Medicare and Reimbursement for Falls-Related Services
Medicare pays for services that are considered medically necessary and reasonable. While there is no single benefit, provider, or procedure for falls, clinicians treating older adults with symptoms predisposing them to falls could receive Medicare-reimbursement and/or incentive (PQRI) payment if the services they provide are medically necessary, reasonable, and billed appropriately.
Physician Quality Reporting Initiative
Physician Quality Reporting System (PQRS) is a voluntary program that can help healthcare providers identify people at risk for falls that might be in need of follow-up services. The Tax Relief and Health Care Act of 2006 authorized the establishment of a physician quality reporting system, which CMS had previously called the Physician Quality Reporting Initiative (PQRI).
Eligible professionals, including physicians, nurse practitioners, physician assistants, occupational and physical therapists, and other practitioners providing services whom are paid under the Medicare Physician Fee Schedule voluntarily reported on a set of quality measures through the Medicare claims they submitted. Professionals who successfully report on measures are eligible for incentive payments.
The PQRS presents an opportunity for providers to screen patients for falls risk and provide follow-up care if medically necessary and reasonable. 2012 PQRS fall-related measures are as follows:
154. Falls: Risk Assessment: Percentage of patients 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months
155. Falls: Plan of Care: Percentage of patients aged 65 years and older with a history of falls who had a plan of care documented within 12 months.
For more information on the specifications for reporting this measure, go to: http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage
The AMA has developed PQRS participation tools to assist clinicians in reporting measures through claims only (not EHR or registry) including an overview of the measures and a data collection sheet that can be accessed at: www.ama-assn.org\go\pqrs-tools
Office Billing
Visit the CMS website for instructions on how to use the CPT II codes that are needed for PQRS or the G codes.
Hospital-Acquired Conditions (Present on Admission Indicator)
Visit the CMS website at:
Falls V-code
The Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) developed a V code to identify older adults who have fallen and are predisposed to recurrent falls. A V code is a type of diagnostic code used to describe a status rather than a specific condition. V codes are most frequently used as secondary diagnoses on a claim, but in some cases may be listed as the principal diagnosis.
The code, V15.88, indicates that the older adult may benefit from a fall risk evaluation and management of fall risk(s). This V-code may be useful for providing further justification of medical necessity and reasonableness for evaluation and management services for time-intensive activities, such as medication review and adjustment, either provided as a result of a falls risk screening conducted as part of the PQRI or not.
Qualification of the Medicare V code 15.88 is based upon the presence and documentation of at least one of the following:
- Recent history of falls in last 6-12 months*
- Health-related falls risk factors*
- Health behaviors related to falls*
*Documentation qualifies for use of Medicare V code 15.88, which is a secondary ICD-9 code to be used with principal ICD- 9 codes. Check with your local Medicare claims processing contractor to find out whether the falls V code can be used as a principal diagnosis on claims.
An ICD-9 code is required for all professional claims, e.g., physicians, non-physician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologist, ambulatory surgical centers (ASCs), and for all institutional claims.