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Each year the Office of Inspector General releases their action plan for the following 12 months. It is the ultimate To Do List; giving us insight into where they will be dedicating resources. Not surprisingly, the OIG is looking at areas of high utilization, improper or incomplete documentation, and providers and suppliers billing for services that are not medially necessary. They have targeted individual providers, practices and facilities across many medical specialty areas. It is foolhardy to believe that anyone can fly below their radar.

Physical therapists—High utilization of outpatient physical therapy services

Billing and Payments: We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations.

Context—Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable or medically necessary or were not properly documented.

Our focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Medicare will not pay for items or services that are not “reasonable and necessary.”

Their text states that the “Documentation requirements for therapy services are in CMS’s, Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15, § 220.3.” Could they be any more explicit? We don’t see how.

If the OIG report alone has not captured your attention, let’s consider the implications of the settlement reached in Jimmo v. Sebelius. The settlement of this recent Vermont case clarifies the coverage parameters for Maintenance Therapy under Medicare. CMS revised parts of Sections 220 & 230 of Chapt. 15 to address the documentation required to support claims for Maintenance Therapy. These changes took effect on January 7, 2014 and indicate that:

Skilled therapy services require the specialized skill, knowledge and judgement of a qualified therapist to establish or design a maintenance program… . The specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.

The determining factor in these cases is whether the skills of a therapist are required. This also indicates that these maintenance services will not be covered by Medicare if they are performed by a PTA or other staff member. We anticipate that this will be another fertile area for Medicare to audit. Consequently it is critical that your staff is properly documenting these cases.

Genco Healthcare helps practices achieve and maintain a culture of compliance. They also assist Healthcare Attorneys in defending their clients who have been audited or subject to pre-payment review. Consequently, Genco Healthcare has their finger on the pulse of precisely what Medicare’s expectations are when it comes to medical documentation. You can reach them at 914-713-3606 or email David Alben at

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