What is the purpose of this comparative billing report?
The purpose of this comparative billing report (CBR) is to inform physical therapists in private practice (specialty 65) about their billing patterns for Current Procedural Terminology (CPT®) codes, 97001, 97035, 97110, 97112, 97140, 97530, and G0283. The CBR team reviewed only the claims data of Fee-for-Service Medicare (also known as Original Medicare) physical therapists. For more information about CBRs, please visit our website link titled, Comparative Billing Reports.
Why was this topic chosen?
This topic was selected for a CBR because the Office of Inspector General (OIG) determined that outpatient services provided by independent physical therapists were not always reasonable and medically necessary and/or were not documented properly. In addition, the OIG found that Medicare spending for outpatient therapy was 72 percent higher in some areas of the country than the national average. For the last seven years, the OIG has included a review of physical therapy services in its work plans.
How many providers received comparative billing reports?
The reports were sent to approximately 8,000 Medicare physical therapists in private practice as submitted on the claims.
How were providers selected to receive the comparative billing reports?
The CBR data team chose providers by analyzing Medicare Part B claims submitted by independent physical therapists with CPT® codes 97001, 97035, 97110, 97112, 97140, 97530, and G0283. Based on the analyses, CBR letters were sent to approximately 8,000 physical therapists in private practice identified as having different billing practices when compared to their peers. Each recipient of CBR201511 has at least 49 beneficiaries and $31,000 in allowed charges for the CPT® codes included in the CBR and is Significantly Higher in at least two of the measures calculated in the CBR. Providers who did not receive a CBR letter can review a sample on our website at the link, CBR201511 Sample CBR.
Does the information in the CBR change the documentation and billing requirements established by the Medicare Administrative Contractors (MACs)?
No. The CBR is only an educational tool. It does not alter, change or negate any of the documentation and billing requirements established by the MACs. If you need to locate your MAC, please see the CMS web link titled, Review Contractor Directory – Interactive Map.
Based on the results of the CBR, will I be audited?
No. The CBR team does not conduct any audits and is not punitive. The CBR is for educational purposes and allows a provider to compare his/her billing patterns to those of his/her 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 CPT® codes are included in this CBR report?
Please see the CPT® 2014 Professional Edition for a complete description of the CPT® codes included in this report. The abbreviated descriptions are below:
• 97001 - Physical therapy evaluation
• 97035 - Application of a modality, ultrasound, each 15 minutes
• 97110 - Therapeutic procedure, exercises to develop strength, each 15 minutes
• 97112 - Therapeutic procedure, neuromuscular re-education, each 15 minutes
• 97140 - Manual therapy techniques, each 15 minutes
• 97530 - Therapeutic activities, direct patient contact, each 15 minutes
• G0283 - Electrical stimulation, unattended, other than wound care
What information must be in the contents of a plan of care for therapy services?
A plan of care must contain 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.” Details on the plan of care can be found in Chapter 15 (Section 220.1.2) at the link, Medicare Benefit Policy Manual.
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
Must a physical therapy plan of care be in writing?
Yes. The plan of care must be written. The Benefit Policy Manual (Chapter 15, Section 220.1.2) states, “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. More details can be found at the link titled, 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.
What if I receive a verbal certification instead of a written one?
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.
How were allowed charges in this CBR calculated?
Allowed charges for this CBR were calculated based on the Medicare Physician Fee Schedule (MPFS). Payment can vary depending on the carrier locality, the type of facility in which the service was rendered, the number of units billed and the use of a modifier. In most instances, Medicare pays the provider 80 percent of the fee schedule allowed amount and the patient is responsible for the balance of the payment. However, there are some exceptions to this rule. The Centers for Medicare & Medicaid Services (CMS) has a database that provides payment information for covered services. To search for payment rates in the MPFS, please see the web link, Physician Fee Schedule Look-Up Tool.
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. For the purposes of this CBR, averages were calculated by specialty for all independent physical therapists in the nation (specialty 65). A geographic practice cost index (GPCI) has been established to account for the variation in practice expenses across the states and nation. More information on the GPCI is available on the CMS website at the link, Documentation and Files - National Physician Fee Schedule and Relative Value Files.
How were claims selected for review for CBR201511?
For this CBR, we chose Medicare Part B claims with allowed services for CPT® codes listed with dates of service from January 1, 2014 to December 31, 2014. 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 October 12, 2015. 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:
• State: 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
• National: 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 January 1, 2014 to December 31, 2014, 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 October 12, 2015.
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 97110 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 is a summary of the provider’s utilization of the CPT® codes included in this CBR, descriptions of the CPT® codes, typical times allowed for exams, allowed charges, allowed services, beneficiary count and number of visits for the CPT® codes in this CBR. The number of visits for CPT® codes 97001 and G0283 are not used in the calculation for average minutes per visit and are therefore not included in the counts in Table 1. For more information, please see the CBR website link titled, CBR201511 Statistical Debriefing.
What does Table 2 mean?
Table 2 is an example that compares the provider’s percentage of beneficiaries with modifier KX to that of his/her state and the nation. In this example, 31 percent of this provider’s beneficiaries with allowed services for the CPT® codes included in this CBR and have at least one claim line submitted with modifier KX. The provider does not exceed the state’s percentage of 33 percent. However, the provider was higher than the national peer group of 20 percent and the chi-square test confirms that this difference is significant; therefore, Significantly Higher was marked in the comparison with the national percentage column. For more details on Table 2, please visit the CBR website link titled, CBR201511 Statistical Debriefing.
What does Table 3 mean?
Table 3 is an example of the provider’s average allowed minutes per visit for the selected CPT® codes. In this example, the provider has an average of 61.75 minutes per visit for the claims submitted with the selected CPT® codes. This provider’s average is Significantly Higher than the state average of 42.21 minutes and national average of 45.36 minutes. Additional information on Table 3 is available at the CBR web link, CBR201511 Statistical Debriefing.
What does Table 4 mean?
Table 4 is an example of the average allowed charges per beneficiary. This provider has an average of $750.59 which is Significantly Higher than his state’s average of $601.20. The provider’s average was higher than the national average of $719.13 but the t- test did not confirm significance so Higher was marked in the comparison column. More details on Table 4 can be found on the CBR website link,CBR201511 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
Are other references and resources available about physical therapy?
Yes. Providers may benefit from additional information available on our CBR website. A description of the tables used in this CBR can be found at the link, CBR201511 Statistical Debriefing.