Help! Medicare rejected my claim — now what?
By Erica Cohen

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So, you submitted a claim lacking functional limitation reporting to Medicare after July 1. Uh-oh. By now, you've probably received a polite rejection letter telling you that Medicare will not be providing you with reimbursement for your services — and neither will the beneficiary.


Have you received a rejection letter from Medicare?
  • 1. Yes
  • 2. No

What's a PT, OT or SLP to do? Well, unless you actually completed a full functional limitation assessment during your patient's evaluative visit and simply forgot to include the corresponding G-codes and severity modifiers, the answer is: nothing. Unfortunately, going back now and changing anything on your documentation to ensure payment is a very, very bad idea. Just ask compliance expert Tom Ambury, who points out that the federal government has won several recent court cases against providers who created inaccurate or unjustifiable documentation — even on accident. Here's what Ambury has to say about one such case in his latest Compliance Chat:
"A U.S. Court of Appeals decision recently upheld the conviction of a provider who had documented inaccurately in the medical record. The provider was found guilty of making false statements relating to healthcare matters, even though Medicare never reviewed the documentation. The provider testified that they were extremely busy and sometimes waited weeks or even months to complete the documentation, which ended up containing inaccurate information."
Ambury also writes:
"It appears from the decision that the False Medical Record statute does not require for there to be a specific intent on the part of the creator of the medical record to deceive or mislead. The information in the medical record just needs to be inaccurate. Conviction under the False Medical Record statute carries penalties of up to five years in prison and financial penalties."
Let's face it: There's no way going back and changing your documentation is worth the risk. Instead, on your patient's next visit — regardless of the visit type — complete and submit functional limitation reporting, and you'll be back on track — albeit a little short on overall reimbursements. This might feel like a hard pill to swallow, but it certainly beats facing an audit, trial and possible jail time.

"Let's learn our lessons as we go, lick our wounds as we need to, and keep moving forward. After all," Ambury says, "our industry is constantly changing and these are life-long learning lessons."

Now, if you did in fact identify your patient's primary functional limitation, complete an outcome measurement tool and document appropriately during the episode of care, you can create an addendum containing the missing G-codes and severity modifiers and resubmit. However, adding an addendum could create red flags for Medicare — so be sure your documentation is in tip-top, super-defensible shape. If you're not confident in adding an addendum, inquire with your local MAC or a compliance consultant on what steps you should take from here.

In the spirit of moving forward, I'll leave you with a few more pieces of advice. To ensure you always receive appropriate reimbursement:
  • Document well during the episode of care.
  • Complete periodic internal documentation audits to ensure defensibility.
  • File your claims in a timely manner.
  • Stay up to date on the latest in reporting regulations and legislation.
  • Seek out a reputable source for compliance information and ask a lot of questions.
Erica Cohen is a writer and editor with experience in both the healthcare and technology industries. After graduating summa cum laude from Arizona State University, Erica obtained her Master of Arts from the University of Chicago in social science. She currently runs her own writing company in San Francisco, and penned this article for WebPT, cloud-based EMR software designed specifically for the rehab community.