October 2015 Newsletter

PRESIDENTS COLUMN
CONTENT
President Eric Tarrs
Column
Insurance News
Update
Fall Conference
Update
WV Medicaid MCOs
Foundation for PT
Fundraiser Recap

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.
Im 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).

 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.

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, youre
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 physicians order for the first 20 PT
visits according to Christine DeRienzo from PEIA. It is incumbent on the
ICD-10 was
provider, however, to determine if the patient has been seen elsewhere,
implemented, October 1,
since those visits will also be counted in the initial 20 visits. If the patient
2015. Look closely at
exceeds 20 visits it will be necessary to have a physicians referral and
EOBs to determine if
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
denials are due to the
also take care of the issue of denials based on the failure of the referral
ICD-10 coding.
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.

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 EOBs 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 patients 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
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one diagnosis code is not sufficient to describe the severity and complexity of the patients 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 providers 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 postprofessional Fellowship in Orthopedic Manual Physical
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.

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.
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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.

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!

SHOULD I BE A PROVIDER FOR WV MEDICAID MCOS?

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 MCOs. So any
credentialing and authorization to serve the MCO patients are now done through those MCOs. Presently
a Medicaid patient can still change MCOs month to month. There is a plan to correct this, but it will take
some time. So frequently verify the patients 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

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 recordbreaking 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 years first place winner was the University of Pittsburgh.
Virginia Commonwealth University earned second place and the The Foundation wishes to thank
University of Miami came in third place. We welcome the
the students of West Virginia
University of Pittsburgh as co-host for the upcoming 2015-2016
University for their strong support
Pittsburgh-Marquette Challenge.

of the Challenge. The recordThe Foundation for Physical Therapy was established in 1979 as
breaking success of the Challenge
a national, independent nonprofit organization dedicated to
improving the quality and delivery of physical therapy care by
would not be possible without
providing support for scientifically-based and clinically-relevant
their valued contribution.
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 Therapys 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 Foundations 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.
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