The final July 1 deadline for reporting Functional Limitation Ratings is fast approaching. I have already expressed my opinion in prior blog articles about the flaws in this requirement, but that does not really matter much, since it is the law of the land.
This past week, we released a set of features in Insight that make the process for including Functional Reporting Classifications and Severity Modifiers on your documentation and claims easy to do.  As July 1 approaches, and this testing phase ends, we are monitoring claims remarks to make sure that claims for your Medicare patients will not be rejected. That is the easy part.

More difficult is assigning a meaningful impairment rating to your patients.  So I have been focusing my efforts to see how we can make complying with this process easier for Clinicient users. 

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I have reviewed transmittals, articles, slide presentations and transcripts from CMS, and similar resources from the APTA to learn more about these requirements and guidelines so I can give our users practical information on assigning impairment ratings.

While I have found reams of information on the mechanics of submitting the Functional Classifications and Impairment Ratings on claims and including that information on your clinical documentation; there is very little practical information on assigning an Impairment Rating for your patients in your clinical documentation.

Presentations from the APTA and from CMS[i] both recommend using widely accepted “Functional Assessment Tools” to determine a current impairment rating. Two of the key slides from the CMS presentationfrom National Provider Call December 12, 2012 presented by Pamela R. West, DPT, MPH are included here.

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The APTA has published an article on translating OPTIMAL[ii] scores to the Medicare Impairment Ratings.[iii]  Others have offered conversion tables or calculators to mathematically convert widely accepted Functional Assessment Tools into Medicare Impairment Ratings.[iv]

Mathematically converting common Functional Assessment Tool Scores to Impairment Ratings is relatively easy, and the information from CMS and the APTA seems to indicate that this method may be used to at least get you “in the ball park” to establish an impairment rating.

For your convenience, we have created some of the common Functional Assessment Tool Scores that are already converted to Impairment Ratings for your use:

• Oswestry Modified for Medicare Impairment Ratings
• Neck Disability Index Modified for Medicare Impairment Ratings
• Shoulder Pain and Disability Index Modified for Medicare Impairment Ratings
• Lysholm Scale Modified for Medicare Impairment Ratings
• Lower Extremity Functional Scale Modified for Medicare Impairment Ratings
• DASH Score Modified for Medicare Impairment Ratings
• Quick DASH Modified for Medicare Impairment Ratings
• Upper Extremity Functional Scale Modified for Medicare Impairment Ratings

Please email me if you would like these modified Functional Assessment Tools exported to your database, or if you have another widely accepted tool that you would like converted for Medicare Impairments. We would be happy to look at those instruments and modify them for you.

As we gain more guidance about the use of these tools, we will continue to share that information with you.

Functional Limitation Reporting is Just Around the Corner

Are you ready? 

A Complimentary Webinar from Clinicient

Watch our complimentary webinar to understand how Clinicient takes the burden of these new requirements off of therapists, practice managers and owners. Join us to learn:

• A review of the new functional limitation reporting requirements
• What therapists will be responsible for
• What needs to be reported and when
• Case studies on how to make initial reports, updates and  discharges, as well as subsequent functional limitations
• How the codes will automatically carry through claim creation in the Clinicient system

This webinar is ideal for therapists and practices who use Clinicient EMR, or who are curious about how Clinicient will be handling the functional limitation reporting in our system.

Clinicient has been helping physical therapy practices manage Medicare compliance for over a decade. As one of the first web-based EMR systems in the physical therapy industry, we’ve helped thousands of therapists gain efficiencies and bring control to their practice in ways that no other EMR or practice management has experience. Attend our webinar to see for yourself.

Webinar recording is available here.

Well, Medicare has been busy.

When CMS decided to keep the Manual Medical Review process for 2013, several questions were left open for clarification. Namely:

• Since 2012 was a mad scramble of reviews and appeals, how will the approval process work for 2013?
• Who will conduct the review, given that MAC’s are not staffed to manage this?
• Is the patient liable for services above the $3,700 threshold if CMS denies payment?

CMS’ recent clarifications should prompt providers to carefully consider their policy for providing treatment to patients above the $3,700 limit.

What have we learned?

1. There is no Pre-approval Process

We’ve known this since the beginning of the year, but it may not have sunk in. Providers are expected to continue to submit claims, and when the patient has exceeded the $3,700 limit, the Additional Documentation Request (ADR) process will be used to determine payment. This moves the review period from right before the cap is reached to after, and puts at risk payment of visits conducted after the cap while waiting for a determination.

2.  The Recovery Audit Contractors (RAC) will conduct the review

This is an enormous change. Recovery Auditors are private, for profit companies contracted by CMS to review provider payments and recover improper payments. There are 4 regions in the US and each region has one contractor. To align incentives, the Audit Contractor receives a portion of all recovered payments as a bonus. If you don’t understand the purpose of the RAC process, there is plenty to review here.

The Recovery Auditors will use their current process for determining whether continued treatment is necessary, so:

a. In Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri, you are subject to Prepayment Approval. That means before any payment is made for the services rendered, the MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor who then has 10 business days to review the provider of payment decision.

b. In all other states, the MAC will flag the claims, request additional documentation and pay the claim. The MAC will send ADR to the provider requesting the additional documentation be sent to the Recovery Auditor. The Recovery Auditor will conduct post-payment review and will notify the MAC of the payment decision.

3.  There is still uncertainty about whether providers will be able to pursue payment from patients

In 2012, when the MMR was first put into practice, CMS was clear that services rendered above the cap were the responsibility of the beneficiary if proper processes were followed. For 2013, as Novitas, a Medicare Administration Contractor so elegantly put it on March 1st:
“Beneficiary vs. Provider Liability for claims denied and/or partially approved based on Manual Medical Review of Therapy Service is TBD.”

What Can We Take From This?

Treating patients above the $3,700 cap will impact cash flow

Whether you are in a Prepayment state where getting paid for services will not happen until after the review process is completed, OR you are receiving the payment and then going through the ADR process with the hope that the payment will not have to be returned,  you can assume there will be an impact to cash flow.

In addition, the time to get a decision may be unpredictable.  While CMS is giving a 10 business day guideline, there is no penalty for taking longer and no automatic assumption of approval.  When you add up the time from the completion of the service, the notification, the gathering of documents, the review, the notification and then the payment or non-payment, much more than 10 days may pass.

Triggering a Manual Medical Review may impact more than just the visits above the cap

Medicare has been very careful to state that they are not precluded from reviewing services below the threshold. And, in reviewing the necessity of continued service for a patient, the Recovery Auditor will need to review the entire case.  Many practices have concluded that there is a reasonable chance that the MMR will open the door to recovery attempts on services prior to the cap when medical necessity wasn’t properly documented.

What should you do?

1. Have a policy

 The risks to your practice from Manual Medical Reviews require a plan.  Consider the conditions under which your practice will even consider exceeding the cap.

2. Document patient goals

It isn’t as much about being good at treatment as it is about being good at documenting the treatment provided.  If your EMR system doesn’t establish clear goals at the outset of treatment and show constant progress towards those goals, invent a manual process or select a system that does.

3. Track the cap

Remember, multiple providers may be drawing from the well.  If there is a Critical Access Hospital or rehab agency involved, they bill once a month and the patient’s available funds could move dramatically.  Your practice management system should be able to track Medicare’s report of used benefits, as well as an up-to-the-minute estimate of expected payments so that you have an accurate picture of when the cap is approaching. If not, then make it a practice to call CMS IVR regularly for updates.

4. Let the patient know where they stand

If you think this is hard for the provider to track, try being the patient.  With liability in question, you have a need to help the patient understand the limits to their benefits.  Try not to communicate estimates like “you have about 10 visits” when totals can change.  If you know the amount remaining, then arm your patient with that knowledge.

Webinar with RAC Expert Nancy Beckley

Our industry has been hit hard with Medicare changes over the past several months, bringing on many challenges. Compliance and RAC auditor expert Nancy Beckley has been extremely gracious in offering a series of complimentary webinars to help keep providers informed in these difficult time of change.  Nancy serves as senior contributing editor to RAC Monitor and conducts weekly podcasts on the Recovery Auditor Program.  She has offered to host another webinar on this topic next week “Medicare Game Changer: RAC Auditors to Perform Manual Medical Reviews. What you need to know to mitigate your risks”  To register for the event, click here.

To download a PDF of this article, click here.

Now that we are 2 months into 2013, the big rush to PQRS adoption for Clinicient users is largely behind us.  Still, I continue to hear a lot of questions about PQRS in discussion groups and from therapists evaluating EMR and Practice Management systems.  Here are some of my thoughts.

What is PQRS?

The Physician Quality Reporting System (PQRS) is a way for CMS to encourage (and soon to require) healthcare providers to use screening and assessment tools during the evaluation and re-evaluation of a patient that might identify risk factors that could impact the course of treatment.  The goal was to improve the quality of care through better information gathering upfront.

CMS tracks successful adherence by having the therapist report each time one of the quality measures is performed.  If a provider reports enough quality measures over the course of a calendar year, then they receive a 0.5% bonus for their efforts.  Beginning in 2013, the effort to report also helps you avoid a 1.5% penalty in 2015 for not participating. Yes, making an effort to participate in 2013 is the way CMS will know whether to penalize you in 2015.

Who can participate?

Any Part B submitters may participate.  This has caused confusion because all PT, OT and qualified SLPs are eligible, but as CMS puts it, only those billing at the individual NPI level may participate.

Does it matter what reporting method I use?

This is probably the most intriguing discussion I’ve heard.  CMS wanted to make sure all qualified healthcare providers could participate so they thought of several ways to submit the info to CMS.  Of the four methods offered, outpatient rehab has the choice of two: Registry and Claims–based reporting.

The Registry method allows a software platform to submit the PQRS directly to CMS on a periodic basis. The Claims-based method allows a software platform to submit the data to CMS on each claim that corresponds to a qualified visit. Each has a different threshold for meeting reporting requirements, with the Registry being a little higher in aggregate reporting requirements than Claims-based.

Stand-alone EMR systems would lean toward using the Registry based process since they can control submission quality that way.  Using Claims-based, for them, means sending it to a partner billing system and losing visibility and control over successful reporting.

An integrated system which provides both EMR and billing from one platform would likely choose Claims-based reporting since that is a simple effective way to control the successful submission.  It also allows you to review the claim before the submission, which cannot be done using the Registry-based method.  This can be a benefit since you cannot resubmit the PQRS.

Regardless, of the reporting method, the important work is being done at the point of documentation.

What should I expect from my software platform?

What really matters is how the therapist is helped to build a PQRS compliant note.  PQRS uses the age of the patient, the diagnosis code and the type of evaluative CPT code recorded in the visit to determine which quality measures are eligible for the patient and how many must be completed to qualify.  PQRS also has guidelines as to what assessment or measure should be documented to support completion of a quality measure.

Your EMR should:

1. Prompt you with a list of measures that qualify
2. Offer clear guidance to the therapist of what CMS considers completion of the measure
3. Tie those measures to notes that support the work
4. Alert the therapist at sign-off if there aren’t enough measures recorded to qualify
5. Alert management any time a visit doesn’t meet the threshold to qualify
6. Track therapist completion throughout the year.
7. Package the codes up and submit them to CMS.

Does this have anything to do with Functional Limitation Reporting or CBOR?

Finally, I’ve heard considerable confusion about relationship of PQRS, the new functional limitation reporting and g-codes. PQRS and Functional Limitation Reporting have nothing to do with each other. They share only one thing, they both use G-Codes to report information to CMS. G-codes are just a set of 5 digit codes that can be submitted like CPT codes but CMS uses them to cover additional requirements. Most people are familiar with G0283 being CMS’ own code for E-stim, but now they’ve branched out and used the series for both PQRS and Functional Limitations.

One other key difference is that PQRS is only for Part B and optional although it has a monetary impact.  Functional Limitation will be required, result in denials and all outpatient rehab providers need to prepare for it regardless of whether you submit institutional or professional claims. More on Functional Limitation later…

For now, I hope this helps outline some of the more critical aspects of PQRS.

If you want more information, please comment below.  I’d be happy to go deeper.

Additional Resources:

Video: PQRS submission with Clinicient is a free with our service, and has been a benefit our customers have been enjoying, as well as the bonus revenue, since the “PQRI” program began years ago. To see how easy it is, watch this 2 minute video.

CMS Requests MACs to Conduct Manual Medical Reviews Within 10 Days

CMS has posted an update regarding the Manual Medical Review (MMR) process to the Medical Review and Education page on the Therapy Cap (click here to be redirected to the page).  Below is a portion of the update:

CMS is developing a long term strategy to deal with manual medical review. However, in the interim, Medicare Administrative Contractors (MACs) will conduct prepayment review on the claims reaching the $3700 threshold. CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process. Additional information will be provided on the MAC websites.  Section 603 (b) of the American Tax Relief Act counts outpatient therapy services furnished in a Critical Access Hospital (CAH) toward a beneficiary’s annual cap and threshold amount using the Medicare Physician Fee Schedule rate. CAHs are not subject to the therapy cap, the manual medical review process, or the use of the KX modifier.

What this means to providers:

• There is no pre-approval process, providers will provide treatment and then documentation will be reviewed;
• Provider will have to treat patient, submit documentation, and wait for payment determination;
• Manual medical review of claims is expected to be completed within 10 days;
• Therapy provided at CAHs counts towards the cap and threshold, although CAHs are not subject to these;
• Your regional MAC should be providing additional direction on this process.

You can contact CMS with questions about the therapy cap and new threshold via a designated e-mail box at therapycapreview@cms.hhs.gov.

This information brought to us courtesy of NARA.

Clinicient automatically tracks Manual Medical Reviews, alerting therapists when patients are approaching the $3700 threshold and tracking approvals. For more information how Clinicient helps physical therapy practices manage Medicare requirements, including therapy caps, Functional Limitation Reporting and PQRS, contact us.

Don’t Be Afraid of the “S” Word:  We’re all in Sales 

I was talking with @Jerry_DurhamPT at the APTA Combined Sections meeting in San Diego, CA in January and we were discussing the fact that most physical therapists wouldn’t see themselves as salespeople. Jerry recommended a book to me by Daniel Pink called To Sell is Human, which I just started reading. The basic premise of the book is (pretty evident from the title) that we all spend a significant amount of our time “moving or persuading” people. In other words, we are all in sales. In fact, the studies in the book indicate that we spend as much as 60% of our time “selling” even if we aren’t in sales.

I think the word “selling” gets a bum rap, especially in physical therapy businesses. When we think about sales we often think of the pushy, annoying salesperson who forces their way into our lives offering a product or service of no apparent benefit to us, just to benefit themselves. However, if we change our viewpoint slightly, we might recognize the need and the value of selling as an essential part of what we do to improve our patients’ lives and to improve our businesses.

In what way is a physical therapy practice in sales? We are selling the benefits of the services we provide. We are selling referring physicians on the value of sending their patients our way to help them achieve their goals. We are selling therapist’s time. We are selling patients on the necessity of coming in, often multiple times a week—and we all know how much harder this has become with the increasing shift of costs to the patient. We are selling patients on complying with their home exercise programs.

It’s important to think about the importance of having a “selling” or “persuading” mindset as you approach your relationship with your staff, your patients and your referral sources. Think about how much you believe in the value of the services you provide. The value of every therapist’s time. The value of your patient’s time. The value of a referring physician’s time and the confidence they place in you when they send you a referral.

How Well Are You Selling Your Therapist’s Time?

With that in mind, what are you doing to make the most of time? I’d like to suggest two metrics that we’d like every practice owner, therapist and front desk person to track as key performance indicators (KPIs) of how we’re managing therapist’s time and your referrals.

• Vacancy Rate – this measures the amount of “unsold” time on a therapist’s schedule as a percentage of the total time available. Both the therapist and the front desk need to be thinking about “selling” this available time.
• Average Scheduled Frequency – this measures the average number of days per week an active referral is scheduled for appointments. Each referral has a “capacity” for visits each week that is documented in your plan of care. Are you getting your patients scheduled and attending? This is key not only to your patient’s improvement and achievement of goals, but also to your relationship with the physician who refers patients to you. They are looking to you to keep the patients compliant with the plan of care.

Why are these important? What gets measured, gets managed. Once you start tracking these metrics, make  a plan to improve these key metrics. As you can see, they are linked. If you have empty space in your schedule, you can fill it with patients who aren’t at full capacity. You’ll also notice patients that have gone “missing in action.” Once you’re doing that and your patients are enjoying the benefits of faster achievement of their goals, you’ll want to communicate the results you’re seeing to your referring physicians. As a result, you’ll start to notice more referrals coming your way, which will further increase your capacity to fill your therapist’s schedules. When a patient cancels, your front desk will have the mindset of “filling the vacancy”.  When you get a referral, you’ll be focused on scheduling the patient in advance and making sure they’re tracking to the frequency dictated by the plan of care.

A good friend of mine once told me “the culture lives in the conversations”.  Try consciously talking to your staff about selling the most valuable asset you have: your therapist’s time. These subtle shifts can go a long way in improving not only your clinical results, but the bottom line for your physical therapy business.

We know that creating, updating and delivering home exercise programs that patients will comply with can be a time-consuming and frustrating task. With Clinicient’s new Home Exercise Program (HEP) solution we’ve set out to help make it easier and boost your patient’s compliance. The Clinicient HEP solution integrates  the market’s most comprehensive home exercise program into clinical documentation, enabling therapists to quickly and easily create and deliver personalized home exercise programs that patients can follow online, at home or on the go. Prescribed exercises are included in the patient’s medical record and may be emailed to the patient, included in the clinic’s website portal, or printed on site. Once patients leave the office, they can access their personal exercise program online to access video demonstrations and other visual aids and detailed instructions anytime.

The new home exercise program provides industry leading home exercise tools with a strong emphasis on video. Research indicates that providing video demonstrations and continuing education for patients during the course of the home exercise program can help improve compliance.

Key Features

• Integrates Physiotec™ home exercise program  into medical record
• Preloaded with more than 5000 exercises including videos, photos, line drawings and detailed instructions
• Reference, update and change home exercise program from charting
• Send branded email with PDF of home exercise program to patients
• Upload  pictures or video of the patient performing the exact exercises in their program
• Optional integration with practice website
• Free support

A free two-month trial is available for Clinicient customers with the signing of a license addendum. The cost of the solution after the trial is $50 per month for one clinic location. For clinics with multiple locations the cost for each additional location is $35 per month.

To learn more or download our datasheet, click here.

To sign up for your free trial, click here

Clinicient is pleased to announce the Mobile Schedule, the first in our family of mobile point of care tools for therapists. Designed from the ground up for smart phones and tablets, the Mobile Schedule enables busy therapists to view their schedules and appointment details on the go from any mobile device including smartphones, ipads or tablets. This makes it easy for therapists to keep track of their schedules when away from their computers, resulting in increased efficiency and better patient care.

Features:

• View schedule from smart phones and tablets
• View appointment details including patient name and phone number, appointment type, date, time and location, blocked and unscheduled times
• Call patients directly from appointment detail screen

Mobile Schedule is the first mobile point of care tool offered by Clinicient in 2013 as part of Clinicient’s modular approach to developing a more robust web-based EMR product. Future mobile tools will include flow sheets, clinical findings, charting and full-featured mobile scheduling capabilities including the ability to add, revise and delete appointments from any mobile device. Stay tuned as we continue to announce additional enhancements over the coming months.

To get started with the Mobile Schedule, do the following:

1. Using the browser on your smartphone or tablet, go to: http://pta.clinicient.com.

2. Login using your Clinicient Insight user name and password

3. Pay attention to the detailed instructions for accessing the Mobile Schedule on your device:   

• If you are using an iPhone or an iPad, when you first access the web page on your browser a pop up screen will be displayed providing instructions on how to save the Clinicient Mobile Schedule to your home page screen
• If you are using an Android smartphone or tablet, you can save the web page as a bookmark.

It’s that easy!

For more information about the Mobile Schedule, please visit our support site.

As someone who is responsible for coming up with practical solutions to comply with complex requirements, I have been observing the online debate over the Medicare PQRS, Medicare MPPR, and Medicare Functional Limitation Reporting programs with a lot of interest. I have got to say, most of the interactions are not helpful and are usually a litany of indignant complaints along the lines of:

• How dare Medicare ask us for additional information on the functional capacity and improvement of our patients?
• We are underpaid already.  You mean they are going to reduce our reimbursement for multiple procedures done during the same visit?
• PQRS is a pain in the butt.

I agree with most of you that the Functional Limitation Reporting program is flawed, that our profession is far from being overpaid for providing valuable services, and that the PQRS program is a pain in the butt that does little to promote quality. But, I don’t believe that my complaint about these programs offers our colleagues any useful information or any practical help.

One of our mantras at Clinicient is Assuming Good Intent.  I would like to propose for the sake of discussion, that we all assume that Medicare’s intent is good.  Assuming good intent, what should we do about MPPR, PQRS, and Functional Limitation Reporting?

In an earlier series of blog posts, I tried to take a fresh look at these issues by asking everyone to look at this from Medicare’s perspective. As I stated before, we have some problems because CMS has no way to know whether or not we provide quality and value.  Here is why:

• The only classification system we have for our patients is based on a disease model (ICD-9).  But, we don’t cure diseases, we work to help our patients improve function that may be caused by disease or injury. (Trivia question… how many ICD-9 codes include the term “gait”? Answer: one.)
• The procedure codes that we use to indicate the services we provide (CPT) were developed by physicians.  Many of the 97xxx CPT codes used by PT and OT are 15 minute time based codes. So, to accurately charge for services provided for a visit longer than 15 minutes, multiple procedure codes must be used. Consequently, the MPPR process greatly affects our reimbursement. We tend to get paid for how much we do (multiple procedures), not what we know (complex decision making).
• The overall cost for our services compared with the rest of health care is small, but it is growing rapidly.

So, let’s assume good intent from CMS and that there are a bunch of smart people working there, and that they understand some of these issues:

• The value we bring to our patients is poorly understood
• The information we provide on claim forms is not an indicator of patient function or of the true value of the services we provide
• They have seen examples of rampant abuse and over utilization in our profession
• They have a responsibility to assure that our patients are receiving quality care

So, CMS has a problem and the only information they get from us on a routine basis comes off of our claim forms. It makes sense that they have designed claims based systems to try to get better information and provide better incentives.

As a result, CMS has created a system to incentivize providing quality services (PQRS) and a mechanism for describing functional improvement (Functional Limitation Reporting) that can be reported on claims in the form of special procedure codes (PQRS codes, Functional Limitation Reporting Codes).

I agree with everyone else about the PQRS pain in the butt and the multiple flaws in the Functional Limitation Reporting, but these programs may be, just may be, a step in the right direction.

Your comments are welcome.

Thursday, January 17th    
1:00 pm EDT / 10:00 am PDT

2013 brings another year of change with the Medicare PQRS requirements. Please join Jerry Henderson in a webinar and learn:

• What the new requirements are
• What the timelines are
• What you should be doing now
• How Clinicient manages PQRS (at no additional charge)
• See a short product demonstration on PQRS

This webinar has already taken place, but you can watch the recording here.