Evergreen Rehabilitation Contract Therapy - Clinical & Compliance Bulletin 2013 Q1

7/30/2019 Evergreen Rehabilitation Contract Therapy - Clinical & Compliance Bulletin 2013 Q1

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2013 Quarter 1

Coding CornerFAQ

. How do I bill for Medicare Part B services delivered for

ontracture management patients?

Billing or Medicare Part B services delivered or contracture

management is dependent on the skilled services provided. Te

most oen skilled services may include: 97110, therapeutic exercise;

7112, neuromuscular reeducation; 97140, manual therapy; 97760,

rthotic management and training; and 97762, checkout or

rthotic/prosthetic use. Each skilled service is detailed below:

7110-Terapeutic Exercises to develop strength and endurance,

ange o motion and exibility (one or more areas, each 15 minutes)

may require the unique skills o a therapist to evaluate the patient’s

bilities, design the program, and instruct the patient or caregiver

n sae completion o the special technique. However, aer the

eaching has been successully completed, repetition o the exercise,

nd monitoring or the completion o the task, in the absence o

dditional skilled care, is non-covered. Documentation should

nclude not only measurable indicators such as unctional loss o

oint motion or muscle strength, but also inormation on the impact

these limitations on the patient’s lie and how improvement in

ne or more o these measures leads to improved unction. For

many patients a passive-only exercise program should not be used

more than 2-4 visits to develop and train the patient or caregiver in

perorming PROM.

7112-Neuromuscular Re-education o movement, balance,

oordination, kinesthetic sense, posture, and/or proprioception

or sitting and/or standing activities (one or more areas, each 15

minutes) would be used i PNF or techniques or tone reduction are

delivered.

7140-Manual Terapy echniques (e.g.,mobilization/

manipulation, manual lymphatic drainage, manual traction), one

r more regions, each 15 minutes. Joint Mobilization (peripheral

nd/or spinal) may be considered reasonable and necessary i

Clinical and Compliance Bulletin877.799.9595 | www.evergreenrehab.com

restricted or painul joint motion is present and documented. It may

be reasonable and necessary as an adjunct to therapeutic exercises

when loss o articular motion and exibility impedes the therapeutic

procedure. Myoascial release/so tissue mobilization, one or more

regions, may be reasonable and necessary or treatment o restricted

motion o so tissue. Documentation should include the area(s) being

treated; so tissue or joint mobilization technique used; objective and

subjective measurements o areas treated (may include ROM, capsular

end-eel, pain descriptions and ratings,) and eect on unction.

97760- orthotic(s) management and training (including assessment

and tting when not otherwise reported), upper extremity(s), lower

extremity(s), and/or trunk, each 15 minutes. Code 97760 includes

initial t and training, additional orthotic management and training

during ollow-up visits including instruction in skin care and

orthotic wearing time, and time associated with modication o the

orthotic due to healing o tissues, change in edema, or interruption

in skin integrity. o bill or training the patient to use the orthotic

the documentation must justiy the need or a skilled qualied

proessional/auxiliary personnel to train the patient in the use and care

o the orthotic. When the management o the orthotic can be turned

over to the patient, the caregiver or nursing sta, the services o the

therapist will no longer be covered. Once the initial t is established

and training is complete, any urther visits or specic documented

problems and modications that require skilled therapy should be

billed with CP 97762. Supportive Documentation Recommendations

or 97760 include: description o the patient’s condition (including

applicable impairments and unctional limitations) that necessitates an

orthotic; any complicating actors; specic orthotic provided and the

date issued; description o the skilled training provided; and response

o the patient to the orthotic. Many contractors have determined that

or uncomplicated conditions, the ollowing services would not be

considered reasonable and necessary as they would not require the

unique skills o a therapist.

• Issuingo-the-shelfsplintsforfootdroporwristdrop

• Issuingo-the-shelffootorelbowcradlesforroutinepressure

relie (these are not considered orthotics)

• Issuing“carrots”(i.e.,cylindrical,cone-shapedforms)ortowel

rolls or hand contractures or hygiene purposes



• Bedpositioning(e.g.,pillows,wedges,rolls,footcradlesto

relieve potential pressure areas)

• Repetitiverangeofmotionpriortoplacinganorthotic/

positioner to maintain the range o motion is not reasonable

and necessary when the therapeutic intent is primarily to

maintain range o motion within a chronic condition.

• Ongoingtherapyvisitsforincreasingwearingtimeare

generally not reasonable and necessary when patient problems

related to the orthotic have not been observed.

7762-checkout or orthotic/prosthetic use, established patient,

ach 15 minutes. Tese assessments are intended or established

patients who have already received their orthotic or prosthetic

device and include patient’s response to wearing the device, whether

he patient is donning/dofng the device correctly, patient’s need or

padding, underwrap, or socks, and o the patient’s tolerance to any

dynamic orces being applied. I the checkout assessment results in

he need or urther training in the use o the orthotic, code 97760

would be appropriate or the training. Supportive Documentation

Recommendations or 97762 include: reason or assessment;

ndings rom the assessment; specic device, modications made,

nd instruction given.

. I have begun to see patients for incontinence. Can you please

eview the billing regulations for use of electrical stimulation and

biofeedback?

CMS Publication 100-03, Medicare National Coverage

Determinations (NCD) Manual, section 230.8 provides guidance

n the use o Non-implantable pelvic oor electrical stimulators

o provide neuromuscular electrical stimulation through the

pelvic oor with the intent o strengthening and exercising pelvic

oor musculature. Pelvic oor electrical stimulation with a non-

mplantable stimulator is covered or the treatment o stress and/or

urge urinary incontinence in cognitively intact patients who have

ailed a documented trial o pelvic muscle exercise (PME) training.

A ailed trial o PME training is dened as no clinically signicantmprovement in urinary continence aer completing 4 weeks o

n ordered plan o pelvic muscle exercises designed to increase

periurethral muscle strength. Stimulation delivered by vaginal or

nal probes connected to an external pulse generator may be billed

s 97032. Stimulation delivered via electrodes should be billed as

G0283. Te patient’s medical record must indicate that the patient

eceiving a non-implantable pelvic oor electrical stimulator was

ognitively intact, motivated, and had ailed a documented trial o

pelvic muscle exercise (PME) training. Some patients can be trained

in the use o a home muscle stimulator or retraining weak muscles. On

1-2 visits should be necessary to complete the training. Once training i

completed, this procedure should not be billed as a treatment modality

the clinic.

Bioeedback is covered or the treatment o stress and/or urge incontin

in cognitively intact patients who have ailed a documented trial o pelv

muscle exercise (PME) training. A ailed trial o PME training is dene

as no clinically signicant improvement in urinary incontinence aer

completing our weeks o an ordered plan o pelvic muscle exercises to

increase periurethral muscle strength. Medicare will allow bioeedback

an initial incontinence treatment modality only when, in the opinion o

physician, that approach is most appropriate and there is documentatio

medical justication and rationale or why a PME trial was not attemp

rst. Bioeedback or incontinence should be billed with CP code 909

which describes bioeedback that is more involved than conventional

bioeedback measures (code 90901) and includes evaluations o the EM

activity o the pelvic muscles, urinary sphincter and/or anal sphincter b

using sensors and/or manometry (measure o pressure o gases or liqui

by use o a manometer). When providing bioeedback procedures or

urinary incontinence, use CP 90901 when EMG and/or manometry

not perormed.

Patient selection is a major part o the process and the patient should b

motivated, cognitively intact, and compliant. In addition, there must be

assurance that the pelvic oor musculature is intact. Bioeedback thera

has proven successul or urinary incontinence when all three o the

ollowing conditions exist:

• thepatientiscapableofparticipationintheplanofcare;

• thepatientismotivatedtoactivelyparticipateintheplanofcare,

including being responsive to the care requirements (e.g., practice

and ollow-through by sel or caregiver); and

• thepatient’sconditionisappropriatelytreatedwithbiofeedback

(e.g., pathology does not exist preventing success o treatment).

Bioeedback is non-covered or:

• homeuseofbiofeedbacktherapy;

• pelvicoorelectricalstimulationlackingdocumentationofthe

ailure o a trial o pelvic muscle exercise (PME) training, unless th

is physician documentation justiying the need to initiate treatme

with bioeedback beore PME is attempted;

• patientswhodonothavesucientcognitiveabilitytoadheretoa

ollow the PME protocol and/or cooperate in keeping a personal

voiding diary.



Decoding CPT Codes

Each quarter we ocus on decoding the mystery o a specic CP

ode. Tis quarter we will ocus on CP code 97140-Manual

Terapy echniques (e.g.,mobilization/manipulation, manual

ymphatic drainage, manual traction), one or more regions, each 15

minutes.• Manual traction may be considered reasonable and necessary

or cervical dysunctions such as cervical pain and cervical

radiculopathy.

• Joint Mobilization (peripheral and/or spinal) may be

considered reasonable and necessary i restricted or painul

joint motion is present and documented. It may be reasonable

and necessary as an adjunct to therapeutic exercises when

loss o articular motion and exibility impedes the

therapeutic procedure.

• Myoascial release/so tissue mobilization, one or moreregions, may be reasonable and necessary or treatment o

restricted motion o so tissues in involved extremities, neck,

and trunk. Skilled manual techniques (active or passive) are

applied to so tissue to eect changes in the so tissues,

articular structures, neural or vascular systems.

• Manipulation, which is a high-velocity, low-amplitude thrust

technique or Grade V thrust technique, may be reasonable and

necessary or treatment o painul spasm or restricted motion

in the periphery, extremities or spinal regions.

• Manual lymphatic drainage/complex decongestive therapy (MLD/CD) MLD / CD is indicated or both primary and

secondary lymphedema. Lymphedema in the Medicare

population is usually secondary lymphedema, caused by

known precipitating actors such as surgical removal o lymph

nodes, brosis secondary to radiation, and traumatic injury

to the lymphatic system. MLD/CD consists o skin care,

manual lymph drainage, compression wrapping, and

therapeutic exercises. Coverage o MLD / CD would only be

allowed i all o the ollowing conditions have been met:

• thereisaphysician-documenteddiagnosisoflymphedema(primary or secondary);

•thepatienthasdocumentedsignsorsymptomsof

lymphedema;

• thepatientorpatientcaregiverhastheabilityto

understand and comply with the continuation o the

treatment regimen at home.

MLD/CD is not covered or:

• conditionsreversiblebyexerciseorelevationoftheaecteda

•dependentedemarelatedtocongestiveheartfailureorother

cardiomyopathies;

• patientswhodonothavethephysicalandcognitiveabilities,support systems, to accomplish sel-management in a

reasonable time;

• continuingtreatmentforapatientnon-compliantwitha

program or sel-management.

Supportive Documentation Requirements or 97140:

• Area(s)beingtreated

• Sotissueorjointmobilizationtechniqueused

• Objectiveandsubjectivemeasurementsofareastreated(may

include ROM, capsular end-eel, pain descriptions and ratings,and eect on unction

• ForMLD/CDP,supportivedocumentationshouldinclude:

•medicalhistoryrelatedtoonset,exacerbationandetiology

the lymphedema

•comorbidities

• priortreatment

• cognitiveandphysicalabilityofpatientand/orcaregiverto

ollow sel-management techniques;

•pain/discomfortdescriptionsandratings;

• limitationoffunctionrelatedtoself-care,mobility,ADLs and/or saety;

• priorleveloffunction;

• limbmeasurementsofaectedandunaectedlimbsatsta

care and periodically throughout treatment;

•descriptionofskincondition,wounds,infectedsites,scars



Keeping Straight on the Regulation Road:

MedPAC Recommends Reforming Outpatient Terapy Payment

Te Patient Protection and Aordable Care Act requires MedPAC

o report recommendations to Congress on changes to outpatient

herapy services by June 15, 2013. Te Medicare Payment Advisory Commission recommended changes to reorm the Medicare

enet or outpatient physical and occupational therapy and

peech-language pathology. Te nal recommendations include

educing the therapy cap to $1,270 and applying a manual medical

eview process or all requests that exceed the cap amount;

permanently including services delivered in hospital outpatient

departments under the cap; and reducing the practice expense

payment by 50% when multiple therapy services are provided

o the same patient on the same day. Te Commission stated

hat the changes would ensure program integrity o outpatientherapy services, ensure access to outpatient therapy services

while managing Medicare’s cost, and improve management o the

enet in the longer term. Congress has not acted on any o these

ecommendations.

CMS released Calendar Year 2013 Final Rule for the Physician

Fee Schedule on November 1, 2012

On November 1st, 2012 the Centers or Medicare & Medicaid

ervices (CMS) issued a nal rule that will update payment policies

nd rates or physicians and nonphysician practitioners (NPPs) orervices paid under the Medicare Physician Fee Schedule (MPFS) in

alendar year (CY) 2013. Tis is the same ee schedule used to pay

or Part B therapies in outpatient and nursing acilities. Highlights

provisions in the nal rule or the physician ee schedule that will

mpact therapy are discussed below.

CY 2013 payment rates ace a 26.5% reduction

Te nal rule includes a 26.5% across-the-board reduction to

Medicare payment rates or physicians, physical therapists, and

ther proessionals due to the awed sustainable growth rate (SGR)

ormula. Since 2003, Congress had enacted legislation preventing

hereductioneveryyear.CMSannouncesthatitis“committedto

xing the SGR update methodology and ensuring these payment

utsdonottakeeect.”Excludingthe26.5%projectedSGR

payment cut, the aggregate impact on payment o changes in the

ule or outpatient physical therapy is a positive 4% in 2013.

Functional Limitation Reporting

As required by the Middle Class ax Relie Jobs Creation Act o 201

CMS will begin to collect data on claim orms about patient unctio

status or patients receiving outpatient physical therapy, speech thera

and occupational therapy beginning January 1, 2013. Terapists wil

required to report new G codes accompanied by modiers on the clorm that convey inormation about a patient’s unctional limitation

and goals at initial evaluation, every 10 visits, and at discharge. Tis

data is or inormational purposes and not linked to reimbursement

Until July 1, 2013, claims will be processed regardless o the inclusion

o unctional limitation codes. Beginning July 1, 2013, all claims mu

include the unctional limitation codes in order to be paid by Medic

Terapy Cap Limitations

Te dollar amount o the therapy cap in CY 2013 will be $1900. Te

exceptions process will no longer be in eect aer December 31, 20

Congressional action is necessary to extend the exceptions process.

Multiple Procedure Payment Reduction (MPPR)

No revisions were made to CMS’s policy regarding application o th

MPPR to outpatient therapy services. MPPR is a reduction to the

practice expense portion o the payment or a therapy procedure wh

more than one unit or procedure is provided to the same patient on

the same date o service. Te MPPR o 25% or services urnished

in an institutional setting and 20% or services urnished in a non-

institutional setting remains unchanged.

2013 Terapy Cap Limitations

Te Balanced Budget Act o 1997, P.L. 105-33, Section 4541(c) set

annual caps or Part B Medicare therapy patients. Tese limits chang

annually. Terapy caps or 2013 will be $1900 or physical therapy an

speech therapy combined and $1900 or occupational therapy.

Terapy Cap Exceptions Process Expires Dec. 31, 2012 Unless

Congress Acts

Section 4541(a)(2) o the Balanced Budget Act (BBA) (P.L. 105-33)

1997, which added §1834(k)(5) to the Act, required payment under

prospective payment system (PPS) or outpatient rehabilitation serv

(except those urnished by or under arrangements with a hospital).

Section 4541(c) o the BBA required application o nancial limitati

to all outpatient rehabilitation services (except those urnished by or

under arrangements with a hospital).



ince the creation o therapy caps, Congress has enacted several

moratoria. Te Decit Reduction Act o 2005 directed CMS to

develop exceptions to therapy caps or calendar year 2006 and the

xceptions have been extended periodically. Exceptions to caps

ased on the medical necessity o the service are in eect only when

Congress legislates the exceptions. In 2006, the Exception Processes

ell into two categories, Automatic Process Exceptions, and Manual

Process Exceptions. Beginning January 1, 2007, there is no manual

process or exceptions. All services that require exceptions to caps

hall be processed using the automatic process. All requests or

xception are in the orm o a KX modier added to claim lines.

Te KX modier is added to claim lines to indicate that the clinician

ttests that services are medically necessary and justication is

documented in the medical record.

Te automatic process or exceptions will expire on December 31,

012 i congress does not act to extend the exception process. Tis

will result in Medicare Part B therapy patients being limited to a cap

$1900 or physical therapy and speech therapy combined and

1900 or occupational therapy in 2013.

013 Medicare Copays and Deductibles

CMS released inormation on the copays and deductibles or

Medicare Part A and Part B services in 2013. Te Part A deductible

paid by a beneciary when admitted as a hospital inpatient will

e $1,184 in 2013, an increase o $28 rom this year’s $1,156

deductible. Te Part A deductible is the beneciary’s cost or up

o 60 days o Medicare-covered inpatient hospital care in a benet

period. Beneciaries must pay an additional $296 per day or days

1 through 90 in 2013, and $592 per day or hospital stays beyond

he 90th day in a benet period. For beneciaries in skilled nursing

acilities, the daily co-insurance or days 21 through 100 in a benet

period will be $148.00 in 2013, compared to $144.50 in 2012. In

013, the Part B deductible will be $147, an increase in $7.00 rom

012 and the Part B copay will remain 20%.

Functional Limitation Reporting Under Medicare Part B

Te Middle Class ax Relie Act o 2012 included a mandate that

CMS collect inormation on Medicare Part B claims regarding the

eneciaries unction and condition, therapy services urnished,

nd outcomes achieved. CMS intends to utilize this inormation in

he uture to reorm payment or outpatient therapy services. Te

policy applies to physical therapy, occupational therapy, and speech

herapy services urnished in hospitals, Critical Access Hospitals

CAH’s), Skilled Nursing Facilities (SNF’s), Comprehensive

Outpatient Rehabilitation Facilities (CORFs), rehabilitation

agencies, home health agencies (when the beneciary is not under a

home health plan o care), and in private ofces o therapists, physic

and nonphysician practitioners. Te reporting o the unctional

limitations on the claim orm will be implemented on January 1, 20

o assure smooth transition, CMS has set orth a testing period rom

January 1, 2013, until July 1, 2013. Aer July 1, 2013, claims submitt

without the appropriate G-codes and modiers will be returned

unpaid.

Functional Limitation Reporting FAQs:

How is this inormation reported?

Under this new rule nonpayable G-codes and modiers will be

included on the claim orm to capture data on the beneciary’s

unctional limitations.

How requently must this inormation be reported? Nonpayable G-codes and modiers will be included on the claim o

to capture data on the beneciary’s unctional limitations (a) at the

outset o the therapy episode; (b) at a minimum every 10th visit; and

(c) at discharge. In addition, the therapist’s projected goal or unctio

status at the end o treatment will be reported on the rst claim or

services and at the end o the episode. Modiers will indicate the ext

o the severity/complexity o the unctional limitation.

What are the nonpayable G-codes or reporting unctional limitation?

G-Codes or Claims-Based Functional Reporting or CY 2013

Mobility: Walking & Moving Around

G8978 Mobility: walking & moving around unctional limitation,

current status, at therapy episode outset and at reporting

intervals


projected goal status, at therapy episode outset, at reporting

intervals, and at discharge or to end reporting


discharge status, at discharge rom therapy or to

end reporting



Changing & Maintaining Body Position

G8981 Changing & maintaining body position unctional

limitation, current status, at therapy episode outset and at

reporting intervals


limitation, projected goal status, at therapy episode outset,at reporting intervals, and at discharge or to end reporting


limitation, discharge status, at discharge rom therapy or to

end reporting

Carrying, Moving & Handling Objects

G8984 Carrying, moving & handling objects unctional

limitation, current status, at therapy episode outset and at

reporting intervals


limitation, projected goal status, at therapy episode outset,

at reporting intervals, and at discharge or to end reporting


limitation, discharge status, at discharge rom therapy

or to end reporting

Self Care

G8987 Sel care unctional limitation, current status, at therapy

episode outset and at reporting intervals

G8988 Sel care unctional limitation, projected goal status, at

therapy episode outset, at reporting intervals, and at

discharge or to end reporting

G8989 Sel care unctional limitation, discharge status, at

discharge rom therapy or to end reporting

Other P/O Primary Functional Limitation

G8990 Other physical or occupational primary unctionallimitation, current status, at therapy episode outset and at

reporting intervals

G8991 Other physical or occupational primary unctional

limitation, projected goal status, at therapy episode outset,

at reporting intervals, and at discharge or to end reporting

G8992 Other physical or occupational primary unctional

limitation, discharge status, at discharge rom therapy or to

end reporting

Other P/ O Subsequent Functional Limitation

G8993 Other physical or occupational subsequent unctional

limitation, current status, at therapy episode outset and a

reporting intervals


limitation, projected goal status, at therapy episode outseat reporting intervals, and at discharge or to end reportin


limitation, discharge status, at discharge rom therapy or

end reporting

Speech Language Pathology Functional Limitation

G8996 Swallowing unctional limitation, current status at time

initial therapy treatment/episode outset and at

eporting intervals

G8997 Swallowing unctional limitation, projected goal status, a

initial therapy treatment/outset and at discharge or to en

reporting

G8998 Swallowing unctional limitation, discharge status, at

discharge rom therapy/end o reporting on limitation

G8999 Motor speech unctional limitation, current status at tim

o initial therapy treatment/episode outset and at reporti

intervals

G9157 Motor speech unctional limitation, projected goal statu

initial therapy treatment/outset and at discharge rom

therapy

G9158 Motor speech limitation, discharge status at discharge ro

therapy/end o reporting on limitation

G9159 Spoken Language Comprehension unctional limitation

current status at time o initial therapy treatment/episod

outset and reporting intervals


projected goal status at initial therapy treatment/outset a

at discharge rom therapy


discharge status at discharge rom therapy/end o reporti

on limitation



G9162 Spoken Language Expression unctional limitation,

current status at time o initial therapy treatment/episode

outset and at reporting intervals


projected goal status at initial therapy treatment/outset and



discharge status at discharge rom therapy/end o reporting

on limitation

G9165 Attention unctional limitation, current status at time o

initial therapy treatment/episode outset and at reporting

intervals

G9166 Attention unctional limitation, projected goal status at


therapy

G9167 Attention unctional limitation, discharge status at


G9168 Memory unctional limitation, current status at time o

initial therapy treatment/episode outset and at reporting

intervals

G9169 Memory unctional limitation, projected goal status at


therapy

G9170 Memory unctional limitation, discharge status at


G9171 Voice unctional limitation, current status at time o initial

therapy treatment/episode outset and at reporting intervals

G9172 Voice unctional limitation, projected goal status at initial

therapy treatment/outset and at discharge rom therapy

G9173 Voice unctional limitation, discharge status at discharge

rom therapy/end o reporting on limitation

G9174 Other speech language pathology unctional limitation,current status at time o initial therapy treatment/episode

outset and reporting intervals

G9175 Other speech language pathology unctional limitation,

projected goal status at initial therapy treatment/outset and


G9176 Other speech language pathology unctional limitation,

discharge status at discharge rom therapy/end o reporting

on limitation

What limitation category should I choose or my patient i I use a

composite unctional tool such as Focus on Terapeutic Outcomes

(FOO)?

In this instance, a composite score should be reported using G89

(Other physical or occupational primary unctional limitation,

current status, at therapy episode outset and at reporting interval

G8991(Other physical or occupational primary unctional

limitation, projected goal status, at therapy episode outset, at

reporting intervals, and at discharge or to end reporting) and G8

(Other physical or occupational primary unctional limitation,

discharge status, at discharge rom therapy or to end reporting).

Should there be the occasion to report on a second condition a

the reporting on the rst had ended, the therapist would use the

G-codesetfor“othersubsequent”functionallimitation,G8993-

G8896.

I my patient has more than one unctional limitation, do I report multiple categories o unctional limitation?

No, at this time you only report one, primary unctional limitatio

to Medicare or each patient. In situations where treatment

continues aer the treatment goal is achieved and reporting ende

on the primary unctional limitation, reporting will be required

another unctional limitation. Tus, reporting on more than one

unctional limitation may be required or some patients, but not

simultaneously. Instead, once reporting on the primary unction

limitation is complete, the therapist will begin reporting on a

subsequent unctional limitation using another set o G-codes.

How is the patient’s unctional limitation severity reported?

Functional limitation severity is reports using one o seven modi

codes seen in the table below.

Severity/Complexity Modiers or CY 2013

Modier Impairment Limitation Restriction

CH 0 percent impaired, limited or restricted

CI At least 1 percent but less than 20 percent

impaired, limited or restrictedCJ At least 20 percent but less than 40 percent

impaired, limited or restricted

CK At least 40 percent but less than 60 percent


CL At least 60 percent but less than 80 percent


CM At least 80 percent but less than 100 percent


CN 100 percent impaired, limited or restricted



How do I determine the appropriate severity modifer or my patient?

Terapists must use a valid and reliable objective measure and/or

ssessment to quantiy unctional limitations. In some instances,

herapists may use more than one assessment tool to determine the

patient’s unctional limitation severity. It is acceptable or therapistso use their proessional judgment in the selection o the appropriate

modier.

Do I need to document how I selected the severity modifer?

Yes, therapists will need to document in the medical record how

hey made the modier selection so that the same process can be

ollowed at succeeding assessment intervals.

How requently must I submit unctional limitation inormation to

CMS on my patient?

Terapists must report the current unctional limitation o theirpatients at outset (initial evaluation), every 10th visit, and at

discharge.

How requently do I report goals on my patient?

Terapists must report the projected goal o their patients at outset

initial evaluation), every 10th visit, and at discharge.

What i my patient does not return or their discharge appointment or

discontinues therapy prior to ormal discharge?

Discharge reporting is required except in cases where therapy

ervices are discontinued by the beneciary prior to the planned

discharge visit.

Do I need to report unction limitation inormation i I perorm a

e-evaluation?

Yes, the therapist is required to begin a new reporting period when

ubmitting a claim containing a CP code or an evaluation or a re-

valuation. In this instance the therapist must submit inormation

n the current unctional status and the projected patient goal.

When do I begin reporting a subsequent unctional limitation i the

rimary limitation has resolved?

the primary unctional limitation is resolved, but care continues to

ddress another or subsequent limitation, the therapist reports that

mitation aer the primary limitation reporting is concluded.

Do I need to document the G-codes in the medical record?

Yes, the G-code descriptor and related modier is required to be

documented in the medical record. In cases where the therapist uses

other inormation in addition to certain measurement tools in order

to assess unctional impairment, documentation o the relevantinormation used to determine the overall percentage o unctional

limitation to select the severity modier should also be included in the

record.

Do I need to include the GP, GO or GN modifer when I report the

unctional limitation G-code?

Yes, or each nonpayable G-code on the claim, that line o service

would also need to contain one o the severity modiers, the

corresponding GO, GP, or GN therapy modier to indicate the

respective occupational, physical, or speech language therapy

discipline and related plan o care; and the date o service it reerences.

What do I submit with each G-code?

When reporting the unctional limitation o a patient to Medicare you

must submit the G-code, a severity modier, and the corresponding

therapy modier (GO, GP, or GN). Additionally, or each line on

the institutional claim submitted by hospitals, SNFs, rehabilitation

agencies, CORFs and HHAs, a charge o one penny, $0.01, can be

added. For each line on the proessional claim submitted by private

practice therapists and physician/NPPs, a charge o $0.00 can be

added.

CMS Released FY 2012 SNF PPS Monitoring Activities Report

CMS released a report detailing the FY 2012 SNF PPS Monitoring

Activities which presents an updated look at the third quarter impact

o the FY 2012 policy changes including the recalibration o the parity

adjustment, allocation o group therapy and changes to the MDS

including the introduction o the Change-o-Terapy (CO) Other

Medicare Required Assessment (OMRA). Below are some o the

highlights.



• Overallpatientcasemixisnotsignicantlydierentfrom

that observed in FY 2011--there have been small decreases in

the Rehabilitation Plus Extensive Services categories, and

increases in some o the medically-based RUG categories,

most notably Special Care.

FY 2011 FY2012 QR 1, 2, & 3

Rehabilitation Plus 2.5% 1.8%

Extensive Services

Rehabilitation 87.9% 88.5%

Extensive Services 0.6% 0.7%

Special Care 4.6% 5.1%

Clinically Complex 2.5% 2.2%

Behavioral Symptoms and 0.4% 0.3%Cognitive Perormance

Reduced Physical Function 1.5% 1.4%

• TepercentageofresidentsinUltra-HighRehabilitationhas

increased rom FY 2011 and although there have been

decreases in the High and Medium therapy RUG-IV

categories, CMS stated that some o the decrease may be due to

index maximization into the Special Care category.

FY 2011 FY 2012 QR 1, 2, & 3

Ultra-High Rehabilitation 44.9% 46.9%

(≥ 720 minutes o therapy

per week)

Very-High Rehabilitation 26.9% 26.2%

(500 – 719 minutes o

therapy per week)

High Rehabilitation 10.8% 10.5%


therapy per week)

Medium Rehabilitation 7.6% 6.5%


therapy per week)

Low Rehabilitation 0.1% 0.1%


therapy per week)

• InitialFY2012dataindicatethataertheallocationofgroup

therapy acilities are providing individual therapy almost

exclusively.

SRIVE FY 2011 FY 2012 QR 1, 2, & 3

Individual 74% 91.8% 99.5%

Concurrent 25% 0.8% 0.4%

Group <1% 7.4% 0.1%

• CMSstatedinthisreportthatpriortotheimplementation

o the CO OMRA, scheduled PPS assessments comprised the

majority o the completed assessments. With the addition o the

CO OMRA, scheduled PPS assessments continue to be the

majority o the completed assessments; however, the CO

OMRA is the most requently completed unscheduled

assessment.

FY 2011 FY 2012 QR 1, 2, & 3

Scheduled PPS assessment 95% 84%

Start-o-Terapy (SO) assessment 2% 2%

End-o-Terapy (EO) assessment 3% 3%

(w/o Resumption)

Combined SO/EO 0% 0%

End-o-Terapy assessment N/A 0%

(w/ Resumption) (EO-R)

Combined SO/EO-R N/A 0%

Change-o-herapy (CO) assessment N/A 11%



Proposed Settlement Agreement Filed in “Improvement

tandard” Case

Attorneys rom the Center or Medicare Advocacy, Vermont Legal

Aid and the Centers or Medicare & Medicaid Services (CMS)

haveagreedtosettlethe“ImprovementStandard”case,Jimmov.

ebelius, No. 11-cv-17 (D.V), led January 18, 2011. A proposed

ettlement agreement was led in ederal District Court on October

6, 2012. When the judge approves the proposed agreement, a

process that may take several months, CMS will revise the Medicare

Benet Policy Manual and other Medicare Manuals to correct

uggestions that Medicare coverage is dependent on a beneciary

improving”whichiscurrentlyoenusedasadenialreason.As

CMS recognizes, the settlement does not change the underlying

aw and regulations governing the Medicare program. Accordingly,

ince the underlying Medicare law is not changed, health care

providers should implement the maintenance standard now. Tus,

health care providers should apply the maintenance standard and

provide medically necessary nursing services or therapy services,

r both, to patients who need them to maintain their unction, or

prevent or slow their decline.

TeJimmosettlementalsoestablishesaprocessof“re-review”for

Medicare beneciaries who received a denial o skilled nursing

acility care, home health care, or out-patient therapy services

physical therapy, occupational therapy, or speech therapy) that

ecame nal and non-appealable aer January 18, 2011 because o he Improvement Standard. Shortly aer the ederal district court

pproves the settlement, CMS will announce how beneciaries can

nvoke the re-review process.

013 OIG Work Plan Released

Te Ofce o Inspector General Work Plan or Fiscal Year 2013

provides brie descriptions o activities that the Ofce o Inspector

General (OIG) plans to initiate or continue with respect to the

programs and operations o the Department o Health & Human

ervices in scal year 2013. For each review, the Work Plandescribes the subject, primary objective, and criteria related to the

opic. In 2013, the areas o ocus or nursing homes are:

Nursing Homes—Adverse Events in Post-Acute Care or Medicare Benefciaries

Te OIG will estimate the national incidence o adverse and

temporary harm events or Medicare beneciaries receiving postacute

care in SNFs and inpatient rehabilitation acilities (IRF). Te OIG will

also identiy contributing actors to these events, determine the extent

to which the events were preventable, and estimate the associated costs

to Medicare.

Nursing Homes—Medicare Requirements or Quality o Care in Skilled Nursing Facilities

Federal laws require nursing homes participating in Medicare or

Medicaid to use RAIs to assess each nursing home resident’s strengths

and needs. Prior OIG reports revealed that about a quarter o residents

needs or care, as identied through RAIs, were not reected in

care plans and that nursing home residents did not receive all thepsychosocial services identied in care plans.

Te OIG will review how SNFs have addressed certain Federal

requirements related to quality o care. Te OIG will determine the

extent to which SNFs use the Residential Assessment Instruments

(RAI) to develop care plans to provide services to beneciaries

in accordance with the plans o care and to plan or beneciaries’

discharges. Te OIG will also describe any instances o poor quality

o care.

Nursing Homes—State Agency Verifcation o Defciency Corrections (New)

Federal regulations require nursing homes to submit correction plans

to the State survey agency or CMS or deciencies identied during

surveys. CMS requires State survey agencies to veriy the correction

o identied deciencies through onsite reviews or by obtaining other

evidence o correction. (State Operations Manual, Pub. No. 100-07, §

7300.3.) A prior OIG review ound that one State survey agency did

not always veriy that nursing homes corrected deciencies identied

during surveys in accordance with Federal requirements.

Te OIG will determine whether State survey agencies veried

correction plans or deciencies identied during nursing home

recertication surveys.



Nursing Homes—Oversight o Poorly Perorming Facilities

Te OIG will identiy poorly perorming nursing homes and

determine the extent to which CMS and States use enorcement

measures to improve nursing home perormance. Te OIG will

lso identiy CMS and States’ ollow up actions to ensure that poorly

perorming nursing homes implement corrective actions. Te OIG

will examine enorcement decisions by CMS and States resulting

rom surveys and complaint allegations

Nursing Homes—Use o Atypical Antipsychotic Drugs (New)

According to 42 CFR § 488.3, nursing homes must comply with

Federal quality and saety standards, including requiring the

monitoring o the prescription drugs prescribed to its residents.

Federal requirements, 42 CFR § 483.25(l)(1), also require thatnursing home residents’ drug regimens be ree rom

unnecessary drugs.

Te OIG will assess nursing homes’ administration o atypical

ntipsychotic drugs, including the percentage o residents receiving

hese drugs and the types o drugs most commonly received. Te

OIG will also describe the characteristics associated with nursing

homes that requently administer atypical antipsychotic drugs.

Nursing Homes—Hospitalizations o Nursing Home Residents

Hospitalizations o nursing home residents are costly to Medicare

nd may indicate quality-o-care problems at nursing homes. A

007 OIG review ound that 35 percent o hospitalizations during

SNF stay were caused by poor quality o care or unnecessary

ragmentation o services. Te OIG will determine the extent to

which Medicare beneciaries residing in nursing homes have

een hospitalized. Te OIG will also determine the extent to

which hospitalizations were a result o manageable or preventable

onditions.

Nursing Homes—Questionable Billing Patterns or Part B ServicesDuring Nursing Home Stays

Te OIG will identiy questionable billing patterns associated with

nursing homes and Medicare providers or Part B services provided

o nursing home residents. A series o studies will examine podiatry,

mbulance, laboratory, and imaging services.

Nursing Homes—Oversight o the Minimum Data Set Submitted by Long-erm-Care Facilities (New)

Certied nursing acilities are required to complete the MDS or all

residents at specied intervals and submit data electronically to the

State. States then submit data to CMS, which uses it or a number o programs, including payment, quality monitoring, and consumer

inormation. Te OIG will determine whether and the extent to

which CMS and the States oversee the accuracy and completeness o

Minimum Data Set (MDS) data submitted by nursing acilities.

Medicare Auditors Becoming More Active, Denying More Claims

A new survey conducted by the American Hospital Association

ound that requests or medical records by Medicare’s recovery audit

contractors (RACs) jumped sharply rom the rst- to the second-quarter o scal year 2012. RACs requested 546,000 medical records in

the second quarter o 2012. Tat’s a 22% increase over the 448,000 the

previous quarter. Providers also experienced an increase in the denial

o claims, both automated and complex over that same time, AHA

survey results showed. Te survey ound that more than hal o the

providers surveyed had spent $10,000 to oversee the audit process, and

9% spent over $100,000 on it.

New Bill Would Limit Power of Medicare Recovery Audit Contractors

In October, Reps. Sam Graves (R-MO) and Adam Schi (D-CA)

proposed the Medicare Audit Improvement Act (H.R. 6575) which

would limit the power o Medicare Contractors. Te bill was reerred

to House Ways and Means, House Energy and Commerce on October

16, 2012, which will consider it beore possibly sending it on to the

House or Senate as a whole.



HR 6575, i passed in the House and Senate and signed by the

President, would:

• Limitthenumberofadditionaldocumentationrequestsmade

by Medicare contractors;

• Imposepenaltiesforfailuretomeetcertaintimeframesandforoverturned appeals;

• Requiremedicalnecessityauditstofocusonwidespread

payment error rates;

• IncreasetransparencyofRACperformance;

• RestoredueprocessrightsundertheABrebilling

demonstration;

• Requireaccuratepaymentforrebilledclaims;and

• Requirephysicianvalidationformedicalnecessitydenials.

Below is a summary o a number o these provisions as they pertain

o RACs, specically.

Limiting Documentation Requests

enacted, the Secretary o HHS (Secretary) must establish a process

where the number o additional document requests o a hospital

made by a Medicare contractor, as it relates to part A claims, in a

ear is the lesser o:

1. 2% o all o the claims or that year; or

2. 500 additional documentation requests during a 45-day period.

mportantly,thisstatuteappliestorequestsmadebya“Medicare

ontractor”notjustaRAC.Medicarecontractor,forpurposes

this bill, means a Medicare administrative contractor, scal

ntermediary, carriers, RACs, Zone Program Integrity contractors,

Program Saeguard Contractors, and Comprehensive Error Rate

esting program contractors.

Penalties and Audits on Widespread Payment Errors

HR 6575 would require the contracts between the Secretary and the

RACs to include the ollowing:

• ImpositionofnancialpenaltiesiftheSecretarydetermines

that the RAC exhibits a pattern o ailure to: urnish a demand

letter in a timely ashion or complete a determination with

respect to each audit in a timely ashion;

• Impositionofpenaltiesforoverturnedappeals;

• TeSecretarywillnotapproveapost-paymentorprepayment

medical necessity audit unless the review addresses a widespread

payment error rate;

• TeRACwillterminateanauditifitisdeterminedthatthe

applicable payment error rate is no longer a widespread payment

error; and

• RACsmayonlyconductprepaymentreviewspursuantto

guidelines established by the Secretary.

ransparency o RAC Perormance

Inormation on RAC perormance would be published annually on

the CMS website and would, with respect to each RAC, display the

inormation on audit rates, denials and appeals outcomes as well

as the results o any perormance evaluation audit conducted by an

independent entity.

Requiring Physician Validation or Medical Necessity Denials

When a RAC denies a claim or medical necessity, that RAC would

have to have a physician review each medical necessity denial and

determine whether the denial by the non-physician RAC employee

was appropriate, sign and certiy the determination, and append the

signed and certied determination to the claim le. I it is determined

that the non-physician RAC employee’s denial was inappropriate, the

claim would be deemed medically necessary.

CMS Released Fiscal Year-End Improper Payment Figures forRecovery Auditors

CMS releases Recovery Auditor overpayment and underpayment

statistics at the close o each scal year (FY) quarter.



n FY 2010, Recovery Auditors collected $75.4 million in

verpayments and identied $16.9 million in underpayments or

total correction amount o $92.3 million. Last year, Recovery

Auditors recouped $797.4 million in overpayments and reported

141.9 million in underpayments or a total correction amount $939.9 million. In FY 2012, Recovery Auditors collected a total

$2.29 billion in overpayments and identied $109.4 million in

underpayments or a total o $2.4 billion in corrections. However,

he report is somewhat incomplete since it does not reect what was

ecouped aer the appeals are done.

FY 2010 FY 2011 FY 2012 otal nationalOct 2009- Oct 2010– Oct 2011– programSept 2010 Sept 2011 Dec 2012

Overpayments $75.4M $797.4M $2,291.3M $3.16Bollected

Underpayments $16.9M $141.9M $109.4M $268.2M

eturned

otal corrections $92.3M $939.M $2,400.7M $3.43B

CMS’ report each quarter includes the top Recovery Auditor issue

per region. For this past quarter, the issues remained the same:

•RegionA:Cardiovascularprocedures

•RegionB:Cardiovascularprocedures

•RegionC:Cardiovascularprocedures

•RegionD:Minorsurgeryandothertreatmentbilledasinpatient

CMS also provides a drilldown o total correction numbers or the

past quarter or each Recovery Auditor region. Perormant Recovery

Region A) and CGI (Region B) both saw their total quarter numbers

dip slightly compared to the previous quarter, while Connolly

Region C) and HealthDataInsights (Region D) saw slight upticks.

Te ollowing chart shows the overpayments, underpayments, and

otal corrections or the quarter and scal year to date, with guresprovided in millions:

Overpayments Underpayments otal quarter FY to datcollected returned corrections correction

Region A $142.0 $10.9 $152.9 $475.6

Region B $42.1 $3.5 $45.6 $277.6

Region C $225.7 $22.1 $247.8 $792.5

Region D $238.2 $10.0 $248.2 $854.9

Nationwide $648.0 $46.5 $694.5 $2,400.7totals

Providers should prepare to face even more audits underhealthcare reform

Providers need to have the appropriate sta and data analytics

programs in place to deend against the onslaught o more Medicare

and Medicaid claims audits, according to healthcare expert Robert

Freedman. As more provisions o the Aordable Care Act areimplemented, Medicare and Medicaid providers should expect

more scrutiny rom Recovery Audit Contractors (RAC), Medicare

Administrative Contractors (MAC), and comprehensive error rate

testing contractors.Freedman said provider compliance ofcers shou

be prepared to spend a lot more o their time appealing and deendin

audits, according to a report by the Bureau o National Aairs. Data

mining and data analytics programs can help providers make sure

their billing operations don’t stand out, Freedman advised.

Report Released on Shortfalls in Medicaid Funding forNursing Center Care

Te bleak Medicaid picture is unlikely to get better in 2013 or nursin

home operators according to a report commissioned by the America

Health Care Association and conducted by Eljay, LLC. Medicaid

underpayments are expected to exceed $7 billion nationally in 2012,

an average shortall o $22.34 per resident day. Tat’s up rom $18.54

2010,notesthe“ReportonShortfallsinMedicaidFundingforNursi

CenterCare.”Brokendownintothecostsforatypical100-bedfacilit

where 63% o residents are on Medicaid, the shortall translates into

$500,000 each year.

Te report notes a ew actors that will make Medicaid unding even

more challenging moving orward: dual-eligible integration likely

will have implications or both Medicaid long-stay occupants and

Medicare-nanced post-acute care average length o stay. Te



ederal government is also pushing or expansion o home- and

ommunity-based services, which also are expected to drive down

verage occupancy rates. Many states also are pushing or managed

are plans or Medicaid beneciaries.

mprovements are Needed at the Administrative Law JudgeLevel of Medicare Appeals

n a study that analyzed all ALJ appeals decided in scal year (FY)

010, policies, procedures, other documents and data on CMS

participation in ALJ appeals and consisted o structured interviews

with ALJs and other sta; Qualied Independent Contractors (QIC),

nd CMS sta, the OIG ound that providers led the vast majority o

ALJ appeals in FY 2010, with a small number accounting or nearly

ne-third o all appeals. For 56 percent o appeals, ALJs reversed

QIC decisions and decided in avor o appellants; this rate varied

ubstantially across Medicare program areas. Dierences between ALJ

nd QIC decisions were due to dierent interpretations o Medicare

policies and other actors. In addition, the avorable rate varied widely

y ALJ. When CMS participated in appeals, ALJ decisions were less

kely to be avorable to appellants. Sta raised concerns about the

cceptance o new evidence and the organization o case les. Finally,

ALJ sta handled suspicions o raud inconsistently.

Te OIG recommended that OMHA and CMS: (1) develop and

provide coordinated training on Medicare policies to ALJs and

QICs, (2) identiy and clariy Medicare policies that are unclearnd interpreted dierently, (3) standardize case les and make

hem electronic, (4) revise regulations to provide more guidance to

ALJs regarding the acceptance o new evidence, and (5) improve

he handling o appeals rom appellants who are also under raud

nvestigation and seek statutory authority to postpone these appeals

when necessary. Further, the OIG recommended that OMHA: (6)

eek statutory authority to establish a ling ee, (7) implement a

quality assurance process to review ALJ decisions, (8) determine

whether specialization among ALJs would improve consistency and

fciency, and (9) develop policies to handle suspicions o raudppropriately and consistently and train sta accordingly. Finally,

he OIG recommended that CMS: (10) continue to increase CMS

participation in ALJ appeals. OMHA and CMS concurred ully or in

part with all 10 o the recommendations.

All Eyes on Therapy

Terapy remains the ocus o many Medicare Administrative

Contractors (MACs)/Fiscal Intermediaries (FIs) as well as the

Regulatory and Law Enorcement Agencies o the Federal

Government as the commitment to deterring raud, waste and abusin the Medicare and Medicaid systems has increased.

OIG Report: Inappropriate Payments to Skilled Nursing Facilitie

Cost Medicare More Tan a Billion Dollars in 2009

In recent years, the Ofce o Inspector General has identied a

number o problems with billing by skilled nursing acilities (SNF),

including the submission o inaccurate, medically unnecessary,

and raudulent claims. Further, the Medicare Payment Advisory

Commission has raised concerns about SNFs’ improperly billing or

therapy to obtain additional Medicare payments. In scal year (FY)

2012, Medicare paid $32.2 billion or SNF services.

Te OIG based this study on a medical record review o a stratied

random sample o SNF claims rom 2009. Te reviewers determine

whether the inormation reported by the SNFs on the Minimum

Data Set (MDS) was supported by and consistent with the medical

record. Te OIG ound that SNFs billed one-quarter o all claims

in error in 2009, resulting in $1.5 billion in inappropriate Medicare

payments. Te majority o the claims in error were upcoded; many

these claims were or ultrahigh therapy. Te remaining claims in er

were downcoded or did not meet Medicare coverage requirements.

addition, SNFs misreported inormation on the MDS or 47 percen

o claims. SNFs commonly misreported therapy, which largely

determines the RUG and the amount that Medicare pays the SNF.

Te OIG recognized that CMS has recently made several signicant

changes to SNF payments and made the ollowing recommendation

to CMS to which CMS concurred with all six:

(1) Increase and expand reviews o SNF claims,

(2) Use its Fraud Prevention System to identiy SNFs that arebilling or higher paying RUGs,

(3) Monitor compliance with new therapy assessments,(4) Change the current method or determining how much

therapy is needed to ensure appropriate payments,

(5) Improve the accuracy o MDS items, and

(6) Follow up on the SNFs that billed in error.



Owner of Old Saybrook Physical Terapy Practice Pleads

Guilty to Obstructing Federal Audit

Te United States Attorney or the District o Connecticut announced

hat odd Roberts, 47, o Old Saybrook, waived his right to

ndictment and pleaded guilty to one count o obstructing a

ederal audit.

According to court documents and statements made in court, Roberts

s the owner and operator o Roberts Physical and Aquatic Terapy,

ocated at 210 Main Street in Old Saybrook. On January 23, 2009, a

Medicare contractor inormed Roberts Physical and Aquatic Terapy

hat the contractor was perorming an audit o the practice. Roberts

nstructed an employee to delay the audit by telling the contractor that

medical records were stored at a nonexistent storage acility. Roberts

hen rented a storage unit at a local acility and used the delay to alter

nd augment patient records. Specically, Roberts, and an employee at

his direction, created and added patient progress notes when no noteshad been created at the time o service. Te notes made it appear

s though Medicare beneciaries had obtained direct, one-on-one

ervice rom a licensed physical therapist when, in act, some o the

ervices had been rendered by unlicensed auxiliary personnel.

udge Underhill has scheduled sentencing or December 18, 2012, at

which time Roberts aces a maximum term o imprisonment o ve

ears and a ne o up to $250,000.

Rajindera Sachdeva Added to Most Wanted Fugitives List

Rajindera Sachdeva was added to most wanted ugitives list.achdeva has been indicted on charges o health care raud. From

pproximately January 2005 until December 2006, Rajindera

achdeva was an occupational therapist who worked with various

Medicare providers. Sachdeva was paid approximately $3.3 million

rom Medicare. According to investigators, Sachdeva created

ccupational and physical therapy les or services that were never

provided to patients. SA Rehabilitation Services billed Medicare or

he physical and occupational therapy services that were not provided.

Te les were then sold to co-conspirator Ehsan Rana, the owner

Alternative Physical Terapy, Incorporated. Alternative Physical

Terapy billed Medicare or occupational and physical therapy ervices that were not provided. Files were also sold to ri-County

Rehabilitation.

Fraudulent Billing for Manual Terapy

acqueline Wheeler was ound guilty o one count o healthcare

raud and 34 counts o making alse statements relating to healthcare

matters and was sentenced to six years, three months in prison and

$6.34 million in nes and restitution. Wheeler also received three

years’ probation and was banned rom the healthcare industry.

Wheeler led more than $7 million in ake Medicaid claims listing

hersel as a medical doctor when she was actually a non-board-

certied naturopath. Prosecutors charged that Wheeler led claimthat showed the center provided rom 20 to 48.5 continuous hours

manual therapy or each patient in 24-hour periods.

Physical Terapist Ph.D. Sentenced to 13 Months of Prison and

Pays More Tan $3 Million Dollars in Restitution, Civil Penalti

and Back axes

Chyawan Bansil, P.., Ph.D. o Farmington Hills, Michigan was

sentenced to 13 months prison on charges o health care raud

and money laundering. Te convictions arise rom an Indictment

which charged that between February 2007 and January 2012, Dr.Bansil derauded Medicare, Medicaid, and Blue Cross Blue Shield

o Michigan o more than $1 million by causing those programs

to be billed or expensive nerve conduction studies and needle

electromyography tests that Dr. Bansil did not perorm.

Detroit-Area Physical Terapy Assistant Sentenced to 30 Month

Prison for Role in $13.8 Million Home Health Care Fraud Schem

A Detroit-area registered physical therapy assistant was sentenced

to serve 30 months in prison or her role in a nearly $13.8 million

Medicare raud scheme. In addition to her prison term, Barot was

sentenced to serve two years o supervised release and ordered to p

$1,336,739 in restitution, jointly and severally with her co-deendan

Barot pleaded guilty on June 26, 2012, to one count o conspiracy

to commit health care raud. According to Barot’s plea agreement,

beginning in approximately May 2009, Barot, a physical therapy

assistant, was paid to alsiy medical documentation or Physicians

Choice Home Health Care LLC, a home health agency owned

by her co-conspirators. Barot created evaluations, therapy revisit

notes and other medical documentation memorializing purportedphysical therapy or patients she did not see or treat. According to

court documents, she was instructed on how to alsiy the medical

documentation by a co-conspirator.



Barot also pleaded guilty to signing therapy revisit notes as a physical

herapy assistant or patients she did not see or treat, knowing that the

documents she alsied and the documents that she signed would be

used to support alse claims to Medicare or home health services.

Barot was subsequently paid to sign alsied medical documentationnd les or First Care Home Health Care LLC, Quantum Home Care

nc. and Moonlite Home Care Inc., which were Detroit-area home

health care companies also owned by Barot’s co-conspirators that

illed Medicare.

From approximately May 2009 through September 2011, Medicare

paid approximately $1,336,739 to the our home health care

ompanies or raudulent physical therapy claims based on alsied

les and notes signed by Barot. Te our home health companies or

which Barot worked were paid in total approximately $13.8 million by

Medicare.

Nine o Barot’s co-deendants have pleaded guilty, and one has been

entenced. Tree co-deendants are ugitives, and six co-deendants

wait trial.

Life Care Centers of America probed for Medicare fraud

Federal prosecutors allege that Cleveland, enn.-based Lie Care

Centers o America has bilked the ederal government o hundreds

millions o dollars through a systematic Medicare raud scheme

ince at least 2006. Court records detail allegations and a ederal

nvestigation that began in 2008 with two whistle-blower lawsuits led

y employees at acilities in Florida and in Morristown, enn.

Prosecutors allege that top-level Lie Care supervisors issued directives

o max out unnecessary and oen harmul therapies to patients or

he highest possible Medicare reimbursement.

n an unsigned letter issued Friday to employees, Lie Care disputed

he government’s claims, saying that the combined whistle-blower

awsuitsappearedto“target”companiessuchastheirsandits

llegations“second-guess,aerthefact,thetrainedmedical

rofessionalswhoprescribedthelevelofcare.”

Te letter also states that the way the company provides therapies

actually saved Medicare an estimated $400 million in cost savings

rom 2006 to 2010.

Medicare Fraud Strike Force Charges 91 Individuals for

Approximately $430 Million in False Billing

On 10/4/2012 Attorney General Eric Holder and Health and Huma

Services (HHS) Secretary Kathleen Sebelius announced that Medic

Fraud Strike Force operations in seven cities led to charges against 9

individuals – including doctors, nurses and other licensed medical

proessionals – or their alleged participation in Medicare raud

schemes involving approximately $429.2 million in alse billing,

Dozens o charged individuals were arrested or surrendered in the la

24 hours as indictments were unsealed across the country. ogethe

those indictments charge more than $230 million in home healthcare raud; more than $100 million in mental health care raud and

more than $49 million in ambulance transportation raud; and

millions more in other rauds. HHS also suspended or took other

administrative action against 30 health care providers ollowing a da

driven analysis and based upon credible allegations o raud.

Te deendants charged are accused o various health care raud-

related crimes, including conspiracy to commit health care raud,

health care raud, violations o the anti-kickback statutes and money

laundering. Te charges are based on a variety o alleged raud

schemes involving various medical treatments and services such as

home health care, mental health services, psychotherapy, physical

and occupational therapy, durable medical equipment (DME) and

ambulance services.

According to court documents, the deendants allegedly participate

in schemes to submit claims to Medicare or treatments that were

medically unnecessary and oentimes never provided. In many cas

court documents allege that patient recruiters, Medicare beneciarie

and other co-conspirators were paid cash kickbacks in return or

supplying beneciary inormation to providers, so that the providercould submit raudulent billing to Medicare or services that were

medically unnecessary or never provided.

Shawn Halcsik

Director of Compliance

414.791.9122

shalcsik@evergreenrehabcom

Contact Information:

Liz Barlow

Vice-President of Clinical Services

502.400.1619

liz@evergreenrehabcom

Documents

Evergreen Rehabilitation Contract Therapy - Clinical & Compliance Bulletin 2013 Q1