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In a move that has left many private practice and other outpatient PTs scratching their heads, Noridian Healthcare Solutions is issuing notifications of postpayment Medicare claims review to outpatient physical therapy providers that include impossible-to-provide requests. Many of the requests call for documentation for elements common to inpatient facilities but that outpatient PTs either aren't required or permitted to do under Medicare.

The inappropriate records include the physician or nonphysician order (or evidence of intent to order), the initial evaluation and/or reevaluation signed by the ordering physician, and records of aide visits. PTs who have received the requests are understandably confused.

Noridian: Review Contractors Will Sort It Out

When APTA contacted Noridian about the problem, the company said it expects the kinks to be worked out by the Medicare supplemental medical review contractors, or SMRCs, as they review the provider responses. Here's what they wrote:

"If the Documentation Requirement element does not pertain to the requirement for the specific claim, the SMRC would not expect that to be submitted, nor issue a denial for the missing element if it was not required. Rather, the SMRC assimilates all documentation submitted to support whether the service was billed in accordance with the applicable policies and statutes."

In other words, if you can't provide it because it wasn't required in the first place, the reviewers won't penalize you.

But just in case the system doesn't work as seamlessly as Noridian expects, APTA advises taking a more careful approach.

APTA's Advice: Play It Safe, Document Why You're Not Providing the Information, and, if Possible, Request an Extension

APTA recommends that you don't take any chances with the SMRC reviews generated by Noridian. Include explanations for all documentation requests that aren't appropriate for your claims. If possible, try to request an extension — this will give you time to provide full explanations (or possibly give Noridian time to rethink the process).

Tips on Writing Your Explanations

Below is some general guidance on responding to inappropriate documentation requests — but, remember, this doesn't constitute legal advice. The important considerations here are caution and careful attention to the particular nuances of the request that's being made. Because of those considerations, the following examples may not be appropriate in every instance. If you need help with an SMRC audit, contact APTA at advocacy@apta.org.

Here are possible requests and potential responses:

Request: Physician/nonphysician order or evidence of intent to order.  
Response: Physician/NPP orders or referrals are not required for outpatient physical therapy per Medicare Benefit Policy Manual Chapter 15 Section 220.11.

Request: History and physical report (include medical history and current list of medications).
Response: Medicare does not require that physical therapists document a patient’s medications. This requirement was discontinued when Medicare terminated Functional Limitation Reporting on Dec. 31, 2018.

Request: Initial evaluation/reevaluation signed by the ordering physician or practitioner.
Response: The MBPM, Chapter 15, Section 220.3(C) indicates that neither the initial evaluation nor reevaluation needs to be signed by a physician.

Request: Signed and dated overall plan of care including short- and long-term goals with any updates to the plan of care.
Response: The MBPM Chapter 15, Section 220.1.2 B requires the plan of care to contain long-term treatment goals but specifically indicates that short-term goals are optional.

Request: Records of aide visits, times, and dates.            
Response: Therapy aides are not permitted to provide outpatient therapy services under Medicare.


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