Avoid Overpayment - Review Documentation for Outpatient Therapy Claims
Outpatient physical therapy claims present an area that has long been fraught with the potential for billing fraud, waste and abuse. The Office of Inspector General (OIG) has issued several reports in past years concerning outpatient physical therapy claims that were not reasonable, not medically necessary and / or not properly documented. Most recently, the OIG has reviewed several high billers of physical therapy according to Medicare and determined one such high biller had a 99% error rate in a sample the OIG reviewed. Because of a high error rate in these type of claims, payers should regularly review physical therapy claims documentation against their requirements and clinical policies in order to avoid potential overpayment.
Five categories of errors identified in the OIG report include:
- Plan of care requirements not met
- Treatment notes requirements not met
- Progress reports untimely or not contained in the medical record
- Medical necessity requirements not met
- Physician certification requirements not met
Under the treatment notes category, timed HCPCS codes were identified as a problem in 75% of the claims reviewed. Physical therapy timed codes are billed for certain procedures in increments of 15 minutes. Each increment of 15 minutes is billed as 1 unit. A code of this type mistakenly billed as 15 units rather than 1 unit represents 225 minutes instead of 15 minutes and would cause the payment to be incorrect. Examples of this type of timed physical therapy code are the following:
- 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
- 97033 Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
- 97035 Application of a modality to 1 or more areas; ultrasound, each 15 minutes
- 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility
- 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
- 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
- 97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
- 97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion)
- 97140 Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
- 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
- 97535 Self-care/home management training (e.g., activities of daily living [ADL] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment), direct one-on-one contact, each 15 minutes
- 97750 Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes
A payer can review these codes throughout all submitted claims and determine variances in billing, such as a provider billing a high number of units for these codes that may actually represent minutes. Once variances are found, clinical correlation with the medical record would determine the validity of the claim.
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