Medicare Audit: 5 Requirements

Medicare Audit: 5 requirements

Medicare suspended most Medicare Fee-For-Service audits in late March due to COVID-19. Beginning August 3, CMS resumed auditing healthcare providers.

If your last 10 Medicare evaluations were audited would they pass these five basic requirements?

Do all Medicare Cases Include a Functional Outcome Test?

Medicare requires an outcome test for all evals, re-evals and discharge visits.

Does each Medicare evaluation contain 150 – 300 words defending the eval code severity?

Defensive documentation must include analysis of body regions, body systems, body structures, relevant history, comorbidities, standardized tests, cognitive status, social history, living environment, and clinical presentation.

The CMS protocol requires segregating the above topics into the four categories shown below:

# of personal factors
# of body structure, body system, activity limitations
Complexity of Clinical presentation
Complexity of Clinical decision making

Each category has a unique scoring algorithm and is scored separately. All pertinent details from each category must be documented in the evaluation.

Systems 4PT data mines the clinical record adds points of complexity in their appropriate category, scores each category and recommends the defendable level of severity along with 150 – 300 words of required defensive documentation. All of this is completed in a nanosecond.

Is Progression of the Identified Functional Deficit(s) Tracked?

G-codes are no longer required. But Medicare still requires therapists to specify relevant functional deficit(s) including initial severity and forecasted ending severity. Re-evals and Discharge notes must include an evidence-based progression of each deficit.

In less than 10 seconds, Sytsems4PT recommends 75 – 100 evidence-based words that quantify the patient’s functional progression.

Does the Plan of Care Defend Each CPT Code’s Role in Restoring the Specified Functional Deficit(s)?

You add the treatment plan, Systems4PT instantly recommends clinical rationale, explaining how each exercise, treatment and modality will restore the specified functional deficit(s). Touch-free.

Are you Compliant with Medicare’s 10% de minimis rule?

2020 CMS Assistant Modifiers are yet another audit trap that our industry is glossing over. ‘True, the 15% assistant discounts don’t hit until 2022, but the 2020 final rule is crystal clear about what’s required today.

2020 Final Rule Documentation Requirements for 10% De Minimis Modifiers

Assistant participation needs to be timed and documented separately from the therapist’s content. The 10% calculation, documentation, and modifier apply to each CPT code for every Medicare date of service.

Systems4PT automates the 10% De Minimis Rule calculation and recommends defensive documentation. This is touch-free for the therapist.