The Difference Between a Re-Eval and Progress Visit
When it is it appropriate to bill 97164?
Therapists often get confused between when they should bill a progress note and when they should bill a re-evaluation. However, there are extremely strict guidelines when it comes to using each code.
Re-evaluations are not routine and shouldn’t be billed routinely. Progress notes are routine and are completed at every 10th visit or every 30 days (whichever comes first).
According to Medicare, “Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services.”
When medical necessity is supported, a re-evaluation (97164) is appropriate for:
A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition.
A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.
If it is appropriate to bill a re-eval, what should it include?
On November 10, 2016, CMS published the following information regarding the re-evaluation code:
97164 – Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and a revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
It is important to note that 97164 can be billed and bundled with other 97xxx codes with the addition of the 59 modifier to indicate the service is separate and distinct. It is also important to note that whenever a 59 modifier is on the claim, we need to indicate in the notes that the services are separate, distinct and medically necessary.
Still confused or have additional questions? Contact LRS at inquiries@lincolnrs.com and we can get them answered for you.
3 Ways to Improve Your Credentialing Process
Utilize a cloud based platform
Organizations such as the Center for Affordable Quality Healthcare (CAQH) can help you stay current and organized. The upfront time it takes to become enrolled with CAQH is undoubtedly worth the time and effort it saves you down the line. Another perk of such a platform, is that you are notified electronically and in real-time of any updates that need to be made to your account. Payers use this one-stop-shop to gather all your credentials, as opposed to you having to send it countless times.
Ensure data is accurate and current
Take the time to ensure all information being sent out for credentialing purposes is 100% accurate the first time. On average, a provider can expect the credentialing process to take 90 to 120 days. When information is inaccurate, this delays the process, resulting in loss revenue.
Communication is key
Follow-up, follow-up, follow-up! Communicate frequently with the payer you are credentialing with to ensure the process is progressing. Ask if there is anything additional they need. When you send documents, always ask for confirmation of receipt. These simple steps take a few minutes but can decrease your wait time, therefore increasing revenue!
Is your credentialing process overwhelming? Contact us today to see how we can help alleviate some of your administrative burden!
3 Operations Mistakes and How to Fix Them
Review Your Cancel/No Show Rate
Your Cancel/No Show rate shows your ability to get your patients to show up for their visits. A high rate of cancellations can be a sign that you are not selling your services and plans of care. Track this metric for all employees to see who could need motivating.
Not Collecting Up Front
Your chances of collection from a patient drop 20% the minute they walk out the door. This is why it is extremely important to verify a patient’s benefits and collect patient responsibility amounts up front as much as possible.
Too Many Denials
A high first pass payment percentage is a sign of a successful billing team. Billers should be consistently reviewing their denial reasons to avoid them in the future.
What Are You Doing to Protect Your Bottom Line Against Declining Medicare Advantage Reimbursement Levels?
Since 2004, the number of beneficiaries enrolled in private Medicare plans has more than tripled from 5.3 million to 19 million in 2018. Over one third of Medicare beneficiaries are enrolled in an Advantage plan and enrollment is expected to continue to grow at a rate between 4 and 7% per year up to 50% of all enrollees by 2022.
Medicare Advantage programs are built on a framework that emphasizes savings and lowering prices for consumers. People like MA plans because they offer predictability, additional benefits, care coordination and lower estimated total annual healthcare costs than are offered by Original Medicare or supplement plans. Sounds great, right?
Not so fast.
If you are a provider, Medicare Advantage plans tend to reimburse significantly less than traditional Medicare.
Plante Moran completed a study looking at the effects of Medicare Advantage on Skilled Nursing Facility profits. In the third quarter of 2018, the average skilled nursing facility brought in $515 per Medicare patient day according to the National Investment Center for Seniors Housing & Care (NIC), compared to $427 for Medicare Advantage plans and $209 for Medicaid.
Patients often don’t understand that Medicare Advantage is not Traditional Medicare. Patients can have high copays and other patient responsibility associated with their plans. This can lead to very difficult conversations whenever patients receive statements for their services.
For these reasons, it is essential that you are verifying patient benefits prior to their initial appointments. Several Medicare Advantage plans also require authorization for different services. If authorization is not obtained, then all services will be denied with no hope for recoupment.
Patients also need to be told up front what their responsibility is estimated to be and as a provider, you need to collect as much upfront as possible. Providers cannot afford to not collect the patient portion of Medicare Advantage plans because of how low the reimbursement is to begin with.
Do you have questions about how Medicare Advantage is impacting your bottom line? Contact us today to learn more about how LRS can help protect you against denials, increase your reimbursements, and keep you from becoming a patient collection agency.
4 Steps to Improve Patient Collections
High deductible health plans are now the norm. Clinicians and practice owners are having to spend more and more time acting as a collection agency and have less and less time available to actually treat patients.
What can you do to help improve your upfront patient collections so you aren’t spending so much time tracking down payments after time of service?
Verify Patient Benefits: Verify eligibility and benefit coverage before the initial appointment. After verification, you can estimate how much the patient will owe per visit and can collect that estimated payment at time of service.
Communicate: No patient likes to be surprised by a large or unexpected bill. Following verification, let your patients know how much of their deductible they have remaining and what that means for their patient responsibility.
Have a Process and Follow-Up Process for Patient Statements: Send them regularly and following a certain number of statements, call patients to remind them payment is needed and if it is still not made, have a process in place to send patients to a collection agency.
Hire the Right People: Make sure your front desk, billing, and operations staff are all on board with the patient collections process and can effectively and accurately verify benefits and communicate with patients.
Struggling with Your EMR? You Aren't Alone
A decade ago, the U.S. government claimed that ditching paper medical charts for electronic records would make health care better, safer and cheaper.
Ten years and $36 billion later, the digital revolution has gone awry, an investigation by Kaiser Health News and Fortune magazine has found.
Read more investigation takeaways on NPR: https://www.npr.org/sections/health-shots/2019/03/18/704475396/why-the-promise-of-electronic-health-records-has-gone-unfulfilled
Do these struggles feel similar to what you are dealing with in your practice? Gaps of interoperability? Lack of support? Burned out? Contact us today to see how we can help you function better within your EMR and alleviate some of the administrative burden associated with EMRs.
Medicare Advantage Eats Into Profits
As Medicare Advantage enrollment surges, these alternative plans are eating into Skilled Nursing Facility profits.
Plante Moran completed a study looking at the effects of Medicare Advantage on Skilled Nursing Facility profits. In the third quarter of 2018, the average skilled nursing facility brought in $515 per Medicare patient day according to the National Investment Center for Seniors Housing & Care (NIC), compared to $427 for managed Medicare and $209 for Medicaid. Trends also continued downward when looking at length of stay. The average stay was 41 days in 2016 to 38 days in 2017.
Facilities and clinics need to be strategic when looking at their new payer mixes on how to not let these changes impact their bottom line. This is where LRS comes in! Contact us today to see how to protect your business from decreased reimbursements.
Learn more about the Plante Moran study on Skilled Nursing News: https://skillednursingnews.com/2019/03/medicare-advantage-eats-into-margin-gains-for-skilled-nursing-facilities/
Medicare Advantage Plan Enrollment Surges
Even though the policy perspective of “Medicare for All” will be dominating the 2020 coverage, Medicare Advantage plans are dominating the market today.
Anthem’s Medicare Advantage enrollment is up over 35% to more than 1 million enrollees.
“Our individual Medicare Advantage business is on track to achieve our mid-double digit growth target,” Anthem CEO Gail Boudreaux told analysts during the company’s fourth quarter earnings call last week. “In total, we estimate our Medicare Advantage growth will exceed 20% by the end of 2019.”
Cigna’s Medicare Advantage and United HealthCare’s enrollments are also both up from last year.
What does this mean for your bottom line though? Medicare Advantage plans typically have lower reimbursement, more authorization requirements, and more up-front patient responsibility. These new plans can have a significant impact on your bottom line as your payer mix shifts from traditional Medicare to Medicare Advantage.
Don’t get left behind! Contact us today to see how we can help you navigate these reimbursement changes in 2019.
High-Deductible Plans Leave Providers Fed Up With Being Debt Collectors
It has been a recurring theme for providers over the last few years: High deductible and cost-sharing health plans leave providers with both the literal and figurative bill. The old danger for providers were patients with no insurance but now that (nearly) everyone is covered by a plan under the Affordable Care Act, the pains are coming from patients whose plans have sky high patient responsibility.
Now, providers are having to spend their time trying to get patients to pay their bills instead of being able to focus on actually treating patients. Even large medical companies with national operations are facing the problem. Quest Diagnostics Inc., the lab-testing giant, said 20 percent of services billed to patients in the third quarter of this year went unpaid, costing the company about $80 million in lost revenue.
There are ways to help your practice avoid lost revenue from unpaid patient statements and to help you as a provider get back to focusing on treatment instead of being a debt collector. Contact us today at inquiries@lincolnrs.com to see how LRS can improve your patient collections processes.
Read more at: https://www.bloomberg.com/news/articles/2018-11-15/doctors-are-fed-up-with-being-turned-into-debt-collectors
Medicare Announces 2019 Cost-Sharing
Every year, Medicare updates the premiums that you pay for Medicare Parts A, B and D, as well as your deductibles, copays, and coinsurance. Sometimes, the Medicare Part B increase is significant. But luckily, that is not the case this year.
Original Medicare has two parts, which provide inpatient coverage and outpatient coverage. Most Medicare beneficiaries pay nothing for their Part A hospital (inpatient) benefits because they have usually pre-paid for these benefits via FICA payroll deductions throughout their working years.
Just like insurance that you’ve participated in during your working years, Medicare has cost-sharing that you pay as you use your benefits. These come in the form of deductibles, copays and coinsurance.
The Medicare Part A deductible will increase by $24 for $1364 next year. This covers your first 60 days in the hospital. Afterward, beneficiaries pay a daily copay of $341 per day for Days 61–90 and $682/day for Days 91–150. If you have a stay in a skilled nursing facility, you’ll pay $170.50 per day for Days 21–100.
When it comes to Medicare Part B (what is used to pay for outpatient services), next year, most beneficiaries will pay $135.50/month for Part B. This is an increase of only $1.50 per month from the 2018 Part B premiums.
The Part B deductible is also going up, but only by $2. It will be $185 in 2019. Once that deductible is satisfied, Part B will pay 80% of your covered expenses. You are responsible for the other 20% unless you have supplemental coverage in place to cover that for you.
Beneficiaries can check their estimated 2019 Medicare premiums by logging into their MyMedicare.gov account.
Prioritizing PT as Front-Line Treatment for Chronic Pain
Chronic pain exacts a terrible toll on human well-being. More than 10 percent of Americans suffer from pain every day, according to the National Institutes of Health, and many more suffer from it sporadically. Academic research has found that pain is one of the biggest sources of unhappiness. Because of chronic pain, the use of opioids has become a public-health crisis – playing a role in some 50,000 overdose deaths in the United States last year.
By recognizing the importance of non-opioid therapies, insurance companies could improve outcomes, increase cost-effectiveness, and reduce opioid use for lower back pain by expanding non-pharmacological coverage such as physical therapy and chiropractic care, according to a new study published in JAMA Network Open.
Expanding beneficiary access to physical therapy, chiropractic, and acupuncture services may allow payers to provide clinically-proven solutions for temporary pain without relying on opioid prescriptions.
Physical therapists partner with patients, their families, and other health care professionals to manage pain, often reducing or eliminating the need for opioids. Research has shown that a simple education session with a physical therapist can lead to improved function, range of motion, and decreased pain.
Many payers already cover non-opioid pain management and treatment services to some degree, but they often limit the duration of services or require administrative actions that could create barriers to care. The study found that sixty-seven percent of commercial and MA plans had visit limits on physical therapy and 62 percent of plans had limits on chiropractic visits.
Given the massive opioid public health crisis, it is time for providers and insurance companies to prioritize physical therapy as a front-line treatment for chronic pain.
Inspector General's Report on Medicare Advantage Plans
Medicare Advantage plans now cover more than 1/3 of all Medicare beneficiaries and that number is on track to rise to 50% by 2021.
But a new report from the Inspector General found that Medicare Advantage plans have "widespread and persistent problems related to denials of care and payment."
Also, Medicare Advantage plans often have onerous and unnecessary prior authorization requirements that traditional Medicare does not. Medicare Advantage reimbursement also tends to be well below what traditional Medicare pays.
Relatively few people appeal denial of Medicare Advantage claims, leaving insurers free to avoid payment. But nearly 75% of appeals are successful with Medicare Advantage plans!
You need a billing company who is working to get you paid every cent you are owed! Contact us to see how Medicare Advantage plans are impacting your payer mix and your bottom line.
Learn more about the Inspector General's Medicare Advantage Report:
https://www.nytimes.com/2018/10/13/us/politics/medicare-claims-private-plans.html
Progress Report Requirements: Get the Low Down
Documentation is extremely important because it serves as a record of patient care, including report of patient status, physical therapy management, and the outcome of physical therapy. Each insurance has different requirements for what must be included in specifically in progress report documentation.
Here are some highlights that you should be aware of every time you are completing a progress report:
Medicare:
Date that the report was written
Date of the beginning and end of the reporting period that this report refers to
Objective reports of the patient’s subjective statements, if they are relevant
Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occur
Assessment of improvement, extent of progress (or lack thereof) toward each goal
Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report
Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician for certification of the next interval of treatment
Signature, and professional identification, or for dictated documentation, the identification of the qualified professional who wrote the report and the date on which it was dictated
Blue Cross Blue Shield:
Time period covered by the report
Start of Care Date
Medical and therapy treatment diagnoses
Statement of the individual’s functional level at the beginning of the progress report period
Statement of the individual’s current status as compared to evaluation baseline data and the prior progress report, including objective measures of the individual’s function that relate to the treatment goals
Changes in prognosis and why
Changes in plan of care and why
Changes in goals and why
Consultations with other professionals or coordination of services, if applicable
Signature and title of qualified professional responsible for the therapy services
Have other main payers in your payer mix that you want to learn more about requirements for? Contact us inquiries@lincolnrs.com with questions.
Are You Ready for MIPS?
By now, you have heard about MACRA, MIPS, APM, VBC, etc. but what do these acronyms mean, why do they apply to you, and what are you doing to prepare for future payment changes?
The Medicare Access and CHIP Reauthorization ACT of 2015 (MACRA) repealed the SGR and required CMS to come up with formula to pay providers based on quality.
MACRA created the Merit-Based Incentive Payment System aka MIPS.
So what is MIPS?
Streamlines several quality reporting programs under Part B into one program. Includes PQRS, the value-based modifier program, and meaningful use of HER technology.
Unlike PQRS, MIPS is performance based and the therapist’s performance will be scored using performance benchmarks.
Currently you can “pick your pace” but the more advanced you choose, the higher the potential incentives.
MIPS adjustments for payments can be anywhere between +/- 5% in 2018, 7% in 2020, 9% beyond 2020.
MIPS is a revenue neutral program. Winners are paid by the losers! Not all metrics and Quality Measures are created equal. To find out how you can differentiate yourselves and prepare yourselves to succeed in the coming years under MIPS, contact us - the MIPS experts - at inquiries@lincolnrs.com
#ChoosePT
October is National Physical Therapy Month!
The American Physical Therapy Association is focusing this year’s awareness month on highlighting how physical therapy is a safe and effective alternative to opioids for the treatment of chronic pain conditions.
The ongoing opioid crisis in the United States reflects the unintended consequences of a nationwide effort to help individuals control their pain. The health care system has, since the mid-1990s, employed an approach to pain management that focuses on the pharmacological masking of pain, rather than treating the actual cause(s) of the pain when its source can be identified.
Chronic pain can be considered a disease state and can persist for months or years. When PTs work with patients in pain, they use tests and measures to determine the causes of that pain and to assess its intensity, quality, and temporal and physical characteristics.
PTs also evaluate individuals for risk factors for pain to help prevent future pain issues. Some of these risk factors might include: disease history, cognitive and psychological factors, beliefs, and sedentary lifestyle. To help address the pain causes, PTs can implement exercise programs, manual therapy, sleep hygiene and stress management.
Join us in celebrating National Physical Therapy month and help raise awareness about physical therapy as a first step in pain management. #ChoosePT
Learn more: http://www.apta.org/NPTM/
Learn more: http://www.apta.org/uploadedFiles/APTAorg/Advocacy/Federal/Legislative_Issues/Opioid/APTAOpioidWhitePaper.pdf