The 8 Most Common Medicare Billing Mistakes You Can Avoid By Leveraging CMSPricer – SaaS-based Medicare Repricing Tool!

In treating adults and Medicare-eligible beneficiaries, operating a private practice that provides occupational, physical, and/or speech language therapy has its own unique set of rules. The federal government continuously focuses on these three specialties, so it’s important for your practice to be up-to-date on Medicare policy.

You can reduce the chances of Medicare repricing mistakes by understanding what Medicare requires and improving compliance:

Common Medicare Repricing Mistakes

Medicare policy is largely defined and interpreted by the Centers for Medicare & Medicaid Services (CMS). When it comes to private practice and Medicare Part B, they set strict regulations for therapy practitioners.

Social media is abundant with uninformed opinions and misguided recommendations. You may receive advice on running a cash-based practice, offering free services or incentive programs, and what Medicare covers. You may not be able to apply them to your practice.

Here are eight Medicare repricing mistakes to avoid:

1. Out-of-Pocket Medicare Billing or Cash Billing

The Social Security Act Section 1848(g)(4) clearly states that physicians and suppliers (which includes therapy practitioners) must bill Medicare for covered services rendered to Medicare beneficiaries – unless they are eligible to opt-out of Medicare. Unfortunately, therapy practitioners (like OTs, PTs, and SLPs) aren’t eligible to opt-out.

Additionally, being a non-participating provider doesn’t exempt you from submitting claims.

2. Free Evaluations and Screenings

Offering free evaluations or screenings to Medicare patients may violate the mandatory claims submission requirement. It’s also a breach of the Anti-Kickback Statute, which states that gifts of a “nominal value,” meaning $15 per item and a maximum of $75 per year, are allowed.

3. Medicare Covers Therapy if the Patient’s Diagnosis Qualifies

The Medicare coverage conditions are not based solely on a patient’s diagnosis. Therapy coverage depends on if the services are reasonable, necessary, and skilled. Even if a patient doesn’t have a diagnosis typically associated with a need for therapy, they may still be eligible for coverage.

4. Justification of Medical Necessity Using the KX Modifier

The KX Modifier is used to confirm that medical necessity is documented in the patient’s chart – not to justify it. The 2022 threshold for the KX modifier is $2150 for OT services and $2150 for SLP + PT services. Make sure to include language that justifies the need for therapy in every note you write.

Medicare Pricing Tool
5. Failure to Read Medicare Guidance Documents

To fully understand Medicare policy, repricing, and claims processing, you should become familiar with the Medicare Benefit Policy Manual – Chapter 15 and the Medicare Claims Processing Manual – Chapter 5. They contain all the information you need to understand how to bill Medicare for therapy services and guidance on therapy coverage.

6. Supervision and OTA/PTA Modifier Specific Factors

Regarding supervision requirements for OTAs and PTAs under Medicare, direct supervision is mandated only in private practice settings. The overseeing therapist must be physically present in the office suite and available for supervision, unless the state has stricter requirements. During the ongoing COVID-19 Public Health Emergency, virtual presence is temporarily allowed for supervision. This adjustment remains in effect until the end of the calendar year in which the emergency expires (active until April 2023).

The OTA/PTA modifier must be included in the claim when services are provided by an OTA or PTA since January 1, 2020. As of January 1, 2022, this modifier results in a 15% payment reduction from Medicare, making the overall reimbursement 12% less.

Applying the OTA and PTA modifier requires specific guidance, especially when treatment time is divided between the therapist and assistant. CMS guidelines should be carefully reviewed in such cases.

7. Ceasing Service Provision Due to the Medicare Cap

Medicare does not impose a limit on medically necessary outpatient therapy services.

The previous financial cap for therapy was introduced as part of the Balanced Budget Act of 1997, which established a strict spending limit for OT, PT, and SLP services. However, after years of advocacy by stakeholders and practitioners, Section 50202 of the Balanced Budget Act (BBA) of 2018 permanently eliminated the therapy cap and its exceptions process. The previous cap has been replaced with a threshold system.

The first threshold level is indicated by the KX Modifier, as discussed earlier. The second threshold level is the Targeted Medical Review, set at $3000 for OTs and $3000 for PTs and SLPs. This mechanism is designed to identify billing anomalies and potential misuse of services.

If your practice consistently exceeds these thresholds or exhibits unusual billing patterns due to the clients you serve, conducting frequent chart audits to ensure quality and defensive documentation can help support your Medicare claims if they are subjected to review.

8. Offering or Receiving Incentives for Referrals

While this may be a popular marketing strategy, engaging in arrangements where you provide or receive incentives for referrals is considered a kickback and is strictly prohibited when it involves beneficiaries of federal healthcare programs.

In summary,

Understanding and avoiding common Medicare repricing mistakes is crucial for healthcare providers seeking efficient reimbursement processes. Thankfully, there’s a solution to streamline your repricing procedures and enhance accuracy. By leveraging CMSPricer, a cutting-edge SaaS-based Medicare repricing tool, you can revolutionize your repricing system.

With CMSPricer’s advanced features and user-friendly interface, healthcare providers can ensure compliance with Medicare regulations and eliminate costly errors. The tool’s capability to handle the most common repricing mistakes empowers providers to maximize reimbursements and improve overall financial performance.

Don’t let repricing errors hinder your practice’s success; visit our website and explore the benefits of CMSPricer as a powerful Medicare repricing tool. Unlock the potential of accurate Medicare repricing and optimized reimbursements with CMSPricer today!