A question I often receive is can I bill and be paid for an evaluation or reevaluation (CPT codes 97161-97168) and a physical performance test and measurement (CPT code 97750) when provided on the same date of service by the same discipline? To obtain the answer, we must refer to the
Archives for May 13, 2019
Last week, the Office of the Inspector General (OIG) published 3 enforcement actions involving physical therapy. I will provide a brief summary of the 3 enforcement actions and a link to each action.
In the first enforcement action, physical therapist Hatem Behiry was found guilty of participating in a $30 million scheme to defraud Medicare and the New York State Medicaid Program. Per the OIG report, Hatem Behiry “pretended to provide physical therapy to many of those same patients, most of whom were receiving cash kickbacks for coming to the Clinics”. In addition, BEHIRY “also prepared and oversaw the preparation of a huge quantity of phony medical and billing records. Among other things, BEHIRY completed thousands of fabricated reports, in which patients were described almost identically, and with little or no regard for actual medical conditions or needs. As with MATHIEU, many of the charts were for patients whom BEHIRY and his team had not evaluated or provided therapy to at all”. To read the report, click HERE.
In the second enforcement action, physical therapist Garrett Okubo was sentence to 3.5 years in prison for committing health care fraud. For almost 7 years, Mr. Okubo submitted claims to TRICARE, Medicare and Medicaid for physical therapy services that he claimed he had personally provided, when in fact, the services were provided by his staff who were not licensed physical therapists or physical therapist assistants. To read the report, click HERE.
In the third enforcement action, Carolina Physical Therapy & Sports Medicine, Inc. agreed to pay $790,000 to resolve false billing allegations. Per the OIG report, “The United States contended that Carolina PT knowingly submitted claims to Medicare and TRICARE for services provided to multiple patients simultaneously as though the services were being provided by a physical therapist or physical therapist assistant to one patient at a time. As a result, Carolina PT received higher reimbursements than it would have if it had accurately represented the services. Additionally, the United States contended that Carolina PT knowingly submitted claims to Medicare and TRICARE for services provided by physical therapy assistants who were not supervised by a physical therapist, as required. Finally, the United States contended that Carolina PT knowingly submitted claims for attended electrical stimulation services when those services were in reality not attended by a licensed therapist or assistant and should have been billed as a lower cost unattended electrical stimulation service”.
This case was initiated due to a lawsuit brought by a former employee of the company, Hilary Moore, under the qui tam or whistleblower provisions of the False Claims Act, which permit private citizens to bring lawsuits on behalf of the United States and share in any recovery. Per the OIG report, “Moore will receive $142,200 from the settlement, and her attorneys will recoup fees from Carolina PT in the amount of $38,000”. To read the report, click HERE.
The above 3 enforcement actions stresses the importance of compliance and education in the areas of documentation, coding, billing and supervision requirements of physical therapist assistants. In addition, it’s extremely important to have policies and procedures in place to address these areas and what is your process when an employee brings a concern to you.