Alan Fredendall // #LeadershipThursday // www.ptonice.com
In today’s episode of the PT on ICE Daily Show, Brick by Brick lead faculty & ICE COO Alan Fredendall discusses tips & tricks for working with Medicare including the ins & outs of documentation/billing. Take a listen to learn how to make more money billing Medicare while spending less time on notes.
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00:00 – Alan Fredendall, PT, DPT
All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. Hope your morning’s off to a great start. My name is Alan. I’m happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at the Institute of Clinical Excellence and a faculty member in our Fitness Athlete Division. We’re here on Thursdays, Leadership Thursdays, All Things Small Business Management, Ownership, Clinic Practice, all topics related to that. Today we’re continuing our series on getting more familiar with Medicare, whether you are not a clinic owner, whether you want to become a clinic owner, whether you just want to get more polished at the Medicare patients and documentation you’re already working with, or whether you are a future clinic practice owner who is considering taking Medicare or not learning the ins and outs. So if you go back, we’ve already done three parts on this series. Every two weeks back, part one, part two, part three, we talked about what is it, how to take it, what it pays, is it worth it to you? And today we’re going to kind of have a cornucopia of things to talk about related to documentation, expectations, that sort of thing. Before we get too deep into the episode, some announcements coming your way. It’s Leadership Thursday. That means it’s Gut Check Thursday. We’re continuing with workout number two from the I Got Your Six virtual competition held by the WarriorWOD, which is a nonprofit group that looks to give six months of functional fitness gym memberships, nutrition coaching, and peer mentorship for our combat veterans. So we’re big supporters of WarriorWOD here at ICE. We supported them last year with our ICE Foundation dollars, and we’re supporting them in this virtual competition. It is a series of partner workouts. If you were here last week, Jeff explained the first workout completely incorrectly, so hopefully you actually read the caption or you went to WarriorWOD and read the actual workout instructions and you did not approach that as a solo workout. These are all intended to be partner workouts where you are sharing some of the workload between you and your partner. This week’s workout, we had the quote unquote pleasure of doing last week. It is a couple of rounds of bike calories. So the workout is going to start. Partner one is going to do 90 seconds on a fan bike, eco bike, a soft bike, whatever you have. Switch. And then you’re going to repeat that. Partner one does another 90 seconds. Partner two does another 90 seconds. So you’re each going to do two rounds of 90 seconds on the bike. You’re really trying to find an aggressive, moderate pace that’s not going to redline you there because your score for the first part of the workout is going to be all the calories you get on that bike. Then you’re going to transition. Partner one is going to go their own way. Partner two is going to go their own way. Partner one is going to have three minutes to find a max load of a complex of one snatch, one hang snatch, and three overhead squats. Yes, those snatches can be power. While partner two is working their way through an AMRAP of eight toes to bar, 12 wall balls and 16 alternating dumbbell hang clean and jerks. And then at the three minute beeper, partner one and partner two switch. The person finding the complex is now doing the AMRAP and the person doing the AMRAP is now maxing that complex. That fatigue from the bike adds up. If you’re doing the AMRAP first, the fatigue adds up when you go to max your complex. You will find that that complex feels significantly more heavy than when you’re warming up. Be kind to yourself. Put up a number that you know for sure you can hit and then maybe have some extra time to go a little bit heavier. That is workout number two for this week and we’ll release and participate in workout three next week. All your scores are due by June 30th. If you do want to participate, you and your partner can sign up. Go to warriorwad.org and sign up through the competition dashboard. It’s $100 for you and your partner. You both get some swag and all of the money goes to support WarriorWOD. That is Gut Check Thursday. The course is coming your way. We have so many to mention. We have a very busy summer and fall. Hundreds of courses coming your way live and online. Head over to ptownice.com and click on courses to see what’s coming your way. Today’s topic, okay, I’ve decided to take Medicare. Whether it’s a participating provider, is a non-participating provider, now what? This is basically a bunch of different questions that you all in the community ask that we’re going to answer in a way that addresses a lot of the hot button issues around Medicare, particularly documentation and what you can bill and not bill for. Just so you know, before we get started, everything I’m referencing is from a document called CMS Pub 100-02. This is the Medicare policy manual. This tells you everything you need to know about taking Medicare, billing Medicare, documentation, expectations. This is straight from Medicare to us as healthcare providers. In this policy manual, it’s 951 pages. In this policy manual are sections related to inpatient, outpatient physical therapy, home health, skilled nursing, all the different settings that you can work in as a physical therapist and how to interact with Medicare based on your setting. I’ve gone through this manual many, many times now and I’ve pulled out answers to your questions and also just general information that I think you all would like to know if you have decided, hey, you know what? I think I am going to start working with this population and I want to know better how to more efficient with our documentation. What’s nice about this is that all other insurance companies, if you’re an insurance based clinic, anchor their expectations off what Medicare puts out. Medicare is considered the gold standard. So if you follow this standard, your documentation will be clean and for any other insurance that you take. So this is the gold standard. If you adhere to this, you’ll never run into problems. Quote unquote, your documentation will become bulletproof. So let’s start from the beginning. So you should know, I’ve heard this, I’ve experienced this myself as a staff clinician that you cannot bill for both evaluation and treatment on the first visit with a patient using Medicare. That is completely untrue. This is from section six, subsection C, sections 220.1.2, part A. So go ahead and peruse yourself to that section. And I quote, the evaluation and any treatment may occur and are both billable on the same day. It is appropriate that treatment begins as a plan of care is established. So yes, you can build a patient for evaluation. You can also build timed codes, manual therapy, therapeutic exercise, gait, balance, neuromuscular read, whatever you’re doing, you can build all of that on the first visit. Now what if you see patients in their home and you do a home visit, but you’re not a home health clinician? This is still a part B visit. This is still an outpatient visit. What’s the difference? Home health is generally covered under Medicare part A, and it allows a little bit more money from Medicare to a lot for your travel to that patient. If you are an outpatient clinic that offers home visits, you should just know you’re not going to be as profitable if you drive to somebody’s house because the money that you receive does not include any extra money for gas, for wear and tear on a personal vehicle, a company vehicle, anything like that. So yes, you can see patients in their home as an outpatient clinician operating under Part B, but you should know it’s just not as profitable. But all the other rules apply as if that person was in your clinic as far as you seeing them, billing them, working with them for physical therapy. Now let’s talk about caps. People have questions about caps. Jess Garcia sent this question in. What about caps and payments? So as of a couple of years ago, there are no more caps, kind of. We have a modifier that goes into your documentation called KX. This allows you to go above the current cap of $2,150 per year. Now there is technically no more cap. You can see a patient as long as it’s medically necessary. That being said, you should know when you cross $3,000 of billable, reimbursable time with a patient, you go on a list where your visits might become subject to medical review. Now this is not the same as an audit, just that somebody working at Medicare might want to look at your notes and make sure that the treatment that you’re rendering above and beyond this $3,000 soft ceiling is medically necessary. Related to billing, you should know about something called MPPR, multiple procedure payment reduction. Many of you are familiar with this, but you’re not sure why you do it or the how and why behind why you do it. This is basically a rule that reduces the amount of money you receive per billable code the more you bill that same code. So multiple charges of the same code. For example, if you bill four units of Therax, you will get paid less for every subsequent charge of therapeutic exercise. So for example, if you would normally have been paid $40, the second, third, and fourth charge will only be paid at half or $20. So you will get $100 total for that visit versus for example, if you had done one code of manual therapy, therapy of exercise, therapy of activity, neuromuscular re-ed, and you got 40 for each of them, you would have made $160 for that visit. So we’re kind of familiar with this. Maybe our manager told us this or we heard it in school or from a friend or something of vary your treatment codes. This is the reason why that when you do the same thing over and over again, you get paid less. This is essentially a system in place to punish low quality clinics. Of Doris comes in, she writes the new step for 20 minutes, she walks for 20 minutes and she does some bandit exercises or some knee extension for 20 minutes and then she goes home and she gets billed four units of Therax. This is punishing that clinic saying, hey, you need to actually do something more productive with your time. You need to vary up your treatment and it should be skilled one-on-one treatment that is progressing that patient towards their goals. So you should know that you should vary up your codes. If not, you should know that you will make less money the more charges of the same code you use each visit. Now there’s another billing problem, quote unquote problem called sequestration. This is essentially a reduction in payments across the board from Medicare to healthcare providers. The amount for physical therapy is an overall 2% reduction in your payment. So if you’re clear on the MPPR and you bill out $100, for example, you should know that you will get 2% less, $2 less sequestration. This is budget management. This is coming down from Medicare. This is balance the budget type legislation that takes place in Congress. Overall it’s really not that much money. As long as you are following the MPPR guidelines and billing a diverse code set. So that’s a little bit nitty gritty behind the scenes with billing. Mainly relevant for those of you who are going to open your own clinic, running your own clinic, already operating your own clinic and you want to know a little bit more about the billing. Now what about referrals and prescriptions? Can I see a Medicare patient direct access? Yes. The answer is yes, provided it’s allowed within your state practice act. Every state allows for direct access. Some states are more liberal about this than others. Some of you, you can only see a patient for the evaluation. Some of you can see a patient indefinitely and most of us are in the middle. You can see a patient for a certain number of time and or visits and then you need to get a signed plan of care or a referral. You do not need that to begin your first visit in any state as an outpatient physical therapist practitioner. A signed plan of care after you complete the evaluation that you get over to the doctor, email, fax, whatever, as long as they sign that and say, I agree to your plan of care, that counts as your referral or prescription. As long as that’s done usually in 30 days. So when Betsy calls and says, I don’t have a prescription for my doctor, can I still come see you? The short answer is yes, you can come see me. We’ll need to do some paperwork on the back end, but you don’t need to go have a doctor’s visit before you come see me with physical therapy. And as long as they have a primary care physician or specialist, whoever they’re working with that knows them that will sign that, then you’re in the clear. This comes from section six, subsection B, section 220, part A. So there’s your reference if you’re looking to see that reference in the Medicare manual. Now this is a question from Megan Long. This is a question about documentation requirements. This is probably the number one question that most physical therapists have, regardless of taking insurance, taking cash, Medicare or not, what do I actually have to write down? It seems like I’m doing notes forever. I’ve had positions where I was told I needed to write a paragraph for every section on my EMR and I submitted novels every day for notes. I spent three or four hours after work every day doing documentation. I will tell you your daily note, regardless of what type of insurance your patient is using or not, if you’re a cash-based practitioner, should be about two minutes. Your evaluation, regardless of the types of insurance you accept or not, if you’re a cash-based practitioner, should be about eight minutes. We’ll talk about what you need to put in there and why the vast majority of you are over-documenting for no reason. Again, these requirements come straight down from Medicare, from the Medicare policy manual. I’m going to quote what needs to be in your evaluation. A separately payable comprehensive service provided by a clinician as defined above, that requires professional medical skills to make professional clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of both patient performance and their function. Evaluations are warranted for a new diagnosis or if a condition is being treated in a new setting. How we teach it in our lumbar and cervical spine management courses when we talk about the symptom behavior model, what are the subjective and objective asterisks for your patient? What are they reporting to you subjectively that they’re having trouble doing functionally? I can’t go up the stairs. I can only go up 10 stairs before I get too weak to continue or I have too much pain. I can go upstairs but not downstairs. Any of those subjective reports of what’s limiting function in their daily life. And then our objective asterisk signs. Things that you can measure clinically. Knee flexion range of motion, five times sit to stand speed, max reps of sit to stand in 30 seconds. Your objective measurements are going to go on your objective asterisk signs. You really don’t need to say more than that. You don’t need to report on the patient’s attitude. You don’t need to tell us what the patient had for breakfast that day or their overall constitution. Right? When we read a lot of notes, when people ask us, hey, what does this note look like? It looks like a bunch of nothing. Right? Doris presented to the clinic today. She had one egg McMuffin for breakfast and she’s feeling kind of fatigued. Nobody cares. What are her progress or non-progress towards subjective and objective asterisk signs since the last time that she was in the clinic? That’s really all you need to say there. On top of your evaluation, you do need to do a progress report with Medicare patients. Again, straight from the Medicare policy manual, I quote, you need to provide justification for continued medical necessity of treatment. That’s it. You need to do this every 10 visits or every 30 calendar days, whichever comes first. You can do this more frequently and this can be done by someone other than yourself. It can be done by another therapist if you’re not there and it can be done by a physical therapy or occupational therapy assistant. This is a quote, description of patients, subjective statements and objective measurements of changes in functional status. It’s literally what has changed since you measured this stuff at evaluation. Again, it does not have to be this long novel about how their grandson moved away and they’re very sad. Only stuff that’s relevant to their lack of progress or the progress that they are actually making towards those goals and those subjective and objective asterisk signs that you’ve already measured or that you’ve introduced since their evaluation. Quote unquote assessment of improvements made or lack thereof towards their goals. Keep it simple and then your plan for continuing treatment. We’re going to keep doing what we’re doing. We’re going to keep progressive overload. We’re going to keep progressing Doris’s deadlift. We’re going to keep progressing her aerobic capacity as measured on the six minute walk test, whatever. And then any changes you may have made to the plan of care since the last time you did an evaluation or progress. No, again, evaluation progress. No, it should not be a 30 minute thing. Should not be a 60 minute thing. It should maybe be a 10 minute thing. What has changed since the last time we tested all this and how has it changed? And if it hasn’t changed, what complications might have been this patient had covid and did not come to physical therapy for a month. Okay, that’s relevant to put in the note. They went on vacation and they didn’t come to physical therapy for a month. Okay, relevant to put in the note to justify why they’re not making the progress you would expect them to make. But again, keep it simple. Stick to that symptom behavior model. Keep your notes short and sweet and just state the subjective and objective data that’s relevant to that patient and that you want to see them make progress in the clinic. Re-evaluation. What about this? We have questions about reevaluation, very similar to evaluation and progress note quote provides additional objective information, not include another documentation. It’s separately payable periodically indicated during episode of care when the professional assessment of clinician indicates a significant improvement or a significant decline in the patient’s condition or functional status that was not anticipated. Maybe the patient was hospitalized for a period of time. Maybe they’re making such great progress that you need to basically rewrite their entire plan of care. You wrote a goal for them to deadlift nine pounds and walk 100 feet on the six minute walk test and they blew that out of the water early on and you’re updating goals, updating goals. So sit down and have a reevaluation. Gather what you think is relevant to the patient. Ask the patient what they think is now relevant to their goals. Now that they’ve met their goals, you’ve already established reestablish new goals and then continue with your care. What should go in the plan of care section? Your diagnosis, right? What’s wrong with them? Don’t say signs and symptoms indicative of 10,000 different things. Keep it simple. Keep it ICD 10 based. This patient presents like they have right knee pain. I’ve ruled out their back. I’m convinced their knee pain is actually knee pain. Boom, done, right? Your physical therapy diagnosis, your goals, specifically only your long term treatment goals. You only need long term goals. You do not need short term treatment goals. Again, straight from the Medicare policy manual. Write out goals, six, eight, 10, 12 weeks and measure your progress against those goals. If they meet them, great. Once they’ve met most or all of them, again, going back, that’s time when you maybe sit down and do a reevaluation. Hey, Betty, you’ve met all your goals. What are the goals you have? Let’s write some more. Let’s take this to another level. So long term treatment goals and then how often you think the patient needs to be in the clinic. You know what? You’re doing really well. I think we can drop to once a week for the next six, eight, 10, 12 weeks. You know what? You’re not making the progress you want to, but you’ve only been here once a week for the past six, eight, 10, 12 weeks. Let’s bump that up. Let’s write and see if two or maybe three times a week will really bump up the frequency, and get the change that we both want to see for you. So that’s our plan of care. Now evaluations done, progress notes done, reevaluations done, whatever you’ve done. And now in between those benchmarks, you’re doing just a daily note. This again, this is relevant for every physical therapist, regardless of if you never say plan to take Medicare, if you’re completely cash based of what needs to be in a note just to basically cover your own butt. And again, all of this from the Medicare policy manual quote, the purpose of these notes is to simply, and it’s bolded in the policy manual, simply create a record of treatment and intervention provided and to record the time of these services to justify your billing. Medicare is telling you, you just need to tell us enough to cover your own butt. Please don’t tell us anymore. No one is probably ever going to read this in your life. So keep it simple. It’s bolded, simply bolded. Quote, treatment notes are not required to document the medical necessary appropriateness of continued physical therapy service. You do not need to write a paragraph every time you do a note about why that patient needs to come back to physical therapy. If they’re in physical therapy, it’s assumed that your evaluation, your reevaluation, your progress note is going to justify why they’re there. And the physician signing off on that is going to be kind of the double stamp that between you and them, the medical system has decided that this patient needs to be in physical therapy. You do not need to explain to anybody or yourself every note, why they need to keep coming to physical therapy. If they don’t need to keep coming to physical therapy, then that’s, you know, when we consider maybe a discharge note instead. But you don’t have to write a paragraph about why physical therapy and how physical therapy can help this person. It’s already implied by them being on your caseload and you measuring goals, visit over visit, note over note, progress note over progress note. Specifics in a daily note such as the specific number of repetitions or sets of an exercise or other fine details already included in your initial plan of care are not needed to be repeated in treatment notes. Again, Medicare is saying stop writing so much junk in your notes. It’s worthless and time wasting for everybody. Stop quote mandatory elements of a daily treatment note include the date of the treatment, the identification of a specific intervention or modality provided. We did dry needling. We did spinal manipulation. We did active exercise. We did aerobic capacity training. We did gait training. Whatever specific thing you did, you should list that, but you don’t need to itemize it. You should have the total time in coded treatment minutes put on your note. That’s it. Hey, we did 20 minutes of exercise. We did some dead lifts and biking. We did 10 minutes of balance training. We did some clock yourself. You don’t need to itemize and be that specific. And then you need to have the signature of a qualified professional in the note. So that’s it. That’s how you get yourself to a two minute daily note. You stop writing dumb stuff that nobody’s going to read. You write literally what they tell you you need to write that they’re looking for if they happen to audit you and want to see your notes. Okay. Kind of segueing from documentation into more nuanced things about treatment. What about treating somebody for more than one condition simultaneously? What about maintenance therapy, those sorts of things? Let’s talk about treating more than one condition. If you’re like me in school and your early career, you learned that somebody needs to go all the way through a plan of care for one condition. Then you need to do an evaluation for the second condition and then see them all the way through there. This is mainly a scheme to get more money out of people. Medicare, again, from the policy manual, section six, subsection B, part A. You can see somebody for more than one condition simultaneously and bill for both at once in the daily note. You don’t need to do two notes for two different diagnoses. You don’t need to see somebody for 12 weeks for knee pain and then see them for 12 weeks for elbow pain. You can do knee and elbow pain at once. I quote, during an episode of care, the beneficiary may be treated for more than one condition, onset that happened after the current episode has already begun. For example, a beneficiary receiving physical therapy for a hip fracture who, after the initial evaluation, develops symptoms of low back pain could also be treated under the same PT plan of care. Now for rehabilitation of their low back pain, you can treat the whole person. They’re telling you it’s okay. So do it. Treat the whole person at once, please. What about maintenance therapy? We have in our mindset as physical therapists that once somebody says, you know what, I don’t have any pain anymore, we freak out. Oh my gosh, get off my caseload before the government comes in here and puts me in prison. Get out of here. Medicare pays for maintenance therapy. Let’s talk about it. I quote, Medicare claims and coverage cannot be denied based on the absence of the potential for improvement or restoration beyond what skilled physical therapy service provides. to improve a patient’s condition or if it’s necessary to maintain the current condition or prevent slow deterioration of current condition. If your patient would get worse leaving your care, then they can be seen for maintenance therapy. If they would regress in function without coming to see you, then maintenance is needed and justified. Especially we know those patients, sometimes they’re upfront about it. Sometimes they’re not of, hey, I’m not going to do this at home. Like, I should come here two to three times a week, right? We see this with patients of all backgrounds and populations of people who are just not self motivated, who need to come and basically get their butt kicked at physical therapy. That is okay. You can continue to treat that person. This is a settlement agreement from January 2013 that covers maintenance therapy in skilled nursing and home health and in outpatient physical therapy. So that’s almost all of you listening right now. You can see patients for maintenance if you are convinced and you can justify that this patient would get worse or regress to where they were before they started physical therapy if they did not continue to see you for physical therapy. How long can we keep that going? For the patient’s entire life? Maybe quote, as long as all of the coverage criteria are met, maintaining the patient’s current condition or the prevention or slowing of further deterioration are covered under skilled nursing facility, home health and outpatient physical therapy benefits. As long as you are setting goals, meeting goals, reestablishing goals, writing progress notes and obtaining that recertification from the primary care physician, then you are good to go. You should not be scared that just because Doris is coming twice a week and she’s doing an upper body split on Tuesday and a lower body split on Thursday and you’re working some balance as accessory work or some cardio or something, you should not be worried that a SWAT team is going to bust down your front door and take you to jail. It’s not going to happen. If it’s justified, if it’s truly justified and you know that you can justify it, you are good to go. How do I frame this to the patient? How do I frame this to other healthcare providers? How would I frame this to you all if you came up to me and asked? I would have you look at the cost of physical therapy versus the cost of pretty much anything else in the healthcare system. Medicare is looking for, I quote, the greatest possible improvement for the most efficient plan of care. They want to know what’s the biggest bang for the taxpayer dollar, for the government’s dollar. Let’s look at some common surgery costs. A heart valve replacement is $170,000. A triple bypass is $150,000. A spinal fusion is $100,000. A hip replacement, $40,000. Knee replacement, a little bit cheaper, $35,000. Angioplasty, $30,000. And just a debridement of the hip or knee, $30,000. So look at the costs of those surgeries and ask yourself, would my patients stay away from that if they came to see me twice a week and they paid about, Medicare paid me about $250 a week, about $1,000 a month, about $12,000 a year? The answer overwhelmingly is yes. Physical therapy, getting strong, staying mobile, staying active, working with a physical therapist, a high quality physical therapist, overwhelmingly is the greatest possible improvement for the most efficient plan of care, the best bang for the government’s dollar. Medicare spends about 33% of its overall budget, about $1 trillion per year on inpatient hospital stays. The average person who goes to the hospital spends $13,000. That’s more than coming to physical therapy twice a week, every week of the year. Just think about the cost savings of that. If you’re thinking, how do I justify this to myself, to my patients, maybe to the manager, the owner of my clinic, to other healthcare providers of why this person should come see me once or twice a week, maybe forever, because it is the most efficient way. Exercise is the most efficient medicine for almost everybody. So that’s the justification for maintenance therapy. So a lot to wrap up here. Documentation, if you’re doing too much, do less, right? Do what Medicare tells you to do, which is not as much as probably most of you are doing. A daily note should maybe take you two minutes. An eval or reval or progress note should maybe take you 10 minutes. Make sure you understand the justification of why we’re billing multiple treatment codes so that you make more money if you are providing high quality physical therapy to that patient. You don’t need a referral prescription to see somebody on their first visit anywhere you live in the United States. You just need to get that plan of care signed at some point and that’s going to vary based on your direct access laws. Again, you’re documenting too much. Document less. Better. Make sure that you understand that maintenance therapy is supported and that you can treat more than one condition at a time and that is supported, justified, billable as well. In summary, you’re doing too much documentation that’s taking away from your time with the patient and you’re probably kicking patients out the door a little bit too early over an unnecessary fear of getting in trouble for things that Medicare says that you are allowed to do. So understand some of these rules. If somebody asks you for your proof, CMS Pub 100-02, 951 pages. Get after it, boss man. Let me know your questions, right? So I’ve gone through this a lot. It’s pretty cut and dry. It’s pretty straightforward. It’s a government manual, right? There’s no fluff about it. It’s pretty in the clear what we’re allowed and what not to do and I would say in general, we over document under bill and we don’t see our patients long enough and see them through actual long-term functional change when they’re in our clinic. So let’s start changing that. So that wraps up our Medicare series. Thanks to everybody over the past couple months who sent in questions. It’s been a great series. It’s been really helpful for you all, I hope, and we’d love to do something like this again. So have a great Thursday. Any questions related to stuff like this, throw them on Instagram, email us, throw them the ICE students Facebook page. We love to get podcast episodes out to you all that are based on the things that you want to hear and see about. So have a great Thursday. Have a great weekend. You’re going to be on an ICE Live course this weekend. Have fun and if you’re going to hit up Gut Check Thursday, have fun, quote unquote fun. Bye everyone.