Red Flags In Physical Therapy RAC Audits

Reg Flags In Physical Therapy RAC Audits
Even if you’re not currently under a RAC Audit, you might be wondering just how to stay out of trouble or not be “flagged” for an audit.  As much as you might have heard about the random nature of an audit, experience tells us that this is not usually the case. In this article we will discuss some of the more obvious red flags in a RAC audit for Physical Therapy clinics (PTC).
One thing to keep in mind is who is going to pay the bill? It is the government. That is why erring on the side of caution is the way to go. However, that no means does that mean work and do not get paid. The red flags outlined below are cautionary areas and service methods that tend to cause overbilling.

  1.  Billing for excessive durations: Is there an end in sight? Billing for excessive durations is common when the PTC uses an approach that mirrors chiropractic care that calls for “keep on coming until it goes away.” However, this does not work for PTC’s.  A proper program/protocol for care will never be so open ended that the care program does not change and/or the patient never gets better. If that is the case, there needs to be a reevaluation and/or a new plan that needs to be implemented.
  2. Reevaluations: The reevaluation or re-examination code 97164 is completely different than a progress note and should not be billed for a progress note. You should only ever bill for a reevaluation if one of the following situations apply:

a)  The PTC’s assessment indicates significant and unanticipated improvement, decline, or change in the patient’s condition or functional status.
b)  The clinical findings come to light
c)  The patients fails to respond to the treatment outlined in the current care plan.
3.  Copay Collection:  You must collect copays! It is illegal, unless,
PTC applies the same criteria to all cases
Last resort (failure to pay)
4.  Double Dipping:  This is the case when two different PT’s are billing the same patient at the same time. Essentially, you just cannot bill separately for the same or different service provided to the same patient at the same time. The PT must limit billing time to the exact length of the session.
5.  Frequent use of the KX modifier
6.  Billing under one PT provider number rather than each separate enrolled PT’s provider number
7. Excessive number of billing codes per session.
Reg Flags In Physical Therapy RAC Audits