BCMS has skillfully guided private practitioners throughout the maze of management challenges and the constant regulatory change we all face. Mary Daulong’s National reputation, comprehensive knowledge, resourcefulness, and attention to detail are what make her solutions-based approach so valuable.

What is a Privacy Breach according to HITECH?

A breach is, generally, an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information such that the use or disclosure poses a significant risk of financial, reputational, or other harm to the affected individual. (3-2012)

Does every permissible use or disclosure have to be reported?

  1. Any “unintentional” acquisition, access or use of PHI by a workforce member or individual acting under the authority of the covered entity or business associate that is made in good faith, within the course or scope of employment or other professional relationship, and is not further used or disclosed in an unlawful manner under the HIPAA Privacy Rule
  2. An “inadvertent” disclosure to another authorized person at the same covered entity, business associate or organized healthcare arrangement, and the PHI is not further used or disclosed in an unlawful manner under the HIPAA Privacy Rule
  3. A disclosure where the covered entity or business associate had a good-faith belief that the unauthorized person to whom the information was disclosed would not reasonably be able to “retain” such information (3-2012)

Can a Physical Therapy Assistant’s services be billed ‘incident-to’ a physician?

No, PTA’s are not permitted to work nor have their services billed under the ‘incident-to’ provision even if a physical therapist is working and billing under the physician’s PTAN/NPI number. Physical Therapy Assistant’s may only bill under therapy benefits, which means the therapist, in the Part B arena have a PTAN and NPI. (1-2012)

Is encryption required for transmitting emails with PHI?

Yes, emails are not secured without encryption and therefore could be accessed by non authorized individuals. There is a very good FAQ published by the AMA on encryption https://www.ama-assn.org/resources/doc/psa/hipaa-phi-encryption.pdf (2-2012)

Do my Business Associates have to have policies and procedures specific to HIPPA Security Measures?

Yes, the HITECH regulations require that business associates comply with HIPAA security by having processes supported by policies and procedures. Business associates, as do covered entities, have the prerogative to base the ‘addressable measures’ based on size and organizational capabilities, but they must implement all ‘required’ measures. (2-2012)

Is it true that therapists are mandated to bill Medicare for all covered services? For example, therapists may not ‘opt-out’ of Medicare if they want to treat Medicare patients.

Yes, this is absolutely correct. Physicians and a few other practitionersmay ‘opt-out’ of Medicare if they comply with the ‘opt-out’ guidelines. Specifically, CMS notes that Chiropractors and therapists are not eligible to ‘opt-out’. (9-2011)

What is the difference between ‘opting-out’ and ‘not participating’?

This is a very confusing issue as they both seem to imply that they both are not in the Medicare program; however this is incorrect. The ‘opting-out practitioner under very specific requirements has ‘dis-enrolled’ in Medicare and does not bill Medicare nor may his/her patients bill Medicare for services delivered. On the other hand the ‘not-participating’ practitioner is enrolled in Medicare but chooses not to accept Medicare’s allowable fees (but it comes with some significant burdens), but they must still bill Medicare. This is a very detailed question is thoroughly addressed on the CMS website. 9-2011

What is Locum Tenens and is it an option for therapists?

Locum Tenens, simply put, is someone typically a physician or clergyman who substitutes temporarily for another member of the same profession. As it applies to physicians the locum tenens physician may bill under the original physician’s NPI. This is not an option for therapist; all outpatient suppliers must be enrolled in Medicare, obtain a Provider Transaction Access Number (PTAN) and bill specifically under his/her NPI number. (9-2010)

What is unsecured PHI?

Unsecured PHI” is PHI (generally, information in any form that concerns the health of an individual) that is not rendered “unusable, unreadable, or indecipherable” through the use of a “technology or methodology,” specified by HHS in its guidance. The guidance listed the two acceptable technologies and methodologies for rendering PHI secure—encryption and destruction— and included specific definitions for each. (8-2010)

What are the regulations for the MPFS in 2012 that impact therapy services?

The following items are in place for 2012:

  1. The therapy cap has been extended with new provisions
  2. The proposed 27.4% payment cut to Medicare providers has been tabled
  3. The Geographic Practice Cost Index (GCPI) will be held at 2011 level (1-1-12)

What are the 2012 provisions for the Therapy Cap Exception Process?

  1. PT & SLP will share a $1,880 cap
  2. PT & SLP will share a $3,700 cap threshold and effective 10-1-12 claims that reach the threshold will be subject to a manual medical review
  3. OT will have a separate $1,880 cap
  4. OT will have a separate $3,700 threshold and effective 10-1-12 claims that reach the threshold will be subject to a manual medical review
  5. Hospital outpatient therapy departments will be subject to the therapy cap exception process effective 10-1-12
  6. Each request for payment on therapy claims starting 10-1-12 must include the NPI # of the physician who reviewed the plan of care (2-20-12)

Is it accurate that in 2012 if a thearapist participates in the Physician’s Quality Reporting System (PQRS) he/she must report on a minimum of three (3) measures?

Yes, that is accurate. Please remember that each of the three (3) measures must meet the 50% threshold if using a claim form or 80% if using a Registry. (1-1-12)

Do you have any suggestions about how our practice can stay up to date on matters related to Medicare in California?

While it is challenging to stay current on all regulations you do have excellent resources available to you.

  1. Maintain an active role in your state association and its Private Practice Group; California Physical Therapy Association and its PPG have very competent leadership.
  2. You and your office administrator should join your MAC email notification service (listserv) so that you can be informed of important updates and changes that could impact your practice. While these email alerts are quite varied it is common for them to have provider specific notification for you to choose from. All you have to do is go to your payer’s website and subscribe; you might have to dig through a few menus, but most reference them on their home page.
  3. Subscribe to our “Seriously Important Practice Alerts (SIPA) which also provides state and federal updates. Page Link (3-1-12)

How do I change information I submitted on my NPI number?

You can go to the NPPES website at the link below and make your changes or you can go to the same site for a mailing address for hardcopy changes. Please remember that all health care providers who are covered entities under HIPAA are required to notify the National Plan Provider Enumeration System (NPPES) of changes in their required NPPES data elements within 30 days of the changes. https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart (1-13-08)

Is it true that rehab agencies are no longer required to provide Medical Social Worker Services?

Yes, that is absolutely correct; however at this point the State Operations Manual and Exhibit E have not been revised to reflect the change. Please go to the link below and view the letter from the State Agency Director regarding this change
https://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Hospital_Outpatient/forms/SC_09-21_Memorandum.pdf (1-2009)

What is an LCD? Why do I need to have it? How do I locate the applicable one for me in my state?

LCD stands for, as it relates to Medicare, Local Coverage Determinations. These are developed in the absence of a National Coverage Determination for the purpose of providing guidance concerning Medicare’s coverage and payment policies for various diagnostic conditions and/or therapeutic interventions. These same LCD’s serve as internal guidelines and edits for medical reviewers and claims management personnel at the payer (Medicare contractor) level. Examples of content are:

  • Documentation requirements
  • Utilization guidelines & covered services
  • Frequency and Duration allowances for modalities and procedures
  • Limitation of Coverage (correlation of diagnosis to treatment intervention)
  • Education scenarios (Group and 1:1, 8 minute rule, etc.)

It is critical that each provider of Medicare services be familiar with his/her Jurisdiction’s specific LCD’s. They can be obtained by going Medicare Administrative Contractor’s website and querying for LCD’s (it is usually classified under physical therapy, therapy or physical medicine and rehabilitation). It is important that you abide by the ‘current’ not draft LCD’s and that you take advantage of the right to comment on any draft policies when the comment period is in force. Many therapists have been successful in thwarting faulty LCD’s by providing practical examples and also by sound and evidence based justifications for consideration. 2-2009

What are the required components of a Plan of Care and can it be included in the evaluation?

The Plan of Care may be included in the initial evaluation as a component of it or may be a standalone document. Regardless of which method is used all elements, as noted below, must be documented:

  1. Diagnosis
  2. Long term functional goals with consistent identifiers
  3. The type, amount, duration & frequency of services
  4. Dated signature and professional designation of the Plan developer
  5. 1Dated signature and professional designation of the Plan certifier


What standardized outcome measures does Medicare recommend? Are these alternative tests that are acceptable to Medicare? Do you have a list of common tests?

  1. The list below represents the instruments recommended, but not required, by Medicare
  2. NOMS- National Outcomes Measurement System for Speech by the SLP Association
  3. Patient Inquiry-Focus On Therapeutic Outcomes by FOTO
  4. AM-PAC Activity Measure – Post Acute Care-by CRECare
  5. OPTIMAL-Outpatient Physical Therapy Improvement in Movement Assessment Log by Cedaron/APTA

Medicare will accept standardized tests that are recognized commercially and professionally, these are just a few examples:

  1. SF-12
  2. SF-36
  3. Disabilities of the Arm, Shoulder and Hand Test
  4. The Lower Extremity Functional Scale
  5. Oswestry Disability Index
  6. Pain Assessment and Management Toolkit
  7. Visual Analogue Pain Scale (VAS)
  8. McGill Pain Questionnaire
  9. Pain Diagram
  10. Roland Morris Disability Questionnaire
  11. Timed Get Up & Go- Mobility Test
  12. Berg Balance
  13. Tinneti Assessment Tool
  14. Motion Sensitivity Test

Note if you are member of the APTA you can access all standardized test on its website under the Guide for Physical Therapists (5-20-07)

How will I know if Medicare has transferred the remainder of a patient’s claim to his/her supplemental insurance company?

Once Medicare has completed the claim processing (and if the claim was completed properly with the secondary payer information) you will see on the Medicare Remittance Advice (RA) if the claim was forwarded to the other insurance for processing (this is called Coordination of Benefits). You should check the Remark/Reason Code for clarification of the transfer. The Codes are listed at the bottom of the RA.( 3-03-06)

How do I know where to affix the 59 modifier for codes that are bundled under the Correct Coding Initiative (CCI)?

The 59 modifier should be appended to column 2 code for both the Column and Mutually Exlusive Categories. You can access the National Correct Coding information at the links noted under Medicare Links (3-03-06)

Do physical therapy services provided by a Home Health Agency apply to financial limits (cap) for part B physical therapy?

Home Health Services are typically provided under Medicare Part A and therefore do not impact the ‘cap’ for Part B services. A prudent provider should make certain that the patient is discharged from the home health agency prior to initiating care so that services provided do not fall under the Consolidated Billing provision for Home Health Agencies. Please note that, while rare, there are situations that Home Health reimbursement is under Part B. Please see FAQ on this subject. (2-16-06)

How can I determine if a patient has had Home Health services or if he/she is still under the Home Health Agency?

Of course, the first line of establishing home health status is by questioning the patient or responsible party, but unfortunately these individuals don’t often understand the full scope of home health and often state that they haven’t ever or are not now participating in any home health. For starters you might ask if his/her physician asked anyone to come to his/her home to help or treat you in any way.

For example:

  1. Help of a home health aide
  2. Services of medical social worker
  3. Nurse
  4. Physical Therapist
  5. Occupational therapist
  6. Speech & Language Pathologist

If the patient states “yes” then further probing should follow to inquire when, who, how long, last visit, etc? The second line of verification to contact the Part A intermediary (sometimes this information is cross-walked to the Part B Carrier also) to see if the patient is currently enrolled in home health. Phone lines and EDI services have been mandated by the HIPAA regulation to assure benefit and eligibility verification. Your carrier or fiscal intermediary can provide you with the appropriate access line information. (2-16-06)

What is the National Provider Identifier? Do I need this and, if so, by when?

The National Provider Identifier (NPI) will take the place of the UPIN (Unique Provider Identification Number and the PIN (Provider Identification Number). It will be required to be used by all providers by May 23, 2007. The application and process is simple and takes only minutes. The application and associated resources are available the link provided on the Medicare Links page (2-16-06)

Is it true that if I billed Medicare at its allowable fee (MPFS) I have to request a refund for the 4.4% underpayment on claims since January 1st, 2006?

Yes, that is correct, Providers who billed the Medicare fee schedule amount, and need to increase their billed amounts, will need to request a redetermination in writing with the appropriate redetermination form (CMS 20027). This is not necessary for providers who billed at his/her usual and customary rates. (2-18-06)

It is my understanding that a provider may not, routinely, waive or discount a Medicare Beneficiary’s co-insurance. Will I be violating the Federal AntiKickBack law if I don’t attempt to colle4.4% retroactive fee that applied to my patient’s co-insurance and deductible for services delivered January 1, 2006 through February 8, 2006 (the date President Bush signed the legislation)?

Ordinarily you are required, unless due to established financial hardship, to collect any cost sharing responsibility the patient has however it appears that CMS is granting some latitude to providers related to inducement/Anti-KickBack violations in this situation. The following support statement has been provided for your reference: (DHHS/CMM Letter January 6, 2006 to Honorable Bill Thomas from Herb Kuhn, Director CMS) made by CMS stating that “we believe that where a beneficiary has already been charged for the appropriate cost sharing amount under an existing physician fee schedule, and an additional cost sharing amount is subsequently due because of a retroactive application of a statutory fee schedule adjustment, a waiver of the additional cost-sharing amount would be unlikely to serve as an inducement to the beneficiary.” (2-18-06)