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CMS Chapter 15: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
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0:00
All right guys, Tony Maritato here. Welcome to the Medicare Minute. In this episode we're going to
0:05
talk about a situation in which you have a patient who wants to come see you. This patient's a
0:11
Medicare beneficiary but they do not have a physician referral. What do you do? Your state
0:18
practice act might say that you're allowed to treat this patient through direct access. However
0:23
that does not mean the payer is going to reimburse you for the visit. So let's look at the Medicare
0:30
guidelines. We're going to jump into chapter 15, the Medicare Benefit Policy Manual. We're going to
0:35
go specifically to page 186 in the PDF and we're going to see what Medicare says about providing
0:43
an evaluation only to a Medicare beneficiary who has a physician referral and what documentation
0:51
is required and then what documentation is required when the patient does not have a
0:57
physician referral. So guys, take a look at my screen and let's go through this word by word
1:03
So when the evaluation serves as a plan of care, and the plan of care is really the important
1:09
thing here. The plan of care is what needs to be certified for Medicare beneficiaries
1:14
So when an evaluation is the only service provided by the supplier in an episode of
1:20
treatment the evaluation serves as the plan of care if it contains a diagnosis and in states where
1:28
you're not allowed to diagnose the patient you have to have the description of the condition
1:33
from which the diagnosis may be determined by the referring physician okay the goal the frequency
1:40
the duration of treatment are implied in the diagnosis and the fact that it's a one-time
1:45
service. The fact that you're doing just an evaluation, there really is no frequency, right
1:51
It one There is no duration It the evaluation And the goal is to get an evaluation That it So you don have to have that stuff in the documentation The referral of the physician is the certification that the evaluation is needed
2:12
and the patient is under the care of a physician. Those are the Medicare requirements
2:18
that it's medically necessary, and that the patient is under the care of a physician
2:23
therefore when the evaluation is the only service being provided the referral and the evaluation
2:33
itself are the only pieces of documentation that are required for reimbursement now if the patient
2:41
presents without a referral and does not require treatment so you're still only doing the evaluation
2:48
but they don't have a physician referral. The physician referral or certification of the evaluation
2:55
is required for a payment. So now you have two options. Patient walks in your door
3:01
Maybe this was a patient that you had treated months ago or a couple of years ago, and they know you
3:06
they like you, they trust you. They wanna come back to you for care
3:10
Something's going on, they're not sure what to do, and they want an evaluation. Okay, so they reach out to you
3:16
You get them on the schedule. you get them in the clinic or you go to their home and they don't have a physician referral
3:22
You have two options. Either you write up your evaluation, you create your plan of care
3:29
which includes your diagnosis and maybe it's a one-time visit because you're just doing the
3:34
evaluation and you send that to the patients, either primary care physician or whomever that
3:42
patient is seen most recently with this complaint. Now, if they haven't seen a physician specifically for this complaint
3:51
hopefully this patient's primary care physician is willing to allow you to send
3:57
over your information from the evaluation and based on that information sign off on your plan of care The other alternative the other option you have is call up the office and request a referral
4:12
Request an order to perform the evaluation. And something like that, basically what it'd be is
4:19
you know, hi, Dr. Smith, this is Tony Maratato. I'm a physical therapist here in Middletown, Ohio
4:26
A patient of yours, Mrs. Jane Smith, is requesting an evaluation for some foot pain that she's been experiencing
4:34
I treated Jane a couple months ago. We have a great relationship
4:39
Would you mind sending over a referral so that I can perform this evaluation
4:46
It's a short conversation like that. It could be a voice message that you leave on the physician's telephone service
4:53
or with their medical assistant, or it could be a written request sent over
4:57
But I can tell you from my practical experience, I find it just much more appealing to just go ahead and do the evaluation, write up that little report and plan of care, send it over to the physician
5:13
And in 18 years, I think I've had two that refused to sign it because there were other comorbidities and concerns related to that patient
5:23
You know, so the big picture here is just because your state allows direct access, that does not mean that the payer is required to reimburse you unless you follow both the payer guidelines and the state practice act guidelines
5:44
And so here Medicare is telling you that if you have the order, the referral, you do the evaluation, your documentation is complete
5:53
If you do not have the order, then you either get an order or you have the plan of care certified by the referring physician
6:04
And now you covered Your services will be reimbursed If you provide treatment on the same day as the evaluation so patient comes to you they have plantar fasciitis you going to evaluate them
6:20
create a treatment plan give them some home exercises and it's still just a one-time session
6:27
but you decided we're going to do some hands-on maybe I don't know you're going to do whatever
6:31
intervention you love to do for that specific condition now the order is no longer enough
6:39
now you do need a plan of care and you need to have that plan of care sent to the referring
6:45
physician and certified because most likely what you ended up doing in the treatment for that
6:52
session was not covered by the referral or the order okay so that's the bonus tip i didn't intend
6:59
to do that, but we got in there anyway. So the bonus tip is if you do more than just the evaluation
7:07
even if the patient has a referral, the referral probably doesn't cover the treatment you're going
7:12
to provide. Certainly it's not going to have goals and the other requirements within the plan of care
7:19
So just write it up, send over a plan of care. The plan of care doesn't need all that much
7:24
information, but this way you've got it certified, you're covered, and you will receive reimbursement
7:31
for that session. Guys, I hope that sheds some light on the difference between direct access
7:36
from a state practice act perspective and direct access as it relates to payer regulations and
7:44
payer guidelines. Because just because you can do something doesn't mean you're going to get paid
7:49
to do that something. Guys, if you haven't subscribed, please take a minute, subscribe to
7:54
the video. Let me know what other topics you want covered. I'm just going to keep working through
7:59
these regulations until somebody says, hey, Tony, I've got a problem with this. What do I do about it
8:04
If you can ask those questions, it helps me produce better content for you
8:09
Otherwise, guys, I'll see you in the next video. Thanks for watching
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