Aotas Stance on Targeted Medical Review After $3000
Medicare Role B is utilized in acute intendance, long-term care, outpatient, and Med B abode health services. Billing occupational therapy under Medicare Part B can be complex as the responsibility to document and nib correctly typically falls on the clinician.
For those working under their ain National Provider Identifier (NPI), accurate coding is even more important. If practitioners practise not take a thorough understanding of how to bill Medicare, it could mean losing your license or underbilling for needed services.
Medicare Function B is billed through CPT codes in a fee-for-service model. Practitioners cannot bill cash for covered services for Medicare beneficiaries. Without a supplemental plan, beneficiaries volition take a 20% copay for Part B services.
When looking for accurate information on billing and coverage, going directly to the source is important. The Medicare Benefit Policy Manual for Office B Services provides details on the type of services covered under Medicare Part B for Occupational Therapy. Chapter xv
Coding and Billing for Occupational Therapy Under Medicare Part B
AOTA'due south Coding and Billing Folio has numerous resource for members and non-members. The videos on billing are beneficial and piece of cake to empathize.
Evaluation Codes
Eval codes are used during the first visit. They are coded as low, medium, or loftier complication based on patient factors. Although there are times associated with the description of each lawmaking, these are only guidelines and do non have to reflect the actual time spent on the evaluation.
Evaluation codes are untimed codes, and so you receive the aforementioned amount of reimbursement regardless of if you pecker eight minutes in the eval or 30. That said, legally, your billed time must accurately correspond the time spent on the evaluation and subjective interviewing of the patient.
Evaluation typically consists of manual musculus testing, range of move measurements, assessments, subjective interviewing, etc. In one case you transition to teaching or prescribing exercises/activities, that is handling vs evaluation. Knowing exactly when this transition occurs relies on the clinician's clinical judgment.
During an eval can, and should, nib treatment codes with the evaluation. This time should be charged nether treatment codes that fall nether the 8-infinitesimal rule. Consider, how would you feel if you went to the doctor and all they did was evaluate you only not prescribe any treatment or provide education well-nigh the diagnosis? Information technology should be rare only to charge an evaluation code.
- AOTA Evaluation Codes
- Evaluation Codes CEU – Gratis to AOTA Members
- AOTA – What are Performance Deficits in New OT Evaluation CPT® Codes?
Timed Codes
The 8-Infinitesimal Rule is used for timed CPT codes. Billable time must be spent face-to-face with the patient. You must provide a skilled, reimbursable service that fits within the CPT lawmaking description.
Time spent before or later the session, such as nautical chart reviews, interdisciplinary collaboration, or documentation, cannot be billed.
To charge a timed code, a minimum of 8 minutes of one-on-1, face-to-face intendance must be provided. At that place is and so a 15-minute window betwixt each unit of service, every bit demonstrated in the tabular array below.
| 1 Unit | 8-22 minutes |
| 2 Units | 23 – 37 minutes |
| iii Units | 38-52 minutes |
| iv Units | 53 – 67 minutes |
| 5 Units | 68 – 82 minutes |
- Web PT – viii-Infinitesimal Rule
- OTA Modifier Required in 2020
- New Cognitive Intervention Codes
OTA Modifier
Every bit of Jan 2020, CMS required a modifier to indicate an occupational therapy assistant provided the services. This change was required as part of the Counterbalanced Budget Human action (BBA) of 2018 (the same neb that repealed the Therapy Cap). The use of the modifier is preparatory for a fifteen% reduction in reimbursement for services provided past OTAs starting January one, 2022. AOTA is actively lobbying Congress to modify the reduction and add exemptions for rural areas through the SMART Act. To learn more about the OTA modifier bank check out this article.
Assistant Supervision
Medicare Part B is the merely setting that requires straight supervision for occupational therapy administration and physical therapy assistants vs distant supervision. This means that an OT/PT must exist on-site in person for an OTA/PTA to provide outpatient Part B services. This supervision cannot be provided through virtual means such as phone or telehealth. There were temporary flexibilities allowed nether the public health emergency, but there is no indication that these flexibilities will get permanent. AOTA and APTA have introduced the SMART Deed in the House of Representatives to work on repealing the straight supervision crave and standardize Medicare regulation.
This is the linguistic communication from CMS:
"An occupational therapist must supervise OTAs. The level and frequency of supervision differs by setting (and by country or local law). General supervision is required for OTAs in all settings except private exercise (which requires direct supervision) unless country do requirements are more than stringent, in which case state or local requirements must exist followed. See specific settings for details. For example, in clinics, rehabilitation agencies, and public wellness agencies, 42CFR485.713 indicates that when an OTA provides services, either on or off the arrangement's premises, those services are supervised by a qualified occupational therapist who makes an onsite supervisory visit at least one time every 30 days or more frequently if required by state or local laws or regulation."
Chapter 15:Medicare Benefit Policy Manual for Office B Services
Is at that place still a therapy cap?
No! The Therapy Cap was permanently repealed nether the Balanced Budget Human activity of 2018. Medicare at present has a therapy threshold and a targeted review. So there is no longer a point where Medicare cuts off therapy at a certain spending level. However, CMS does monitor for trends where clinicians or practices routinely bill over the thresholds. If a clinic or therapist routinely bills over the threshold, this indicates to CMS that the therapist/clinic may exist involved in fraud by over-providing therapy that isn't reasonably/necessary or skilled.
Therapy Threshold/ KX Modifier
The KX Modifier is utilized to indicate medical necessity, specifically for services over the therapy threshold. The threshold is typically updated annually so be certain to check Medicare guidelines each year. For 2021, the therapy threshold is $2110 for occupational therapy and $2110 for physical and speech communication therapy services. For 2022, the therapy threshold will exist $2150.
Of note, it is of import to document medical necessity for therapy services in each note, not only when utilizing the KX modifier. Whatsoever claim may be denied for diverse reasons. Not simply those above the threshold.
Targeted Medical Review
Services provided over $3000 for the calendar yr may be subject to a targeted medical review. This ways that not all claims volition be reviewed. However, if you consistently bill over the threshold, your chances of beingness reviewed may increase. The purpose of the targeted review is to prevent bad actors from billing for unnecessary services. There is not a hard cap on therapy services. CMS does empathise that some clients require extensive therapy and if your clinic routinely serves circuitous patients, CMS should exist able to identify that in your submitted documentation.
Diagnostic Coding
THERE IS NO SUCH Affair Every bit THERAPY-ONLY DIAGNOSTIC CODES. OTS CAN USE ALL ICD-x CODES. EVEN THOSE Not USED BY THE Md. That said, OTs cannot diagnose any NEW conditions.
For example, if the patient's diagnostic code is for a CVA, simply does not include a lawmaking for left upper extremity hemiplegia, you can even so apply this code. The diagnostic code should reflect the patient's diagnosis and the programme of intendance.
Pecker the most relevant diagnosis. Equally always, when billing for therapy services, the
CMS Medicare Claims Processing Transmission – Chapter 5
diagnosis lawmaking that all-time relates to the reason for the handling shall exist on the claim,
unless there is a compelling reason to report another diagnosis code. For example, when
a patient with diabetes is being treated with therapy for gait training due to amputation,
the preferred diagnosis is aberration of gait (which characterizes the treatment). Where
information technology is possible in accord with Country and local laws and the contractors' local coverage
determinations, avoid using vague or general diagnoses. When a claim includes several
types of services, or where the medico/NPP must supply the diagnosis, it may non exist
possible to employ the about relevant therapy diagnosis lawmaking in the primary position. In that
example, the relevant diagnosis lawmaking should, if possible, be on the claim in another position.
Codes representing the medical status that acquired the treatment are used when in that location is
no code representing the treatment. Complicating conditions are preferably used in nonprimary positions on the merits and are billed in the primary position merely in the rare
circumstance that there is no more relevant lawmaking.
So, if you use generalized weakness as your therapy lawmaking, CMS would wait that your programme of care volition address weakness.
Therapy Diagnostic Coding – ICD-10 Coding Resource
Merit-Based Incentive Payment Organization (MIPS)
MIPS is the value-based payment model for Medicare Function B. Occupational therapists and occupational therapy clinics may be subjected to MIPS depending on your patient caseload. You may besides exist able to opt into MIPS. The full general premise is that there are certain outcomes that are tracked for your patients which provides a quality rating.
Check out the information in the link below to see if you or your clinic needs to exist reporting to MIPS. OTs are eligible to opt-in even if not required to report to MIPS. –> AOTA Resources
Questions about Billing Medicare Office B?
Amplify OT and AOTA's Regulatory Affairs Team is here to aid! You tin reach them at Regulatory@aota.org. Keep in mind you must be a member of AOTA to receive a response to inquiries due to a high volume of letters.
Other Resource
- Documentation – AOTA Documentation and Reimbursement Resources
- AOTA Telescopic of Practice Q&A
- CMS – Affiliate 15 Medicare Manual
- AOTA – OT in Master Care
- CPT®Codes: What Are They, Why Are They Necessary, and How Are They Developed? – Adv Wound Care 2013
- How CPT Codes are Developed and Valued: Encounter the Members Who Make it Happen – AOTA 2020 (Members Only)
- 2021 CPT® Codes for Occupational Therapy – AOTA (Members Only)
- CMS Medicare Claims Process Manual – Chapter 5
Source: https://amplifyot.com/how-to-bill-occupational-therapy-under-medicare-part-b/
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