WIXLIB

Physical and Occupational TherapyBilling Best Practices

Flatirons Practice ManagementFull-service RCM company based in Boulder, ColoradoPT/OT billing for 19 yearsBill for a few hundred PTs/OTs/STsBill tens of thousands of PT/OT claims each month

AgendaFront desk best practicesFLR codingProper modifier usagePQRSNetwork statusWorking your unpaid claimsKey Performance Indicators (KPI’s)

Verifying eligibility and benefitsThis is NOT optionalMust verify eligibility and benefits at least on new patients and at thebeginning of a new calendar or plan year for active patients. Thisapplies to primary and secondary insurances as applicable.Who do we bill for primary and secondary claims?You need a robust Financial PolicyPatients must signThey are responsible for anything their insurance doesn’t payInclude attorney’s fees and collection costsHave them authorize you to call their cell phones to collect

Accuracy is keyAll data entry must be accurate and should match what’s on thepatient’s insurance card.Know the difference between Medicare and a Medicarereplacement plan.Can’t get a claim paid if you don’t send it to the correct payer.

Auths and visit limitationsIs a pre-auth required?Worker’s compMVA/Personal InjuryCommercial payers and third party administrators, such asOptum Health & OrthoNetAny restrictions on visits?Medicare CapAnnual PT limitsWhat’s already been consumed?Your EHR software should track this for you.

Time-of-service collectionsCo-paysUnmet deductiblesCo-insuranceCredit card on file

Calculating co-insurance to collect at 12971169714097530Procedure DescriptionNew Patient EvaluationRe-EvaluationMechanical TractionE-Stim - unattendedE-Stim - attendedIontophoresisUltrasoundTherapeutic ExercisesNeuro-Muscular Re-educationGait TrainingManual TherapyTherapeutic ActivitiesUnitsAllowed111111111111 94.45 51.09 19.73 18.25 22.14 34.22 15.85 38.16 39.92 33.80 35.74 41.06Deductible 10% coins 15% coins 20% coins 25% coins 94.45 51.09 19.73 18.25 22.14 34.22 15.85 38.16 39.92 33.80 35.74 9.45 5.11 1.97 1.83 2.21 3.42 1.59 3.82 3.99 3.38 3.57 14.17 7.66 2.96 2.74 3.32 5.13 2.38 5.72 5.99 5.07 5.36 18.89 10.22 3.95 3.65 4.43 6.84 3.17 7.63 7.98 6.76 7.15 23.61 12.77 4.93 4.56 5.54 8.56 3.96 9.54 9.98 8.45 8.94 41.06 4.11 6.16 8.21 10.27You can replicate this by payer with your actual contracted rates

Timely charge entryPatient charts should be completed prior to charge entryBest practice same dayThis applies to finalizing and signing your notes tooMediLinks allows you to document your charges real-time as you’reinteracting with the patientQuicker charge entry quicker billing quicker payments

FLR codingRequired when Medicare is primary or secondary. Medicarereplacement plans are excluded.Select a primary limitation per patient along with their current statusand their goal status.Must report with the initial evaluation, every re-evaluation (at leastevery 10th visit) and at discharge or you won’t get paid. You canreport earlier than the 10th visit in conjunction with a re-evaluation.You are not required to report if the patient self-discharges but it’s agood idea in case they come back.

FLR codingThere are 6 code sets with 3 codes per set.Example – MobilityG8978 – Current StatusG8979 – Goal StatusG8980 – Discharge StatusReport 2 codes with severity modifiers with each reporting event: Current status and the goal statusWhen discharging the patient, the discharge status is the currentstatus. You still need to report the goal.

FLR codingSeverity Modifiers:CH – 0 percent impairedCI – 1 to 20 percent impairedCJ – 20 to 40 percent impairedCK – 40 to 60 percent impairedCL – 60 to 80 percent impairedCM – 80 to 100 percent impairedThe key to FLR management is simply keeping track of your visitsand MediLinks will do this for you.

Know your modifiersMedicare: GP, GO, GN, KXX series – preferred by Medicare and must use for 2 modifiers ona given claim. Used to unbundle CPT codes.59 – still permissible today when using only one on a given claim.Being phased out and replaced by the X series modifiers.

X modifiersXE Separate Encounter: A service that is distinct because itoccurred during a separate encounterXS Separate Structure: A service that is distinct because it wasperformed on a separate organ/structureXP Separate Practitioner: A service that is distinct because it wasperformed by a different practitionerXU Unusual Non-Overlapping Service: The use of a service that isdistinct because it does not overlap usual components of themain service.

Advance Beneficiary Notices (ABNs)Use the GA modifier when you anticipate that Medicare will denythe charges so that Medicare will deny them to patientresponsibility rather than as a contractual adjustment.The patient must sign the ABN, it must be date of service specific(no blanket ABNs are allowed), and it must cite the CPT codesthat you expect Medicare to deny.

PQRSProvide PQRS codes or accept a 2% reduction from the Medicarefee scheduleCan be claims-based or registryExamples of PQRS codes:1101F – Fall reporting codeG8420 – Body Mass Index calculated codeG8440 – Pain Assessment not documented codeG8427 – Current medication documented

PQRS

PQRS: Errors to Avoid

PQRSMust report on all required measures (6 for PT) on at least 50% ofall Medicare evaluations and re-evaluationsFailing to include PQRS codes on re-evaluations is a commonreason for failing PQRSWe recommend incorporating PQRS into your FLR processes

PQRS rg/practice/federalstate-regulations/pqrs

In or out-of-network?In-network providers agree to accept contractual rates, which maynot always be desirable.When you’re out-of-network, you can bill whatever you want andyou can bill the patient for whatever the insurance doesn’t pay.Or not. Note that this does not apply to Medicaid patients.Your reimbursement per visit is obviously better when you’re OON.But you’re likely to get fewer patients.

In or out-of-network?Referring physicians do like one-stop shopping.Strategic decision with no right or wrong answer.When in doubt, we recommend being in-network.If you have an unusual sub-specialty (e.g., wound care) this willoften open up previously closed networks.

Resolving unpaid claimsThis is where the rubber meets the roadPossibly the single most important task in maximizing your totalcollections

Resolving unpaid claimsOrganize and prioritize - don’t lose sight of timely filing limitsDrive accountabilityWhen things get toughDon’t forget about the patients

Patient statisticsThe average deductible for people with employer-provided healthcoverage rose from 303 to 1,077 between 2006 and 2015.(source: Kaiser Family Foundation, 4-12-2016)We routinely see patients with annual deductibles of 5,000 ormore, especially family “aggregate” deductibles.

The patient’s share is on the rise

Maximizing total collectionsThe patient is responsible for 28% of the costs of their healthcare(source: Dept. Health and Human Services - 2011 data)1 in 3 workers has a 1,000 plus deductible (source: Kaiser FamilyFoundation)The percentage of patients with high deductible health plans isrising at 15% annually (source: America’s Health InsurancePlans annual census – July 2014)

Patient collectionsIf you collected at the TOS this is less of an issueStatements protocolReminder phone callsNot all billing organizations do this

Optimizing your reimbursement to payrollratioDisclaimerMPPR – more yet shorter visits equals better reimbursementPer diem and case rates

Key Performance Indicators (KPIs)The Hawthorne effectAverage reimbursement per visitAverage collection rate(s)Average charges per visitDays in A/R (DSO)Total aging relative to chargesA/R over 90 days

Average reimbursement per visitCollections for the period divided by visits for the same periodVaries dramatically according to:Payer mixFee-for-service vs. per diem rates vs. case ratesFee schedules and specific CPT code utilizationNumber of units per visitCan quantify a future expected amount based on historic dataTrend over time

Average collection ratesCollections for a period divided by the charges for the same periodCan vary dramatically based on charge fee schedule and averagereimbursement per visitExample:Avg. charge per visit - 180Avg. collections per visit - 90Collection rate 50%Trend over time

Average collection ratesWe report:Rolling 3 months collections rateRolling 12 months collections rateYTD collections rateLooking at the trends

Average charges per visitTotal charges for a period divided by visits for the same periodTrend over timeHarbinger for collections per visit

Days in A/R (DSO)Average number of days to convert claims into money in the bankEnding A/R divided by charges for last 3 months times 91Example:Ending A/R - 100,0003 months’ charges - 250,000Days in A/R 36.4 daysPT/OT national average is 44 days

Total aging relative to chargesYour total aging should be proportionate to your billed chargesThe lower the ratio the betterA 30 day collections cycle translates to a 1:1 ratioExample:Billed charges for July 150,000Total aging as of July 31st 150,000Ratio of aging to charges 1:1Similar to DSO

A/R over 90 daysPercentage of your total A/R that’s 90 days old or olderThe lower the betterGenerally should be 20% or lessHighly impacted by:TOS collectionsPayer mixAccuracy of insurance verificationsAccuracy of data entryEtc.

SummaryHave well established practices in placeHave strong discipline in implementing your practicesDon’t let the tail wag the dog on collectionsTrack your key metrics and trend them over time to quickly identifybudding issues before they bloom into cash-flow problems

Questions?David AllenPresident and CEOFlatirons Practice Management(303) .com

Full-service RCM company based in Boulder, Colorado . PT/OT billing for 19 years . Bill for a few hundred PTs/OT