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Coding & Billing

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Payment Reform

Information for Payers

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APTA Medicare Information Update

(June 2013) Starting on July 1, physical therapists must report a functional limitation category, and the patient’s severity level within that category at the start of a therapy episode, at a minimum every 10th visit, and at discharge. The functional limitation categories are reported using nonpayable G-codes, and the severity level is reported using a two digit modifier. Failure to report these will result in nonpayment for services.
 
APTA has a web page dedicated to Functional Limitation Reporting. This page is perhaps the most comprehensive information available that is specific to physical therapists. It can be found at
http://www.apta.org/Payment/Medicare/CodingBilling/FunctionalLimitation/.
 
In addition, the Medicare Benefit Policy Manual (publication 100-02), chapter 15 <
http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf>  for Covered Medical and Other Health Care Services, specifically sections 220.3 and 220.4 contain the documentation requirements for therapy services, and functional reporting. And, quick links to Therapy Services information is available on this page <http://www.cms.gov/Medicare/Billing/TherapyServices/> .
 
There are several unanswered questions right now, despite the fact that we are just two weeks away from the mandatory implementation. We are eagerly awaiting CMS’s release of an FAQ to address all of the unanswered questions. That will be published in our PT in Motion News Now <
http://www.apta.org/PTinMotion/NewsNow/?blogid=10737418615&navID=10737422527>  as soon as we get the information and are able to publish it.

 

NEWS ALERT from APTA - Silent Preferred Provider Organizations

According to a November 7, 2012 American Medical Association (AMA) Practice Management Alert:

“The AMA has learned that Preferred Medical Claims Solutions (PMCS), a client of MultiPlan, is attaching notification to reimbursement checks stating that by depositing the check, your practice agrees to being reimbursed by your MultiPlan contracted rate within 10 working days and that you wish to participate in the Advanced Funded Program (AFP) with PMCS going forward. If you do not wish to be included in the PMCS AFP program, for the specific claim or any future claims, do not deposit the check and contact PMCS. Visit the PMCS website at www.pmcsonline.com , or call PMCS at (800) 905-2589 with any questions.”

According to their website, PMCS “was established to assist Payers and Providers with medical claims processing, claim negotiations, and claim settlement process – especially out of network claims.” PMCS processes over $1 billion in claims through their Proprietary Network each year, “saving payers and participants hundreds of millions of dollars annually.” MultiPlan  has nearly 900,000 contracted healthcare providers, offering healthcare cost management solutions.

APTA has not received any inquiries from members at this time, but we are concerned about the strategy being used to “opt in” to contracted rates for out of network claims. If you have mechanisms to alert your membership, please consider spreading the word.

Visit the Private Insurance area of the APTA website for more information about Silent Preferred Provider Organizations.

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