On March 14, the U.S. Department of Health and Human
Services, Office of Inspector General (OIG) issued a report, “Many Medicare Claims for Outpatient Physical Therapy Services Did Not
Comply With Medicare Requirements” that has been reported in various print
and web publications.
The OIG reports that 61 percent of Medicare
claims for outpatient physical therapy services that they reviewed did not
comply with Medicare medical necessity, coding, or documentation
requirements.
The OIG recommended that the Centers for Medicare &
Medicaid Services (CMS):
1) Recover overpayments,
2) Establish better oversight
of outpatient therapy claims, and
3) Improve provider education.
CMS
responded that they believed the OIG misinterpreted Medicare coverage policy,
particularly related to the definition of skilled services as clarified
subsequent to the January 2013 Jimmo
settlement, and disagreed that the error rate was as high as
reported. CMS also indicated that a significant portion of the errors
were likely more related to coding errors. However, CMS agreed that
improvements can be made in monitoring and provider education.
AHCA notes that this report is specific to Medicare
outpatient physical therapy (PT) services only, and more specifically,
outpatient PT services of 300 claims performed in office-based private
practices from July-December 2013. Outpatient PT services furnished in
skilled nursing facilities (SNFs) WERE NOT part of this audit.
For
context, the official CMS
CERT error rate report for 2017 indicates that the error rate for SNF
outpatient services was 4.1 percent (p.45 - PT/OT/SLP combined) and PT private
practice was 16.9 percent (p.53).
While the OIG report is not specific to SNF outpatient
therapy services, the same coverage and coding requirements apply to all
outpatient therapy providers. AHCA recommends that providers share this
report and the CMS response with therapy and billing personnel so they are
aware of the coverage, documentation, and coding policies where the OIG and CMS are focusing their audit efforts.
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