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Written by: Darlene D'Altorio-Jones (1959-2015) on Wednesday, March 7, 2012 Posted in: Outpatient Rehab

Just recently you may have stumbled upon a blog post at that defined take backs in the state of New York that stemmed back to 2009 based on overpaid charges related to CCI edit coding errors.  Rick Gawenda, PT, responded and clarified that it appeared that the CCI Edits Rule was being followed and that therapy services provided on the same day by the same provider required a ’59‘ modifier in order to pay distinct and separately for those services. These are the facts- therapy services provided on the same day will always be subject to CCI Edit Rules.

Communication and the ability to link usage of the same CPT code across disciplines to trigger modifier usage at the point of documentation is available in the MediLinks OP software solution.  When a therapist charts, interventions are linked to CPT codes and the ingenuity of cross-referenced occurrences are alerted at the point of documentation which enables therapists to apply the 59 modifier up front; securing appropriate documentation with the bill as it is created.  This workflow curtails many pain points encountered when edits are applied after the fact, especially mounting take backs, error rate testing and denials of payment that can be applied by various Medicare contractor agencies.  With less than adequate tools, leaders must increase awareness and responsiveness to ensure appropriate billing knowledge is applied by all clinicians. Let’s learn a little about CCI edits and modifiers and risks associated with non-compliance.

An excellent Medicare Learning Matters education flyer was posted in 2006 explaining when and how CCI edits would be applied.  The education article states, “Application of the CCI edits ensures that all therapy providers are subject to the same billing and coding rules and requirements. It is believed that these changes will have a positive budgetary effect as it incorporates safeguards against improper coding and over-payment of therapy services.”  Some managers are confused and believe that the plan of care or discipline specific code edits should also indicate distinct and separate care; this is NOT the case.

The claim must include one of the following modifiers to distinguish the ”skilled” discipline of the plan of  care under which the service is delivered in outpatient therapy (Benefit policy manual definition of skilled provider):

GN – Services delivered under an outpatient SLP plan of care
GO – Services delivered under an outpatient OT plan of care
GP – Services delivered under an outpatient PT plan of care

Recall that there are situations when ‘always therapy’ or ‘sometimes therapy’ must be applied depending on who renders the various procedures.  The ANNUAL THERAPY UPDATES (posted Dec. 8, 2011) provide instructions on why and how GN, GO and GP modifiers should be used. Situations such as, “They are billed by practitioners/providers of services who are not therapists, i.e., physicians, clinical nurse specialists, nurse practitioners and psychologists; or they are billed to fiscal intermediaries by hospitals for outpatient services which are performed by non-therapists”, are examples of when the modifiers are NOT applied, however those providers are also subject to CCI edits – hence two sets of codes are needed.

Unfortunately, again many managers believe that GN, GO and GP is enough to denote ‘distinct and separate’ billable care.  However, particularly in multi-discipline clinics, there are often co-treatments provided and the time is not necessarily ‘distinct and separate’.  Providers are able to bill for co-treatment in various ways.  The provider can place all time billed to one discipline, or share the time between two disciplines, as defined through CMS: “Where a physical and occupational therapist both provide services to one patient at the same time, only one therapist can bill for the entire service or the PT and OT can divide the service units.” Be aware there are newer guidelines for counting of minutes for Skilled Therapy (published August, 2011) and if you work in skilled you must review the newest guidelines for that level of service.

HOW CAN YOU keep all of this straight?  Billing software is not often able to view across disciplines to recognize CCI edit scenarios.  When edits are not properly applied, this warrants take backs for “overpaid” claims on the same day for a provider.  I often see scrubbers apply edit information in an automated fashion that is not connected with documentation by the therapist at all.  These types of occurrences lay the groundwork for improper billing.  MediLinks embeds these tools to reduce probability of adverse occurrence.

It is far more effective in managing compliance at the front end, rather than paying for mis-communicated CCI edit pairings after the fact and/or only being reimbursed for portions of the care provided because distinct and separate CCI edit coding was not applied to the bill.

Should errors lead to an unacceptable error rate percentage, all Medicare claims could be placed into prepayment review. Prepayment review has serious cash flow consequences.  CMS reports a take back of $34.3 billion in improper payments in 2010. As electronic claims analysis becomes more expedient, take backs will increase. Payment extrapolation (statistically applying fault recouped payments based on historical sample), for those with continuous high error rates or previous education/training on faulty practices can see exponential take backs applied for years of service for which you have already been paid.

One of the best education primers I have seen on the subject of audits was published by AHIMA.  ”Understanding Governmental Audits.” Journal of AHIMA 82, no.7 (July 2011): 50-55 (see chart below).  I highly recommend placing a book mark to this site and using it to educate staff on the complexity and ever-growing vigilance for leaders in healthcare.



Courtesy: AHIMA

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