Business Briefs: 2011 Medicare Payment for Therapists in Wound Clinics

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  Therapists (physical and occupational) are valuable members of the wound care team and provide their services in multiple sites of service. Because this journal focuses on wound clinic work, this article provides an overview of the 2011 Medicare payment for therapists who are employed by hospitals and who provide “therapy services” or “wound care services” to outpatients in either the outpatient rehabilitation department or in a hospital-based outpatient wound care department (HOPD).

  In some areas, therapists assist physicians by providing therapy services to patients with chronic wounds in the outpatient rehabilitation department. In other areas, therapists work as part of the multi-disciplinary team in the HOPD. Some therapists actually provide therapy services both in the outpatient rehabilitation department and in the HOPD. Many therapists are also certified wound specialists and perform “non therapy” wound care services in HOPDs under a physician plan of care.

  Medicare payment for therapists varies by site of service and by the business model under which they work. Therefore, therapists MUST carefully discuss their coding and billing practices with their Medicare financial advisors. For example:

    • When therapists provide “therapy services” under a “therapy plan of care” in an outpatient rehabilitation department or in an HOPD, they are paid by the Medicare Physician Fee Schedule (MPFS).
    • When therapists, who are certified wound specialists, provide “wound care services “in HOPDs under a “physician plan of care”, the HOPD is paid by the Medicare Ambulatory Payment Classification (APC) system.

  Therapists are required to append the therapy modifiers to all therapy services provided in all sites of service:
    GN Services delivered under an outpatient speech language pathology plan of care
    GO Services delivered under an outpatient occupational therapy plan of care
    GP Services delivered under an outpatient physical therapy plan of care

  The appropriate revenue codes should always be used when coding and billing for therapy services. This includes “therapy services” performed in HOPDs: if a physician orders a “therapy service”, the therapist must develop a therapy plan of care and must code and bill that service under one of the therapy revenue codes.
    0420 Physical Therapy Services
    0430 Occupational Therapy Services
    0440 Speech-Language Pathology Services

  If a therapist, acting as a certified wound care specialist, performs a “wound care” service only (e.g. assists the physician during an HOPD clinic visit), the HOPD uses an appropriate HOPD revenue code (e.g. 0510) to code and bill for the clinic visit.

    CAUTION: Not writing a separate therapy plan of care and not using the appropriate therapy modifier and revenue code are some of the largest mistakes that therapists make when they work in HOPDs.

    Remember that therapists must always have a therapy plan of care for all therapy services performed. (See Table I.) Likewise, therapists must always append the therapy modifier to the codes that represent therapy work performed. Finally, outpatient therapy services must be coded and billed to the appropriate therapy revenue code. Double check that your Charge Description Master is set up to appropriately code and bill your therapy work performed in an HOPD.

  When therapists provide outpatient Medicare Part B “therapy services” to patients in outpatient rehabilitation departments or in an HOPD, the Medicare therapy caps do not apply. However, pay close attention to the following cautions:
    CAUTION: Only services billed by the hospital on bill types 12X (Inpatient Medicare Part B only) or 13X (Hospital outpatient) are exempt from therapy caps. CAUTION: Therapists must contract directly with skilled nursing facilities (SNFs) to provide “therapy services” during a Medicare beneficiary’s Part A covered stay. In those cases, the therapy cap does apply.

  National Correct Coding Initiative (NCCI) edits apply to all therapy providers. Be sure to check the NCCI edits at the beginning of each quarter. For 2011, pay particular attention to the NCCI edits for the newly revised descriptions of medical debridement codes 97597 and 97598.

2011 Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services

  Prior to 2011, Medicare paid therapists 100% of the Medicare allowable when they provided multiple therapy services to a patient on the same day or multiple units of the same therapy (for time-based codes) on the same day. Effective January 1, 2011 Medicare began applying a new Multiple Procedure Payment Reduction (MPPR) to the Practice Expense (PE) component of “always therapy” codes that are paid under the MPFS, regardless of the type of provider or supplier that furnishes the services. This new payment reduction will be similar to the physicians’ reduction when he/she performs multiple surgical procedures on the same day.

  • Full payment is made for the unit or procedure with the highest PE payment.

  • For subsequent units and procedures furnished to the same patient on the same day in an office setting or other non-institutional setting, full payment is made for the work and malpractice components and 80% payment is made for the PE component of “always therapy” codes.

  • For subsequent units and procedures furnished to the same patient on the same day in an institutional setting, full payment is made for the work and malpractice components and 75% payment is made for the PE component of “always therapy” codes.

  Note: The 20% reductions apply to professional claims submitted using the CMS-1500 claim form or 837 Professional electronic transaction. The 25% reductions apply to institutional claims submitted using the UB-04 claim form or 837 Institutional electronic transaction.

  When therapy services are furnished by a group practice or “incident to” a physician’s service, the MPPR applies to all services furnished on the same day, even if the services are provided by multiple disciplines, such as by physical therapy, occupational therapy, or speech-language pathology.

  See Table II for an example of how the MPPR will be applied when therapists perform two “always therapy” procedures on the same visit for the same patient.

Summary

  Medicare has dedicated an entire section of their website to therapy services. Because therapists can be working in more than one business model at the same time, they should refer to this very detailed resource for specific guidelines: https://www.cms.gov/TherapyServices/

  The Medicare contractor who pays your claims is the best source of answers to specific Medicare questions. Almost every contractor has Local Coverage Determinations (LCDs) that pertain to therapy services. If you do not find your answer on the Medicare website or in an LCD, contact your Medicare Contractor and/or the Medical Director who authored the LCD. If you have difficulty communicating with your Medicare contractor, use the CMS Regional Offices’ web page to identify the CMS Regional Office servicing your area of operations: you may call their toll-free number or send a written inquiry to seek assistance.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleend­schaum@bellsouth.net.