The manual medical review of therapy claims is well on its way for phase 1 providers.  I am going to take a break from the Manual Medical Review this week and talk about our focus for the fourth quarter—coding and diagnosis selection.

Therapy coverage requirements per CMS must require the skills of a qualified therapist as described in the Code of Federal Regulations, be furnished by a physician, qualified non-physician practitioner, therapist, or an assistant supervised by a therapist; be medically reasonable and necessary; be appropriate in type, frequency, intensity, and duration for the individual needs of the patient; be furnished while the patient is under the plan of care certified by a physician or Nurse Practitioner; and  follow other Medicare policies as outlined in CMS manuals.

It is important for therapists to choose the most relevant medical and treatment diagnoses at the time of the evaluation.  Since ICD-9 coding is a key component in the submission and payment of therapy claims, therapists should be aware that the diagnoses and ICD-9 codes they choose can have an effect on claim payment.  The ICD-9 codes that the therapist selects communicate valuable information about the patient and can help support the medical necessity of the therapy intervention.  The MAC local coverage determinations (LCDs) help guide therapists in selection of appropriate and covered ICD-9 codes.

Accurate coding creates a “clean” claim for favorable payment and may help prevent denials through medical necessity support.  Additionally, accurate coding will show how the skilled services provided to the patient support the services billed.

Partnership between the business office manager and therapy manager is extremely crucial to obtain the most favorable payment outcome.  If therapy ICD-9 codes are not included on the UB04 then the HCPCs billed will not be supported.  It is important that the therapy manager is involved in a triple check process in the facility to ensure all of the therapy ICD-9 codes are included on the UB04 prior to submission for payment.

This quarter, Functional Pathways employees will receive coding tips weekly from our compliance department and our Regional Managers will be focusing on coding practices during their monthly site visits.  Collaboratively as a team, we can impact claim processing to decrease the risk of financial liability with claim processing.

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