Prior-Authorization is Required for Humana Part B Through Optum/OrthoNet

Effective January 1, 2020 prior authorization from Optum/OrthoNet is required for all physical therapy, occupational therapy, and speech therapy providers as well as any provider type billing one of the below CPT codes for Humana Commercial, Medicare Advantage, and dual Medicare-Medicaid plan members:

420, 421, 422, 423, 424, 429, 430, 431, 432, 433, 434, 439, 440, 441, 442, 443, 444, 449, 92507, 92508, 92520, 92526, 92606, 92609, 92630, 92633, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97127, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97763, 97799, G0129, G0283, S9152, V5362, V5363, V5364

Physicians who have contracts with Humana to perform office-based physical, occupational or speech therapy and outpatient physical, occupational and speech therapy performed in a hospital will require Optum/OrthoNet prior authorization.

Inpatient rehabilitation, rehabilitation services performed in the home (including but not limited to those provided by a home health agency), services provided by chiropractors, and cardiac and pulmonary rehabilitation are excluded from Optum/OrthoNet management.

HTS Partners, see your Regional Director for helpful resources.

A Note from the field:

Many of our communities did not have news or much guidance about this new requirement prior to January 1st. Our Regional Directors report that partner clients were able to successfully fax in the information (per the request of Optum) and gain authorization for claims started after January 1st. If the claim originated in December and continued past January 1, 2020, a pre-auth is not required unless you anticipated the services extending past February 1, 2020.

Anthem Following in March:

Anthem has also merged with Optum/Ortho-Net and the prior-authorizations for Anthem Part B through the Optum site will be required starting March 1, 2020.

 

Please contact your HTS Regional Director for any questions and assistance.

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SLP Case-Mix Group: What We’ve Learned

Accurate coding for the SLP Component under the PDPM reimbursement methodology has been an area of opportunity across the industry. HTS has uniquely positioned itself with a team of seasoned therapists and nurses to analyze data and trends to optimize systems and processes to assure a smooth transition into PDPM. Now that we have three months of PDPM under our belt, here is what we have learned:

  • A tool to communicate SLP evaluation findings to the IDT will streamline the process and optimize IDT collaboration. Our MDS coordinators have enough on their plates. Let’s make it as easy as possible to present them with information so they can make the best coding decisions. HTS has created a tool for this, “HTS IMA SLP Component Communication Tool.” This tool is completed by the SLP and/or OT to provide information regarding sections B, C, I, and K related to the SLP therapy PDPM component. The tool is also equipped with a coding reference to assure that therapists are familiar with the RAI language and coding instructions.
  • Best practices when administering the BIMS is an area of opportunity. HTS recommends reviewing interview guidelines from the RAI, coding tips, and BIMS basics. Use HTS’ “Cognitive Assessment Quick Reference” for a guide to optimize practices in these areas. Also, remember the BIMS is a brief test and is not sensitive enough to capture some cognitive deficits such as executive functioning impairments. Even if a patient is “cognitively intact” (BIMS score of 13, 14, or 15), they still may benefit for cognitive-communicative therapy. The SLP will have formal testing to identify these areas of deficit and create short term goals associated with these areas.
  • If a patient scores in the SA case mix group indicating there are no items coded for the SLP component, the patient can still qualify and benefit from therapy. As mentioned in #2, the formal testing selections by a SLP will be more sensitive to cognitive impairment and therefore capture deficits more brief tests will not. However, if a patient is coded as “SA” and would benefit from speech-language therapy, HTS recommends going over the patient record to assure coding accurately reflects the patient’s medical complexities. Often times aphasia in section I4300 of the MDS may be a coding opportunity but also may require querying the physician. Additionally, section K coding best practices could also result in a more accurate SLP case-mix group.
  • Section K coding and optimization requires IDT collaboration. 2017 CMS data analytics revealed that section K coding was also an area of opportunity. In the past many have relied solely on the dietary department for section K coding. We’ve learned the SLP observations are also an important factor when coding section K accurately. For this reason, HTS created a “Quick Reference Optimize Coding in Section K” and “RAI Instructions for Completion of Section K.” Additionally, a webinar is available on the partner portal, “PDPM: SLP Component and Accurate Reporting of SLP Comorbidities.”

As we continue to navigate new waters under the PDPM methodology, we have adapted and modified our systems and processes to assure patient-centered care is at the forefront and best practices are in place. Accurate SLP component coding allows us the opportunity to more accurately depict the patient’s medical status and individualized needs. HTS will continue to provide the resources and tools to achieve IDT collaboration for the best patient outcomes possible so together we can drive quality improvement.

Written By: Sheena Mattingly, M.S., CCC-SLP, RAC-CT, Director of Clinical Outcomes

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Cognitive Therapy Coding Changes Effective 1/1/2020

The CY 2020 Physician Fee Schedule Final Rule updates payment policies, rates and provides other provisions for services under the Medicare Physician Fee Schedule (PFS) effective January 1, 2020. Below are changes related to cognitive therapy coding.

 

Deleted CPT Codes Effective January 1, 2020

97127 Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact (Report 97127 only once per day)

G0515 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

 

New CPT Codes Effective January 1, 2020

97129 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes (Report 97129 only once per day)

97130 Each additional 15 minutes (list separately in addition to code for primary procedure)

(Use 97130 in conjunction with 97129) 97129 represents the first 15 minutes of therapy. Report 97130 in conjunction with 97129 when therapy extends beyond the first 15 minutes.

(Do not report 97129, 97130 in conjunction with 97153, 97155)

References:

CY 2020 Physician Fee Schedule Final Rule

ASHA

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2020 OIG Work Plan

The Office of Inspector General (OIG) 2020 workplan includes residents who were receiving Medicaid nursing home care and then were hospitalized. The beneficiary then returned to the same facility and received Medicare covered post-hospital SNF care. In some cases, hospital physicians discharged beneficiaries to home rather than the SNF, yet nursing facility physicians certified that skilled care was needed. Because Medicare pays substantially more for SNF care than Medicaid for nursing home care, nursing home facilities have financial incentives to increase the level of skilled care. This will be the focus of OIG medical review.

 

What will the OIG use to determine if the post-hospital SNF care is dually eligible?

  • the SNF level of care was certified by a physician (e.g., a hospital or SNF physician) or a physician extender (i.e., a nurse practitioner, clinical nurse specialist, or physician assistant);
  • the condition treated at the SNF was a condition for which the beneficiary received inpatient hospital services or a condition that arose while the beneficiary was receiving care in a SNF for a condition for which the beneficiary received inpatient hospital services;
  • daily skilled care was required
  • the services delivered were reasonable and necessary for the treatment of a beneficiary’s illness or injury; and
  • improper Medicare payments were made on the claims we review. We will also determine whether any of the hospital admissions we review were potentially avoidable

 

Prepare for the 2020 OIG Work Plan:

  • Develop policies and procedures related to admission and determination of appropriate level of care and individualize them for your facility.
  • Assure your process for attaining hospital records is timely. This is crucial for not only response to OIG review requests but also for timely PDPM processes including identifying NTA components.
  • Review your facility’s communication for medical review. Did you know HTS partners with a third-party company to complete medical reviews on your behalf? Ask us about our Denials Management Processes today!

 

Bottom Line: There is a very short timeframe for response.

  • Hospital discharge records requested within 7 days and remaining documents within 15 days
  • Specific policies and procedures must be submitted for review as well as facility specific questions related to determining level of care:
    • Policies and procedures related to admission of patients into SNF care
    • Policies and procedures related to determination of appropriate level of care (unskilled/custodial care and skilled care)

Read more

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Winter Threats to Your Heart

Winter and bitter cold temperatures pose danger for those with heart disease and especially for older adults. Understanding your personal heart attack risk is vitally important during winter months. It is also important to be aware of the threats cold weather can bring and take appropriate precautions to ensure your safety.

 

Safety Tips for Cold Weather:

  • Avoid alcohol as it gives you a false sense of warmth and can cause your heart to work harder.
  • Don’t overdo it, start your morning off slow. The cardiovascular system can adapt to slow, progressive change. Avoid sudden exertion like shoveling snow and take frequent breaks.
  • Prevent hypothermia by wearing a hat and layers of clothing to protect you from
    cold temperatures. Older adults have lower subcutaneous fat and are more prone to suffer from hypothermia.
  • Remain hydrated and drink water regularly to prevent overexertion and dehydration.
  • Breathe through your nose in cold weather; your nose has various defense mechanisms to prevent impurities and excessively cold air entering your body.

 

If you would like to learn more about a heart-healthy lifestyle, visit our therapy department. Physical and Occupational therapists can help you to develop a healthier lifestyle and reduce many of the risk factors that cause cardiac conditions. Cardiac rehabilitation programs are designed to help you control your symptoms and resume an active and productive life within the limits of your condition.

 

References: American Heart Association

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Assistive Devices to Help Promote Independence

As you get older, you may start to have trouble with everyday tasks such as bathing, picking up things off the floor, or even just getting around.  Assistive devices are products and tools that can make life easier. They might be new things you add to your home, or improvements to something you already have.  The first step is recognizing when and where you could use some extra help. Sometimes people adapt to changes in their ability level, giving up things they like to do without even recognizing it.

Here are some ideas that could help make your daily activities easier:

Getting Around:

  • A cane or crutch used on the opposite side of a painful knee or hip makes walking easier and helps the joint last longer.
  • Reachers are long rods with a grip handle on one end and a grabber on the other. They let you pick up small objects without having to bend over or reach uncomfortably.
  • Elevated chair legs make it easier to get in and out of your seat. The chairs you have can usually be fitted with extenders.

In the Kitchen & Bedroom:

  • Rearrange your kitchen so that the things you use most often are the easiest to reach.
  • Use lamps activated by touch or by your voice.
  • Getting dressed could be easier if you switch to big buttons, button hooks, or velcro closures.
  • Find sock aids and zipper pulls. A sock aid can help you pull up your socks without bending your legs. A zipper pull makes zippers easier to grab and zip.

In the Bathroom:

  • A tub bench or shower seat lets you bathe more comfortably and reduces the chance of falls.
  • Grab bars make it easier to get in and out of the bath and on and off the toilet.
  • A raised toilet seat with side rails reduces the strain of getting on and off.
  • Long-handled sponges help you to wash your legs and feet without bending.

 

Occupational Therapists specialize in helping older adults to safely perform activities and do the things they want to do.  Being able to perform basic self-care activities is very important for older adults to safely live independently. They may have other ideas for assistive devices or home modifications that could make a world of difference.  If you are having trouble with completing day-to-day activities, talk with your doctor about physical and occupational therapy to restore your mobility and function as soon as possible.

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Experience the HTS Difference

Expect More When You Use HTS for Contract Therapy.

As health care continues to evolve, we know your therapy team needs to walk beside you — and even a little ahead of you — to bring solutions, navigate change and anticipate needs. Our dedicated experts keep you well informed and ahead of changes effecting our industry.

Partnering with HTS Means You’ll Receive 

  • Custom Marketing Solutions
  • Commitment to Compliance
  • Clinical Expertise

Click here to learn more about our Contract Therapy Services.

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PDPM Numbers After a Month: Looking Good

Article by James M. Berklan, www.mcknights.com

Journalists are supposed to be “words” men and women, but to be honest, I love a good set of numbers as much as anything. Especially when they’re tied to a pertinent analysis.

That’s why I find this period of transition with the Patient Driven Payment Model intoxicating. There’s mystery (Will providers fare well under the drastic overhaul?), cunning (How might providers get the best bang for their buck?) and suspense (What will regulators yank back if they don’t like what they’re seeing?).

And numbers. Lots and lots of numbers.

Wednesday I got a chance to talk initial PDPM numbers with three of the biggest LTC numbers crunchers around, Marc Zimmet, Vince Fedele and Steven Littlehale. We talked about Zimmet Healthcare Services Group’s initial PDPM reimbursement analysis of October Medicare claims.

The overall impression coming out of it? You’re going to be alright, providers. Just as many had predicted, those who did their homework — and vow to keep getting better — should be just fine.

In fact, as colleague Danielle Brown writes in today’s top Daily Update news item, many providers who paid attention in their PDPM educational classes are making, on average, more than $50 more per patient day then they would have under the old RUGs-IV system. When adjusted for one-time exceptions, it’s about half that, but it’s still a big positive. In addition, Zimmet estimates that providers can gain another $40 per patient day more once they get better at coding and, well, simply remembering to claim what they have coming.

While OT and PT therapy pay rates won’t necessarily budge much, better can be had in speech language therapy, nursing and non-therapy ancillary services, Zimmet explained.

A big caveat here: The analysts were clear that theirs was not a random sample and should not be taken as an ironclad predictive argument. The sample included a lot of East Coast clients, and they tended to be on the larger size, but it was still significant and close to what others should be finding.

The biggest worry isn’t so much what PDPM will do to providers’ bottom lines, but, much as I predicted a few weeks ago after talking to a long time marketplace exec: What the Centers for Medicare & Medicaid Services will do to the flow of cash when it eventually recalibrates pay rates. Because we can assume with these kinds of cheery numbers Uncle Sam will want to get back what he feels is rightly his.

Zimmet predicted with “95% confidence” that a rate readjustment will be coming, eventually. Providers will know in “less than a quarter” how finances will shake out, but CMS will likely take about six months before it makes any pronouncements about rate readjustments.

Make no mistake: This is good. It means you’re not getting riffed right now, wondering how to make ends meet. The CMS policy is not going to be budget neutral — but in a good way.

And the best thing of all is, you can do even better at it once you get better at coding and stop leaving money on the table.

Click here to continue reading this blog.

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We LOVE Celebrating Successful Recoveries!

Southfield Village Therapy Team Celebrates a Successful Recovery!

Patient, Brenda, enjoyed therapy so much that she dressed up for her last day at Southfield Village.

Pictured left to right are Derek Gokee PT, Brenda, and Brian Kemp PTA.

Follow along with our Facebook page to see how we’re helping communities just like yours!

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Poor Posture Takes a Toll on Overall Health

Everyone has heard the phrase “Stand Up Straight! Don’t Slouch!” Behind those long forgotten words lies a very valuable and surprisingly simple message: Good posture is important because it helps your body function at top speed. It promotes movement efficiency and endurance and contributes to an overall feeling of well-being.

Our bodies change as we age. If you have poor posture, your bones are not properly aligned, and your muscles, joint and ligaments take more strain than nature intended. These natural changes make it especially important for older adults to maintain good posture, strength, flexibility and balance. Good posture can decrease your risk of falls!

Poor Posture Can Cause:

  • Headaches & Fatigue
  • Back, Neck & Shoulder Pain
  • Breathing Problems

Tips for Maintaining Good Posture:

  1. Avoid staying in one position for long periods of time; inactivity causes muscle tension and weakness.
  2. Maintain a healthy weight; excess weight exerts a constant forward pull on the back muscles and weakens the abdomen.
  3. Sleep on a firm mattress and use a pillow under your head just big enough to maintain the normal cervical-neck-curve.
  4. Wear comfortable and well-supported shoes. Avoid high heeled or platform shoes, which distort the normal shape of the foot and throw the back’s natural curves out of alignment.
  5. Walk with good posture; keep head erect with chin parallel to the ground, allow arms to swing naturally, and keep feet pointed in the direction you are going.

For more exercise and posture tips, talk with your doctor about physical and occupational therapy. Therapy can help correct your bad posture and help alleviate chronic pain. No matter what age you are, every BODY will feel the benefits of better posture.

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