The pace at which regulations and requirements change is so rapid that even the best prepared practitioner is hard pressed to establish and maintain the training, policies, and standards related to documentation of and coding for clinical services. Despite the importance of providing for adequate documentation and appropriate coding and billing for physical therapy services, most physical therapists do not receive adequate, if any, training to ensure that they comply with the ever-evolving requirements in these areas. In addition, the issue of medical necessity has become the primary reason for payer and agency audits in an environment that requires documentation to justify clinically appropriate services. Even further, documentation shapes the process of clinical reasoning, and provides the justification for payment of physical therapy services.

Given recent and ongoing studies from the Office of the Inspector General (OIG) and current government initiatives such as the Comprehensive Error Rate Testing (CERT) program and the Recovery Audit Contractor (RAC) program, Medicare and others have renewed and accelerated their efforts to reduce and recover overpayments for services. Although in the past the lack of adequate documentation of medical necessity would have resulted in the provider having to repay any monies collected from the insurer, today’s environment has made billing for services that are not adequately justified in the medical record an issue of potential fraud or abuse, carrying a much greater risk to the provider.

The principals of Fearon & Levine are nationally recognized experts in the areas of CPT coding, the Resource Based Relative Value Scale (RBRVS) payment methodology and its application to fee schedule development, physical therapy peer and utilization review, and documentation education and training, and electronic medical records. This expertise will provide the confidence you need when dealing with issues surrounding these areas of compliance:

• Assessment of current documentation content, format, methodology, and compliance
  
  
• Assistance with prepartation for and transition to an Electronic Medical Record
  
  
• Assessment of current CPT coding applications and billing procedures
  
  
• Assessment of ICD-9 diagnosis coding and related compliance with local payment policy
  
  
• Analysis and assessment of facility/practice charge master and fee schedule
  
  
• Analysis and assessment of charge capture methodology
  
  
• Identification of areas of risk and vulnerability related to documentation, coding, and billing practices
  
  
• Performance of documentation and billing audits using Fearon & Levine’s government-accepted audit tool
  
  
• Assessment of practice compliance with federal medical necessity guidelines
  
  
• Identification of potential claims and documentation audit review flags used by payers to identify suspect cases
  
  
• Development of strategies to minimize risk of audits
  
  
• Assistance with fee schedule development and/or modifications
  
  
• Assistance with minimizing risk of Medicare audit and recovery
  
  
• Training in methods to minimize the impact of any CERT or RAC audit
  
  
• Staff education and training related to adequacy and compliance with documentation, coding, and billing requirements
  
  
• Education and training in internal peer review and utilization management methodologies and techniques
  
  
• Assistance with development of self assessment tools for documentation, coding and billing compliance
  
  
• Assistance with payer relations in regards to coverage issues, contract negotiations, and payment policy issues
  
  
• Identification of viable and effective electronic documentation platforms that will promote staff efficiency and provide the form and structure to ensure that documentation of services justifies the coding and billing submitted to third party insurers