Answers to Frequently Asked Questions about Medical Review

Ambulance

Do we issue an advanced beneficiary notice (ABN) to a beneficiary who chooses to be taken to a hospital 30 miles further than the closest appropriate facility because that is where his family physician practices?
In any emergent situation, the patient is considered to be under duress and therefore an ABN should not be issued. ABNs should only be issued in non-emergent situations. Ambulance suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services for which the ABN is not appropriate.

Medical Records Submission

If a single beneficiaries claims suspend for medical review, for multiple dates of service, can one set of documentation be submitted or do we need to submit documentation to support each bill that suspended?
Since we conduct an independent review of each suspended claim, a separate set of the records needs to be submitted for each requested period of service billed. This applies to multiple requests for the same beneficiary.

Inpatient Psych Facilities

When the physician documents a recertification, should the progress note specifically state "recertification"?
You do not have to make a red flag to say recertification, but you do need to have all of the necessary components to support the recertification. The recertification should state that:
- inpatient psychiatric hospital services furnished since the previous certification or recertification were, and continue to be, medically necessary for either treatment which could reasonably be expected to improve the patient's condition or a diagnostic study AND
- the hospital records indicate that the services furnished were either intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services. (CMS Publication 100-1, Chapter 4, Section 10.9)

What timeframe must the recertifications follow?
First recertification is required no later than the 12th day of hospitalization. The second recertification is required by no later than the 18th day. Subsequent recertifications must be made at intervals established by the utilization review committee (on a case by case basis), but in no event may the interval between recertifications exceed 30 days. (CMS Publication 100-01, Chapter 4, Section 10.9).

Can we continue to bill Medicare for services if we have a patient that is ready for discharge but at the time, there is not a safe facility available to discharge them to?
Payment for inpatient psychiatric hospital services is to be made only for active treatment that can reasonably be expected to improve that patient's condition. Services without active treatment would be considered custodial in nature. (CMS Pub 100-2, Chapter 2, Section 20)

CERT

What do we need to do to change our address for CERT, so requests for medical records from the CERT contractor get to our correct address?
Change of address for the CERT contractor (CDC) can be made at http://www.certcdc.com/certproviderportal/pages/ following the instructions under Provider Address Directory.

Where should appeals regarding CERT denials be sent to?
All claims denied by CERT are subject to the same appeal rights as other denials and can be appealed by the provider or beneficiary. Most appeals requests should be made with WPS-Medicare, since we processed the original claim.

The only exception to this is for non-response and insufficient documentation denials from CERT. These will appear as reason codes 55715/55716, CERT code 21, for Insufficient Documentation, and 55677, CERT code 16, for No documentation.
Additional documentation for claims that were denied due to non-response or insufficient documentation should be sent to the CERT Documentation Contractor.

Is there a time limit for responding to a "Request for Additional Documentation/Tech Stop" request letter from CERT?
Yes, the CERT contractor permits 26 calendar days from the date of the "Request for Additional Documentation/Tech Stop" letter for the submission of the additional documentation. WPS Medicare places reminder calls when the additional documentation remains outstanding after 10 calendar days from the date of the "Request for Additional Documentation/Tech Stop" letter. For additional documentation on CERT, please refer to the WPS Medicare CERT website.

What happens if a provider fails to respond to the "Request for additional Documentation/Tech Stop"?
As with any other CERT record request, failure to submit the requested documentation within the allotted timeframe could result in services being reduced or denied, an overpayment adjustment, and the possibility of a referral to the Office of Inspector General (OIG). It is very important that providers respond to all CERT record requests within the allotted timeframes. For additional documentation on CERT, please refer to the WPS Medicare website.

Inpatient Rehabilitation Facility

Can non-physician practitioner/physician extenders write orders in an IRF?
Non-physician practitioner/physician extenders may write orders and participate in team conferences (with the caveat that they don't take the place of the physician. Non-physician providers (effective January 1, 1998) had restrictions removed on the type of areas and settings for which they can be paid. They can write orders in all settings in which they receive Medicare payments (assuming their state licensure allows them to do so.)

Pub 100-4, Chapter 12, Section 120.

Can non-physician practitioner/physician extenders sit in on the IRF Team Conferences?
If the non-physician practitioner wants to sit in on the care conference, that is OK, but the physician must participate in the Team Conference. A very important component of the medical necessity criteria for IRF admission is that the patient must require the 24 hour availability of a physician with special training or experience in the field of medical rehab. Thus, at a minimum, the multidisciplinary team that meets to assess and evaluate the patient'' condition should consist of a physician, a rehab nurse and one therapist. This section of the regulations should not be interpreted in any way to mean that a non-physician practitioner could substitute for the physician, especially since the physician is required to be actively involved in the patient's care.

Pub 100-2, Chapter 1, Section 110.4.

Where can I find a listing of the classification criteria for an Inpatient Rehabilitation Facility? (IRF)
On the CMS website at: www.cms.hhs.gov/InpatientRehabFacPPS/ or in the CMS Internet Only, Medicare Benefit Policy Manual 100-4, Chapter 3, Section 140

Skilled Nursing Facilities

If a patient is discharged to the hospital prior to receiving therapy evaluations, but the therapies were ordered, can Section T still be used to predict the patient into a Rehab Medium category?
No. Only if therapy has evaluated the resident and plans to provide therapy during the first 15 days, can you estimate the therapy days and minutes through day 15 even though the resident discharges. If orders exist, consult with the therapists involved to determine if the initial evaluation is completed and therapy treatment(s) has been scheduled. If therapy treatment(s) will not be scheduled, skip to Item T2. If the resident is scheduled to receive at least one of the therapies, have the therapist(s) calculate the total number of days through the resident's fifteenth day since admission to Medicare Part A when at least one therapy service will be delivered.

Then have the therapist(s) estimate the total PT, OT, and SP treatment minutes that will be delivered through the fifteenth day of admission to Medicare Part A.

RAI Manual, Chapter 3, Section Tb

Is it acceptable for Physical Therapy (PT) Assistants or Occupational Therapy (OT) Assistants to sign the MDS?
Yes, according to the RAI Manual, all persons participating in the completion of the MDS should sign it. However, Section R of the MDS must be signed by the Registered Nurse (RN) coordinating the assessment.
- PARTICIPANTS IN THE ASSESSMENT PROCESS
  Federal regulations require that the RAI assessment must be conducted or coordinated with the appropriate participation of health professionals. Although not required, completion of the RAI is best accomplished by an interdisciplinary team that includes facility staff with varied clinical backgrounds. Such a team brings their combined experience and knowledge together for a better understanding of the strengths, needs and preferences of each resident to ensure the best possible quality of care and quality of life. In general, participation by all relevant
  interdisciplinary team members will encourage more active and appropriate assessment and care planning processes. Facilities have flexibility in determining who should participate in the assessment process as long as it is accurately conducted. A facility may assign responsibility for completing the RAI to a number of qualified staff members. In most cases, participants in the assessment process are licensed health professionals. It is the facility's responsibility to ensure that all participants in the assessment process have the requisite knowledge to complete an accurate and comprehensive assessment.
- AA9. Signatures of Persons Completing These Items
  Coding: All staff responsible for completing any part of the MDS, MPAF, and/or tracking forms must enter their signatures, titles, sections they completed, and the date they completed those sections. Read the Attestation Statement carefully. You are certifying that the information you entered on the MDS, MPAF, and/or tracking form is correct. Penalties may be applied for submitting false information.

Can therapy treat on the day of discharge when the patient is remaining in the facility? For example, the discharge is planned for 6/27 but the provider could not complete the discharge paperwork until 6/28.
If the beneficiary was discharged on 6/27, then the skilled therapy services would end on that day. The discharge paperwork should be finished on the day of the planned discharge. Payment for Part A services would end on the discharge day. No skilled days are utilized on the discharge day. The facility would still report any therapy services but there would be no additional reimbursement for those services.

Pub 100-4, Chapter 6, Section 40.3.5

If a patient is admitted to the hospital on day 4 of the 5-day assessment period without staying the entire day, can you choose day 4 as the Assessment Reference Date (ARD) date?
Yes, even though you cannot bill for that day, the patient was still in the facility on day 4. By finishing the MDS assessment on this day, you will be able to bill a RUG category rather than default.

RAI Manual

When is a delayed certification for Medicare Part A services acceptable?
"Skilled nursing facilities are expected to obtain timely certification and recertification statements. However, delayed certifications and recertifications will be honored where, for example, there has been an isolated oversight or lapse.

In addition to complying with the content requirements, delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the skilled nursing facility considers relevant for purposes of explaining the delay. The facility will determine the format of delayed certification and recertification statements, and the method by which they are obtained. A delayed certification and recertification may appear in one statement; separate signed statements for each certification and recertification would not be required as they would if timely certification and recertification had been made."

Publication 100-1, Chapter 4, Section 40.5 - Delayed Certifications and Recertifications for Extended Care Services

How do I bill for SNF services when the beneficiary is out of the facility at midnight on a leave of absence (LOA)?
A leave of absence occurs when the beneficiary is absent, but not discharged, from the SNF, at midnight. Leave of absence days are shown on the bill with revenue code 018X and LOA days as units. However, charges for leave of absence days are shown as zero on the claim, and the SNF cannot bill the beneficiary for them.

Publication 100-4, Chapter 6, Section 40.3.4 and 40.3.5.2

Is there a written list of the types of services that are considered skilled?
There is no written list of the services that are considered skilled, however, there are many references that help to define skilled services. The Medicare Benefit Policy Manual, Chapter 8, Section 30 defines skilled services. The Resident Assessment Instrument (RAI) Manual helps facility staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. It also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status. The RAI simply provides a structured, standardized approach for applying a problem identification process in long-term care facilities.

Can patients admitted to the SNF from an inpatient psychiatric hospital qualify for skilled services?
While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term "non-covered care" refers to any level of care, which is less intensive than the SNF level of care, and is covered under the program. Publication 100-2, Chapter 8, Section 20.1

In order for admissions to a skilled nursing facility, for psychiatric services, to be considered for coverage, the services provided must support the need for skilled services that can only safely and effectively be provided in a skilled nursing facility.

Are beneficiaries that are tube fed always considered skilled patients? Do they ever receive another benefit period?
Enteral feedings that comprise at least 26 percent of daily calorie requirements and provide at least 501 milliliters of fluid per day are considered a direct skilled nursing service. As long as the beneficiary continues to receive enteral feedings that comprise at least 26 percent of daily calories and 501 milliliters of fluid per day, they are considered skilled. If the beneficiary remains in the skilled nursing facility and continues to meet the tube feeding requirements, they will exhaust their 100 benefit days and will not be able to start another benefit period until 60 consecutive days have passed during which he/she is not an inpatient of the SNF or the feeding requirements drop below the skilled level of care requirements for 60 consecutive days.

Publication 100-2, Chapter 8, Section 30.3

If the Minimum Data Set (MDS) Assessment Reference Date (ARD) was set within the appropriate timeframes, but was not transmitted to the State timely, can the facility still bill the appropriate RUG code once the MDS is completed and transmitted, even if it is late, or must they bill at the default rate only?
The provider must submit the MDS to the State system before a claim is submitted for payment to Medicare. If the provider has not submitted the MDS to the state, a claim cannot be submitted to Medicare for payment, even at the default rate. Once the MDS has been submitted to the state, even if it is late, the bill may be submitted to Medicare.

RAI User's Manual Chapter 6.4

When is it appropriate to bill at the default rate?
The default rate applies when: An assessment is early or late, based on the Assessment Reference Date (ARD), or the resident is discharged or expires before the 5-day Medicare-required assessment is completed.

RAI User's Manual Chapter 2.9

If a patient is on a leave of absence, is the day of that leave reimbursable to the SNF?
If a patient begins the leave of absence and returns before midnight the same day, the day of the leave is reimbursable to the SNF. However, if the patient has not returned to the SNF by midnight of the day of leave, that day is not reimbursable to the SNF. The non-reimbursable leave days do not count against the beneficiary's 100 day SNF benefit, but do count as part of the "episode of care" period. They should be billed included in "Non-covered Days" under Revenue Code 018X. Occurrence span code 74 is used to report the dates the leave began and ended.

Please refer to Pub. 100-2, Chapter 8, Section 30.7.3 and 60 .

Could you explain what is meant by the lookback period in SNF services?
The look back period is the observation period prior to the Assessment Reference Date (ARD). It is the time period during which data is captured for inclusion on the MDS assessment. Reference: RAI Users Manual Chapter 3, Section 3.3, Section A3 PPS payments are per diem rates based on the patient's condition as determined by classification into a specific Resource Utilization Group (RUG). This classification is done by the use of a clinical assessment tool, the Minimum Data Set (MDS) and is required to be performed periodically according to an established schedule for purposes of Medicare payment. Each MDS represents the patient's clinical status based on an assessment reference date and various look back periods for the time that is covered by that MDS. Medicare expects to pay at the rate based on the most recent clinical assessment, i.e., MDS, until the next required assessment is due or until skilled care is no longer needed. Pub. 100-8, Chapter 6, Section 6.1

Therapy

Do we need to have the therapist's signature on the daily grid (service log) that reports minutes?
The staff that provides the service should initial the log.
Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment (i.e., the signature of Kathleen Smith, PTA, with notation of the help of Judy Jones, PT, supervisor, when permitted by state and local law). The signature and identification of the supervisor need not be on each Treatment Note, unless the supervisor actively participated in the treatment, but the supervisor's identification must be clear in the Plan of Care, or Progress Report. When the treatment is supervised without active participation by the supervisor, the supervisor is not required to cosign the Treatment Note written by a qualified professional. When a supervisor is absent, the presence of a similarly qualified supervisor on that day is sufficient documentation and it is not required that the substitute supervisor sign or be identified in the documentation. Since a clinician must sign the Progress Report, the name and professional identification of the supervisor shall be included in the Progress Report.

Pub 100-2, Chapter 15, Section 220.1.1E Treatment Note

What is the correct way to bill if treatment time for three different modalities add up to 18 min? For instance, 7 minutes of gait training (HCPCS 97116), 5 minutes of therapeutic exercises (97110) and 6 minutes of massage (97124) were provided in one session.
One unit of gait training would be billed since the total minutes of therapy are enough to qualify for one unit and the majority of the minutes were spent on gait training.

How do we bill timed and untimed therapy codes?
If the service being provided does not fall under a timed code, it can only be billed as 1 unit.

Example 1 - HCPCS 97001 (PT Evaluation); even if the Initial Evaluation takes 30 minutes, only 1 unit may be billed and the time does not count towards total treatment time for timed codes.

Example 2 - HCPCS 97032, electrical stimulation (manual), each 15 minutes is a timed code and application from 8 to 22 minutes would be counted as 1 unit.

Counting Minutes for Timed Codes in 15 Minute Units

When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be billed. Time intervals for 1 through 8 units are as follows:

Units	Number of Minutes
1 unit:	> or = 8 minutes through 22 minutes
2 units:	> or = 23 minutes through 37 minutes
3 units:	> or = 38 minutes through 52 minutes
4 units:	> or = 53 minutes through 67 minutes
5 units:	> or = 68 minutes through 82 minutes
6 units:	> or = 83 minutes through 97 minutes
7 units:	> or = 98 minutes through 112 minutes
8 units:	> or = 113 minutes through 127 minutes

The pattern remains the same for treatment times in excess of 2 hours.

If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit. If the service is performed for at least 30 minutes, that service shall be billed for at least two units, etc. It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes.

For further explanation and billing examples go to Publication 100.4, Chapter 5, Section 20.2

Do we need to record time in and time out for outpatient therapy services?
Reporting of actual therapy time is essential to ensure accurate billing of therapy services. However, in accordance with Publication 100-4, Chapter 5, Section 20.3 : "Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and Post-delivery services are not to be counted in determining the treatment service time. In other words, the time counted as "intra-service care" begins when the therapist or physician is directly working with the patient to delivery treatment services. The patient should already be in the treatment area and prepared to begin treatment."

So the reporting of therapy time, should be for time spent in direct delivery of therapy services and not including the time any pre- or post-delivery minutes.

Is functional electrical stimulation (Vital Stim) covered for the treatment of dysphagia?
Review of current literature does not support the efficacy of electrical stimulation for dysphagia. Therefore, electrical stimulation is not a covered modality for the treatment of dysphagia.

Is an evaluate and treat order written by the physician acceptable for the therapist (PT, OT, SLP) to perform an evaluation and begin treatment immediately or is something else required?
The physician must certify/approve the plan of care developed by the therapist. It is appropriate to evaluate the patient and start therapy on the day of the evaluation, while waiting for approval of the plan of care (POC), however, the certification should be on the chart within several days of initiation therapy services.

Pub 100-02, Chapter 15, Sections 220.1.3 and 220.1.1

When is it appropriate to bill a re-evaluation verses an initial evaluation? For example, a patient is receiving physical therapy due to a total knee replacement and during this time period he falls and fractures his wrist. The patient now needs therapy on his wrist in addition to the knee therapy.
If the patient is receiving therapy for any given condition, and he/she has a significant change that warrants an evaluation of a second rehab need, then a re-evaluation would be appropriate and billed to Medicare. (HCPCS 97002)

Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, section 220.1.3

When performing outpatient physical therapy, occupational therapy, or speech-language pathology services, is the therapist required to perform and bill a re-evaluation every 30 days for a patient who requires therapy services longer than 30 days?
No. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation. Indications for a re-evaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care. Re-evaluation may also be appropriate at a planned discharge. CMS Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, sections 220 and 230 define outpatient rehabilitation services and details coverage guidelines.

Page Last Updated: Wednesday, 03-Mar-2010 16:42:22 CST