Medicare Vulnerabilities: 

EMRs are Creating False Confidence

Amidst all of today’s distractions, Medicare compliance is as important as ever.

Have you noticed how EMRs are marketing built-in Medicare compliance?

Consider the following three Medicare topics that are not covered by other EMR software.  It’s a dangerous situation as therapists are told to trust their EMR’s compliance claims but are actually at heightened audit risk.

Three examples Medicare Compliance.  Systems 4PT is the only EMR to cover these.

1. Defense of Evaluation Complexity

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

The Medicare requirement began 1/1/2017.   Defensive documentation must include analysis of body regions, body systems and 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.    The category with the lowest score is the defendable level of complexity.  All pertinent details from each category must be documented in the “eval code defense” section of the evaluation.

Is your EMR compliant?

Systems 4PT keeps you compliant by data mining the clinical record, adding points of complexity in their appropriate category, scoring each category and recommending the defendable level of severity along with 150 – 300 words of defensive documentation.  All of this is completed in a nanosecond.

2. Medicare’s 10% Deminimis 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:

“Correct billing requires sufficient documentation in the medical record to support the codes and units reported on the claim, including those reported with and without an assistant modifier… the documentation in the medical record must be sufficient to know whether a specific service was furnished independently by a therapist or a therapist assistant, or was furnished “in part” by a therapist assistant in sufficient detail to permit the determination of whether the 10 percent standard was exceeded.”

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

In 2021, failure to comply is not a 15% reduction, it could leave you vulnerable to a 100% reduction.

Is your EMR compliant?

Systems 4PT automates the 10% De Minimis Rule and recommends defensive documentation.  This is touch-free compliance for the therapist.

3. MIPS: Your Best Objective Measure of Medicare Compliance

For years EMRs have exaggerated their capabilities related to compliance and collections, but you have never had a way to validate results.  MIPS provides the solution.  Every EMR works with the same complex set of MIPS rules.  CMS judges MIPS performance by calculating a year end score.

MIPS is an objective window into your EMR’s compliance capabilities.

2020 Results:

All Systems 4PT practices large enough to participate for MIPS,

achieved a 100-point score in 2020

No other EMR reported over 5% of practices achieved 100-points

Remember, if your EMR can’t reliably deliver 100-point MIPS scores, they can’t reliably cover other Medicare requirements either.   (MIPS is a measurement of true compliance.)

Is your EMR Compliant?

And don’t forget about the valuable MIPS bonus.  While the dreaded 9% Medicare pay cuts were lowered to just under 4% at the end of 2020, for 100-point Systems 4PT practices, the 2021 fee cuts have been reduced to ½ of 1%.

You’ve just reviewed three Medicare compliance requirements

Are you satisfied with your ERM?

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