Encore Keynote – October 2022

It’s National Physical Therapy Month!

Each year October brings with it the start of colder weather, the change in colors, preparation for the holidays, and Physical Therapy month. While “physiotherapy” has its roots in Sweden, dating back to the early 1800s, physical therapy didn’t significantly impact the United States until the “reconstruction aides” working with soldiers in 1918. These pioneering 18 women were provided approximately four months of training and were given the huge job of helping the recovering American Soldiers during World War I.

Today’s physical therapists receive an average of 7 years of collegiate responsibility, over seven months of hands-on clinical training, and extensive science background. They are trained to work with all ages, disease processes, and many specialty areas. As experts in anatomy, pathophysiology, exercise science, and the body’s healing process, physical therapists have become critical to each level of the health care continuum. They are finding new roles in schools, athletics, industry, and research.

To help celebrate the progression of the physical therapy profession, this October, Encore will celebrate the critical roles that physical therapists and physical therapy assistants play in keeping their community healthy and functioning at their highest level of wellness and independence. We ask that you join us in appreciating our physical therapy team members and consider your clientele’s clinical needs as we celebrate our team’s broad training and expertise.

Noridian, the Supplemental Medical Review Contractor for CMS, is conducting post-payment reviews of Medicare Part A claims on dates of service from March 1, 2020, through December 31, 2021. The reviews will target claim samples for which the 3-day prior hospitalization requirement for coverage of a SNF stay was waived during the Public Health Emergency (PHE).

Prior to the PHE due to the COVID-10 pandemic, a Medicare Part A beneficiary was required to have a medically necessary hospital stay of at least three consecutive hospital days to meet SNF coverage requirements. In response to cases where patients may have been prevented from having a qualifying hospital stay due to the effects of the emergency, CMS used the authority under Section 1812(f) of the Social Security Act to waive the requirement for the 3-day stay and provide SNF coverage without it.

Upon analysis, CMS identified a potential area of vulnerability with the use of the waiver and is conducting the reviews to ensure that all other coverage requirements were met. The waiver does not change all other requirements for SNF coverage, such as the SNF level of care criteria, which must be present as supported in the medical record for services billed for Part A care. The medical record should support the medical necessity of the skilled care rendered, per the requirements in the Medicare Benefit Policy Manual in Chapter 8.

The webpage for Noridian 3 Day Stay Waiver Reviews can be found at:
https://noridiansmrc.com/current-projects/01-056/

A CMS article regarding waiver information and Medicare response to the PHE can be found at: https://www.cms.gov/regulations-and-guidanceguidancetransmittals2020-transmittals/se20011

It’s been over a year since The Centers for Medicare and Medicaid Services (CMS) announced that Targeted Probe and Educate (TPE) audits would resume. Once Medicare Administrative Contractors (MAC) select specific providers subject to TPE review, an initial written notice is sent to give an overview of the process. Following that, up to three rounds of audits can take place, with a sample of 20-40 claims reviewed each round. The focus of the reviews is to ensure the services billed were medically necessary per Medicare guidelines.

It’s important to note that although three rounds of requests can occur, that doesn’t have to be the case. Providers who “pass” the first round and are found to be compliant will not be reviewed again for at least one year on the selected topic. So, what can providers do to help reduce the risk of being found non-compliant? Providers can be proactive to ensure that reasons frequently cited for denial rationale are addressed before the records are submitted for review by the MACs. A common offender involves the physician’s timely signature on medical records contributing to missing or incomplete certifications. When collecting the documents requested for the audits, the facility certification form (if applicable) and therapy evaluations and recertification should be examined to ensure the physician has: 1) signed the document and 2) dated it timely. While SNFs are expected to obtain timely cert/recert statements, delayed cert/recerts will be honored where, for example, there has been an isolated oversight or lapse. In addition to compliance with the content requirements, delayed certs/recerts must include an explanation for the delay and any other relevant evidence the SNF considers relevant.

If the originally signed document is missing or a delayed signature is present, ask the physician if they would be willing to sign a delayed certification statement to include. Completing this document to accompany medical records when submitted for TPE reviews can prevent front-end denials.

Respiratory Therapy enhances the clinical care for medically complex patients and reduces hospital readmissions rates resulting in a higher quality measure and better star rating.