what is bone density or Bone Mass measurment

Bone Density: Time to Get It Tested

Bone Mass Measurement (BMM), or bone density screening is a test that identifies bone mass, detects bone loss, and may determine bone quality. BMM can be performed with a bone 'densitometer' or an approved bone 'sonometer system.' Bone densitometry uses an X-ray or some other form of radiation, and the test will determine your bone density according to the rate at which this radiation is absorbed by your bones. There are usually three methods of testing: a stationary machine kept in one location, such as your doctor’s office or a hospital; a mobile unit, such as you see with mammography units, or with a portable machine. Bone sonometers are ultrasound machines and do not use radiation. You often see these machines in doctors’ offices. This is the same ultrasound technique used for gallbladders, bladders, etc.

Medicare may cover BMM screening once every two years (at least 23 months have passed since the month the last covered BMM was performed) or more often when medically necessary for persons who are at risk for osteoporosis and meet other conditions. This test is free (deductible and coinsurance/copayment are waived) if your doctor or health care provider accepts assignment. To 'accept assignment' means your doctor or health care provider or suppler has a signed agreement to be paid directly by Medicare and to accept the Medicare approved amount. They cannot bill you for any more than the Medicare deductible and coinsurance.

Medicare covers bone mass measurement when:

• It is ordered by a physician or qualified health care practitioner who is treating you, following an evaluation of the need for the BMM

Physical Therapy Plan of Care Requirements

The Centers for Medicare & Medicaid Services (CMS), is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern identified in the CERT data is denial of outpatient rehabilitation therapy services due to missing physician/non-physician practitioner signature and dates on the certification of the plan of care. This has led to Novitas Solutions, Inc recouping overpayments totaling over $164.70. More importantly, when CMS and CERT extrapolate these errors to the universe they will account for approximately $19.3 million in claims payment errors for the November 2011 report.

Medicare defines rehabilitative services as those services that lead to "recovery or improvement in function and, when possible, restoration to a previous level of health and well-being."

Outpatient rehabilitation therapy services must relate directly to a written treatment plan (also known as the plan of care or plan of treatment).  Medicare states "The plan of care shall contain, at minimum, the following information: diagnoses, long term treatment goals, and type, amount, duration, and frequency of therapy services."

The plan of care is established by a physician, non-physician practitioner, physical therapist, an occupational therapist, or a speech-language pathologist  The signature and professional identity of the person who established the plan of care and the date it was established must be documented within the plan of care.  The plan of care must be established before the therapy treatment can begin.

Establishing the plan of care is different than certifying the plan of care.  Medicare states that certification of the plan of care requires a dated signature on the plan of care, or some other document, by the physician or non-physician practitioner who is the primary care provider for the patient.  In the absence of a formal certification document, a physician progress note indicating the physician's agreement with the plan of care is acceptable. The certification of the plan of care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment.  Payment may be denied if the physician does not certify the plan of care; therefore, the therapist should forward the plan to the physician as soon as it is established. Recertification of the plan of care, which also requires a physician or non-physician signature and date, should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification.  A therapy provider, per Medicare, may obtain a verbal order for certification or recertification of the plan of care; however, the verbal order must be signed and dated by the physician/non-physician practitioner within 14 calendar days.

Advance Beneficiary Notice of Non-coverage: When Should You Sign an ABN?

Medicare has broad coverage, but there are some services that are not covered because they are considered reasonable, medically necessary, and appropriate. The purpose of the ABN is to give you the necessary information to make informed decisions about whether or not to get the services your provider is suggesting.

The following are some examples of when an ABN can be used for non-covered services:

• Services where there is no legal obligation to pay (e.g., for the purchase of some vaccines). In those cases, your doctor can charge Medicare for administering the vaccine, but they cannot charge Medicare for the vaccine.

• Services paid for by a government entity other than Medicare

• Personal comfort items

• Routine eye care

• Dental care

• Routine foot care

ABNs cannot be issued for services that the provider knows is medically necessary and is covered by Medicare. In addition, an ABN cannot be issued for emergency ambulance transportation because the patient is presumed to be under ‘great duress’. An ABN cannot be issued to a patient if they are under great duress.

An ABN must be given to you (or your representative) prior to receiving the item or service in question. The Centers for Medicare & Medicaid (CMS) mandates your provider give you the ABN far enough in advance for you to have time to consider your options and make an informed choice.

CMS has created a standardized ABN form to use; however, it does allow your health care provider to use their own form, as long as it contains the same information.

If your provider asks you to sign an ABN, the document must:

• Give the name or description of the service they are providing

• Provide a statement that explains why they believe the services may not be covered by Railroad Medicare. Some common statements are: 'Medicare does not pay for this test for your condition,' 'Medicare does not pay for this test as often as this (denied as too frequent)', or 'Medicare does not pay for experimental or research tests.'

• Give you the estimated cost of the service or procedure

• Provide you with three options, worded in the following ways:

Diagnostic Tests- CMS Requirements - Medicare denial

The Centers for Medicare & Medicaid Services (CMS), is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern identified in the CERT data is denial of diagnostic tests due to missing physician/non-physician practitioner order or intent within the medical record.  This has led to the recoupment of overpayments by Novitas Solutions, Inc totaling over $355.64. More importantly, when CMS and CERT extrapolate these errors to the universe, they will account for approximately $22.1 million in claims payment errors for the November 2012 report.

Medicare defines a Diagnostic Test as including: 

"All diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary."

And further defines Clinical Laboratory Services as:

"The biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition."

CMS also gives direction that Clinical Laboratory Services "must be ordered and used promptly by the physician who is treating the beneficiary."

CMS defines an order as:

" A communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y)."

An order can be written in the beneficiary's record or can be a telephone order from the physician's office to the testing facility.  If a telephone order, both the treating physician and the testing facility must have documented in the beneficiary's record the telephone call and the extent of the diagnostic tests being ordered. 

Therapy and rehabilitation services FAQs

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.

End Stage Renal Disease Facility Providers

This page provides basic information about being certified as a Medicare and/or Medicaid End Stage Renal Disease (ESRD) provider and includes links to applicable laws, regulations, and compliance information.

ESRD is that stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplant to maintain life.

Types of ESRD Facilities:

•    Renal Transplantation Center

A hospital unit which is approved to furnish, directly, transplantation and other medical and surgical specialty services required for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement.  A renal transplantation center may also be a renal dialysis center.

•    Renal Dialysis Center

A renal dialysis center is a hospital unit that is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or under arrangement and outpatient dialysis).  A hospital need not provide renal transplantation to qualify as a renal dialysis center.

•    Renal Dialysis Facility

A renal dialysis facility is a unit that is approved to furnish dialysis service(s) directly to ESRD patients.

•    Self Dialysis Unit

A self-dialysis unit is a unit that is part of an approved renal transplantation center, renal dialysis center, or renal dialysis facility, and which furnishes self-dialysis services.

who is Home Health Providers

This page provides basic information about being certified as a Medicare and/or Medicaid home health provider and includes links to applicable laws, regulations, and compliance information.

A Home Health Agency (HHA) is an agency or organization which: 

•    Is primarily engaged in providing skilled nursing services and other therapeutic services;Has policies established by a group of professionals (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services which it provides;

•    Provides for supervision of above-mentioned services by a physician or registered professional nurse;

•    Maintains clinical records on all patients;

•    Is licensed pursuant to State or local law, or has approval as meeting the standards established for licensing by the State or locality;

•    Has in effect an overall plan and budget for institutional planning;

•    Meets the federal requirements in the interest of the health and safety of individuals who are furnished services by the HHA; and

•    Meets additional requirements as the Secretary finds necessary for the effective and efficient operation of the program.

For purposes of Part A home health services under Title XVIII of the Social Security Act, the term “home health agency” does not include any agency or organization which is primarily for the care and treatment of mental diseases.

Hospital visit definiton

Hospitals 

This page provides basic information about being certified as a Medicare and/or Medicaid hospital provider and includes links to applicable laws, regulations, and compliance information.

A hospital is an institution primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services or rehabilitation services. Critical access hospitals are certified under separate standards. Psychiatric hospitals are subject to additional regulations beyond basic hospital conditions of participation. The State Survey Agency evaluates and certifies each participating hospital as a whole for compliance with the Medicare requirements and certifies it as a single provider institution.

Under the Medicare provider-based rules it is possible for ‘one' hospital to have multiple inpatient campuses and outpatient locations. It is not permissible to certify only part of a participating hospital. Psychiatric hospitals that participate in Medicare as a Distinct Part Psychiatric hospital are not required to participate in their entirety.

However, the following are not considered parts of the hospital and are not to be included in the evaluation of the hospital's compliance:

•    Components appropriately certified as other kinds of providers or suppliers. i.e., a distinct part Skilled Nursing Facility and/or distinct part Nursing Facility, Home Health Agency, Rural Health Clinic, or Hospice; Excluded residential, custodial, and non-service units not meeting certain definitions in the Social Security Act; and,

•    Physician offices located in space owned by the hospital but not functioning as hospital outpatient services departments