Updated on: January 29, 2013

Problems with Therapy Untimed Codes (Again!): One Plus One, Does Not Necessarily Equal Two

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Original story posted on: January 10, 2011

nbeckleyPennsylvania providers have reported receiving demand letters from DCS, the Region A RAC, on the CMS-approved issue of untimed codes.

DCS posted this issue on June 17, 2010, outlining it as follows: "A potential vulnerability may exist if certain codes are billed for more than one unit. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B in this manner." DCS refers providers to additional information by referencing CMS Pub 100-04, Ch. 5, § 20.2 and CMS Pub 100-04, Transmittal 1019, dated Aug. 3, 2006, pages 7-11.

As the therapy community knows, service-based, or untimed, codes only may be billed for a unit of service that is equal to one regardless of the actual time spent on a therapy encounter. For example, a therapy evaluation that takes 30 minutes may be billed for one unit, but a therapy evaluation that takes 60 minutes would be billed the same. There is no prohibition in CMS Transmittal 1019 (which since has been incorporated into the Medicare Claims Processing Manual), however, against billing two separate and distinct untimed codes, for example a physical therapy evaluation on the same day as a speech-language pathology evaluation. Additionally, the NCCI edits do not prohibit billing these codes in pairs. But it would appear that DCS has interpreted this practice as one plus one equals two, and therefore is sending demand letters to providers.

Transmittal 1019 refers to codes that only are permitted one unit for "allowed units" in a chart identifying therapy codes that "may be billed no more than once per provider, per discipline, per date of service, per patient." While the chart does have a prohibition against a physical therapist billing for an occupational therapy evaluation, there is nothing to suggest that two therapy evaluations (untimed codes) with different CPT codes cannot be completed and billed on the same day.

A similar issue arose when RAC activity began as Connolly Healthcare, the Region C RAC, was the first to have the issue of untimed codes approved for automated review by CMS. However, Connolly described the issue as follows: for "CPT codes (excluding modifiers KX and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service."

RACmonitor covered this story in two separate articles: Florida Providers Report Seeing Demand Letters, and The RAC Race Has Begun- There is Still Time to Turkey Trot Your Way to Success.

DCS is the RAC covering the following states: Connecticut, Delaware, the District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

Stay tuned for further updates, as well as the Monitor Monday podcast, for additional information as providers weave through the process of dealing with what seems to be a misinterpretation of a Medicare-cited regulation.

For a refresher on avoiding problems with the issue of untimed codes, there are suggestions in the following article: Catch Me If Your Can: Staying Ahead of the RAC Reviews of Untimed Codes.

The June 17, 2010 DCS reference can be reviewed at: http://www.dcsrac.com/IssuesUnderReview.aspx

About the Author

Nancy Beckley is a founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, CORFs, SNFs and private practice. Nancy is certified in healthcare compliance by the Healthcare Compliance Board.  She is on the Board of the National Association of Rehab Providers & Agencies.  She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities.

Contact the Author

nancy@nancybeckley.com

Nancy J. Beckley, MB, MBA, CHC

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practices. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, where she serves as a senior national correspondent.

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