Maximizing Outpatient Reimbursement. Teresa Heskett, RHIT, CCS,CCDS . Common Problem Areas. Modifier Assignment Medical Necessity Injection and Infusions Therapy Services RAC. Modifier Use. -Inappropriate assignment of - 59 – Missing modifier assignment
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Teresa Heskett, RHIT, CCS,CCDS
Coding Hierarchy Rules
(second IV ATB of same drug, report once per same drug)
(not reported for keep vein open)
CMS awarded RTI a contract to help develop alternatives to the current Medicare payment cap and exceptions processes for Part B outpatient therapy services.
2. Request Physician H&P, operative reports
3. Document pre-therapy functionality especially with chronic conditions.
4. Review Local Coverage Determination
IOM Pub. 100-04, chapter 8
Missing documentation; physical therapy treatment log with actual minutes of treatment for each billed code or documentation of total treatment time provided on the date of service.
Missing documentation to support time or incorrect units billed.
When using the ABN form as a voluntary notice, the form requirements specified for its mandatory use do not apply. The beneficiary should not be asked to choose an option or sign the form. The provider should include the beneficiary’s name on the form and the reason that Medicare may not pay in the space provided within the form’s table. Insertion of the following reason is suggested:
“Services do not qualify for exception to therapy caps. Medicare will not pay for physical therapy and speech-language pathology services over (add the dollar amount of the cap and the year or the dates of service to which it applies, e.g., $1860 in 2010) unless the beneficiary qualifies for a cap exception.” Providers are to supply this same information for occupational therapy services
CMS RAC http://www.cms.gov/RAC/