Coverage/Documentation
requirements
If a physical therapy evaluation is signed by the physician, may it be used as
the certification?
The criteria for “timely certification” of the initial plan of therapy have
been met when the physician/non-physician practitioner’s certification of the
plan has been documented (by signature or verbal order) and has been dated
within the 30 days following the first day of treatment (including evaluation).
Certification requirements have been met when the physician has certified the
plan of care. If the signed order includes a plan of care, no further
certification of the plan is required.
Does Medicare require a prescription/order for therapy and the plan of
care to be signed by the physician?
An order for therapy services, if it is documented in the medical record,
provides evidence of both the need for care and that the patient is under the
care of a physician. However, the plan of care differs in that the plan must be
certified. For example, if during the course of treatment -- under a certified
plan of care -- a physician sends an order for continued treatment for two more
weeks, then the order is acceptable as a certification to continue treatment
for that time period under that plan of care, which is considered to be
separate.
Are the documentation elements for the discharge summary the same as for the
progress report?
The progress report provides justification for the medical necessity of
treatment being provided. At a minimum, the progress report period is every 10
treatment days, or at least once during each certification interval or 30
calendar days, whichever is less. The discharge summary is required for each
episode of outpatient treatment and must cover the reporting period from the
last progress report to the date of discharge. The progress report includes an
assessment of improvement of the patient’s condition toward each goal and their
extent of progress; if there hasn’t been any improvement that needs to be noted
as well. The progress report should also include: any plans for continuing treatment;
reference to additional evaluation results; treatment plan revisions if
applicable; changes to long or short term goals; or discharge. The discharge
note can be the progress report written by the clinician.
KX modifier/automatic exception
What are the financial limits for therapy caps?
Limits for therapy caps may vary from year to year. For 2013, the limit for
physical therapy and speech-language pathology services combined was $1900.00,
and the 2013 limit for separate occupational therapy services was $1900.00.
In 2014, the limit for physical therapy and speech-language pathology services
combined was increased to $1,920.00, and the 2014 limit for separate
occupational therapy services was also changed to $1,920.00.
What is an “automatic exception”?
An “automatic exception” may be made when a beneficiary’s condition has been
justified by documentation indicating that he or she requires continued skilled
therapy (i.e., therapy beyond the amount payable under the therapy cap) to
achieve his or her prior functional status or maximum expected functional
status within a reasonable amount of time.
Clinicians may utilize the automatic process for exception for any diagnosis
for which they can justify services exceeding the cap.
May I append the KX modifier to all of my therapy claims?
No. The modifier only applies to medically necessary services that exceed the
limitation, not before.
Is the KX modifier to be used for services exceeding the cap even if the
patient is not diabetic?
When exceptions are in effect and the beneficiary qualifies for a therapy cap
exception, the provider must add a KX modifier to the therapy Healthcare Common
Procedure Coding System (HCPCS) code subject to the cap limits. In addition to
the KX modifier, the GN (Services delivered under an outpatient speech-language
Pathology), GO (Services delivered under an outpatient occupational therapy
plan of care), and GP (Services delivered under an outpatient physical therapy
plan of care) modifiers are to continue to be used. By appending the KX
modifier, the provider is attesting that the services billed:
• Are reasonable and necessary services that require the skills of a therapist
• Are justified by appropriate documentation in the medical record
• Qualify for an exception using the automatic process exception
Whether or not a patient is diagnosed with diabetes does not have a direct
correlation for appending the KX modifier to a claim.
Will usage of the KX modifier continue to be permitted by Medicare?
On April 1, 2014, the President signed the “Protecting Access to Medicare Act
of 2014,” which extends the exceptions process for outpatient therapy caps
through December 31, 2014.
Really I enjoy your site with effective and useful information. It is included very nice post with a lot of our resources.thanks for share. i enjoy this post. Braunfels Mobile PT
ReplyDelete