1

October 2015 Newsletter

PRESIDENT’S COLUMN ERIC TARR, PT, DPT, MBA, OCS PRESIDENT, WVPTA

It has been such a privilege to serve the WVPTA over the past 17 years.

I first served on a committee for the association in 1998, when Nancy

Tonkin, then Executive Director for the WVPTA, stopped me in the

Capitol, introduced herself and asked me to serve on the State Affairs

Committee as an attempt to wrangle me in as I was angrily addressing

legislators over some physical therapy issues that I did not realize the

Association was already working on. Physical Therapists ability to

influence the regulation of physical therapy and state health concerns

in general seemed miniscule relative to what we know today.

I’m sure you know that we now have physical therapists in the

legislature, non-physical therapist legislators in leadership, and state

department officials that not only listen to our counsel, but also seek

our counsel. As a professional organization, we have matured a great

deal. It is entirely due to the professional and effective

Interim Joint Committee on Health. Pictured above from right to left: Eric Tarr, PT, DPT, MBA, OCS (Policy Advisor to Chairman of

WV Senate Health Committee, Vice Chair of WV Senate Judiciary Committee); Chairman Ryan Ferns, PT, DPT (Chair of WV Senate

Health Committee); Delegate Mick Bates, PT (Delegate for Raleigh County) speaking to Delegate Denise Campbell (Delegate for

Randolph and Pocahontas counties).

CONTENT

President Eric Tarr’s

Column

Insurance News

Update

Fall Conference

Update

WV Medicaid MCO’s

Foundation for PT

Fundraiser Recap

2

involvement of our membership. So this past Monday,

during interims, I had surreal sensation when seeing the

effect of our efforts. If, as an Association member, you’re

not actively seeking to be involved with Association events

and activities, you are missing out on incredible professional

opportunities that in my experience are rare. If you want to

become involved, my advice to is to tag along with someone

who is involved. Volunteer your assistance and time. Those

efforts mature into being sought for your expertise in ways

you may not now know exist.

Congratulations to Dr. Ryan Ferns on Senate President Bill

Cole appointing Ryan to Vice Chairman of the Senate Judiciary Committee. Also congratulations to the

Honorable Mick Bates on his recent appointment by Governor Tomblin to the WV Industrial Council and

his recognition by the APTA to represent physical therapists ability to successfully offer pain control

alternatives to opioids. Finally, I would

like to congratulate our membership on having these gentlemen representing you as a professional

physical therapist at high levels in WV government. I very much look forward to seeing which

Association member will be the next to step up. I bet you can find something that peaks your interest in

the newsletter that follows.

INSURANCE UPDATES SALLY OXLEY, PT, OCS, CHT, CMDT WVPTA Payer Relations Committee Chair

PEIA – “PEIA will no longer require a physician’s order for the first 20 PT

visits” according to Christine DeRienzo from PEIA. It is incumbent on the

provider, however, to determine if the patient has been seen elsewhere,

since those visits will also be counted in the initial 20 visits. If the patient

exceeds 20 visits it will be necessary to have a physician’s referral and

submit it to PEIA. During the West Virginia Payer Forum in October 2014

this issue was discussed with Ted Cheatham, CEO of PEIA. This should

also take care of the issue of denials based on the failure of the referral

and initial evaluation to be accessed together during the payment process.

Highmark – The new practice profile scorecards for PTs were to be sent

out in early October. According to Jamie Ray from Highmark the time has

been extended to January, 2016. PTs and practices are graded on certain criteria and if they make the

grade they will be put in a tier that they would have less stringent requirements for requesting

authorization for visits. If you have questions regarding your results contact Jamie Ray at Highmark.

ICD-10 was

implemented, October 1,

2015. Look closely at

EOB’s to determine if

denials are due to the

ICD-10 coding.

… we now have physical therapists

in the legislature, non-physical

therapist legislators in leadership,

and state department officials that

not only listen to our counsel, but

also seek our counsel.

3

Medicaid – Effective October 1, 2015 APS Healthcare began performing all prior authorizations and

other utilization management functions on behalf of Molina Medicaid. WVMI will no longer be

performing those functions. Effective October 1st all Molina Medicaid patients, traditional plan and

alternative plan must be pre-authorized before initiating treatment. The initial visit does not need to be

pre-authorized.

All Medicaid Expansion Plan (Alternative Benefit Plan or “ALT”) patients were transitioned to a managed

care provider September1, 2015. The plans offered were Coventry Care, Unicare, WV Family Health and

The Health Plan. Prior authorization requirements vary according to the plan. Most patients will require

authorization after the initial evaluation. Patients can change HMOs monthly so providers need to check

insurance cards monthly to ensure they are billing the correct one.

Members of the WVPTA met with Cindy Beane, Acting Director of the WV Bureau of Medical Services and

Director of Medicaid, responding to the proposed changes to their rules. She reported that Medicaid was

going to try to make the pre-authorization requirements uniform for the participating HMOs, simplifying

the process for providers and would also only allow participants to changer HMOs yearly rather than

monthly, as it is now.

Medicare – Medicare is requiring that DMEPOS (durable medical equipment, prosthetics, orthotics and

supplies) providers keep records for 7 years. All providers and suppliers who either furnish, order or

certify DMEPOS items are responsible for maintaining records for seven years and providing them to

Medicare upon request. If they fail to do so, they may be dropped from the program. If PTs supply splints

or orthotics the appropriate code along with the supply, the code for the supply and where they were

sent must be in the documentation.

Medicare has clarified what is required to authorize payment of the re-evaluation code 97002. When a

provider bills the code 97002, it is automatically sent to medical review. An ADR (Additional

Development Request) is sent to the provider that documentation will be reviewed to determine the

description of the item must be in the documentation. If the patients is referred elsewhere to get a

medical necessity for the code. This code should only be used to document a significant change in

condition or functional ability that requires a change in long term goals or treatment plan. This may

occur if the patient has been hospitalized or has made a significant gain in functional status. The change

must be well documented in the re-evaluation note. A re-evaluation is not a routine, recurring service.

As it stands presently, the Medicare exceptions process will be in force until December 31, 2017.

ICD-10 – ICD-10 was implemented, October 1, 2015. Look closely at EOB’s to determine if denials are

due to the ICD-10 coding. All visits completed before October 1st should be submitted with ICD-9 codes.

Visits completed October 1st and after must be submitted with ICD-10 codes. The diagnosis codes do not

have to match the referring physician code to be paid, and in most cases will not be since theirs may be an

initial encounter and ours will be a subsequent encounter. It will only be an initial encounter for PTs if

the patient is direct access and has not been seen by a physician for that problem. ICD-10 coding affords

PTs the opportunity to document the severity and complexity of the patient’s problem. For example, if a

patient is referred for a wrist fracture and they are unsteady walking and have osteoporosis, a code

should be submitted for each of the problems identified. The documentation must support these codes

and may, in fact, be considered if the patient exceeds the $1940.00 cap during treatment. In many cases

4

one diagnosis code is not sufficient to describe the severity and complexity of the patient’s clinical

situation.

CMS has announced that for a one year period starting October1st, 2015 Medicare claims will not be

denied solely on the specificity of the ICD-10 diagnoses codes provided, as long as the provider submitted

an ICD-10 code from the appropriate family of codes. In addition, Medicare claims will not be audited

based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes.

This policy will be followed by the Medicare Administrative Contractors and Recovery Audit Contractors.

CMS will establish an ICD-10 Ombudsman to help receive and triage provider’s problems that need to be

resolved during the transition.

WVPTA FALL CONFERENCE UPDATE KRISSY GRUBLER PT, DPT Education Committee Chair

The WVPTA Fall Conference, Transition from Acute to Chronic Musculoskeletal Pain: Implications for

Physical Therapy, will be held on November 7th, 2015 at Marshall University School of Physical

Therapy. For more information and to register for this course, please use the following

link: http://www.wvpta.org/events/.

This course will offer 7 Contact Hours of Continuing

Education will be presented by Carol A. Courtney, PT, PhD,

ATC. Dr. Courtney is a Clinical Associate Professor at the

University of Illinois at Chicago. She received a Bachelor of

Science in Physical Therapy from Washington University in

St. Louis, Master of Science from the University of South

Australia and Louisiana State University, and a PhD from

the University of Miami. Dr. Courtney is a licensed physical

therapist and athletic trainer, and has been recognized as a

fellow of the American Academy of Orthopaedic Manual

Physical Therapists. At UIC, she is faculty in the Department

of Physical Therapy and serves as the director of the post-

professional Fellowship in Orthopedic Manual Physical

Therapy.

Dr. Courtney has clinical expertise in the management of chronic musculoskeletal pain and sports injury.

In 1991 and 1992, she was chosen to serve on the USA medical staffs for the Pan American Games in

Havana, Cuba, and the Olympic Games in Barcelona, Spain. Her research investigates the effects of knee

joint injury and osteoarthritis on pain processing and joint function, as well as modulation of pain

mechanisms through manual therapy interventions. She has over 80 peer-reviewed publications, book

chapters and conference presentations and has presented both nationally and internationally on this

research. Dr. Courtney serves as co-chair of the Standards Committee of the American Academy of

Orthopaedic Manual Physical Therapists and is a deputy editor of the Journal of Manual and Manipulative

Therapy.

The WVPTA Fall Conference,

Transition from Acute to

Chronic Musculoskeletal

Pain: Implications for Physical

Therapy, will be held

on November 7th, 2015 at

Marshall University School of

Physical Therapy.

5

Course Description: Our understanding of musculoskeletal pain has expanded greatly in recent years. In

fact, some researchers and clinicians have suggested that we should be making a ‘pain diagnosis,’

indicating that there may be clinical correlates in the patient presentation that relate to specific

alterations in pain processing. This course will discuss some of these clinical features of acute and chronic

pain, including both psychological and physical findings. In addition, this course will discuss how some of

our typical physical therapy interventions influence nociceptive processing. Finally, the physical therapist

role as ‘pain modulator’ will be discussed.

SHOULD I BE A PROVIDER FOR WV MEDICAID MCO’S? ERIC TARR, PT, DPT, MBA, OCS PRESIDENT, WVPTA

Delegate Mick Bates, Chairman Ryan Ferns, and I met with Karen Bowling, Secretary of the Department of

Health and Human Resources, then subsequently with Cynthia Beane, MSW, LCSW, Acting Commissioner

for the Bureau for Medical Services to discuss our concerns with difficulties physical therapy providers

have been reporting in credentialing and authorization with Medicaid. Both Secretary Bowling and

Acting Director Beane were very helpful.

As of September 1st, all Medicaid patients except those that receive SSI, IDD Waiver, Medicare as a

primary, and patients in a nursing home or long term care are now covered by MCO’s. So any

credentialing and authorization to serve the MCO patients are now done through those MCO’s. Presently

a Medicaid patient can still change MCO’s month to month. There is a plan to correct this, but it will take

some time. So frequently verify the patient’s payer.

Acting Director Beane provided us the following Matrix:

CLICK HERE TO ACCESS THE FULL DOCUMENT or copy and paste the following link:

http://www.wvpta.org/download?path=Miscellaneous%20Downloads/Physical%20Therapy%20Matrix%20OCT2015.pdf

SPRING CONFERENCE UPDATE The WVPTA Spring Conference will be held at Stonewall Jackson Resort April 29 - May 1,

2016.

The WVPTA Golf Scramble is set for April 29th, the Friday of the Spring Conference.

Details for the Spring Conference and the Annual Golf Scramble to come!

6

PT & PTA STUDENTS BREAK RECORD IN THE 2015 CHALLENGE TO RAISE FUNDS FOR PHYSICAL THERAPY RESEARCH CAROLINE MILLER, SPT & ALLI CZAPLEWSKI, SPT

In support of the Foundation for Physical Therapy, a total of 146 schools participated in the record-

breaking 2014-2015 Miami-Marquette Challenge. The Challenge raised $275,423, the highest annual

total in the history of the fundraiser. Thanks to the participation of PT and PTA students from 235

different schools the Challenge has now raised over three million dollars since its inception in 1989!

The Foundation wishes to thank the students of West Virginia University for their strong support of the

Challenge. The record-breaking success of the Challenge would not be possible without their valued

contribution.

This year’s first place winner was the University of Pittsburgh.

Virginia Commonwealth University earned second place and the

University of Miami came in third place. We welcome the

University of Pittsburgh as co-host for the upcoming 2015-2016

Pittsburgh-Marquette Challenge.

The Foundation for Physical Therapy was established in 1979 as

a national, independent nonprofit organization dedicated to

improving the quality and delivery of physical therapy care by

providing support for scientifically-based and clinically-relevant

physical therapy research and doctoral scholarships and

fellowships. The annual Marquette Challenge is a grassroots

fundraising effort coordinated and carried out by physical

therapist and physical therapist assistant students across the country to support the Foundation for

Physical Therapy’s mission.

Jan Hughes-Austin, PT, MPT, PhD, a post-doctoral fellow in the Department of Family and Preventative

Medicine at the University of California, San Diego, is the recipient of the 2014 Miami-Marquette

Challenge Research Grant. Her project will examine first-degree relatives of patients with rheumatoid

arthritis; specifically, their vertebral bone mineral density, inflamed joints, and physical activity will be

studied. The Challenge also funded a PODS Scholarship in 2015, which went to Trevor Lentz, PT, MPT, of

the University of Florida.

Students of all PT and PTA programs in the state of West Virginia are encouraged to support the

Foundation for Physical Therapy and physical therapy research. To learn how you can support the

Challenge, please visit the Foundation’s Web site at www.Foundation4PT.org/, call the Foundation at

800/875-1378, or email Marquette student coordinators at Challenge4PT@gmail.com. Contributions for

the 2015-2016 Pittsburgh-Marquette Challenge should be submitted by April 21, 2016.

The Foundation wishes to thank

the students of West Virginia

University for their strong support

of the Challenge. The record-

breaking success of the Challenge

would not be possible without

their valued contribution.