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  • Correction to Applying Therapy Caps to Maryland Hospitals and Billing Requirement for Rehabilitation Agencies and Comprehensive Outpatient Rehabilitation Facilities (CORFs)

Correction to Applying Therapy Caps to Maryland Hospitals and Billing Requirement for Rehabilitation Agencies and Comprehensive Outpatient Rehabilitation Facilities (CORFs)

4 Feb 2016 1:56 PM | Zachary Edgar (Administrator)

February 4, 2016

This Change Request (CR) modifies the requirements of CR 9223 to ensure therapy caps are applied correctly to claims from certain Maryland hospitals.

Background:Change Request (CR) 9223 applied the therapy caps and related policies to Maryland outpatient hospital claims (Types of Bill 012x and 013x submitted with CMS Certification Numbers (CCNs) beginning with 21). The CR applied cap amounts based on the submitted charge amount on covered outpatient therapy service lines, before applying coinsurance or deductible. This is the correct application of the cap amounts for the majority of Maryland hospitals.

However, certain specialty hospitals in Maryland are not paid under the Maryland All-Payer Model. These hospitals are paid for therapy services using the Medicare Physician Fee Schedule (MPFS) amounts. The therapy cap amounts for these claims should be the MPFS amount, before applying coinsurance or deductible, not the submitted charge. Since these hospitals also have CCNs beginning with 21, the implementation of CR 9223 caused Medicare systems to begin using the submitted charge amount instead.

As a result of this error, the therapy cap and threshold totals for beneficiaries served by these specialty hospitals is incorrect. In many cases the totals may be overstated. The requirements below correct the error in Medicare systems and instruct the Medicare Administrative Contractors to adjust claims to correct the therapy cap totals for affected beneficiaries.

Additionally, this CR adds instructions to the Medicare Claims Processing Manual to add a new billing requirement for rehabilitation agencies and CORFs when these providers operate multiple sites in differing payment localities as determined by the MPFS. These MPFS payment localities are determined by the 9- digit ZIP code where services are provided. .

Policy:For MD hospitals, this CR contains no new policy. It corrects the implementation of the policy established in CR 9223.

This CR adds a new billing requirement policy for rehabilitation agencies and CORFs. When rehabilitation agencies and CORFs furnish a service in an off-site location that is in a different 9-digit ZIP code from that of the primary or parent location, the off-site location ZIP code must be reported on the claim. Since these providers are paid subject to the MPFS, the new billing requirement ensures that payments are adjusted based on the applicable payment locality. Until now, rehabilitation agencies and CORFs did not have a mechanism to accurately report the 9-digit ZIP code for the services they provide in off-site locations with differing payment localities. Where a rehabilitation agency or CORF has only one service location, the ZIP code of the primary site of record is used as the MPFS payment locality.

Reference

Medicare Transmittal # R3454CP

February 4, 2016


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