In early March, our counterparts in Texas, the Texas Physical
Thearapy Association, met with several representatives from
Trailblazer Health. In their meeting they discussed the new
requirements set forth by the LCD and the therapy cap. The following
information is taken directly from their meeting summary which was
reviewed and approved for accuracy by Trailblazer Health. Please
review, there are some very interesting points made regarding the
ICD 9/procedure crosswalk that was put into play the by the new LCD.

Also, do not forget the teleconference tomorrow with Trailblazer
Health during which many of these topics will be discussed. The call
in information can be found in the previous message from
payerrelationsspecialist.

________________________________________________________________

Representatives from Trailblazer Departments with specific authority
over
Physical Medicine & Rehabilitation (Therapy Services ) under Part B
MPFS
in Delaware, Maryland, Virginia, Washington D.C. & Texas

• Manager of Coverage Policy (1)
• Manager of Medical Policy (1)
• Manager of Medical Review (1)
• Medical Directors (2)
• Provider Outreach Education Trainer Specialist (1)
• Specialists, Coverage Policy (2)



Representatives from Texas Physical Therapy Association

• PT , PP Owner & Federal Governmental Affairs Committee Liaison (1)
• PT, Former PP Owner & Reimbursement & Compliance Consultant (1)
• PT, Reimbursement Chair, TPTA (emergency excused absence)




Meeting Focal Points

Trailblazer's Local Coverage Determination for P M & R


1) Trailblazer `s LCD Reconsideration Process handout was provide to
us to
review and use for any subsequent formal revisions/comments


Comment: Medical Review, Manager stated that her department would
open

an informal input window to allow providers to submit comments and

recommendations on/for:

a) Diagnosis that are absent from either or both the `suspended'
Trailblazer
LCD and the CMS ICD-9 List
b) CPT Code Description & Bifurcated Code (97140)
c) Frequency Directive at Modality/Procedure Level that have
conflicting
directives for passive and active interventions (25% passive
expectation
e.g.16 modality services/month and 12 procedure services/month)
d) Two-Month Duration `Expectations' set by Trailblazer for non-
neurological
musculoskeletal conditions to incorporate therapeutic rationale for
including post operative and other healing time in the episode
e) Service/Unit Utilization Guideline conflicts with diagnostic
categories (1-
01-06 diagnosis to procedure crosswalk and CMS exceptions)


ACTION: TPTA representatives will contact the other therapy
jurisdictions to
determine interest in forming a Task Force to provide comments
and input regarding the LCD's to Trailblazer


2) Trailblazer's LCD Status
a) LCD will remain enforce as the PMR Guiding Tool
i) Medical Review for medical necessity
ii) Claims edit guidance
b) LCD components edits suspended (2-3 month evaluation period):
i) Procedure to Diagnosis Edit (limited coverage crosswalk)
ii) Utilization Guidelines (will continue to be considered if under
Medical
Review necessitated by questionable or aberrant billing practices)

Comment: TPTA participators commented on the inconsistencies
noted among the Utilization Guideline requirements, the 1-1-06 LCD
limited coverage crosswalk and the CMS Therapy Cap Exceptions;
Trailblazer appeared willing to review and rectify

Comment: Per Trailblazer participants: CMS expects contractors to
have Limited Coverage (procedure to diagnosis edits) crosswalks in
place, therefore, Trailblazer will be evaluating how it will modify
its
current crosswalk/edits to include the CMS Exceptions as well as to
provide consistent education and edit tools

c) CMS Therapy Cap Exception Requirements will be fully employed
including, but not limited to, the ICD-9 Conditions and Complexities
d) Exception Process to be implemented by 3-13-06 and posted 3-10-06


3) Documentation Requirements
a) All medical necessity documentation guidelines remain in effect
per
Transmittal 36/CR 3648 unless in conflict with Transmittal 47/CR4364
requirements which will then supersede any previous requirements


4) ICD-9 & Proper Claim Coding
a) CMS Transmittal 735/CR 4097 is the recommended tool for billing
guidelines
b) Medical ICD-9 / Functional and/or Therapeutic ICD-9's
i) Trailblazer indicated that PTs should code to the Greatest Level
of
Specificity regardless of diagnostic category
ii) Trailblazer indicated that PTs should use Medical rather than
Rehabilitation/Intervention diagnosis when coding claims. They
stated
that they would expect to see all diagnosis relevant to the
treatment on
the claim (in cases where there are more than four diagnosis
Trailblazer would expect to see the remaining ones documented in the
clinical record)
iii) Trailblazer clarified ICD-9s coding directives for claims
filing stating
that we could use up to (four) 4 diagnoses1 (Medical/Co-Morbidity/
Rehab) in Item/Box 21 on the 1500 or equivalent 837 1(soon to be 8)
iv) Trailblazer stressed that only one (1) diagnostic code could be
use in
Item/Box 24 E
v) Trailblazer reiterated that multiple units of the same CPT code
must be
entered on the same line (24G) if performed on the same date of
service
vi) Trailblazer clarified the Item/Box 19 requirement for : Date
Last Seen
(DLS) and UPIN number; Trailblazer only looks for a `valid date' and
UPIN, they expect that the DLS represents the last time the patient
was seen by his/her attending; it is not the Plan of Care or
Referral
date unless they are actually the DLS. Its purpose is to validate
that
the patient is under the care of the doctor and that (per
Transmittal
735) a certified or re-certified Plan of Care is being maintained on
file
Problems Discussed: Single diagnosis per Item 24G/DOS when
two separate and distinct diagnoses are being managed on the same
DOS and procedure frequency limitation per DOS or per condition

Comment: Trailblazer expressed understanding and concern, but no
immediate resolution other than entering the opportunity to enter a
"Unusual Circumstance" note" in the electronic comment field
indicating the two diagnoses for situations such as: same procedure,
2
units of 97110 for the knee and 2 units of 97110 for the shoulder on
the
same date of service

vii) Trailblazer stated that 2006 LCD Y-18B-R1 only pertained to the
97000
series CPT codes listed and that this did NOT mean these were the
only CPT codes available to PTs. They did state PTs would need to
follow the rules established for whatever codes we billed outside
the
97000 series and be familiar and comply with any related LCD's for
those areas

5) Medical Necessity
a) The LCD will still be the guiding document for reviewers:
b) Medical necessity policies will be based on information provided
by the
CAC, NCD and other reliable sources
c) Provider documentation (per CR 3648 & CR 4364) to support
coverage &
policy requirements is a requirement for all claims submission
whether for
routine and or `excepted' claims
d) Provider signature on claim or manual request is an attestation
that proper
and adequate documentation to support the claim is present, prior to
the
filing of the claim
e) Providers can be subject Progressive Correction Action resulting
in
placement into the Local Provider Education Training (LPET) program
or
placement on pre-payment review if analysis of data reveals
potential or
actual documentation problems

6) Claims Denied for Limited Coverage (Procedure to Diagnosis
Crosswalk) from the January 1, 2006 LCD
a) Claims with Dates of Service from January 1, 2006 and January 2,
2006
must use the Redetermination Process and suggest using form CMS
20027
b) Claims with Dates of Service from January 3, 2006 through March
13,
2006 there will be two options for dealing with these denials
i) Option I: Resubmit the Claim (must be for DOS after 1-2-06
ii) Option II. Use the Redetermination Process noted below in 7(iii)

7) Claims Denied for Exceeding the Cap Prior to Exception Process
a) Claims denied for exceeding the Cap that would have qualified for
an
automatic exception
Procedure: Re-file the claim with a KX modifier
b) Claims denied for exceeding the Cap that would not have qualified
for an
automatic exception but that might qualify as a manual exception
Procedure: Follow the exception process outlined by Trailblazer on
the
following link: http://www.trailblazerhealth.com/notices.asp?
action=detail&id=3547
i) Must be a written/signed request for a re-opening for the denied
claim
ii) May be submitted on the CMS 20027 (Redetermination Form) but
must minimally include:
(1) Provider name*
(2) Medicare provider number*
(3) Beneficiary name*
(4) Health insurance Claim (HIC) number*
(5) Contact name and telephone number
(6) Indicate if this is for a manual exception request or
retroactive
reopening
(7) Required supporting documentation:
(a) Number of treatment days requested
(i) Number of retrospective days requested
(ii) Number of prospective days requested
(b) Evaluation and certified Plan of Care
(c) Re-certifications and re-evaluations (if applicable)
(d) Progress reports
(e) Treatment encounter notes (incl. flow sheets, etc.)
(f) Justification documentation (part of or separate documents)
iii) Submit requests for manual exception to: Fax (800) 592-536
iv) Requests for reopening should only be submitted for
medically necessary services that have been denied for
exceeding the cap and do not meet the automatic exception
v) Requests for manual exceptions should be submitted when
the patient is nearing the cap limit and does not meet the
requirements for an automated exception but the provider
believes it is medically necessary for further therapy services.
Fax these requests with all of the documentation outlined in
Transmittal 47 Pub. 100-02.
www.cms.hhs.gov/transmittals/downloads/R47BP.pdf

Appeals Process

• Re-opening for minor errors
o Does not eliminate the right to appeal subsequent submissions
o Must be written and should (recommended) use CMS 20027
o Does not require clinical records to be submitted


• Redetermination – claim denied due to lack of medical necessity
o Is typically considered the first level of appeal
o Must be written and should (recommended) use the CMS
Redetermination Form CMS 20027
o Requires full medical records submission for all dates of services
denied


• Reconsideration—
o Processed by Qualified Independent Contractors (QIP)
o Replaces the Fair Hearing
o Must be written per QIP directives
o Requires clinical records and all documents requested


• Administrative Law Judge
• Appeal Board
• Federal Court


These Minutes have been read and approved by Trailblazer Health and
should not be modified without the expressed permission of
Trailblazer
and/or TPTA.


Submitted by Mary R. Daulong, PT/CHC & Bobbie Hurt, PT

Texas Physical Therapy Association 3-17-06