeliness.
At a minimum, a certified plan of care must include: diagnoses, long term goals and type/amount/frequency and duration of services.
Document all attempts at obtaining MD signatures and provide proof of attempts, as this will not result in a denial in and of itself.
Ensure all provider signatures are legible and on all required documentation, including flow sheets or exercise sheets.
“Paint a picture” of why a beneficiary needs continued therapy beyond the therapy cap ‘threshold’.
- A level of complexity and sophistication should be shown to support the services of a qualified skilled therapist.
Provide adequate objective data to support beneficiary progress in a reasonable amount of time.
Correct billing and calculation of timed and untimed minutes needs to be in all treatment encounters/notes.
Provide a valid and signed ABN when services do not support medical necessity.