Rehabilitation Clinics Can Level the Playing Field

Leveraging Electronic Charting Solutions to Improve Documentation, Coding Accuracy and Billing Processes
By Ron Miller, M.D. and Betty Esposito

Today’s rehabilitation clinics need to level the playing field if they are to compete effectively and earn a profit. The numerous manual processes that the majority of clinics use to track and bill for care is prone to human error that can lead to compliance issues, claims denials and even audits. In contrast, commercial payers and Medicare use sophisticated software applications to review each claim for potential errors and inconsistencies, as well as to identify trends that can uncover inappropriate billing. Of course, payers must protect against fraud and abuse, but most non-compliant claims are simply the result of human errors, inattention to details, or a lack of understanding about the increasingly complex system of billing that clinics must use to get paid for the care they deliver.

Fearful of being audited by the Centers for Medicare & Medicaid Services (CMS), many clinics have instilled a sense of “playing it safe” among their coding and billing staffs because there is such a large and growing Medicare population. Rather than trying to earn maximum reimbursement for all the care they deliver, there is a sense among many coders that they should avoid aggressive billing – even when the documentation supports it – or undercode when in doubt. As a result, numerous clinics are effectively leaving money on the table and jeopardizing the financial stability of their organizations.

The fears of a CMS audit are well founded – especially during the past few years. In March 2008, CMS concluded a pilot program in California, Florida and New York that enlisted independent recovery audit contractors (RACs) to review claims from fiscal years 2005 through 2007. The RACs identified and collected $1.03 billion in improper payments during this program, according to a report that CMS published in July 2008. Among those improper payments, $992.7 million were classified as overpayments and $38 million in underpayments. Although the majority of these overpayments (85%) were collected from inpatient hospitals, 6% of them were collected from inpatient rehabilitation facilities, and 4% from outpatient providers. The success of the program has prompted CMS to plan a nationwide roll-out of the program in the coming years.

Leveling the Playing Field
The increased scrutiny of claims – not just from Medicare, but from commercial payers as well – means that rehabilitation clinics need to be more vigilant than ever in their efforts to educate their staffs on how to improve clinical documentation, coding and billing processes. Beyond this, clinics should seek out technology that can prevent errors before claims are submitted, and automate processes that are prone to human error.

Electronic charting software provides tools that help therapists create accurate clinical documentation to comply with Medicare and commercial payer regulations. These systems alert therapists when documentation is incomplete or does not support billing requirements. From a coder’s perspective, these systems not only help prevent inappropriate coding, but also alert coders when the documentation supports missed billing opportunities. The following sections explore areas where electronic charting software can help clinics level the playing field with technology-enabled resources and automation.

Correct Coding Initiative (CCI) Edits
CCI Edits are a CMS billing provision to prevent the unbundling of services. CMS publishes a quarterly list of edits that include comprehensive/component and mutually exclusive code pairs that cannot be billed together on the same date of service. Although CCI Edits originated in the Medicare program, many other insurance companies have the same or similar types of edits. As a result, coders are expected to know the nuances of the CCI Edits for each individual insurance company that is billed by the clinic. Another challenge is that CCI Edits change quarterly for Medicare billing and many commercial payers. The variation of edits among the various insurers, coupled with quarterly changes, once again opens the door for potential billing errors.

Within CCI Edits, the comprehensive/component code pairs are those codes where a limited procedure (component) cannot be billed in conjunction with a more extensive procedure (comprehensive) that traditionally includes the limited procedure as well. For example, Gait Training, CPT 97116, is a component of Orthotic Fitting and Training, CPT 97540. Mutually exclusive code pairs are those pairs of services that cannot be logically performed together on the same date of service, and therefore cannot be billed on the same date. For example, Physical Therapy Evaluation 97001 and Physical Therapy Re-evaluation (97002) cannot be billed together on the same date of service.

CMS does, however, publish a table quarterly that lists when instances of billing these code pairs together is acceptable (http://www.cms.hhs.gov/providers/hopps/cciedits/default.asp). In the table, code pairs are labeled either "0" or "1". If the pair is labeled “0,” there are no circumstances where billing the combination of codes would be appropriate. If the code pair is labeled “1,” a Current Procedural Terminology (CPT) modifier (-59) can be attached to the component code to provide a brief explanation as to why the two procedures occurred on the same day.

In short, all of this is quite difficult to track manually. With an electronic charting solution, users can load the CCI Edits and their quarterly updates into the system, which helps coders comply with regulations and avoid claim errors. Such a system can alert coders when a service or code is payable by the payer, and notify the coder when an appropriate modifier should be added to two distinctly separate services. Clinics evaluating electronic charting solutions should make sure that systems can accommodate CCI Edits.

Time Tracking
In May 2000, CMS issued a transmittal notifying the provider community about the implementation of what is commonly known as the “eight-minute rule.” The rule governs the billing of a service unit for timed codes, with each unit being defined as 15 minutes. The “eight-minute rule” means that the therapist must deliver at least 8 minutes of care before a 15-minute unit of care can be billed. Therefore, one unit of care is billed when the therapist delivers between 8 and 23 minutes of care (8 minutes qualifies for the first unit of care, and the therapist must deliver more than 23 minutes of care to qualify for billing a second unit of care).

Until recently, only Medicare used the “eight-minute rule” as a standard for tracking units of care. However, some clinics are now adopting this rule for all patient types, so they are incorporating the tracking of care delivery times into their documentation in anticipation of Medicaid and commercial payers possibly adopting this time-tracking policy in the future. As a result, it’s important that therapists are aware of these rules when they document their care delivery.

Electronic charting solutions can help with the tracking of this by not only including a time field for therapists to input their care delivery, but by also alerting them when the field is incomplete. This helps create accurate documentation to support coding, and also helps coders take the guess work out of creating claims. Another benefit of electronic solutions is that they help therapists document their treatment time to generate the correct billing unit, as well as help them comply with commercial payers that adopt time-tracking rules in the future.

Account Tracking
To help track individual episodes of care, many rehabilitation clinics are now including patient account numbers on all documentation. Typically, the patient account number has been used primarily by the billing staff and less frequently on documentation. The benefit of using the account number on all documentation is that it provides yet another tool for the staff to track charges by individual episodes of care. Clinics can use a patient account number to more easily reconcile charges per episode of care in the event of an audit. In contrast, reconciling charges using just the patient record number can be cumbersome, since the patient record contains many episodes of care. In addition, tracking episodes of care using the patient account number sets the stage for clinics to measure patient outcomes and participate in pay-for-performance initiatives. And, rather than manually writing the account number on multiple forms, electronic charting solutions can perform this task automatically.

Authorizations
A large percentage of administrative resources at outpatient facilities are consumed by tracking authorizations – whether it’s contacting insurance companies to authorize care delivery or having physicians authorize plans of care. These authorizations are necessary for rehabilitation clinics to obtain reimbursement, and clinics failing to gain the necessary authorizations are leaving money on the table.

For insurance authorizations, an electronic charting solution can help therapists and schedulers quickly view if authorization has been obtained and for how many visits, as well as track the number of visits consumed and when the authorization will expire. Although this type of functionality is sometimes available in billing systems, therapists and schedulers do not typically have billing system access. Clinics evaluating electronic charting solutions should make sure the system can be configured to support the insurance authorization rules from multiple payers.

For physician authorization on plans of care, it’s important for the system to alert therapists when a plan of care needs to be signed by a physician to comply with payer rules, as individual payers require physician authorizations at different intervals. The system selected by a clinic should allow users to send, receive and track the signed plans of care from physicians. Clinics possessing a clear record of physician signatures on plans of care can readily supply proof of authorization in the event of an audit.

Preparing for an Audit, Whether it Happens or Not
An important benefit of electronic charting solutions is that it helps clinics accurately bill for all the care they deliver, rather than having the staff adopt an attitude of “playing it safe” and undercoding when in doubt. Besides helping to increase revenue and reduce claim rejections and denials, these solutions help organizations improve their clinical documentation to support compliance with regulations. And, in the event of an audit, electronic charting solutions can improve the access to the documentation necessary to defend coding practices.

About the authors

Ron Miller , MD, is President and Chief Medical Officer of Chart Links, Inc.,New Haven, Conn.

Betty Esposito is VP of Chart Links, Inc.
http://www.chartlinks.com.