Upon receiving an initial start of care referral from a physician, we determine that the primary diagnosis the physician has indicated in the documentation is not a diagnosis that maps to a PDGM clinical category (e.g., questionable encounter). Can we change the diagnosis to one that maps to a PDGM category and have the physician simply sign the 485?
The referring physician should be contacted regarding the need for a diagnosis change or clarification. If the physician agrees with the change, a verbal order should be included in the 485 that then would be sent to the physician for signature and confirmation of the change.
Does a patient need to be seen by rehab the last covered day under PDPM?
The number of therapy days and minutes do not impact Medicare Part A payment under PDPM. There is no requirement for therapy to be provided on the last covered day.
If a Physician Assistant (PA) refers a patient for hospice, what is the timeframe for the physician(s) to sign the certification of terminal illness (CTI), and how does that line up with the patient signing the Election statement?
A PA can refer a patient for hospice care, but this is no different than the patient being referred by a family member or other healthcare professional. PAs may not certify the terminal illness or admit a patient to hospice. Therefore, the CTI must be signed by a physician according to current policy, regardless of whether or not the patient was referred by a PA. According to the Medical Benefit Policy Manual, Chapter 9, Section 20.1, the hospice “must obtain, no later than 2 calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice IDG, and the individual’s attending physician if the individual has an attending physician.” The written certification must be on file in the patient’s hospice record prior to submitting the claim. The Notice of Election (NOE), which includes the signature of the patient or representative, must be filed within five calendar days of the hospice admission date (the effective date of hospice election) to be timely.
Is there a specific regulation for the time frame allowed for the physician/nurse practitioner to sign and date the Attestation Statement after completing the required hospice face-to-face visit?
The Medicare Benefit Policy Manual, Chapter 9, does not specify a timeframe for signature of the attestation. However, it should be signed before billing for services. CGS, a Medicare Administrative Contractor, has the following information posted on their website (CGSMedicare.com): “Before submitting claims to CGS, hospice agencies should ensure: 1) All FTF requirements are met; and 2)The written certification, including the narrative and FTF, is signed prior to billing the claim.”
When billing for Advance Care Planning services, if the visit is 44 minutes long, can the provider (i.e., MD, NP, PA) bill both CPT 99497 and 99498 even though the duration of time for the “additional 30 minutes” is only 14 minutes?
AMA guidelines for billing timed CPT codes state, “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed…A second hour is attained when a total of 91 minutes is elapsed.” (AMA 2020 CPT Manual, Professional Edition, page xvii)
CPT codes 99497 and 99498 are described as follows:
- CPT 99497, Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
- CPT 99498, each additional 30 minutes (list separately in addition to code for primary procedure)
Following AMA billing guidelines, the midpoint must be passed in order to bill a timed unit. In this example, an additional 16 minutes of advance care planning would need to be delivered in order to bill one unit of 99498 in addition to one unit of 99497 as both codes are timed for 30 minutes.
We have several veterans in our area, as well as on service with our hospice. A veteran recently joined our team as a volunteer with the intent to help veterans in a meaningful way. Can we count small construction/ home improvement projects towards volunteer hours?
CMS conditions of participation (State Operations Manual, Appendix M) state the hospice may use volunteers to “help patients and families with household chores, shopping, transportation, and companionship.” In order for the time to count under the “level of activity” standard, the volunteer must have direct contact with the patient and family. As long as the volunteer has direct contact with the patient and family, then the time the volunteer spends on “construction/home improvement projects” may be counted.
Is a hemiarthroplasty due to a hip fracture considered a “major joint replacement” for PDPM categorization purposes?
A hemiarthroplasty is a joint replacement of half of the joint (e.g., femoral head only). The ICD-10-CM code Z47.1, aftercare following joint replacement surgery, would be used for a total joint arthroplasty or a hemiarthroplasty, and maps to the Major Joint Replacement or Spinal Surgery clinical category under PDPM.
What is best practice on scoring Section GG? Should providers use the 07 (resident refused), 09 (not applicable), 10 (not attempted due to environmental limitations), or 88 (not attempted due to medical condition or safety concern) “activity did not occur” options?
The RAI Manual, Chapter 3, Section GG, page GG-10 states the resident’s performance for both self-care and mobility is to be based on “direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the three-day assessment period.” CMS goes on to state on page GG-12, “Only use the ‘activity not attempted codes’ if the activity did not occur; that is the resident did not perform the activity and a helper did not perform that activity for the resident” during the 3-day assessment period.
What are the rules for “days of therapy” under PDPM? Is it the same as the current requirements under RUG-IV (e.g., 5 days of one discipline, 3 days of another)?
There are no specific requirements for frequency or number of disciplines for therapy under PDPM as there is in the RUG-IV system. That being said, the overall requirement for “the need for skilled care on a daily basis, provided by or under the direct supervision of skilled nursing or rehabilitation professionals” remains a requirement for Medicare Part A coverage (RAI Manual, Chapter 6, page 6-10).
If a patient is discharged to the hospital and returns to the same SNF within three calendar days (i.e., during the interruption window), must the MDS Coordinator complete a DC/OBRA assessment?
Yes. In this scenario, an OBRA Discharge record is required. The RAI Manual (v1.17 effective October 1, 2019), Chapter 2, page 44 states, “If a resident leaves the facility for an interrupted stay, no Part A PPS Discharge Assessment is required when the resident leaves the building at the outset of the interrupted stay; however an OBRA Discharge record is required if the discharge criteria are met…” The discharge criteria are described in Chapter 2, page 10, and include “Resident is admitted to the hospital or other care setting.”
Is there a specific assessment timeframe for the BIMS to be completed during the look-back period?
According to instructions in the RAI Manual (v1.17 effective October 1, 2019), Chapter 3, page C-2 (found at this link), the BIMS interview “is conducted during the look-back period of the Assessment Reference Date (ARD).” The RAI also says the interview should be conducted “preferably the day before or the day of” the ARD. With the transition to PDPM on October 1, CMS has clarified in the RAI manual (page C-2) that, only in the case of an unexpected discharge from Part A prior to the completion of the BIMS, the assessor should proceed with a staff assessment of cognition to ensure the cognitive level is determined as part of the SLP component of payment under PDPM. Casamba strongly recommends providers carefully read this section of the RAI manual to ensure accurate coding of Section C on all PPS assessments.
Which dysphagia diagnosis code can or should be used as a speech therapy treatment diagnosis given that ICD-10 codes R13.10 – R13.19 are designated as “Return to Provider” under PDPM?
The “Return to Provider” designation under PDPM applies to diagnosis codes (ICD-10-CM codes) entered in MDS item I0020B as the primary reason for the SNF stay, not to therapy treatment diagnoses codes on the plan of care. These codes can be used as treatment diagnoses for speech therapy as appropriate and applicable.
What is the lookback period for the Interim Payment Assessment (IPA)?
Instructions on the MDS 3.0 item set for the Interim Payment Assessment version 1.17.1 (effective 10/1/2019) states that the “look back period for all items is 7 days unless another time frame is indicated.” The look back period for Section GG items (the new “interim performance” items) is 3 days – the ARD of the IPA and two days prior.
The MDS item sets can be found on the CMS website, click here.
Is functional limitation reporting (i.e., documenting and reporting “G codes”) still required for Medicare Part B?
Functional limitation reporting was eliminated for Medicare Part B effective January 1, 2019. In the Medicare Benefit Policy Manual, Chapter 15, Section 220.3.B, CMS states “NOTE: Functional reporting and its associated documentation requirements are no longer applicable for claims or medical records for dates of service on and after January 1, 2019.”
Does Medicare require time in and time out to be documented in a daily treatment note?
Time in and time out are not required. The Medicare Benefit Policy Manual, Chapter 15, Section 220.3.E states the following regarding required content of the daily treatment note:
“Documentation of each treatment shall include the following required elements:
- Date of treatment; and
- Identification of each specific intervention/modality provided and billed, for both timed and untimed codes…
- Total timed code treatment minutes and total treatment time in minutes…the amount of time for each specific intervention/modality provided to the patient may also be recorded voluntarily, but contractors shall not require it…
- Signature and professional identification of the qualified professional who furnished or supervised the services…”
What is timeframe requirement for the face-to-face encounter for a hospice beneficiary entering the third benefit period?
According to the Medicare Benefit Policy Manual, Chapter 9, Section 20.1, the face-to-face encounter must occur no more than 30 calendar days prior to the third benefit period, and no more than 30 calendar days prior to every subsequent recertification thereafter. A face-to-face encounter may occur on the first day of the benefit period and still be considered timely. In cases where a hospice newly admits a patient who is in the third (or later) benefit period, exceptional circumstances may prevent a face-to-face encounter prior to the start of the benefit period. In such documented exceptional cases, a face-to-face encounter which occurs within 2 days after admission will be considered timely.
Does MIPS apply to providers delivering Medicare Part B services in a SNF?
No. Facility-based providers (SNFs, hospital outpatient departments, rehab agencies, CORFs, etc.) who bill Medicare Part B are not eligible to participate in MIPS in 2019. MIPS applies only to therapists in private practice, i.e., those who bill under their own NPI on a CMS 1500 form.
Does rehab need to provide a Notice of Medicare Non-Coverage (NOMNC) to a Medicare Part A patient when the patient is discharged from therapy services but remains eligible for Medicare Part A coverage due to continued skilled nursing needs? And, in this scenario, can the patient request an appeal regarding the therapy discharge?
The Notice of Medicare Non-Coverage (NOMNC) form is to be issued to Medicare Health Plan enrollees – that is, patients with Medicare Advantage, when their Medicare covered services are ending (in a SNF, HHA, or CORF). In the scenario presented, the patient has Medicare Part A, not a MA plan. Therefore, the appropriate form to issue in the event that Medicare Part A coverage is ending is the SNF Advanced Beneficiary Notice (SNF ABN). If the patient is being discharged from therapy only and remains eligible for Medicare Part A SNF benefits due to skilled nursing needs, the SNF ABN should NOT be issued. The patient can request an expedited appeal (or determination) regarding the termination of Medicare Part A benefits in the SNF, not regarding their discharge from skilled therapy only.
Instructions on issuing the SNF ABN for Medicare Part A (and the NOMNC for MA can be found on CMS’s website.
In reviewing the CMS PDPM ICD-10 Mappings for SLP comorbidities, I saw that the only ICD-10 codes for dysphagia, “other speech and language deficits,” and apraxia in the mapping tool are codes from the I69 series, representing sequelae or deficits following a cerebrovascular incident (or stroke). If the patient has dysphagia due to something other than a stroke, should I use the “unspecified cerebrovascular disease” code to be able to capture dysphagia as a comorbidity for SLP classification under PDPM?
An ICD-10 code describes a specific medical condition, illness, injury, or symptom and cannot be used to describe or represent any other condition or illness. Therefore, the codes in the I69 series can only be used to describe patients who have suffered a cerebrovascular incident such as an infarct, hemorrhage, or subdural hematoma as specifically outlined in the description of each individual ICD-10 code. The “unspecified cerebrovascular disease” codes would only be used if specific information about the type and laterality of the deficit is unknown. For dysphagia, the symptom or deficit-based ICD-10 codes representing the phase of dysphagia (i.e., those in the R13 series) should be used to indicate the specific phase of impairment (oral, pharyngeal, etc.) in addition to the code describing the reason for dysphagia.
If the cause of the patient’s dysphagia is a condition other than a stroke (or cerebrovascular incident), then the medical diagnosis code representing that condition should be utilized. Remember, a medical diagnosis code can only be documented and chosen by a physician or non-physician practitioner.
With respect to PDPM classification, the ICD-10 codes CMS lists in their mappings tools are the codes they identified in their data analysis to be ones that impact the amount of resources or cost of providing care. Diagnosis codes or conditions that are not found in the mapping tool will not trigger as a comorbidity for SLP.
Do all of the ICD-10 codes need to map to PDPM or just the primary medical diagnosis?
Come October 1, 2019, the ICD-10 code in MDS item I0020B must map to a PDPM clinical category for the purposes of PT, OT, and SLP case-mix group (CMG) classification. This code is to represent the primary reason for admission to the SNF. And, if the patient is evaluated for PT, OT or ST, this diagnosis code will likely also represent the primary medical diagnosis on the therapy plan of care. Therefore, within Casamba Skilled, the primary medical diagnosis should map to a PDPM clinical category. The therapy treatment diagnoses should represent the conditions, deficits, or impairments being addressed in the therapy plan of care, and most likely will not correlate to a PDPM clinical category.
In PDPM, does a diagnosis of depression or major depression disorder factor in to nursing or NTA classification?
Depression, as coded via the PHQ-9 in Section D of the MDS, is a factor in nursing case-mix group classification in PDPM in the same way as it is today under RUG-IV. Signs and symptoms of depression are used as a third-level split for Special Care High, Special Care Low, and Clinically Complex categories. Depression does not factor in to non-therapy ancillary, or NTA, classification. Refer to CMS’s PDPM Classification Walkthrough document for details.
Can CPT code 97760 be billed more than once during a therapy episode of care?
CPT codes 97760 (orthotics management and training) and 97761 (prosthetics training) were modified effective 1/1/2018 to include the description “initial encounter.” Both of these codes are to be billed only for the first, initial visit (the initial encounter) during an episode of care. All subsequent visits for either orthotics or prosthetics training are to be billed using the new “subsequent encounter” code, CPT 97763.
Can a therapist assistant complete a weekly progress note for a Medicare Part A patient in a skilled nursing facility (SNF)?
The only specific CMS reference for content and timing of therapy progress notes refers to the Medicare Part B 10th Visit Progress Report. The Medicare Benefit Policy Manual (Chapter 15, Section 220.3.D) outlines this requirement and clarifies what an assistant can and cannot document. There is no specific requirement for a weekly progress note in Medicare Part A – this has simply been an industry standard for many years. Chapter 8 of the Medicare Benefit Policy Manual, Section 22.214.171.124 addresses coverage and documentation requirements for SNF Part A, but simply states that the medical record must demonstrate that services are skilled and medically necessary. If the content of a weekly progress note for a Medicare Part A patient includes an assessment of the patient’s progress/status and modifications to the goals or treatment plan, then Medicare is clear in Chapter 15 that this falls outside the scope of what an assistant can do and document.
Which CPT code should I bill for dry needling services?
The American Medical Association (AMA) has released two new CPT codes representing trigger point dry needling effective for dates of service on or after January 1, 2020.
- CPT 20560: Needle insertion(s) without injection(s), 1 or 2 muscles
- CPT 20561: Needle insertion(s) without injection(s), 3 or more muscles
In the CY 2020 Medicare Physician Fee Schedule Final Rule released November 1, 2019, CMS clarified that they will not pay for these codes in 2020 “unless otherwise specified” in a National Coverage Determination (NCD). CMS has assigned these codes a non-covered status in 2020. Other payers may reimburse for them in 2020. Providers will need to check with each specific payer.
Can PTAs and OTAs treat TRICARE patients?
Currently, PTAs and OTAs are not authorized providers for TRICARE in any venue. The National Defense Authorization Act passed into law in December 2017 added assistants as eligible providers of therapy services, but this change cannot be implemented until the rule-making process is completed and the regulations are finalized and published by the Department of Defense (DoD).
On December 20, 2018, the DoD published a Proposed Rule in the Federal Register to add PTAs and OTAs as authorized providers of therapy services under TRICARE. If finalized, this Rule will align TRICARE with Medicare policy. The earliest the rule-making process could be completed and implemented is fall of 2019, but it could be as late as early 2020. Until this happens, PTAs and OTAs remain unable to treat TRICARE beneficiaries.
For additional information, click here.
Are all PTs, OTs and SLPs providing outpatient therapy services to Medicare Part B beneficiaries eligible to participate in MIPS?
No. Only therapists who bill for Medicare Part B services on professional claims (i.e., the CMS 1500 or 837p) can participate in the Merit-based Incentive Payment System, or MIPS. Therapists working for institutional providers, such as hospitals and skilled nursing facilities, or rehab agencies (i.e., those billing on the UB-04) are not eligible to participate.
Who should complete Section GG of the MDS – nursing or therapy?
Since Section GG is coded based on the patient’s “usual performance,” the information should be completed with input from both nursing and therapy. Section GG assessment is to be based on direct observation, patient self-report and the report of direct care staff.
If a patient is admitted to the hospital during an episode of outpatient therapy, does the therapist need to discharge the patient and then complete a new evaluation if the patient resumes care under Medicare Part B?
In the Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230, CMS does not discuss or address requirements for discharge and/or new evaluations related to hospital admissions. Individual state practice acts (for each discipline) should be reviewed for any state-specific requirements regarding discharge and evaluation or re-evaluation due to hospital admission. Clinicians should carefully consider the nature of the hospital admission (i.e., reason for admission, duration, clinical condition of the patient) when determining if the current/initial course of treatment remains appropriate or if the situation warrants a new evaluation or a re-evaluation.