Medicare Compliance for Outpatient Physical and Occupational Therapy Services
Last year BWH's Medicare fiscal intermediary conducted a prospective review of outpatient physical and occupational therapy services billed to Medicare that resulted in a denial rate in excess of 50 percent. Most of the denials were made because physician ìcertificationsî were lacking for the treatment provided, or the ìcertificationî was excessively late. Certifications signed by physicians more than five days past the date of service were routinely denied.
Medicare regulations require that the “ordering” physician “certify” the necessity of physical and/or occupational therapy and that they review and sign off on the plan of care developed by the therapist. The initial referral physicians give to patients when referring them for care does not satisfy this requirement. It covers the initial visit and evaluation only. An additional process, the Medicare certification, must be completed in a ìtimelyî mannerówithin five daysófor BWH to receive reimbursement for the entire episode of care. Care that extends beyond 30 days requires “re-certification.”
To expedite the process of physician review and signature of the Medicare certification form, especially the timeliness of the turn around, the form and the entire process have been placed in BICS. (See below for summary of instructions.) The information on the electronic form includes all of the required elements for reimbursement. The treatment plan and goals, frequency and duration of treatment, onset of the condition, onset of care (PT or OT), the date the physician reviewed the plan of care, and a statement attesting the need for physical or occupational therapy, are all Medicare-required elements. Medicare uses the date the physician approved or certified the plan of care to determine the ìtimelinessî of the review. The therapist completes the form electronically on the day of the initial visit, and it electronically is sent to the referring physician for review and electronic signature.
As of January 10, 2000, physicians who have Medicare certifications to review will receive an electronic message logging onto ìCIî in BICS. Please review
the instructions. For more information about the process or to arrange a demonstration of the system, contact Linda Arslanian, director of Rehabilitation Services.
HOW TO REVIEW and sign MEDICARE CERTIFICATIONS IN BICS
Log on to the CI System
If you have certifications in queue for your review you will be alerted. Answer ëYí
to access your queue.You may also access your queue from the menu by selecting:
A - Ambulatory Options
K - Physician Rehab Certification
Signing Date: Defaults to todayís date. To ensure reimbursement, this date should
not be more than five days from the Certification Date.
Therapist Comments: Click on this button to view the therapistís comments.
Physician Comments: Click on this button to enter your comments
or e-mail your comments directly to the therapist.
Note: If you SIGN this certification, your comments become a permanent part
of the certification. If you DO NOT sign, they are not saved.
Goals, Plan, Progress, and Assessments: Use the mouse to scroll through these
boxes.
Sign It: Click on this button to make this certification a permanent (electronically signed) part of the patientís medical record.