With designated modifiers and "sometimes" and "always" therapy codes disrupting practices' billing success, therapy codes are under scrutiny. A big change is afoot in 2018 as Medicare administrative contractors (MACs) will turn on edits that may lead to a flurry of automatic denials.
To gain a better sense of the issues at stake and secure some practical tips you can emplace before Jan. 1,
Part B News sat down with billing expert Heidi Jannenga, PT, DPT, ATC/L, president and co-founder of
WebPT, a Phoenix-based business solutions provider for therapy professionals. The Q&A below has been condensed and edited for clarity.
Part B News: CMS says that, upon review, it found that the "always therapy codes and modifiers are not always used in a correct and consistent manner," leading to "non-compliant billing." How big of a problem is this?
Heidi Jannenga: Two of the top three denial errors that we see time and time again are missing claim information (an absence of codes and modifiers altogether) and data-entry mistakes (incorrect use of codes and modifiers). The latter accounts for more than 90 percent of denials. So, this is a widespread problem from a billing perspective.
The larger issue, though, is what these modifiers represent. One of their main purposes is to help CMS track patient progress toward the Medicare therapy cap, which places an annual limit on the amount Medicare will reimburse for the PT [physical therapy], OT [occupational therapy] and SLP [speech/language pathology] services provided to each individual patient. Rehab therapists have long struggled to fight for their position as the go-to provider for patients with neuromusculoskeletal issues, and the therapy cap has been a very large barrier in that battle, as it prevents or deters many therapists from treating and healing their patients efficiently and effectively.
Now, the therapy cap exceptions process — which requires the use of a different modifier, the KX modifier — does provide a means for therapists to continue treatment after a Medicare patient has exhausted his or her annual payment allotment for therapy services. As such, we’ve had a love-hate relationship with the cap: it’s not ideal, but it could be worse. The problem is that confusion over the cap and the exceptions process leads to even more billing errors — which makes it pretty tough to defend the current system.
PBN: With the new release, CMS appears to be taking a hard line with billing for therapy services. What does that suggest to you? Should providers seek to up their compliance when it comes to reporting these codes? Any tips?
Jannenga: Providers should always work to improve compliance for several reasons. For one, with CMS cracking down on the proper use of modifiers, you can bet the number of claim denials will increase. Perhaps more importantly, though, when therapists fail to use billing codes and modifiers accurately, it muddies the data that CMS collects. And because CMS will use that data to inform future payment policies and structures, it’s absolutely imperative that we provide data that paints a clear picture of the services we are providing.
I think most of us in the rehab therapy world can agree that we need a better system — one that ensures patients always have access to the therapy services they need. The therapy cap creates a barrier to that access, and if we aren’t giving CMS data that accurately portrays patient utilization of our services, then it’s going to be tough for us to build a case for greater access.
PBN: Are there other billing pitfalls that may be causing problems? Any areas to keep a close eye on?
Jannenga: One thing we’ve been keeping a close eye on for the past six months is
the use of the new CPT codes for therapy evaluations. The trends we’re seeing could impact the future of coding requirements and reimbursement rates. For instance, the data revealed that older patients are undergoing not only more PT and OT evaluations overall, but also more high-complexity evaluations — and that could impact Medicare’s future decisions regarding a tiered, complexity-based reimbursement structure. And while this data is still is still fairly new, it highlights the strong need for rehab therapy among the most vulnerable patient populations, including the elderly.