Medicare Part A Update Jennifer Bogenrief, JD Manager, Regulatory Affairs AOTA AOTA Specialty Conference: Effective Documentation Friday, September 12, 2014 1 Topics Medicare Therapy Documentation Requirements IRF SNF Home Health Jimmo v. Sebelius Inpatient Hospital Admissions Policy Hospice LCDs OIG Report Tips for Successful Documentation Responsibilities for Practice Producing Quality Outcomes 2 AOTA Medicare Part A Update 9/12/14 1
Medicare Coverage for OT Generally, OT is covered if it meets the following criteria: Services are ordered by a physician & furnished under a physician certified plan of care (developed by an OT based on therapist s assessment) Services must be performed by a qualified OT or OTA under general supervision of an OT and Services must be reasonable & necessary Services must be documented in the medical record, planned & periodically evaluated 3 Medicare Requirements Services must be reasonable and medically necessary Services must be skilled and rehabilitative Services must be provided by a clinician or qualified professional under supervision of a therapist Key is whether the skills of a therapist are needed to treat the illness or injury See Medicare Benefit Policy Manual, Ch. 15, 220.2 4 AOTA Medicare Part A Update 9/12/14 2
Medicare Documentation Requirements Medical record & claim must consistently & accurately report covered therapy services Must be legible, relevant & sufficient to justify the services billed Types of documentation: Evaluation & Plan of Care Certification & Recertification Progress Reports (includes Discharge Summary) Treatment Notes for each treatment day Separate justification statement may be included (not required if record justifies treatment without further explanation) See Medicare Benefit Policy Manual, Ch. 15, 220.3 5 Key Components of Documentation Typical amount, frequency & duration of services Patient s medical complexity & need for care Use of objective tests & measures to validate findings Demonstrate why the skilled services of a therapist are needed Appropriate signatures Tell a story Medicare wants details to justify payment for services 6 AOTA Medicare Part A Update 9/12/14 3
Key Components of Evaluation Initial evaluation must include a diagnosis and pertinent medical or therapy history that could affect the plan of care Objective evaluation data must be documented with therapist s interpretation or analysis of its meaning for the client Record of medical care prior to current episode Evaluation must include client s prior level of function, as well as all conditions & complexities that may impact treatment 7 Medicare Part A Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) Parts A, B, C & D Medicare Part A Paid by Medicare payroll taxes; Open to all eligible beneficiaries Includes: Inpatient (hospital, SNF, IRF, etc.), home health services, hospice Most Part A services paid on a prospective payment system (PPS) 8 AOTA Medicare Part A Update 9/12/14 4
Inpatient Rehab Facilities IRF PPS final rule pub. 8/6/14; Effective 10/1/14 Therapy Definitions: Group = treating 2 to 6 patients at the same time who are performing the same or similar activities Concurrent = treating 2 patients at the same time who are performing different activities 9 Inpatient Rehab Facilities New therapy data collection requirements IRF-PAI Therapy Information Section record for each discipline: How much therapy What type of therapy For weeks 1 & 2 of patient s IRF stay Starts 10/1/15 Go to http://www.cms.gov/medicare/medicare-fee-for- Service-Payment/InpatientRehabFacPPS/IRFPAI.html to compare IRF-PAI versions 10 AOTA Medicare Part A Update 9/12/14 5
Skilled Nursing Facilities SNF PPS final rule pub. 8/5/14; Effective 10/1/14 Allows COT OMRA for a resident not currently classified into a RUG-IV therapy group or receiving a level of therapy sufficient for classification into a RUG-IV therapy group Only allowed when resident had qualified for a RUG-IV therapy group on a prior assessment during current Med A stay and Had no discontinuation of therapy bet. day 1 of COT observation period (for the COT OMRA that classified resident into current non-therapy RUG-IV group) & the ARD of COT OMRA that reclassified the patient into a RUG-IV therapy group Example in final rule; More guidance to come in RAI Manual http://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual.html 11 Home Health Home Health PPS proposed rule pub. 7/7/14; Final rule expected early November 2014 Revise therapy reassessment timeframes Eliminate 13 th & 19 th reassessment visit requirements Require therapist to provide needed therapy service & functionally reassess the patient at least every 14 days AOTA recommended every 30 days Eliminate the narrative requirement for physician face-to-face encounter AOTA supported; CMS should use the full medical record to establish eligibility for home health 12 AOTA Medicare Part A Update 9/12/14 6
Home Health OASIS: Outcome and Assessment Information Set Used to collect & report core items of assessment for home health patients OASIS-C1 approved on 2/6/14 but delayed due to ICD-10 delay Current OASIS-C remains in effect through 12/31/14 Modified OASIS-C1/ICD-9 Version must be used for all Medicare & Medicaid assessments completed on or after 1/1/15 http://www.cms.gov/medicare/quality-initiatives-patient- Assessment-Instruments/HomeHealthQualityInits/OASIS-C1.html 13 Home Health CMS HHA Center: http://www.cms.gov/center/provider-type/home-health- Agency-HHA-Center.html CMS Therapy Q&A Revised 2/28/13: http://www.cms.gov/medicare/medicare-fee-for-service- Payment/HomeHealthPPS/Downloads/Therapy_Questions_ and_answers.pdf CMS HH Face-to-Face Encounter Q&A Revised 5/9/14: http://www.cms.gov/medicare/medicare-fee-for-service- Payment/HomeHealthPPS/Downloads/Therapy_Questions_ and_answers.pdf 14 AOTA Medicare Part A Update 9/12/14 7
Jimmo v. Sebelius Nationwide class action lawsuit brought because CMS was employing an illegal improvement standard to deny coverage SNF, HH, Outpatient claims This standard had no basis in statute or regulation and was an improper use of CMS discretion Settlement reached w/ HHS & DOJ Oct. 2012 Stipulates that skilled services to maintain an individual s condition or to prevent or slow their decline are covered by Medicare Any improvement standard by CMS or its contractors is illegal 15 Jimmo v. Sebelius CMS had 1 year to revise Medicare manuals & complete educational campaign; claims review Manuals updated 12/6/13, 1/14/14, 3/14/14 (Transmittals 175, 179 & 2911; MLN #MM8458); National Provider call 12/19/13 & Open Door Forum calls Settlement retroactive back to date case was filed (1/18/11) More info: http://www.aota.org/en/advocacy-policy/federal- Reg-Affairs/News/2013/Medicare-Policy-Improvement.aspx 16 AOTA Medicare Part A Update 9/12/14 8
Inpatient Hospital Admissions Policy CMS clarified: Physician expects patient to require a stay crossing at least 2 midnights Physician admits the patient based on that expectation Observation Stay issue observation services aren t counted as inpatient Why does this matter? May bill Part B outpatient Part B documentation & billing requirements apply: G-codes & modifiers Medicare Benefit Policy Manual, Ch. 15, 220.4 Consider using G-codes for all patients Enforcement delay until 3/31/15 17 Hospice Hospice final rule pub. 8/22/14; Effective 10/1/14 National implementation of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey Dry run begins 1/1/15 Monthly participation begins 4/1/15 18 AOTA Medicare Part A Update 9/12/14 9
Local Coverage Determinations Medicare Administrative Contractors (MACs) adopt LCDs to determine coverage of specific services (i.e., Physical Medicine & Rehab, OT-PT, Dysphagia, etc.) Coverage may vary by MAC/state/jurisdiction AOTA monitors LCDs and submits comments on draft LCDs What should OTs do? Read the LCDs that are relevant to you Sign up for your MAC s listserv & check web site for updates Watch for draft LCDs and policy changes Submit comments to AOTA or directly to your MAC 19 OIG Report: Medicare Requirements Not Met August 2014 OIG Report found PT received $635,000 in improper Medicare reimbursements The PT was 1 of IL s highest Medicare billers in 2011 Part B errors included: 97 claims that didn t meet Medicare plan of care requirements 95 that didn t meet Medicare treatment note requirements 49 that had progress reports that were either untimely or weren t included in the patient s medical record 44 that were for therapy services that weren t medically necessary 39 that didn t meet Medicare physician certification requirements OIG recommended that the PT return the $635,000 20 AOTA Medicare Part A Update 9/12/14 10
Tips for Successful Documentation 1.Focus on skilled services 2.Reasonable and predictable period of time 3.Typical amount, frequency and duration of services 4.Patient s medical complexity and need for services 5.Using objective tests and measures to validate findings 6.Why the skills of a therapist are needed to perform these services 7.Types of documentation and related key elements 21 Responsibilities for Practice Comply with state laws & regulations check your state practice act Provide only reasonable & medically necessary services Medicare Benefit Policy Manual, Ch. 15, 220.2 Recognize the importance of your documentation Legal record Support specific OT skills Medicare Benefit Policy Manual, Ch. 15, 220.3 Know your company & facility policies & procedures Know payer requirements & adhere 22 AOTA Medicare Part A Update 9/12/14 11
Responsibilities for Practice Know your payer s policies Check National Coverage Determinations (NCDs) and LCDs; available on Medicare Coverage Database www.cms.gov/medicare-coverage-database Be an advocate for change when policies are too restrictive Communicate why the skills of a therapist are needed Use the appeals process 23 Producing Quality Outcomes Reforms in post-acute care Uniform assessment for all settings (i.e., CARE Tool) Payers expecting quality, efficient & effective occupational therapy with quality outcomes Show distinct value of OT IMPACT Act Would require use of standardized patient assessment instruments based on individual patient characteristics 24 AOTA Medicare Part A Update 9/12/14 12
Resources AOTA Advocacy & Policy http://www.aota.org/en/advocacy-policy.aspx CMS Manuals http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html Medicare Benefit Policy Manual, Chapter 15, Section 220 http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/bp102c15.pdf QIES Technical Support Office (Part A resources) www.qtso.com Medicare Coverage Database (LCDs) http://www.cms.gov/medicare-coverage-database Medicare Administrative Contractors http://www.cms.gov/medicare/medicare-contracting/medicare- Administrative-Contractors/MedicareAdministrativeContractors.html AOTA Official Documents http://www.aota.org/practice/manage/official.aspx 25 Questions? Jennifer Bogenrief, JD Manager, AOTA Regulatory Affairs jbogenrief@aota.org regulatory@aota.org www.aota.org/advocacy-policy/federal-reg-affairs.aspx (301) 652-6611, ext. 2015 26 AOTA Medicare Part A Update 9/12/14 13