With rapidly changing Medicare rules, it's a sad reality that reimbursement is often driving practice, rather than the other way around. Fortunately, today's physical therapy documentation software developers are creating products that deliver real-time evidence to clinicians while prompting alerts to ensure documentation is in line with third-party payer requirements.
Software developers promise this solution will reduce adverse audit risk as well as capture total revenue, but the mission of OptimisCorp is more altruistic. The Marietta, Georgia-based company was the philanthropic brainchild of Alan Morelli, a retired entrepreneur who received substandard care during his rehabilitation from an injury acquired in a long-course triathlon.
"I quickly learned the quality of physical therapists varied dramatically," he recalled. "Doctors of physical therapy knew more about soft-tissue injury than medical doctors," but others weren't completely current on evidence-based care guidelines, he said.
Long story short, Morelli wanted to provide tools so physical therapists could have the evidence delivered to them during the patient encounter - not back in the office - as a way to help professional clinicians stand out.
Back in 2005, the company's founding partners used clinical algorithms to store and retrieve data they called clinical evidence. Joe Godges, DPT, was brought on board to create a model for clinical evidence. The clinical guidelines coordinator for the orthopedic section of the APTA published treatment guidelines, which would eventually be pushed to clinicians at the point of care. With the evidence portion under control, Morelli and his partners were just waiting for the development of the tablet to optimize the product and for Medicare to mandate additional records.
Apple fulfilled part of the vision by introducing the iPad. In 2006, a beta version of the software was released, enabling clinicians to comply with the eight-minute rule and other Medicare requirements.
"We knew only elite physical therapists would use this software," Morelli said. "Practitioners do what they're paid to do. We were just waiting for the day when Medicare and private payers would necessitate more documentation."
The beta program became open to select practices in 2010. Concurrently, word began circulating that physical therapists would need to publish outcomes and that third-party payers were paying attention to the care being rendered. When the American Recovery and Reinvestment Act included the first provisions on reasonable use and the electronic medical record, the developers knew their golden hour was near.
"When I looked at the definition of the certified electronic health record, it was our business plan from 2005," Morelli recalled.
Clues on Compliance
Today, hundreds of companies offer compliance tools but few offer the evidence piece, according to some industry insiders.
Helene Fearon, PT, principal at Fearon & Levine Consulting and owner of Fearon Physical Therapy in Phoenix, spent years analyzing the marketplace and couldn't identify any vendor or product that focused on assisting therapists in appropriately adhering to the third-party and regulatory compliance requirement. She signed on to join the company's software creation team, which is now operating in every state in the country and every practice setting.
One of her highest priorities was alerting therapists that their patients were approaching the Medicare therapy cap.
"It's a big issue. If you go beyond the cap and add the required modifier on the billing claim, your documentation must support medical necessity," she said. "Now therapists are warned they'll have to attach the modifier and can decide whether or not to keep seeing the patient."
The software can be personalized based on each patient's insurance status so alerts on the therapy cap only appear when applicable, Fearon said. Clinicians view a color-coded chart that displays payer and visit types.
Functional limitation reporting is another important feature. The software uses the World Health Organization's International Classification of Functioning (ICF) terminology to offer therapists the appropriate G-code to describe the functional limitation category that the goals will approach. PTs may then apply a severity indicator and proposed goal. The software automatically fills in the documentation once the G-code and modifier are inputted.
"Our program is the link between impairment, goals and function," explained Fearon. "Instead of just reporting on impairment, our software links it to the functional finding and a goal pulls it together. It's one of the biggest problems with documentation. Traditionally, it's been very impairment-based with nothing to indicate how the patient's function is impaired. We take measures and impairment findings and establish a plan of care so the therapist can demonstrate medical necessity."
The inclusion of Physician Quality Reporting System (PQRS) measures and codes provide for efficient reporting and complete capture of the information required for the submission of the most accurate claims information. Fearon said it's a seamless, often forgotten, step. The system provides the eight quality measures most commonly used by physical therapists so those in private practice can collect government incentives for reporting quality measures prior to 2015 (or avoid retroactive penalty later on).
Connecting Scheduling and Billing
Another important note, said Morelli, is realizing the connection between billing and scheduling.
"We came to the realization that billing starts at check-in for the visit," he said. "If you've started scheduling the visit, you can't go back in time to get your documentation right. We designed a module to integrate with leading billing systems." Morelli's company is currently in the process of integrating with a global billing system.
With such an increased focus on capturing revenue, it's easy to get lost in the financial side of practicing physical therapy, which is exactly the scenario software developers set out to avoid.
"Compliance is important to the therapists, so they buy the software. As an ancillary benefit, they're now delivering even better care," Morelli said.
It all goes back to the chicken-egg question on the relationship between practice and reimbursement.
"The key is to treat the patient first, then document, then apply," said Fearon. "If you apply the rules first, you find reimbursement driving practice. Our mission is to have practice driving reimbursement and encouraging documentation of clinical decision-making."
Robin Hocevar is on staff at ADVANCE. Contact: firstname.lastname@example.org
Does the patient have to be present during a home eval?
By Pauline M. Franko, PT, CEEAA
Question: I work in a SNF and need information on home evaluations. We have been doing them without the patient; therefore, not billing for them. Does Medicare reimburse for home evaluation when the patient is present? If so, what is the code we bill under?
Answer: You can only charge for services when the patient is with you. For home evaluations, you "bill" for the type of service you are providing. For example, taking the patient to the car would be covered under gait and transfer training, in the house transfer training including access to bathroom, etc.
The only guidelines are from the 1999 Final Rule, which says the treatment may occur inside or outside the facility. This includes a home visit.
Remember, under Part A you are billing the time it takes for you to provide skilled services. The allocation to CPT codes is an administrative requirement. So just think of what you are doing that is skilled and allocate it accordingly.
DISCLAIMER: The answers provided are based on Medicare guidelines for what is payable under the Medicare Part A and Part B benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the state practice act and the state administrative code. In any scenario, the practitioner must go with the most stringent requirement to be compliant. The information provided is current as of the time of publication.
Pauline M. Franko is owner of Encompass Consulting & Education LLC in Tamarac, FL. The company specializes in Medicare seminars and webcasts as well as consulting and compliance training. Visit www.encompassmedicare.com