Reimbur$ement: Reimbur$ement:

Show Me the Show Me the

Money!Money!

Carolyn A. Dobson, MT-BCCarolyn A. Dobson, MT-BCAMTA Reimbursement Committee AMTA Reimbursement Committee RepresentativeRepresentative

WRAMTA Conference - Long Beach, CAWRAMTA Conference - Long Beach, CA

April 1, 2011April 1, 2011

Reimbursement Reimbursement SourcesSources

MedicareMedicare

– Partial Hospitalization (PHP)Partial Hospitalization (PHP)

Healthcare Common Procedure Healthcare Common Procedure

Coding System (HCPCS)Coding System (HCPCS)

Activity Therapy Code: G0176 Activity Therapy Code: G0176

Reimbursement Reimbursement SourcesSources

MedicareMedicare– Prospective Payment System Prospective Payment System

(PPS)(PPS)

In-Patient Rehab & PsychiatryIn-Patient Rehab & Psychiatry

HospiceHospice

Skilled Nursing Facilities (SNFs)Skilled Nursing Facilities (SNFs)

Reimbursement Reimbursement SourcesSources

MedicareMedicare

– Minimum Data Set (MDS)Minimum Data Set (MDS)

Restorative CareRestorative Care

Section O: Special Treatments,Section O: Special Treatments,

Programs, And Programs, And Procedures Procedures

O0400: TherapiesO0400: Therapies

MDS 3.0 Section OMDS 3.0 Section OImportance of OImportance of O

0400104001

Item Rationale Item Rationale – Health-related Quality of Life Health-related Quality of Life

Maintaining as much independence as possible in activities of daily Maintaining as much independence as possible in activities of daily living, mobility, and communication is critically important to most living, mobility, and communication is critically important to most people. Functional decline can lead to depression, withdrawal, people. Functional decline can lead to depression, withdrawal, social isolation, breathing problems, and complications of social isolation, breathing problems, and complications of immobility, such as incontinence and pressure ulcers, which immobility, such as incontinence and pressure ulcers, which contribute to diminished quality of life. The qualified therapist, in contribute to diminished quality of life. The qualified therapist, in conjunction with the physician and nursing administration, is conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents. and duration of, the therapy services provided to residents.

Rehabilitation (i.e., via Speech-Language Pathology Services and Rehabilitation (i.e., via Speech-Language Pathology Services and Occupational and Physical Therapies) and respiratory, Occupational and Physical Therapies) and respiratory, psychological, and recreational therapy can help residents to psychological, and recreational therapy can help residents to attain or maintain their highest level of well-being and improve attain or maintain their highest level of well-being and improve their quality of life. their quality of life.

MDS 3.0 Section OMDS 3.0 Section OCriteria for Applicable Treatments, Criteria for Applicable Treatments,

Procedures, & Programs Procedures, & Programs

Applicable treatments/ procedures include: Applicable treatments/ procedures include: Services provided by or under the direction of a qualified Services provided by or under the direction of a qualified

occupational or physical therapistoccupational or physical therapist Skilled therapy services onlySkilled therapy services only Respiratory, psychological, and recreational therapy that Respiratory, psychological, and recreational therapy that

meet specific criteria onlymeet specific criteria only

Applicable treatments/ procedures do not include: Applicable treatments/ procedures do not include: Services provided solely in conjunction with surgical services Services provided solely in conjunction with surgical services

and diagnostic servicesand diagnostic services Non-skilled servicesNon-skilled services

Minimum Data Set (MDS) 3.0 Section O August 2010 Minimum Data Set (MDS) 3.0 Section O August 2010

Purpose of O0400 TherapiesPurpose of O0400 TherapiesConduct the AssessmentConduct the Assessment

Purpose of O0400 TherapiesPurpose of O0400 TherapiesConduct the AssessmentConduct the Assessment

Determine :Determine : Therapy(ies) the resident receivedTherapy(ies) the resident received Mode for each therapy receivedMode for each therapy received How many minutes the resident spent in each mode of therapy How many minutes the resident spent in each mode of therapy

during the look-back periodduring the look-back period Number of days of therapy during the look-back periodNumber of days of therapy during the look-back period Document the start and end date of each therapy.Document the start and end date of each therapy.

Review the resident’s medical record. Review the resident’s medical record. Rehabilitation therapy evaluationRehabilitation therapy evaluation Treatment recordsTreatment records Recreation therapy notesRecreation therapy notes Mental health professional progress notes Mental health professional progress notes Consult with each of the qualified care providers.Consult with each of the qualified care providers.

The RAI Version 3.0 Manual states that Recreation Therapy is NOT a skilled 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, service according to the Security Act however, for purposes of the MDS, providers should record services for recreational therapy when the providers should record services for recreational therapy when the conditions for the provision of recreation therapy are as follows: conditions for the provision of recreation therapy are as follows:

The physician orders Recreation Therapy that provides therapeutic The physician orders Recreation Therapy that provides therapeutic stimulation beyond the general activity program; stimulation beyond the general activity program;

The physicians order must include a statement of frequency, duration, The physicians order must include a statement of frequency, duration, and scope of treatment; and scope of treatment;

The services must be directly and specifically related to an active written The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a treatment plan that is based on an initial evaluation performed by a therapeutic recreation specialist; therapeutic recreation specialist;

The services are required and provided by a state licensed or nationally The services are required and provided by a state licensed or nationally certified therapeutic recreation specialist or therapeutic recreation certified therapeutic recreation specialist or therapeutic recreation assistant who is under the direct supervision of a therapeutic recreation assistant who is under the direct supervision of a therapeutic recreation specialist; and specialist; and

The services must be reasonable and necessary for the resident’s The services must be reasonable and necessary for the resident’s condition. condition.

Special Treatments and Special Treatments and Therapies: Therapies: Section OSection O

Special Treatments and Special Treatments and Therapies: Therapies: Section OSection O

Remember……… Remember……… Remember……… Remember………

The assessor records the number of days and the The assessor records the number of days and the minutes that recreation therapy was administered over minutes that recreation therapy was administered over the 7 day look back period. Sessions must be at least the 7 day look back period. Sessions must be at least 15 minutes in length. The RAI Version 3.0 Manual states 15 minutes in length. The RAI Version 3.0 Manual states that therapy logs are not a MDS requirement but is that therapy logs are not a MDS requirement but is standard of good clinical practice by all therapy standard of good clinical practice by all therapy professionals. professionals.

It’s also important to note that when two clinicians work It’s also important to note that when two clinicians work together, which may be common with a recreational together, which may be common with a recreational therapist and an occupational therapist, the clinicians therapist and an occupational therapist, the clinicians must split the time between the two disciplines. must split the time between the two disciplines.

Music Therapy is included under Recreational Music Therapy is included under Recreational Therapy as well. Therapy as well.

Reimbursement Reimbursement SourcesSources

MedicaidMedicaid

– Approved ProvidersApproved Providers

– Waiver ProgramsWaiver Programs

Reimbursement Reimbursement SourcesSources

Private InsurancePrivate Insurance– IndemnityIndemnity– Preferred Provider Preferred Provider

Organization (PPO)Organization (PPO)– Health Maintenance Health Maintenance

Organization (HMO)Organization (HMO)– Point of Service (POS)Point of Service (POS)

Reimbursement Reimbursement SourcesSources

Workers’ CompensationWorkers’ Compensation

TRICARETRICARE

Automobile InsuranceAutomobile Insurance

Reimbursement Reimbursement SourcesSources

Adoption SubsidyAdoption Subsidy State and County State and County

Boards/DepartmentsBoards/Departments

– HealthHealth

– Social ServicesSocial Services

– Developmental DisabilitiesDevelopmental Disabilities

Reimbursement Reimbursement TerminologyTerminology Diagnostic CodesDiagnostic Codes

– ICD 9 (CM)ICD 9 (CM)

Procedural CodingProcedural Coding– CPTCPT 2011 2011– HCPCSHCPCS

Revenue CodesRevenue Codes

Reimbursement Reimbursement ProcessProcess

Step One: Obtain your National Step One: Obtain your National

Provider Identifier Number Provider Identifier Number (NPI)(NPI)

– ““Respiratory, Developmental, Respiratory, Developmental,

Rehabilitative Rehabilitative and Restorative and Restorative

Service Providers” Service Providers”

https://nppes.cms.hhs.gov/NPPES/Welcome.do

Reimbursement Reimbursement ProcessProcess Step Two: Seek ReferralsStep Two: Seek Referrals

Physicians, Psychologists, Social Physicians, Psychologists, Social Workers, Case Managers, Parents, Workers, Case Managers, Parents, Clients, Allied Healthcare ProvidersClients, Allied Healthcare Providers

Step Three: Collect Insurance Step Three: Collect Insurance InformationInformation

– Music Therapy Pre-Approval FormMusic Therapy Pre-Approval Form– Assignment of Benefits FormAssignment of Benefits Form– HIPAA NoticeHIPAA Notice

Reimbursement Reimbursement ProcessProcess Step Four: Determine Client Step Four: Determine Client

NeedsNeeds

– Initial Assessment: Brief or Full Initial Assessment: Brief or Full

– Define the scope, duration, and Define the scope, duration, and

frequency of music therapy frequency of music therapy

treatmenttreatment

– Determine Medical/Behavioral Determine Medical/Behavioral

NecessityNecessity

Reimbursement Reimbursement ProcessProcess Step Five: Prepare Marketing Step Five: Prepare Marketing

Materials Materials

– Music Therapy DefinitionMusic Therapy Definition

– Supportive ResearchSupportive Research

– Health Care Industry RecognitionHealth Care Industry Recognition

– QualificationsQualifications

Reimbursement Reimbursement ProcessProcess

Step Six: Contact Primary Care Step Six: Contact Primary Care

Physician Physician – Provide MT information Provide MT information – Seek Written Referral Seek Written Referral – Request Diagnostic CodesRequest Diagnostic Codes

International Classification of International Classification of

Diseases-Diseases-

99thth Revision (ICD-9) Revision (ICD-9)

Reimbursement Reimbursement ProcessProcess

Step Seven: Select Procedure Step Seven: Select Procedure

Codes that best describe Codes that best describe

MT interventionsMT interventions

– Current Procedural Terminology Current Procedural Terminology

(CPT) (CPT) – Determine Rates/Fees Per CodeDetermine Rates/Fees Per Code

Reimbursement Reimbursement ProcessProcess Step Eight: Call the Insurance Step Eight: Call the Insurance

Company Company – Request Case Manager ReviewRequest Case Manager Review– Present Diagnostic (ICD-9) and Present Diagnostic (ICD-9) and

Procedure Codes (CPT) Procedure Codes (CPT) – Review Pre-Approval ProcessReview Pre-Approval Process– Negotiate Rates Negotiate Rates – Request Reporting Requirements Request Reporting Requirements

Reimbursement Reimbursement ProcessProcess Step Nine: Provide MT Step Nine: Provide MT

InterventionsInterventions

– Document all elements of treatmentDocument all elements of treatmentAssessmentAssessment

Treatment DescriptionsTreatment Descriptions

Potential Cost SavingsPotential Cost Savings

Client Response to Treatment Client Response to Treatment

Functional Outcomes AchievedFunctional Outcomes Achieved

Reimbursement Reimbursement ProcessProcess

Step Ten: Complete Claim FormsStep Ten: Complete Claim Forms– CMS 1500 CMS 1500

– http://www.cms.hhs.gov/manuals/http://www.cms.hhs.gov/manuals/

downloads/clm104c26.pdfdownloads/clm104c26.pdf

Step Eleven: Submit ClaimStep Eleven: Submit Claim– Include Required AttachmentsInclude Required Attachments

Reimbursement Reimbursement ProcessProcess Step Twelve: Follow-up with PayerStep Twelve: Follow-up with Payer

– Appealing an Adverse DecisionAppealing an Adverse Decision What was the reason for denial?What was the reason for denial? Who made the initial decision?Who made the initial decision? What is the appeals process?What is the appeals process? What additional information is needed What additional information is needed

to to review the appealed case?review the appealed case? Involve the referring physicianInvolve the referring physician Involve the patient/familyInvolve the patient/family

Reimbursement TipsReimbursement Tips

– Don’t Stop at “NO”Don’t Stop at “NO”

– Develop Relationships with Insurance Develop Relationships with Insurance

Company Case ManagersCompany Case Managers

– Present Clear and Accurate InformationPresent Clear and Accurate Information

– Respond to All Communication in a Respond to All Communication in a

Timely and Professional MannerTimely and Professional Manner

ResourcesResources

www.musictherapy.orgwww.musictherapy.org

www.cbmt.orgwww.cbmt.org

www.cms.hhs.govwww.cms.hhs.gov

www.ingenixonline.comwww.ingenixonline.com

www.amapress.comwww.amapress.com

AMTA Reimbursement AMTA Reimbursement Committee RepresentativeCommittee Representative

Carolyn A. Dobson, MT-BCCarolyn A. Dobson, MT-BCcarolynwebb@earthlink.net

214-923-2477214-923-2477