No Prior Authorizations Required
Effective 1/1/25, there will be no prior authorization requirement for Medicaid-covered outpatient physical therapy (PT), occupational therapy (OT), and speech language pathology (ST) services for Vermont Medicaid members under the age of 21. For adult members, the threshold for combined outpatient PT/OT/ST services per calendar year will increase from 30 to 60 visits per calendar year before prior authorization is required.
Primary Care Provider Endorsement for Physical, Occupational, and Speech Therapy Services
Effective 12/1/24, primary care provider endorsement for Physical, Occupational, and Speech Therapy (PT/OT/ST) services will no longer be required on DVHA PT/OT/ST prior authorization request forms.
Providers are expected to maintain clinically appropriate documentation, including MD orders, in members’ charts to support evidence of medical necessity.
Audits
Jeff Albertson of the APTA VT spoke with the VT Medicaid special investigations unit performing the audits.
When choosing which clinics to audit, they are looking for “outliers” within the large volume of claims that are generated. They selected ~ 10 providers. Selected ~ 10-15 records per provider. They reviewed both coding and documentation. A larger audit was not triggered if problems were found.
Most common findings were:
27% There was an evaluation code on claim but documentation existed that an eval was performed.
36% – Not documentation of time codes – Must be time for each CPT code AND total time of the visit
51% – there was insufficient detail within documentation to support the CPT code that was chosen. Ex. a CPT code was billed and little to no information was there to support it.
At times, they also seeing Lack of Signature on documentation
Take home messages:
- Review CPT codes and make sure that you are using the most appropriate code
- Provide sufficient details to support your CPT code
- Have both total treatment time and amount of time spent for each CPT code in the notes
- Make sure you provide documentation of the evaluation if you are doing an evaluation
- Review each insurer’s specific requirements for documentation in the PDFs provided
Resources organized by APTA VT leaders:
- BCBS Physical Therapy/Medicine Corporate Medical Policy
- Vermont Medicaid Physical Therapy/Occupational Therapy/Speech Language Therapy Supplement
- Medicare Claims Processing Manual Chapter 5 – Part B Outpatient Rehabilitation and CORF/OPT Services
- Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services
Resources: provided by DVHA
- Gainwell Provider Services: providers can reach out to find their specific Provider Representative at 802 925 1706
- Review the many DVHA provider manuals, available at: https://dvha.vermont.gov/providers/manuals. The following may be particularly useful:
http://www.vtmedicaid.com/assets/manuals/PT_OT_STSupplement.pdf
http://vtmedicaid.com/assets/manuals/CMS1500UB04BillingGuide.pdf
http://www.vtmedicaid.com/assets/manuals/GeneralBillingFormsManual.pdf - The national professional organization has wonderful assistance with information about best practices in documentation, billing and coding:
https://www.apta.org/siteassets/pdfs/policies/guidelines-documentation-patient-client-management.pdf https://www.apta.org/your-practice/documentation - Coming soon: an updated selection of power point presentations including presentations that are specific to adult and pediatric therapy. They will be available on the Vermont Medicaid portal shortly.
- Attached is the July 2023 Advisory that was published specific to the Therapy audit. This document also has some helpful information as to what the auditors were looking for and what they found during the audit process. Therapists can use this information when reconsidering their current documentation and billing practices.
