Vol. 12 Issue 9
Understanding Medicare coverage guidelines is the cornerstone of good documentation.
As far back as clinicians can recall, documentation has been a challenge. While the Medicare standards governing documentation haven't changed much over the years, their interpretation and application always seem to be in a state of flux.
The challenges escalate when you add the proliferation of new reimbursement structures and coding requirements. The basic requirements remain the same, such as documenting for medical necessity, skilled intervention and functional outcomes. But interpreting these components, particularly medical necessity and skilled intervention, has become more sophisticated and increasingly stringent.
Knowing and understanding Medicare coverage guidelines is instrumental to providing good documentation. It's the only way to provide guidance and clarify services. However, many clinicians find regulations vague and peppered with words and phrases, such as "reasonable and necessary," "significant" or "inherently complex." Although these terms are used to deny claims, they also can and should be used to advocate for services patients need.
Documentation should clearly point out why a particular service was reasonable and necessary in a patient's unique situation. That's imperative. A procedure that's not considered skilled for one patient can be skilled for someone else due to his medical complexity.
In addition, coding is a frequent source of documentation frustration. You must clearly understand how ICD-9 (International Classification of Diseases) and CPT (Current Procedural Terminology) codes are used, and the consequences of improper coding.
ICD-9 codesdiagnostic codesuse three, four or five digits to describe diagnoses or symptoms. Failing to use appropriate ICD-9 codes or using nonexistent codes can result in a rejected claim. With ICD-9 coding, you should cross-reference each diagnosis between the alpha and the numeric sections of the codebook. Without cross-referencing, you run the risk of using a code that doesn't accurately reflect your patient's diagnosis or symptoms.
This problem is evident with code 780.99. Prior to January 2003, it was four-digit code 780.9. Clinicians, particularly occupational therapists, often use this code because the code name in the alpha section of the ICD-9 coding book is identified as "decreased functional activity." While this sounds like an appropriate code to use for patients, cross- referencing to the numeric section puts that idea quickly to rest. Code 780.99 actually covers "other general symptoms: amnesia, chills, generalized pain, hypothermia."
Using a nonexistent code may cause a claim rejection until you submit a true code. And incorrect coding using true ICD-9 codes can cause closer scrutiny of a claim, which can produce an Additional Development Request or denial.
However, clear documentation of a patient's medical history and situation should override any problems with an ICD-9 code. If a denial occurs from incorrect coding, and nothing else, an appeal should yield a positive outcome.
CPT codes are a different story. Incorrectly using CPT codes can cause denial and result in an unsuccessful appeal attempt.
CPT codes describe services rendered. The Medicare edits (guidelines to correct billing), have created many misinterpretations of CPT code use. The edits identify specific code pairs that are considered to be mutually exclusive and can't be billed together. They also identify code pairs that aren't typically billed together because one of the services is considered to be a component of the other.
While mutually exclusive codes can never be billed together, component code pairs can be, if done correctly. To bill these component code pairs together, the documentation must clearly demonstrate that they're distinct and separate services.
Either because of misinformation or fear of denial, many providers won't bill any of these code pairs, even those that are allowed in the right situation. Misapplying these edits can result in less effective patient treatments or even accusations of fraud.
For example, CPT edits indicate that therapeutic activity and gait training aren't typically billed in the same session because therapeutic activity is a component of gait. It's considered to be a component of gait because a patient must be transferred to standing before ambulation can begin. However, it's a widely accepted practice .for physical therapists to provide focused transfer training to improve independence with the transfer, instead of simply standing the patient. It's not unusual to spend time on transfer training, in addition to gait training.
If therapeutic activity and gait training are performed within the same treatment session, it's your responsibility to demonstrate to the fiscal intermediary (FI) or carrier that the services were distinct and separate. This process varies among intermediaries. Modifiers are two-digit codes attached to a CPT code to "lift" an edit. Modifier Ð59 indicates to the FI or carrier that you understand one code is considered to be a component of the other, but, in this particular case, they're distinct and separate services.
However, not all FIs accept modifiers, although they may still deny claims based on the edits. Nevertheless, documentation must clearly demonstrate that transfer training and gait training are distinct, separate services. It's important for you to check with your FI or carrier to learn if it accepts modifiers or to ensure that you're billing correctly.
Each CPT code billed must be clearly supported. An easy way to do this is to use the phrase "followed by" between descriptions of services rendered. Consider this description for documentation: "Gait training focused on improved right weight shifting and on increasing left step length, followed by transfer training emphasizing increased trunk forward bend to come to stand." This makes it clear that transfer training was a separate entity, not a component of gait.
If you choose not to provide transfer training and gait training in the same treatment sessioneither out of fear or lack of understandingyour patient loses out.
Patients benefit from consistent, but varied, treatment sessions. For instance, you can work on a variety of tasks over consecutive treatment sessions for the best carry over of benefits. Providing only transfer training at one treatment session and gait training at another isn't in the patient's best interest.
In other situations, gait and transfer training are provided within the same treatment session, but one code captures the time spent on both. This tells me that the clinician feels it's medically necessary to address both treatments in the same treatment session, but is afraid or unaware that they can be billed together. The clinician may feel it's a creative way to capture the time. However, billing something under a different code to improve reimbursement success can easily be construed as fraudulent.
But Medicare doesn't say you can never bill these two codes together. CMS simply wants to ensure that they're distinctly separate services, which can be accomplished through documentation and by using modifiers if your FI or carrier accepts them.
Frequently, poorly supported CPT codes are the reason behind denials. Don't fall into the trap of many providers. Don't stop providing services to a patient with a particular diagnosis, or who needs particular code pairs, or service just because you received a denial.
And don't base future clinical decisions for similar patients on one denial without thoroughly researching and understanding the reasoning behind it.
Just because an FI or carrier denies a claimwhether it's related to medical necessity, a diagnosis or CPT codingdoesn't mean the FI or carrier was correct in applying the guidelines. Don't stop providing necessary services to patients if regulations don't support the denial, but your documentation and coding support the level of care provided.
You must have a thorough understanding of ICD-9 code and CPT code use. Be prepared to defend your decisions and advocate for patient services allowed by Medicare. Keep up with changes in Medicare coverage guidelines, ICD-9 codes and CPT codes to make accurate decisions about your patients' care. Remember to take advantage of the appeals process if you believe a FI has misinterpreted Medicare guidelines.
While documentation and coding issues can be frustrating, mastering them allows you to provide better, more effective patient care.
Cathy DeMartinis is president and owner of a Woodstock, Ill.-based company that provides compliance audits, coding assistance, denials and appeals management, and documentation training for physical, occupational and speech therapy practices. She can be reached at (815) 337-6880.