10 Things To Know
Sixty-one percent of Medicare claims for outpatient physical therapy services reviewed by the OIG did not comply with Medicare medical necessity, coding, or documentation requirements.
For its report, OIG reviewed $635.8 million worth of Medicare Part B claims during the six-month period. After examining a stratified random sample of 300 claims, OIG determined 61 percent of the claims failed to comply with Medicare coding, documentation and medical necessity rules.
Of the 300 claims in the stratified random sample, therapists claimed $12,741 in Medicare reimbursement on 18415 claims that did not comply with Medicare requirements. Therapists properly claimed Medicare reimbursement for the remaining 116 claims.
- For 91 claims,16 therapists received Medicare reimbursement when the beneficiaries’ medical records did not support the medical necessity of the services.
- For 30 claims, we did not find any evidence that the medical records showed that the services provided would have been effective.
- For 26 claims, all of which were for beneficiaries who were on rehabilitative programs, the medical reviewers determined that the expected rehabilitation potential was insignificant in relation to the extent and duration of the physical therapy services required to achieve that potential or that the beneficiary did not improve significantly enough in a reasonable period of time to justify continued treatment.
- For 145 claims,18 therapists received Medicare reimbursement for claims that did not meet Medicare coding requirements.
- For 86 claims, the number of timed units claimed did not match the number of timed units documented in the treatment notes.
- For 78 claims that CMS required to contain functional reporting information, the medical record or claim or both were missing the proper G-codes or modifiers.
- For 59 claims, providers incorrectly coded the services.
- For 112 claims,21 therapists received Medicare reimbursement for services that were not provided in accordance with one or more Medicare documentation requirements.
- For 80 claims, there were plan-of-care deficiencies.
- For 74 claims, there were treatment note deficiencies.
On the basis of the sample results, the OIG estimated that Medicare paid $367,039,705 for outpatient physical therapy services that did not comply with Medicare requirements during the 6-month audit period.