What is the purpose of this comparative billing report?
This comparative billing report (CBR) was created to inform physical therapists (PTs) in private practice (specialty 65) about their billing patterns. The CBR team reviewed Fee-for-Service Medicare (Original Medicare) data for therapists who submitted claims with Current Procedural Terminology (CPT®) codes 97001, 97002, 97035, 97110, 97112, 97140, 97530, and G0283. For more information about CBRs, please visit our website link titled, Comparative Billing Reports.
Why was this topic chosen?
We selected physical therapy as a topic for a CBR because the Office of Inspector General (OIG) has found that Medicare spending for outpatient therapy was 72 percent higher in some areas of the country than the national average. Additionally, the OIG determined that outpatient services provided by independent physical therapists were not always reasonable and medically necessary and/or were not documented properly. For the last nine years, the OIG has included a review of physical therapy services in its work plans. To access those plans, please select the following web link: Archives - Work Plan.
How were providers selected to receive the comparative billing reports?
To choose providers for this CBR, the CBR data team analyzed Medicare Part B claims of independent physical therapists with the CPT® codes covered in this CBR. Letters were then sent to approximately 15,000 physical therapists in private practice identified as having different billing practices when compared to their peers. Providers who did not receive a CBR letter can review a sample on our website at the link, CBR201702 Sample CBR.
Based on the results of the CBR, will I be audited?
No. The CBR is not punitive, and the team does not conduct any audits of medical charts. The CBR is for educational purposes and allows providers to compare their billing patterns to those of their peers. If interested in resources that may be helpful with setting up an audit process, please visit our CBR website page at the link titled, Self-Audit Help.
Does receiving a CBR mean that I am billing incorrectly?
No. Receiving a CBR does not mean you are billing your claims incorrectly. We recognize that billing patterns can differ for a variety of reasons. The goal of the CBR report is to allow you to compare your billing to your peers in your state and the nation and to assist you with understanding Medicare coverage and billing guidelines. If you have questions and or concerns about your CBR, you may contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.
What are the documentation requirements for therapy services?
Documentation requirements for therapy services can be found at the link titled, Medicare Benefit Policy Manual (Chapter 15, Section 220.3). Documentation must include:
- Evaluation and Plan of Care to include initial evaluation and re-evaluations
- Certification (physician/NPP approval of the plan)
- Progress Reports (include discharge notes, if applicable)
- Treatment notes for each day (can serve as progress reports if included in notes)
- Separate statement (not required) but may be included to justify treatment
Is there specific information that must be included in a plan of care for therapy services?
Yes. A plan of care must include a diagnosis, long term treatment goals and type, amount, duration and frequency of therapy services. Per the Medicare Benefit Policy Manual, “The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources.” For details about the plan of care, see Chapter 15 (Section 220.1.2) at the link, Medicare Benefit Policy Manual.
Must a physical therapy plan of care be in writing?
Yes. According to the Benefit Policy Manual (Chapter 15, Section 220.1.2), “The services must relate directly and specifically to a written treatment plan as described in this chapter. The plan, (also known as a plan of care or plan of treatment) must be established before treatment is begun.” This is establishing a plan. Please note, establishing the plan is not the same as certifying the plan. For more information, select the following link: Medicare Benefit Policy Manual.
What should providers include when certifying a plan of care?
Certification of a plan of care requires a signature and date on the plan or documentation showing the plan of care has been approved. The Medicare Benefit Policy Manual states, “It is not appropriate for a physician/NPP to certify a plan of care if the patient was not under the care of some physician/NPP at the time of the treatment or if the patient did not need the treatment. Since delayed certification is allowed, the date the certification is signed is important only to determine if it is timely or delayed. The certification must relate to treatment during the interval on the claim. Unless there is reason to believe the plan was not signed appropriately, or it is not timely, no further evidence that the patient was under the care of a physician/NPP and that the patient needed the care is required.” For more information, please see Chapter 15 (Section 220.1.3) at the link, Medicare Benefit Policy Manual.
How much time do I have to obtain initial certification of a plan?
Certification should be obtained as soon as possible after establishing the plan of care unless delayed requirements are met. Per the Medicare Benefit Policy Manual, this “means that the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment. Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is established. Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification.” Should you need addition information, see Chapter 15 (Section 220.1.3) at the link, Medicare Benefit Policy Manual.
Can a provider give verbal certification instead of a written certification plan?
Per the Medicare Benefit Policy Manual, “Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation). If the order to certify is verbal, it must be followed within 14 days by a signature to be timely. A dated notation of the order to certify the plan should be made in the patient’s medical record. Recertification is not required if the duration of the initially certified plan of care is more than the duration (length) of the entire episode of treatment.” This information is found in Chapter 15 (Section 220.1.3) at the link, Medicare Benefit Policy Manual
What are some examples of insufficient documentation errors by physical therapists?
Some examples of insufficient documentation include missing physician signatures on the certification/recertification, dates of service, professional identification, missing modality information and failure to document the total time spent rendering services. A provider stating on the claim that patient has “pain” would be insufficient documentation. Per the Medicare Benefit Policy Manual, “To be payable, the medical record and the information on the claim form must consistently and accurately report covered therapy services, as documented in the medical record. Documentation must be legible, relevant and sufficient to justify the services billed. In general, services must be covered therapy services provided according to Medicare requirements. Medicare requires that the services billed be supported by documentation that justifies payment.” Providers can find documentation guidelines for therapy services in Chapter 15 (Sections 220 and 230) at the link, Medicare Benefit Policy Manual.
What is the Episode of Outpatient Therapy?
According to the Medicare Benefit Policy Manual, “An outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that discipline in that setting.” Detailed information can be found at the following web link: Medicare Benefit Policy Manual, Chapter 15, Section 220 A. Definitions.
What is active participation?
Per the Medicare Benefit Policy Manual, “ACTIVE PARTICIPATION of the clinician means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.” This information is available at the following link: Medicare Benefit Policy Manual, Chapter 15, Section 220 A. Definitions.
Is the GP modifier still required with the new PT CPT® codes?
Yes. According to the CMS web page titled Therapy Services - Spotlight, “The new CPT® code descriptors for PT…evaluative procedures include specific components that are required for reporting as well as the corresponding typical face-to-face times for each service. These new codes represent ‘always therapy’ services and always require the corresponding discipline-specific therapy modifier: (a) the new PT codes (97161 – 97164) require the ‘GP’ modifier…” For more information, select the following web link: Therapy Services - Spotlight.
When should the KX modifier be appended?
The KX modifier should be appended to a claim if the therapy cap has been met, the beneficiary’s condition requires further medically necessary treatment and documentation supports the medical necessity. For details on the use of the KX modifier, see the First Coast Service Options article at the link titled The Proper use of the KX Modifier for Outpatient Therapy Services.
How were claims selected for review for CBR201702?
For this CBR, we chose Medicare Part B claims with allowed services for CPT® codes listed with dates of service from July 1, 2015 to June 30, 2016. The rendering National Provider Identifier (NPI) specialty is denoted as physical therapist in private practice (65) on the claims and each claim line was submitted with modifier GP. The analyses were based on the latest version of claims available from the Integrated Data Repository (IDR) as of December 8, 2016. For information on the IDR, please visit the link titled, CMS Integrated Data Repository (IDR).
How are the peers defined?
A single rendering provider was identified by National Provider Identifier (NPI). The peer groups for comparison with the individual provider are listed below:
- All Medicare Part B providers located in the provider’s state as indicated in the National Plan and Provider Enumeration System (NPPES), with the specialty of physical therapy in private practice (65) submitted on the claim and with allowed charges for the CPT® codes listed
- All Medicare Part B providers in the nation with the specialty of physical therapy in private practice (65) submitted on the claim and with allowed charges for listed CPT® codes
How was the data obtained for this report?
The data for this CBR analysis includes Part B claims for the CPT® codes identified in the CBR. These claims, with dates of service July 1, 2015 to June 30, 2016, were downloaded from CMS Integrated Data Repository (IDR), and loaded into the Palmetto GBA Medicare Data Warehouse. The analyses were based on the latest version of claims available from the IDR as of December 8, 2016. Each recipient of CBR201702 has at least 50 beneficiaries and $30,000 in allowed charges for the CPT® codes included in the CBR and is Significantly Higher in at least one of the measures calculated in the CBR.
My allowed charges are higher than the national averages. This is because I am in a region with a higher cost of living and thus a higher allowed amount, such as San Francisco, California. Are my allowed charges being compared to providers in other states that have lower allowed charges?
We are aware that the Medicare Physician Fee Schedule (MPFS) allowed amounts vary from area to area. A geographic practice cost index (GPCI) has been established to account for the variation in practice expenses across the states and nation. You can check the GPCI for your area at Physician Fee Schedule Search. For the purposes of this CBR, averages were calculated by state and nationally. This CBR is only for educational purposes; variations may be justifiable due to location or other supporting documentation.
What is a Visit?
For the purposes of this CBR, a Visit is defined as every service provided to a beneficiary on a particular date of service from a particular provider. For example, if a provider provided a beneficiary with one service of CPT® code 97001 and one service of CPT® code 97112 on the same date of service, both services would be considered as the same visit.
What does Table 1 mean?
Table 1 provides information for each procedure code included in CBR201702. The first column lists the HCPCS and CPT® codes, and the second column provides the abbreviated description for each procedure code. To review an example of the CBR, select the following link: CBR201702 Sample CBR.
What does Table 2 show?
Table 2 provides a Summary of Your Utilization of the procedure codes used in this CBR. For each procedure code, the allowed charges, allowed services, and distinct visit and beneficiary counts are included. To view more details on Table 2, please visit the CBR web link titled CBR201702 Sample CBR.
What is the significance of Table 3?
Table 3 is the analysis of the Percentage of Beneficiaries with the KX Modifier. The KX modifier indicates that the services are at or above the therapy caps. This metric was designed to focus on providers who are billing this modifier at rates above their peers. Although adding this modifier is justifiable, the percentage of beneficiaries needing additional care should be comparable across providers in the peer groups. In Table 3, the provider’s percentages are compared to those of the provider’s state and the nation. Additional information on Table 3 is available at the CBR web link, CBR201702 Statistical Debriefing.
What is the meaning of Table 4?
Table 4 is an analysis of the Average Minutes Per Visit. The average allowed charges per beneficiary was calculated for each provider of physical therapy to potentially identify overutilization of services for all of the procedure codes included in this report. In the sample CBR, the provider has an average of 52.81 minutes per visit, which is Significantly Higher than the state’s average of 44.85 minutes and the national average of 45.67 minutes. More details on Table 4 can be found at the CBR website link, CBR201702 Statistical Debriefing.
What is the explanation of Table 5?
Table 5 is an analysis of the Average Allowed Charges per Beneficiary. This provider has average charges of $835.12, which Does Not Exceed the state’s charges of $908.46; however, the provider’s charges are Significantly Higher than the national average of $724.03. More details on Table 4 can be found at the CBR website link, CBR201702 Statistical Debriefing.
What do the comparison outcomes mean?
There are four possible outcomes for the comparisons between the provider and the peer groups:
- Significantly Higher is displayed if the provider’s value is higher than the value of the peer group and the statistical test used confirms significance.
- Higher is displayed if the provider’s value is higher than the value of the peer group, but the statistical test does not confirm significance.
- Does Not Exceed is displayed if the provider’s value is not higher than the value of the peer group.
- N/A (Not applicable) is displayed if the provider does not have sufficient data for comparison.