Plan of Care (POC) and Its Importance in a RAC Audit
The Plan of Care (POC) is what will make or break you in an audit. Physical Therapists often get hurt during the RAC audit when their POC is not well documented and/or in some cases even adhered to. It really comes down to how you document a medical necessity.
When CMS first starts the audit, they will take a few charts. When they see problems with the POC on a recurring basis, that will instantly set off a series of demands for more charts.
Understanding the 8 Minute Rule
The 8 Minute Rule tells us that you can only bill a maximum of 4 units per hour. But we need to admit that not all sets of 8 minutes were created equally.
Key Considerations:
- Are you seeing multiple patients at the same time?
Medicare clearly states that total billable time is decreased when you are going back and forth between patients. - Are you seeing Medicare and private patients at the same time?
Again, Medicare does not allow Physical Therapists to go back and forth between Medicare and private payees. - Do you provide skilled intervention or a maintenance program?
The key here is that the patient needs to keep making progress.- If they are not making progress, make sure you’re easing the POC every 3–4 weeks.
- Then, tell them to see their doctor to get a new prescription.
Red Flags to Avoid
Red Flag: Watching your patients exercise is not billable.
Red Flag: Application of heat is not a billable service in and of itself.
- What if you ask the patient to clench a ball while you apply heat?
That is a therapeutic service, but this falls into a major gray area.
Remember: You cannot bill Medicare for maintenance, but only for skilled intervention.
Frequently Asked Questions
What is the role of the Plan of Care (POC) in a RAC audit?
The POC is central to demonstrating medical necessity during a RAC audit. Poor documentation or failure to follow the POC can trigger broader audits and potential recoupment of payments.
Why does the 8 Minute Rule matter for physical therapists?
The 8 Minute Rule governs billing practices, allowing a maximum of 4 billable units per hour. Misapplying this rule, especially when treating multiple patients, can lead to billing discrepancies and audit risks.
Can I bill Medicare for services provided to multiple patients at once?
No. Medicare does not allow therapists to bill for time spent switching between patients, whether they are all Medicare beneficiaries or a mix of Medicare and private pay.
What’s the difference between skilled intervention and a maintenance program?
Skilled intervention requires the patient to show measurable progress, making it billable. Maintenance programs, on the other hand, are not reimbursed by Medicare unless progress is being documented consistently.
Is applying heat therapy a billable service under Medicare?
No, applying heat alone is not billable. However, if it is part of a skilled intervention, like engaging the patient in an active task during application, it may qualify, though it remains a gray area and should be documented carefully.