Transcript Reimbursement Process

Reimbur$ement:
Show Me the Money!
Carolyn A. Dobson, MT-BC
AMTA Reimbursement Committee Representative
WRAMTA Conference - Long Beach, CA
April 1, 2011
Reimbursement Sources
 Medicare
–Partial Hospitalization (PHP)
 Healthcare
Common Procedure
Coding System (HCPCS)
 Activity
Therapy Code: G0176
Reimbursement Sources
 Medicare
–Prospective Payment System
(PPS)
 In-Patient
Rehab & Psychiatry
 Hospice
 Skilled
Nursing Facilities (SNFs)
Reimbursement Sources
 Medicare
–Minimum Data Set (MDS)
 Restorative
 Section
Care
O: Special Treatments,
Programs, And Procedures
O0400: Therapies
MDS 3.0 Section O
Importance of O
04001
Item Rationale
– Health-related Quality of Life
 Maintaining as much independence as possible in activities of daily
living, mobility, and communication is critically important to most
people. Functional decline can lead to depression, withdrawal, social
isolation, breathing problems, and complications of immobility, such
as incontinence and pressure ulcers, which contribute to diminished
quality of life. The qualified therapist, in conjunction with the
physician and nursing administration, is responsible for determining
the necessity for, and the frequency and duration of, the therapy
services provided to residents.
 Rehabilitation (i.e., via Speech-Language Pathology Services and
Occupational and Physical Therapies) and respiratory, psychological,
and recreational therapy can help residents to attain or maintain
their highest level of well-being and improve their quality of life.
MDS 3.0 Section O
Criteria for Applicable Treatments,
Procedures, & Programs
Applicable treatments/ procedures include:
 Services provided by or under the direction of a qualified
occupational or physical therapist
 Skilled therapy services only
 Respiratory, psychological, and recreational therapy that meet
specific criteria only
Applicable treatments/ procedures do not include:
 Services provided solely in conjunction with surgical services and
diagnostic services
 Non-skilled services
Minimum Data Set (MDS) 3.0 Section O August 2010
Purpose of O0400 Therapies
Conduct the Assessment
Determine :
 Therapy(ies) the resident received
 Mode for each therapy received
 How many minutes the resident spent in each mode of therapy
during the look-back period
 Number of days of therapy during the look-back period
 Document the start and end date of each therapy.






Review the resident’s medical record.
Rehabilitation therapy evaluation
Treatment records
Recreation therapy notes
Mental health professional progress notes
Consult with each of the qualified care providers.
Special Treatments and
Therapies:
Section O
The RAI Version 3.0 Manual states that Recreation Therapy is NOT a skilled
service according to the Security Act however, for purposes of the MDS,
providers should record services for recreational therapy when the conditions
for the provision of recreation therapy are as follows:

The physician orders Recreation Therapy that provides therapeutic stimulation
beyond the general activity program;

The physicians order must include a statement of frequency, duration, and
scope of treatment;

The services must be directly and specifically related to an active written
treatment plan that is based on an initial evaluation performed by a
therapeutic recreation specialist;

The services are required and provided by a state licensed or nationally
certified therapeutic recreation specialist or therapeutic recreation assistant
who is under the direct supervision of a therapeutic recreation specialist; and

The services must be reasonable and necessary for the resident’s condition.
Remember………



The assessor records the number of days and the minutes
that recreation therapy was administered over the 7 day look
back period. Sessions must be at least 15 minutes in length.
The RAI Version 3.0 Manual states that therapy logs are not a
MDS requirement but is standard of good clinical practice by
all therapy professionals.
It’s also important to note that when two clinicians work
together, which may be common with a recreational therapist
and an occupational therapist, the clinicians must split the
time between the two disciplines.
Music Therapy is included under Recreational Therapy as
well.
Reimbursement Sources
 Medicaid
–Approved Providers
–Waiver Programs
Reimbursement Sources
 Private
Insurance
–Indemnity
–Preferred Provider Organization
(PPO)
–Health Maintenance
Organization (HMO)
–Point of Service (POS)
Reimbursement Sources

Workers’ Compensation

TRICARE

Automobile Insurance
Reimbursement Sources


Adoption Subsidy
State and County
Boards/Departments
– Health
– Social Services
– Developmental Disabilities
Reimbursement
Terminology
 Diagnostic
Codes
–ICD 9 (CM)
 Procedural
Coding
–CPT 2011
–HCPCS
 Revenue
Codes
Reimbursement Process

Step One: Obtain your National
Provider Identifier Number
(NPI)
– “Respiratory, Developmental, Rehabilitative
and Restorative Service Providers”

https://nppes.cms.hhs.gov/NPPES/Welcome.do
Reimbursement Process

Step Two: Seek Referrals
Physicians, Psychologists, Social
Workers, Case Managers, Parents,
Clients, Allied Healthcare Providers

Step Three: Collect Insurance
Information
– Music Therapy Pre-Approval Form
– Assignment of Benefits Form
– HIPAA Notice
Reimbursement Process

Step Four: Determine Client Needs
– Initial Assessment: Brief or Full
– Define the scope, duration, and
frequency of music therapy
treatment
– Determine Medical/Behavioral
Necessity
Reimbursement Process

Step Five: Prepare Marketing
Materials
– Music Therapy Definition
– Supportive Research
– Health Care Industry Recognition
– Qualifications
Reimbursement Process

Step Six: Contact Primary Care
Physician
– Provide MT information
– Seek Written Referral
– Request Diagnostic Codes
 International
Classification of Diseases-
9th Revision (ICD-9)
Reimbursement Process
 Step
Seven: Select Procedure
Codes that best describe
MT interventions
– Current Procedural Terminology (CPT)
– Determine Rates/Fees Per Code
Reimbursement Process

Step Eight: Call the Insurance
Company
– Request Case Manager Review
– Present Diagnostic (ICD-9) and
Procedure Codes (CPT)
– Review Pre-Approval Process
– Negotiate Rates
– Request Reporting Requirements
Reimbursement Process

Step Nine: Provide MT Interventions
– Document all elements of treatment
 Assessment
 Treatment
 Potential
 Client
Descriptions
Cost Savings
Response to Treatment
 Functional
Outcomes Achieved
Reimbursement Process

Step Ten: Complete Claim Forms
– CMS 1500
– http://www.cms.hhs.gov/manuals/downloads/
clm104c26.pdf

Step Eleven: Submit Claim
– Include Required Attachments
Reimbursement Process

Step Twelve: Follow-up with Payer
– Appealing an Adverse Decision
 What
was the reason for denial?
 Who made the initial decision?
 What is the appeals process?
 What additional information is needed to
review the appealed case?
 Involve the referring physician
 Involve the patient/family
Reimbursement Tips
– Don’t Stop at “NO”
– Develop Relationships with Insurance
Company Case Managers
– Present Clear and Accurate Information
– Respond to All Communication in a
Timely and Professional Manner
Resources

www.musictherapy.org

www.cbmt.org

www.cms.hhs.gov

www.ingenixonline.com

www.amapress.com
AMTA Reimbursement
Committee Representative
Carolyn A. Dobson, MT-BC
[email protected]
214-923-2477