Page 12 - OPTA Access September 2017 Volume 45, Issue 2

Payment Policy Report
Berni Willis – Payment Policy Specialist
CMS Proposed Fee Schedule (PFS)
The proposed 2018 Medicare physician fee schedule (PFS) was released by the U S Centers for Medicare and Medicaid Services (CMS) CMS is reviewing many
of the CPT codes as potentially disvalued, putting them at risk for sizable reductions (See the notice below ) However, there are proposed
increases in a few of the codes APTA will be advocating to maintain these proposed payment values in the nal rule which will be released in November 2017 and will submit comments to CMS by the September 11 deadline CMS has also published a fact sheet summarizing the proposed rule
Practice Payer Issues
1 Anthem is processing CPT code 97140 as Massage code only when submitted for Physical Therapy care
The clinic was verifying bene ts, the customer service representative informed the clinic that CPT code 97140 was not a covered bene t, that it was a considered a Massage only code
The clinic(s) have now appealed the denial determination and are awaiting the nal determination. The provider representative was contacted; however, she indicated that she could not assist, that the Practice(s) would have to follow the appeal process
2 Humana is auditing for non-medical necessity treatment
The request rst comes to the clinic as a record request. Humana second communication is a letter indicating that there may be an overpayment The third piece of correspondence follows with the amount that the clinic owes for overpayment and appeal instructions
Practice(s) are reporting that after they follow the appeal in 100% of the cases Humana has determined that there has been no overpayment
3 Traditional Medicare (Red, White & Blue) cards will be issuing new ID cards with non-Social Security numbers Cards become effective April 1, 2018 and will be release in the fall of 2017. Providers are asked to remind patients to contact Medicare to ensure their address is accurate They will not receive a replacement unless they verify their address. Medicare will allow claims to continue to be led until December 31, 2019
4 CMS is reviewing frequency of general modalities of various CPT codes (97012, 97016, 97018, 97022, 97024, 97032, 97033, 97035, 97035, 97039, G0283) They were going to implement frequency edits effective May 25, 2017 There have been no other publications regarding frequency guidelines
Recently a Practice reported that claims are being held for review of G0283 by CGS Currently there is no determination from CGS to report at this time
5. Updated ABN forms went into effective June 21, 2017. The changes you will see is required non-discrimination statement (required under Section 1557 of the Affordable Care Act (ACA) and added expiration date of March 2020 Also, is available in both English and Spanish
When a payer requests documentation, whether it was for one day or a date span, you are being audited for the care that was provided and the units billed It is important that the Practice has an internal peer to peer audit process For example, the audit check list would include various check points:
• Adhering to the Patient Policy Limitations / Utilization • Functional reporting addresses the issues treated
within the current Episode of Care
• Evaluation and treatment notes support medical
necessity
• Visual and/or direct PT supervision noted as appropriate
• Documentation indicates review of diagnosis/prognosis
• Required reports have been timely completed, signatures have been received
For more information, contact the OPTA of ce at:
opt@ohiopt org
ptember 2017 | OPTA
12 | Se
Legislative & Payment Policy Report