Every practice does their best to file accurate, compliant claims, but sometimes the definitions of what exactly is “compliant” can differ from place to place, even among major organizations. Recently, the Office of Inspector General (OIG) conducted an audit of 300 physical therapy claims and found that 184 of them did not fit their notion of medical necessity, documentation, or coding standards. While a 61% error rate is certainly cause for alarm, the situation may not be as bad as the statistics make it seem. Despite OIG’s findings, the Centers for Medicare and Medicaid Services (CMS) disagreed with the overall results, claiming that OIG had misinterpreted their policies.
Given that this study led OIG to estimate that that Medicare had overpaid $367 million in just six months during the time of the audit, this debate is no small matter. CMS, however, argued that the sample size was too small and that OIG misunderstood the mandated compliance level. While the matter is still up for debate, both groups agreed on one aspect: regional Medicare Administrative Contractors (MACs) need to agree on a unified interpretation of CMS guidelines in order to stop the same claims from being reimbursed differently based on dissenting views.
For the average coder handling physical therapy claims, this issue can cause more than its fair share of headache. After all, if the major organizations who write and enforce these rules can’t agree on their meaning, then how are individual practices supposed to file their claims? While the big groups hash it out, the best course of action for PT practices is to make sure that your interpretation of the documentation guidelines is firmly established and catalogued in case of an audit. That way, even if OIG or your MAC disagree with what you report, you will have a concrete paper trail to backup your reasoning for how you filed your physical therapy claims.