Therapy Comply Medicare Blog and Updates

2025 Final Rule Medicare Physician Fee Schedule

Zachary Edgar — Sat, 02 Nov 2024 00:09:17 GMT

CY 2025 PFS Rate Setting and Conversion Factor

By factors specified in law, average payment rates under the PFS will be reduced by 2.93% in CY 2025, compared to the average amount these services were paid for most of CY 2024. The change to the PFS conversion factor incorporates the 0% overall update required by statute, the expiration of the temporary 2.93% increase in payment for CY 2024 required by statute, and a relatively small estimated 0.02% adjustment necessary to account for changes in work relative value units (RVUs) for some services. This amounts to an estimated CY 2025 PFS conversion factor of $32.35, a decrease of $0.94 (or 2.83%) from the current CY 2024 conversion factor of $33.29.

Supervision Policy for Physical Therapists (PTs) and Occupational Therapists (OTs) in Private Practice

For CY 2025, CMS is finalizing a regulatory change to allow for general supervision of physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) by PTs in private practice (PTPPs) and OTs in private practice (OTPPs) for all applicable physical and occupational therapy services. This finalized change will give PTPPs and OTPPs more flexibility in meeting the needs of beneficiaries and safeguard patient access to medically necessary therapy services, including those experiencing challenges accessing these services in rural and underserved areas, and it will align with general supervision of PTAs and OTAs by PTs and OTs who work in institutional providers.

Certification of Therapy Plans of Treatment with a Physician or NPP Order

For CY 2025, CMS is finalizing amendments to the certification regulations to lessen the administrative burden for therapists (PTs, OTs, and speech-language pathologists (SLPs)) and physician/NPPs. These changes will provide an exception to the physician/NPP signature requirement on the therapist-established treatment plan for purposes of the initial certification, in cases where a written order or referral from the patient’s physician/NPP is on file and the therapist has documented evidence that the treatment plan was transmitted to the physician/NPP within 30 days of the initial evaluation. CMS also solicited comment, as suggested by interested parties, as to the need for a regulation to address the amount of time during which the physician/NPP who signed the written order for therapy services could make changes to the therapist-established treatment plan by contacting the therapist directly, but CMS did not adopt such a timeline restriction. Instead, CMS clarified that, for the cases meeting the exception to the signature requirement policy, payment should be made available for any therapy services furnished prior to a physician/NPP-modified treatment plan if all payment requirements are met. The comment solicitation as to whether there should be a 90-day (or other) limit to the physician/NPP order extending from the order date to the first date of treatment/evaluation by the therapist did not result in a policy being adopted by CMS.

Reference

CMS Newsroom

Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule

2025 Proposed Medicare Physician Fee Schedule

Zachary Edgar — Thu, 11 Jul 2024 17:51:55 GMT

Payment Rate Cut

Average payment rates under the PFS are proposed to be reduced by 2.93% in 2025 compared to the average amount these services are being paid for most of 2024. The change to the PFS conversion factor incorporates the 0.00 percent overall update required by statute, the expiration of the 2.93% increase in payment for 2024 required by statute, and a relatively small estimated 0.05% adjustment necessary to account for changes in work relative value units (RVUs) for some services. This amounts to a proposed estimated 2025 PFS conversion factor of $32.36, a decrease of $0.93 (or 2.80%) from the current 2024 conversion factor of $33.29.

Supervision Policy for Physical Therapists (PTs) and Occupational Therapists (OTs) in Private Practice

CMS is proposing a regulatory change to allow for general supervision of physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) by PTs in private practice (PTPPs) and OTs in private practice (OTPPs) for all applicable physical and occupational therapy services.

General supervision means that supervising PTs and OTs can be off-site while PTAs and OTAs treat patients, therapists must be available by phone.

This proposed change will give PTPPs and OTPPs more flexibility in meeting the needs of beneficiaries and safeguard patient access to medically necessary therapy services, including those experiencing challenges accessing these services in rural and underserved areas; and it will align with general supervision of PTAs and OTAs by PTs and OTs who work in institutional providers.

Certification of Therapy Plans of Treatment with a Physician or NPP Order

CMS is proposing amendments to the certification and recertification regulations to lessen the administrative burden for therapists and physician/NPPs. These changes, if finalized, would provide an exception to the physician/NPP signature requirement on the therapist-established treatment plan for purposes of the initial certification in cases where a written order or referral from the patient’s physician/NPP is on file and the therapist has documented evidence that the treatment plan was transmitted to the physician/NPP within 30 days of the initial evaluation.

CMS is also soliciting comments, as suggested by interested parties, as to the need for a regulation addressing the amount of time during which the physician/NPP who has written an order for therapy services could make changes to the therapist-established treatment plan by contacting the therapist directly, and whether there should be a 90-day (or other) limit to the physician/NPP order extending from the order date to the first date of treatment/evaluation by the therapist.

Lymphedema Compression Treatment Items

Zachary Edgar — Wed, 01 May 2024 15:07:42 GMT

Coverage

Coverage of lymphedema compression treatment items is available as of January 1, 2024 for treating beneficiaries with any diagnosis of lymphedema. The lymphedema compression treatment items must be prescribed by a physician (or a physician assistant, nurse practitioner, or a clinical nurse specialist. Coverage of lymphedema compression treatment items for any non-lymphedema diagnosis is not allowed. The items must be furnished by an enrolled DMEPOS supplier. All suppliers, including physical therapists and other practitioners furnishing bandaging systems must be enrolled as a DMEPOS supplier to be paid under Medicare Part B for furnishing lymphedema compression treatment items.

The following categories of lymphedema compression treatment items are covered when determined to be reasonable and necessary for the treatment of lymphedema:

Standard daytime gradient compression garments
Custom daytime gradient compression garments
Nighttime gradient compression garments
Gradient compression wraps with adjustable straps
Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of a gradient compression garment or wrap
Compression bandaging supplies
Other items determined by CMS to be lymphedema compression treatment items under the benefit category determination process. These procedures consider public consultation via public meetings and in writing for new lymphedema compression treatment items.

With respect to lymphedema compression treatment items:

Custom fitted gradient compression garment means a garment that is uniquely sized and shaped to fit the exact dimensions of the affected extremity or part of the body, of an individual to provide accurate gradient compression to treat lymphedema.
Gradient compression means the ability to apply a higher level of compression or pressure to the distal (farther) end of the limb or body part affected by lymphedema with lower, decreasing compression or pressure at the proximal (closer) end of the limb or body part affected by lymphedema.

Replacements and Frequency Limitations

Payment for replacement of lymphedema compression treatment items can be made for garments or wraps that are lost, stolen, or irreparably damaged.

If a patient’s medical condition has changed enough to warrant the need for a new size or type of garment or wrap, payment can be made for the new garment or wrap.

Except for replacements of lymphedema compression treatment items addressed above, no payment may be made for gradient compression garments or wraps with adjustable straps furnished other than at the following frequencies:

Three (3) units of daytime gradient compression garments or wraps with adjustable straps per affected extremity or part of the body once every six (6) months.
Two (2) garments for nighttime use per affected extremity or part of the body once every two (2) years.

There are no set frequency limitations for compression bandaging supplies. The DME MACs have discretion to determine the replacement and frequency of compression bandaging supplies that are reasonable and necessary.

Reference

Medicare Benefit Manual. Chapter 15 – Covered Medical and Other Health Services § 145

Congress Reduces Medicare Rate Cut

Zachary Edgar — Sat, 09 Mar 2024 18:22:57 GMT

The Consolidated Appropriations Act, 2024 (H.R. 4366) will reduce Medicare Part B cuts from 3.4% to 1.7% for the remainder of 2024.

When signed into law this will effectively increase current payments rates by 1.7% compared to rates so far in 2024.

Expect rate increases in either April or May.

Physician Fee Schedule 2024 Final Rule - Therapy Servicws

Zachary Edgar — Fri, 03 Nov 2023 16:35:12 GMT

CY 2024 PFS Ratesetting and Conversion Factor

Overall payment reduction of 1.25% in 2024.

By factors specified in law, overall payment rates under the PFS will be reduced by 1.25% in CY 2024 compared to CY 2023. CMS is also finalizing significant increases in payment for primary care and other kinds of direct patient care.

The final CY 2024 PFS conversion factor is $32.74, a decrease of $1.15 (or 3.4%) from the current CY 2023 conversion factor of $33.89.

Supervision Policy for Physical and Occupational Therapists Assistants in Remote Monitoring

Therapy assistants do not need on-site supervision for remote monitoring services.

Since 2005, CMS has required PTs and OTs in private practices (PTPPs and OTPPs, respectively) to provide direct supervision of their therapy assistants. CMS is finalizing a regulatory change to allow for general supervision of therapy assistants by PTPPs and OTPPs for remote therapeutic monitoring (RTM) services.

Supervision Policy for Physical and Occupational Therapy Assistants in Private Practice

No Change.

In the proposed rule, CMS solicited comments on whether to revise the current direct supervision policy for therapy assistants working with PTPPs and OTPPs to require general supervision for all therapy services, not just for RTM services. In particular, CMS sought feedback and any available supporting data on the potential effects of implementing such a policy, including but not limited to patient quality of care, patient safety, and changes in utilization. CMS received feedback in response to all of the questions and will take it into consideration for future rulemaking.

Payment for Outpatient Therapy Services when Furnished by Institutional Staff to Beneficiaries in Their Homes Through Communication Technology

Institutional providers are able to continue to bill for physical therapy, occupational therapy, speech-language pathology, DSMT and MNT services on the telehealth list furnished remotely the same way that they could during the PHE through the end of CY 2023. CMS is finalizing the proposed policy that — with the addition of a requirement to use the 95 modifier on all claims, except Method II critical access hospitals (CAHs), and — to note specifically for outpatient hospitals that patients’ homes no longer need to be designated as provider-based entities — CMS continues to allow institutional providers to bill for outpatient therapy, DSMT, and MNT services furnished remotely at least through the end of CY 2024.

Reference

Centers for Medicare & Medicaid Services

Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule

Home Health Final Rule - Lymphedema Compression Garments

Zachary Edgar — Thu, 02 Nov 2023 16:34:15 GMT

Lymphedema Compression Treatment Items

Section 4133 of the CAA, 2023 establishes a Medicare Part B benefit for standard and custom-fitted gradient compression garments and other compression treatment items for the treatment of lymphedema that are prescribed by an authorized practitioner.

Compression garments for treatment of lymphedema have not been previously covered by Medicare because, prior to the enactment of the CAA, 2023, there was no statutory benefit category for such items. This rule addresses the scope of the new benefit by defining what constitutes a standard- or custom-fitted gradient compression garment and identifying other compression items used for the treatment of lymphedema that fall under the new benefit category, beginning January 1, 2024.

The rule sets forth Medicare payment for gradient compression garments for both daytime and nighttime use as well as ready-to-wear, non-elastic, gradient compression wraps with adjustable straps and compression bandaging systems applied in a clinical setting as part of phase one decongestive therapy as well as during phase two maintenance therapy. The rule establishes that Medicare will pay for an increase in daytime garments over the amount previously proposed.

Medicare will pay for three daytime garments every six months and two nighttime garments every two years for each affected extremity or part of the body. This rule establishes the initial Healthcare Common Procedure Coding System (HCPCS) codes and the payment methodology for these items and outlines how future coding, benefit category, and payment determinations for these items will be made.

The payment basis that we are finalizing for lymphedema compression treatment items approximates the payment methodology by the Department of Veterans Affairs, which is the average Medicaid State agency payment amounts plus 20 percent. In the event that Medicaid State agency payment rates are not available, payment rates will be based on the average of payment amounts established by TRICARE and internet retail prices.

If neither Medicaid nor TRICARE payment amounts are available, Medicare payment rates will be based on the average internet retail prices for a lymphedema compression treatment item.

Medicare 2024 Proposed Physician Fee Schedule Changes to Assistant Supervision

Zachary Edgar — Fri, 14 Jul 2023 18:10:11 GMT

Supervision Policy for Physical and Occupational Therapists in Private Practice

Since 2005, CMS has required PTs and OTs in private practices (PTPPs and OTPPs, respectively) direct supervision of their therapy assistants. CMS is proposing a regulatory change to allow for general supervision of their therapy assistants by PTPPs and OTPPs for remote therapeutic monitoring (RTM) services. This will align with the RTM general supervision policy that CMS finalized in CY 2023 rulemaking.

CMS is also soliciting comments on whether to revise the current direct supervision regulatory policy for PTPPs and OTPPs of their therapy assistants to the general supervision policy for all services, not just for RTM services. CMS is particularly interested in receiving comments, including any available supporting data, on the potential effects of implementing such a policy, including but not limited to patient quality of care, patient safety, and changes in utilization.

Calendar Year (CY) 2024 Home Health Prospective Payment System Proposed Rule

Zachary Edgar — Fri, 30 Jun 2023 17:15:20 GMT

On June 30, 2023, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2024 Home Health Prospective Payment System (HH PPS) Rate Update proposed rule, which would update Medicare payment policies and rates for Home Health Agencies (HHAs). This rule proposes a permanent, prospective adjustment to the CY 2024 home health payment rate to account for the impact of the implementation of the Patient-Driven Groupings Model (PDGM). This adjustment accounts for differences between assumed behavior changes and actual behavior changes on estimated aggregate expenditures due to the implementation of the PDGM and 30-day unit of payment as required by the Bipartisan Budget Act of 2018, which amended section 1895(b) of the Social Security Act (the Act). CMS previously finalized, for CY 2023, a permanent adjustment that was half of the estimated required permanent adjustment.

In addition, CMS is also proposing to rebase and revise the home health market basket; revise the labor-related share; recalibrate the PDGM case-mix weights; update the low utilization payment adjustment (LUPA) thresholds, functional impairment levels, and comorbidity adjustment subgroups for CY 2024; codify statutory requirements for disposable negative pressure wound therapy (dNPWT), and establish regulations to implement payment for items and services under two new benefits: lymphedema compression treatment items and home intravenous immune globulin (IVIG). The actions CMS is taking in this proposed rule would help improve patient care and also protect the Medicare program’s sustainability for future generations. In addition, the proposed rule includes several hospice-related enrollment provisions. We believe these provisions would help protect hospice beneficiaries by more closely scrutinizing hospice owners and ensuring that they do not pose program integrity risks.

CY 2024 Proposed Payment Updates and Policy Changes Updates for Home Health Agencies

This rule proposes routine, statutorily required updates to the home health payment rates for CY 2024. The proposed home health payment update percentage is a proposed 2.7 percent increase (approximately $460 million). Accounting for an estimated 5.1 percent decrease^[1] , as required by statute, that reflects the effects of the proposed prospective, permanent behavior assumption adjustment ($870 million decrease), and an estimated 0.2 percent increase that reflects the effects of a proposed update to the fixed-dollar loss ratio (FDL) used in determining outlier payments ($35 million increase,), CMS estimates that Medicare payments to HHAs in CY 2024 would decrease in the aggregate by 2.2 percent, or $375 million compared to CY 2023, based on the proposed policies.

PDGM and Behavior Assumptions

On January 1, 2020, CMS implemented the home health PDGM and a 30-day unit of payment, as required by section 1895(b) of the Social Security Act, as amended by the Bipartisan Budget Act of 2018. The PDGM better aligns payments with patient care needs, especially for clinically complex beneficiaries. The law required CMS to make assumptions about behavior changes that could occur because of the implementation of the 30-day unit of payment and the PDGM. In the CY 2019 HH PPS final rule with comment period, CMS finalized three behavior assumptions (clinical group coding, comorbidity coding, and LUPA threshold). The law also requires CMS to annually determine the impact of differences between assumed behavior changes and actual behavior changes on estimated aggregate expenditures, beginning with 2020 and ending with 2026, and to make temporary and permanent increases or decreases, as needed, to the 30-day payment amount to offset such increases or decreases. Additionally, in the CY 2019 HH PPS final rule (83 FR 56455), CMS stated that we interpret actual behavior change to encompass both behavior changes that were previously outlined, as assumed by CMS when determining the budget-neutral 30-day payment amount for CY 2020, and other behavior changes not identified at the time the 30-day payment amount for CY 2020 was determined. In the CY 2023 HH PPS final rule, using CY 2020 and 2021 claims, CMS finalized a methodology for analyzing the differences between assumed versus actual behavior changes on estimated aggregate expenditures and calculated levels of actual and estimated aggregate expenditures. Based on analyses of CYs 2020 and 2021 claims data, CMS determined a permanent adjustment was needed. In CY 2023, CMS finalized implementing half (-3.925 percent) of the permanent adjustment estimated at the time (-7.85 percent).

For the CY 2024 HH PPS proposed rule, using updated CY 2022 claims and the methodology finalized in the CY 2023 HH PPS final rule, CMS determined that Medicare paid more under the new system than it would have under the old system. CMS is proposing an additional permanent adjustment percentage of -5.653 percent in CY 2024 to address the differences in the aggregate expenditures. The proposed permanent adjustment of -5.653 percent includes the remaining -3.925 percent (to account for CYs 2020 and 2021) not applied to the CY 2023 payment rate and accounts for actual behavior changes in CY 2022. The law provides CMS the discretion to make any future permanent or temporary adjustments in a time and manner determined appropriate through analysis of estimated aggregate expenditures through CY 2026. As such, we are not proposing to implement a temporary adjustment in CY 2024.

Rebasing and Revising the Home Health Market Basket

Since the HH PPS was implemented, the market basket used to update HH PPS payments has been rebased and revised to reflect more recent data on home health cost structures. CMS last rebased and revised the home health market basket in the CY 2019 HH PPS final rule with comment period, where a 2016-based home health market basket was adopted. For CY 2024, CMS is proposing to adopt a 2021-based home health market basket, which includes proposed changes to the market basket cost weights and price proxies. Additionally, we are proposing that the market basket update for the final rule be based on the most recent data available at the time of rulemaking.

Updating the Labor-Related Share

As a result of the proposed rebasing and revising of the home health market basket, the proposed CY 2024 labor-related share (LRS) is 74.9 percent, which is based on the proposed 2021-based home health market basket compensation cost weight (the current labor-related share is 76.1 percent). Additionally, we are proposing to implement the revised labor-related share in a budget-neutral manner.

Proposal for Disposable Negative Pressure Wound Therapy

In accordance with Division FF, section 4136 of the Consolidated Appropriations Act (CAA), 2023, CMS is proposing to codify statutory requirements for negative pressure wound therapy (NPWT) using a disposable device for patients under a home health plan of care. The CAA, 2023 requires that beginning January 1, 2024, there is a separate payment for the device only. Payment for the services to apply the device is to be included under the home health prospective payment system. There are also changes to now report the disposable device on the type of home health claim most familiar to Home Health Agencies.

Recalibration of PDGM Case-Mix Weights

Each of the 432 payment groups under the PDGM has an associated case-mix weight and LUPA threshold. CMS’ policy is to annually recalibrate the case-mix weights and LUPA thresholds using the most complete utilization data available at the time of rulemaking. In this proposed rule, CMS is proposing to recalibrate the case-mix weights (including the functional levels and comorbidity adjustment subgroups) and LUPA thresholds using CY 2022 data to more accurately pay for the types of patients HHAs are serving.

Request for Information on Access to Home Health Aide Services

CMS is soliciting comments from the public, including home health providers, as well as patients and advocates, regarding information related to ensuring the appropriate access to and provision of home health aide services for all beneficiaries receiving care under the home health benefit. This proposed rule also includes additional questions regarding any notable barriers and obstacles to recruiting and retaining home health aides, as well as ways to ensure that home health aides are consistently paid wages that are equivalent to other care settings and commensurate with the impact they have on patient care.

Home Health (HH) Quality Reporting Program (QRP)

CMS is proposing the adoption of the following measures:

COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date (Patient/Resident COVID-19 Vaccine) measure to the HH QRP beginning with the CY 2025 HH QRP.
CMS also proposes to adopt the Functional Discharge Score (DC Function) measure to the HH QRP beginning with the CY 2025 HH QRP.

The COVID-19 Vaccine measure continues CMS’s commitment to promoting the uptake of the COVID-19 vaccine and ensures alignment with current CDC guidance.

CMS is proposing the removal of the following measures:

With the addition of the Discharge Function measure, we propose to remove the Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Application of Functional Assessment/Care Plan) measure from the HH QRP beginning with the CY 2025 HH QRP.
Additionally, CMS is proposing removal of two OASIS items no longer necessary for collection, the M0110 – Episode Timing and M2220- Therapy Needs items.

CMS is proposing the public reporting of four measures:

Discharge Function;
Transfer of Health (TOH) Information to the Provider—Post-Acute Care (PAC) Measure (TOH-Provider);
Transfer of Health (TOH) Information to the Patient—Post-Acute Care (PAC); and
COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date.

We are also proposing technical changes to § 484.245(b) to codify our requirement that HHAs must meet or exceed a data submission threshold set at 90 percent of all required OASIS and submit the data through the CMS-designated data submission systems. We are also seeking input on future HH QRP measure concepts and providing updates on HH QRP health equity initiatives.

Expanded Home Health Value-Based Purchasing (HHVBP) Model

Applicable Measure Set used in the expanded Home Health Value-Based Purchasing (HHVBP) Model

For the expanded HHVBP Model, CMS is proposing to:

Codify in the Code of Federal Regulations the measure removal factors finalized in the CY 2022 HH PPS final rule;
Replace the two Total Normalized Composite Measures (for Self-Care and Mobility) with the Discharge Function Score measure effective January 1, 2025;
Replace the OASIS-based Discharge to Community (DTC) measure with the claims-based Discharge to Community-Post Acute Care (PAC) Measure for Home Health Agencies effective, January 1, 2025;
Replace the claims-based Acute Care Hospitalization During the First 60 Days of Home Health Use and the Emergency Department Use without Hospitalization During the First 60 Days of Home Health measures with the claims-based the Potentially Preventable Hospitalization measure effective January 1, 2025;
Change the weights of individual measures due to the change in the total number of measures; and,
Beginning with performance year CY 2025, we propose to update the Model baseline year to CY 2023 for all applicable measures in the proposed measure set, including those measures included in the current measure set with the exception of the 2-year DTC-PAC measure, which would be CY 2022 and CY 2023.

Appeals Process

CMS is proposing to add an additional opportunity to request a reconsideration of the annual Total Performance Score (TPS) and payment adjustment.

Public Reporting Update

CMS is including an update to remind HHAs and other stakeholders that public reporting of HHVBP performance data and payment adjustments will begin in December 2024.

Health Equity Update

CMS is including an update on health equity to let stakeholders know that we are committed to developing approaches to meaningfully incorporate the advancement of health equity into the expanded HHVBP Model. As we move this important work forward, we will continue to take input from home health stakeholders and monitor the application of proposed health equity policies across CMS initiatives, such as proposed payment adjustments in the Hospital and SNF Value-Based Purchasing Programs. At this time, however, we would like to give HHAs time to learn the requirements of the expanded Model, gather at least two years of performance data, and study effects of the expanded Model on health equity outcomes before incorporating any potential changes to the expanded Model regarding health equity.

Home Intravenous Immune Globulin (IVIG) Items and Services

As required under Division FF, section 4134 of the CAA, 2023, CMS is proposing regulations to implement coverage and payment of items and services related to administration of IVIG in a patient’s home for a patient with a diagnosed primary immune deficiency disease (PIDD). Currently, Medicare pays for the IVIG product using the average sales price (ASP) methodology, and the items and services needed for in-home administration of IVIG for the treatment of PIDD are paid under a Medicare demonstration program. This demonstration program will end on December 31, 2023, and the CAA, 2023 establishes permanent coverage and payment of the items and services needed for in-home administration beginning on January 1, 2024.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Policy Issues

Lymphedema Compression Treatment Items

Section 4133 of the CAA, 2023 establishes a Medicare Part B benefit for standard and custom-fitted gradient compression garments and other compression treatment items, for the treatment of lymphedema that are prescribed by an authorized practitioner. Compression garments for treatment of lymphedema have generally not been covered by Medicare because, prior to the enactment of the CAA, 2023, there was no statutory benefit category for such items. This rule would address the scope of the new benefit by defining what constitutes a standard- or custom-fitted gradient compression garment and identifying other compression items used for the treatment of lymphedema that would fall under the new benefit category, beginning January 1, 2024. The rule proposes that Medicare would cover gradient compression garments for both daytime and nighttime use as well as ready-to-wear, non-elastic, gradient compression wraps with adjustable straps, and compression bandaging systems applied in a clinical setting as part of phase one decongestive therapy. This rule would establish the initial Healthcare Common Procedure Coding System (HCPCS) codes and the payment methodology for these items and propose how future coding, benefit category, and payment determinations for these items would be made. The proposed payment basis for lymphedema compression treatment items is the average Medicaid State agency payment amounts plus 20 percent. In the event that Medicaid State agency payment rates are not available, this rule proposes to base payment rates on the average of TRICARE and internet retail prices. If neither Medicaid nor TRICARE payment amounts are available, this rule proposes to base Medicare payment rates on the average internet retail prices for a lymphedema compression treatment item.

Medicare Definition of Brace

This proposed rule would also codify the longstanding Medicare definition of brace to provide clarification on the scope of the Medicare Part B benefit for leg, arm, back, and neck braces and as a result, would classify certain exoskeleton-type devices as braces for Medicare payment purposes.

Safeguarding Taxpayer Dollars

DMEPOS Refill Policy

In response to concerns related to auto-shipments and delivery of DMEPOS supplies that may no longer be needed or not needed at the same level of frequency/volume, CMS instituted policies to require suppliers to contact the beneficiary prior to dispensing DMEPOS refills. CMS is proposing to codify its long-standing refill policy, with some changes. We are proposing to require documentation indicating that the beneficiary confirmed the need for the refill within the 30-day period prior to the end of the current supply. Additionally, we are proposing to codify our requirement that delivery of DMEPOS items (that is, date of service) be no sooner than 10 calendar days before the expected end of the current supply. CMS is also seeking comments for consideration in future rulemaking on ways to balance beneficiary burden with the potential risks/burdens of not verifying the beneficiary’s actual need for recurring supplies for certain individuals with permanent health conditions.

Hospice Enrollment Provisions

CMS is also proposing several provider enrollment regulatory changes to prevent and address hospice fraud, waste, and abuse in the future. CMS believes that these provider enrollment provisions related to hospice ownership and management will strengthen protections against hospice fraud schemes and improve transparency. The proposed hospice enrollment-related regulatory changes in this proposed rule include:

Subjecting hospices to the highest level of provider enrollment application screening, which includes fingerprinting all 5 percent or greater owners of hospices;
Expanding the HHA change in majority ownership provisions in 42 CFR § 424.550(b) to include hospice changes in majority ownership; and
Clarifying that the definition of “Managing Employee” in 42 CFR § 424.502 includes the administrator and medical director of a hospice.

Other Provider Enrollment Provisions

Finally, to further protect the Trust Funds and Medicare beneficiaries, we are proposing additional provider enrollment provisions, which include, but are not limited to, the following:

Reducing the period of Medicare non-billing for which a provider or supplier can be deactivated under § 424.540(a)(1) from 12 months to 6 months.
Strengthening the program integrity safeguards associated with a provisional period of enhanced oversight under section 1866(j)(3) of the Social Security Act.

Reference

Centers For Medicare and Medicaid. News Room. Calendar Year (CY) 2024 Home Health Prospective Payment System Proposed Rule (CMS-1780-P)

Fiscal Year 2024 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule

Zachary Edgar — Mon, 03 Apr 2023 21:30:19 GMT

On April 3, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update Medicare payment policies and rates under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program (QRP) for fiscal year (FY) 2024. CMS is publishing this proposed rule in accordance with the legal requirements to update Medicare payment policies for IRFs on an annual basis.

For FY 2024, CMS is proposing to update the IRF PPS payment rates based on the proposed IRF market basket update, less a proposed productivity adjustment. The proposed rule includes annual updates to the prospective payment rates, the outlier threshold, the case-mix-group relative weights and average length of stay values, the wage index, and associated impact analysis. In addition, the rule includes a proposal to revise and rebase the IRF market basket, as well as a proposal to modify its regulations to allow hospitals to open and begin billing Medicare for an excluded IRF unit anytime within the cost reporting year.

CMS is also proposing two new and one modified measure proposals for the IRF Quality Reporting Program (QRP). In addition, CMS is proposing three measure removals and is proposing one public reporting policy.

This fact sheet discusses the provisions of the proposed rule. The FY 2024 Inpatient Rehabilitation Facility Prospective Payment System proposed rule (CMS-1781-P) can be downloaded from the Federal Register at https://www.federalregister.gov/public-inspection/2023-06968/medicare-program-inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal .

Proposed Updates to the FY 2024 IRF PPS Payment Policies

For FY 2024, CMS is proposing to update the IRF PPS payment rates by 3.0 percent based on the proposed IRF market basket update of 3.2 percent less a proposed 0.2 percentage point productivity adjustment. CMS is proposing that if more recent data become available (for example, a more recent estimate of the market basket update or productivity adjustment), CMS would use these data, if appropriate, to determine the FY 2024 market basket update and the productivity adjustment in the final rule. In addition, the proposed rule contains an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent of total payments. This adjustment would result in a 0.7 percentage point increase in outlier payments. CMS estimates that overall IRF payments for FY 2024 would increase by 3.7 percent (or $335 million) relative to payments in FY 2023.

Proposed Modification to the Excluded Unit Regulation

CMS proposes to allow hospitals to open a new IRF unit and begin being paid under the IRF PPS at any time during the cost reporting period, provided the hospital notifies the CMS Regional Office and the Medicare Administrative Contractor in writing at least 30 days before the date of the change and maintains the information needed to accurately determine the costs attributable to the IRF unit. Such a change would also remain in effect for the rest of the cost reporting period. CMS believes this will alleviate unnecessary burden and administrative complexity placed upon hospitals and increase access to care.

Rebase and Revise the IRF Market Basket

Approximately every four years, CMS rebases and revises the IRF market basket used to update IRF PPS payments to reflect more recent data on IRF cost structures. CMS last rebased and revised the IRF market basket in the FY 2020 IRF PPS rule, where CMS adopted a 2016-based IRF market basket. The proposal for FY 2024 would be to adopt a 2021-based IRF market basket and includes proposed changes to the market basket cost weights, price proxies, market basket update, and labor-related share.

Proposed Updates to the IRF QRP

The IRF QRP is a pay-for-reporting program. IRFs that do not meet reporting requirements are subject to a two-percentage point reduction in their Annual Increase Factor.

In the FY 2024 IRF PPS proposed rule, CMS is proposing to:

Adopt the Discharge Function Score measure beginning with the FY 2025 QRP

This measure assesses functional status by assessing the percentage of IRF patients who meet or exceed an expected discharge function score, and uses mobility and self-care items already collected on the IRF Patient Assessment Instrument (IRF-PAI). The adoption of this measure would replace the Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan (Application of Functional Assessment/Care Plan) measure.

Adopt the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date (Patient/Resident COVID-19 Vaccine) measure beginning with the FY 2026 IRF QRP

The measure reports the percentage of stays in which patients in an IRF are up-to-date with recommended COVID-19 vaccinations in accordance with the Centers for Disease Control and Prevention’s (CDC’s)most recent guidance. Data would be collected using a new standardized item on the IRF-PAI.

Modify the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP COVID-19 Vaccine) measure beginning with the FY 2025 IRF QRP

This measure tracks the percentage of healthcare personnel (HCP) in IRFs who are considered up to date with recommended COVID-19 vaccination in accordance with the CDC’s most recent guidance. The prior version of this measure reported only on whether HCP had received the primary vaccination series for COVID-19, while the proposed modification of this measure would require IRFs to report the cumulative number of HCP who are up-to-date with recommended COVID-19 vaccinations in accordance with the CDC’s most recent guidance.

Remove three measures from the IRF QRP beginning with the FY 2025 IRF QRP

The measures CMS is proposing to remove are: (1) the Application of Functional Assessment/Care Plan measure; (2) the IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (Change in Self-Care Score) measure; and (3) the IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (Change in Mobility Score) measure. We propose removal of the Application of Functional Assessment/Care Plan measure because it meets conditions for measure removal factors one (that is, measure performance among IRFs is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made) and six (that is, the proposed DC Function measure is more strongly associated with desired patient functional outcomes). We propose removal of the Change in Self-Care Score and Change in Mobility Score measures because they meet the condition for measure removal factor eight (that is, the costs associated with a measure outweigh the benefits of its use in the IRF QRP). Additionally, the Change in Self-Care Score and Change in Mobility Score measures are similar or duplicative of other measures within the IRF QRP.

Begin the public reporting of the Transfer of Health Information to the Provider—PAC Measure and the Transfer of Health Information to the Patient—PAC Measure beginning with the September 2024 Care Compare refresh or as soon as possible

These measures report the percentage of patient stays with a discharge assessment indicating that a current reconciled medication list was provided to the subsequent provider or to patients or their families or caregivers at discharge or transfer.

Reference

Centers for Medicare and Medicaid

Newsroom – April 3, 2023

Fiscal Year 2024 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule (CMS-1781-P)

Dually Eligible Beneficiaries

Zachary Edgar — Wed, 25 May 2022 21:09:18 GMT

Dually eligible beneficiaries are low-income beneficiaries enrolled in both Medicare and Medicaid. This includes beneficiaries enrolled in Medicare Part A, Part B, or both, and getting full Medicaid benefits or only help with Medicare premiums or cost-sharing.

Billing Dual Eligible/QMBs

Medicare providers cannot bill QMB beneficiaries for Medicare cost-sharing. This includes

Medicare deductibles, coinsurance, and copayments. In some cases, a beneficiary may owe

a small Medicaid copayment. Medicare and Medicaid payments are considered payment in full.

This prohibition applies even if the provider or supplier doesn’t participate in Medicaid.

Providers are subject to sanctions if they bill a QMB above the total Medicare and Medicaid payments, even when Medicaid pays nothing.

If a provider bills a QMB for Medicare cost-sharing, or turn a bill over to collections, the provider must recall it. If a provider collecst any QMB cost-sharing money, it must be refunded.

Verifying Dual Eligible/QMB

Providers should use the Medicare 270/271 HIPAA Eligibility Transaction System (HETS) and

the Medicare Remittance Advice to identify if a beneficiary is a QMB and owes no Medicare

cost-sharing.

Advanced Beneficiary Notification of Non-Coverage (ABNs)

Providers cannot bill the dually eligible beneficiary up front when an ABN is provided.

Once Medicare and Medicaid adjudicates the claim, the provider may only charge the beneficiary in these circumstances:

· If the beneficiary has QMB coverage without full Medicaid coverage and Medicare denies the claim, the ABN could allow the provider to shift financial responsibility to the beneficiary under Medicare policy.
· If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or won’t pay because you don’t participate in Medicaid), the ABN could allow the provider to shift financial responsibility to the beneficiary under Medicare policy, subject to state laws that limit beneficiary responsibility.

Types of Dually Eligible Beneficiaries

1. Full Medicaid (only)

Benefits

Full Medicaid coverage refers to the package of services beyond Medicare premiums coverage and cost-sharing certain beneficiaries get when they qualify for certain eligibility groups under a state’s Medicaid Program. States must cover some of these groups (like Supplemental Security Income [SSI] recipients). States have the option to cover others, like the special income level institutionalized beneficiary group, home- and community-based waiver participants, and medically needy individuals.

Dually eligible beneficiaries who get Medicaid only are enrolled in Part A and or Part B and qualify for full Medicaid benefits but not for MSP groups. States may pay their Part B premium.

Qualifications

States decide income and resource criteria.

States can require Part A or B enrollment if they pay the beneficiary’s premiums for these parts.

Beneficiaries must show they need a certain level of care or meet state-specific medical criteria to qualify for certain categories.

2. Qualified Medicare Beneficiary (QMB) Only Without Other Medicaid

Benefits

Medicaid pays Part A (if any) and Part B premiums.

Medicaid is liable for Medicare deductibles, coinsurance, and copayments

for Medicare-covered items and services. Even if Medicaid doesn’t fully

cover these charges, the QMB isn’t liable for them.

Qualifications

Income can be up to 100% of the Federal Poverty Level (FPL).

Resources can’t be more than 3 times the SSI resource limit, increased

annually by the Consumer Price Index (CPI).

QMB qualifications include enrollment in Part A (or if uninsured for Part

A, have filed for premium Part A on a conditional basis).

3. Qualified Medicare Beneficiary Plus (QMB+)

Benefits

Medicaid pays Part A (if any) and Part B premiums.

Medicaid is liable for Medicare deductibles, coinsurance, and copayments

for Medicare-covered items and services. Even if Medicaid doesn’t fully

cover these charges, the QMB+ isn’t liable for them.

Get full Medicaid coverage plus Medicare premiums and cost-sharing coverage.

Qualifications

Meet QMB-related eligibility requirements described in Table 2 and full Medicaid eligibility requirements in Table 1.

4. Specified Low-Income Medicare Beneficiary (SLMB) Only Without Other Medicaid

Benefits

Medicaid pays Part B premium.

Qualifications

Income between 100%–120% of FPL.

Resources can’t be more than 3 times the SSI resource limit, increased annually by the CPI.

Enrolled in Part A.

5. Specified Low-Income Medicare Beneficiary Plus (SLMB+)

Benefits

Medicaid pays Part B premium.

Get full Medicaid coverage plus Medicare Part B premium coverage (see Table 1 for a definition of full Medicaid coverage).

Qualifications

Meet SLMB-related eligibility requirements described in Table 4 and full Medicaid eligibility requirements in Table 1.

6. Qualifying Individual (QI)

Benefits

Medicaid pays Part B premium.

Benefits limited to first-come, first-served.

Qualifications

Income between 120%–135% of FPL.

Resources can’t be more than 3 times the SSI resource limit, increased annually by the CPI.

Enrolled in Part A.

QI beneficiaries aren’t eligible for any other Medicaid coverage.

7. Qualified Disabled Working Individual (QDWI)

Benefits

Medicaid pays Part A premium.

Qualifications

Income up to 200% of FPL.

Resources up to 2 times the SSI resource limit.

Individuals under 65 with a qualifying disability who lost premium-free Part A coverage after returning to work and now must pay a premium to enroll in Part A.

QDWI beneficiaries aren’t eligible for any other Medicaid coverage.

2022 KX Modifier and Targeted Review

Zachary Edgar — Wed, 01 Dec 2021 21:42:41 GMT

2022 KX threshold amount: $2,150 for PT and SLP services combined.

2022 KX threshold amount: $2,150 for OT services.

The KX modifier applies to all Part B outpatient therapy settings and providers including:

Therapists’ Private Practices;
Offices of Physicians and NPPs;
Part B Skilled Nursing Facilities;
Home Health Agencies;
Rehabilitation Agencies (also known as ORFs);
Comprehensive Outpatient Rehab Facilities;
Outpatient Hospital Departments; and
Critical Access Hospitals.

By using the KX modifier on the claim, the therapy supplier or provider is attesting that the services are medically necessary, and that supportive justification is documented in the medical record.

The threshold is based on the incurred expanses made for the patient’s outpatient therapy services. It does not matter if therapy services are provided by one therapist or multiple therapists.

Claims for outpatient therapy services incurred above the threshold amounts without the KX modifier will be denied. Must be appended to all claims filed after the threshold amount has been reached.

Targeted Medical Review

The BBA of 2018 retains the targeted medical review (MR) process but at a lower threshold amount of $3,000. For CY 2022 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services.

To prevent improper payments, Medicare contractors operate the medical review program. Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.

Therapists can check the amount of expenses that have been made year to date (YTD) for the patient on the MAC websites:

CGS - First Coast - National Government Services - Noridian - Novitas - Palmetto - WPS

Reduced Payment for Physical Therapy and Occupational Therapy Services Furnished In Whole or In Part by a Physical Therapist Assistant (PTA) or Occupational Therapy Assistant (OTA)

Zachary Edgar — Mon, 22 Nov 2021 19:21:38 GMT

Issue Date: 11/22/21

Effective Date: 1/3/22

This MLN Matters Article is for physical and occupational therapists and therapy providers billing Medicare administrative Contractors (MACs) for services of physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) provided to Medicare patients.

Section 53107 of the BBA of 2018 added section 1834(v) to the Social Security Act that requires CMS, through the use of new modifiers, to reduce the payment for physical and occupational therapy services provided in whole or in part by PTAs or OTAs. We’ll make the reduced payment at 85% of the otherwise applicable Part B payment amount. This reduced payment applies to dates of service on and after January 1, 2022.

The reduced PFS payment affects physical therapists (PTs) in private practice (PTPPs) and occupational therapists (OTs) in private practice (OTPPs), including PTPPs and OTPPs who have reassigned their benefits to physician groups or to groups of certain nonphysician practitioners (NPPs), including physician assistants, nurse practitioners and clinical nurse specialists when the PTPP/OTPP National Provider Identifier (NPI) appears as the rendering provider on the claim.

The reduced PFS payment for PTA/OTA services also applies to institutional therapy providers, including comprehensive outpatient rehabilitation facilities, with the exception of critical access hospitals and other providers that aren’t paid using Medicare Physician Fee Schedule (MPFS). This payment policy is applicable to the following bill types: 12X, 13X, 22X, 23X, 34X, 74X, and 75X.

In the CY 2019 final rule (83 FR 59654 through 59660), we created 2 new modifiers for the services that PTAs/OTAs provide. We have required the CQ/CO modifiers on claims, alongside the GP/GO therapy modifiers ─ which are used to indicate the services are furnished under a physical therapy or occupational therapy plan of care, respectively ─ from PTPPs, OTPPs, and therapy providers for services furnished in whole or in part by PTAs/OTAs for dates of service on or after January 1, 2020. They are:

CQ: Outpatient physical therapy services provided in whole or in part by a physical therapist assistant
CO: Outpatient occupational therapy services provided in whole or in part by an occupational therapy assistant

In that CY 2019 PFS final rule, we also finalized a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10 percent of a service – whether timed or untimed ─ is furnished by the PTA or OTA.

In the CY 2020 final rule (84 FR 62702 through 62708), we finalized applications of the de minimis standard that requires the CQ/CO modifier to be on claims when the PTA/OTA, independent of the PT/OT, provides:

More than 10% of an untimed service or
More than 10% of a 15-minute timed unit of service

We required the CQ/CO modifiers beginning with claims for dates of service on and after January 1, 2020.

In the CY 2022 final rule (86 FR 65169 through 65177), we finalized a de minimis policy that requires the CQ/CO modifier to be on claims when the PTA/OTA provides more than 10% of a unit of service for other time intervals than the 15-minute one. This includes the 20-minute time increment of the new codes for remote therapeutic monitoring (RTM) services.

Also, during PFS rulemaking for CY 2022, in response to concerns raised by stakeholders and to promote appropriate care, we finalized a policy for which the de minimis standard is not applicable. Specifically, we finalized rules for applying the CQ/CO modifiers by introducing the midpoint rule, also known as the “8-minute rule,” in which the PT/OT provides at least 8 minutes (more than half, or 7.5 minutes, of the 15-minute unit). In these cases, the PT/OT bills the final unit of a multi-unit scenario without the CQ/CO modifier.

We also defined a limited number of cases in which there are 2 units left to bill in which you bill one 15-minute unit with the CQ/CO modifier and the other 15-minute unit without it. These cases include scenarios in which the PT/OT and the PTA/OTA each provide between 9 and 14 minutes of a 15-minute timed service when the total time of therapy services provided in combination by the PT/OT and PTA/OTA is at least 23 minutes, but no more than 28 minutes.

We also finalized the following policies, where the CQ/CO modifiers do apply:

Services wholly provided by PTAs and OTAs.
In cases where one final 15-minute unit (of a multi-unit scenario) remains to be billed, the de minimis standard is applied to:
- Services where the PTA/OTA provides 8 or more minutes of a 15-minute unit of service and the PT/OT provides less than 8 minutes – bill with the CQ/CO modifier as the de minimis standard is exceeded.
- Services where both the PTA/OTA and the PT/OT each provide less than 8 minutes of a service – bill with the CQ/CO modifier if the minutes provided by the PTA/OTA exceed the de minimis standard.

We finalized the below policies where the CQ/CO modifiers don’t apply:

When PTs and OTs wholly provide the services.
When a PT/OT and a PTA/OTA provide care to a patient at the same time the patient requires both providers – these scenarios show cases in which the assistant is helping the therapist to provide a highly skilled procedure or one in which both providers are needed for safety reasons.
When outpatient physical and occupational therapy services are provided by, or incident to, the services of physicians or certain nonphysician practitioners (NPPs). This is because therapy regulations require that the individual who does the therapy service incident to the service of a physician or NPP must meet the qualifications and standards for a therapist (other than state licensure).
In cases where there is 1 final 15-minute unit left to bill on a treatment day, the “8- minute rule” rule is applied when the PT/OT provides 8 or more minutes (the Medicare billing requirement for that final 15-minute service unit) – that final unit is billed without the CQ/CO modifier because the PT/OT provided enough minutes on their own (more than half) to report the service. Any minutes provided by the PTA/OTA are immaterial for purposes of billing.

In cases where there are 2 units left to be billed, and the PT/OT and the PTA/OTA each provide between 9 and 14 minutes of a 15-minute timed service when the total time of therapy services provided by the PT/OT and PTA/OTA is at least 23 minutes, but no more than, 28 minutes:

Bill 1 unit without the CQ/CO modifier (for the unit the PT/OT provides), and
Bill 1 unit of the service with the CQ/CO modifier (for the unit provided by the PTA/OTA)

Reference

Centers for Medicare and Medicaid

MLN Matters: MM12397

2022 Medicare Parts A & B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts

Zachary Edgar — Fri, 12 Nov 2021 17:57:36 GMT

On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) released the 2022 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2022 Medicare Part D income-related monthly adjustment amounts.

Medicare Part B Premium and Deductible

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.

Each year the Medicare Part B premium, deductible, and coinsurance rates are determined according to the Social Security Act. The standard monthly premium for Medicare Part B enrollees will be $170.10 for 2022, an increase of $21.60 from $148.50 in 2021. The annual deductible for all Medicare Part B beneficiaries is $233 in 2022, an increase of $30 from the annual deductible of $203 in 2021.

The increases in the 2022 Medicare Part B premium and deductible are due to:

Rising prices and utilization across the health care system that drive higher premiums year-over-year alongside anticipated increases in the intensity of care provided.
Congressional action to significantly lower the increase in the 2021 Medicare Part B premium, which resulted in the $3.00 per beneficiary per month increase in the Medicare Part B premium (that would have ended in 2021) being continued through 2025.
Additional contingency reserves due to the uncertainty regarding the potential use of the Alzheimer’s drug, Aduhelm™, by people with Medicare. In July 2021, CMS began a National Coverage Determination analysis process to determine whether and how Medicare will cover Aduhelm™ and similar drugs used to treat Alzheimer’s disease. As that process is still underway, there is uncertainty regarding the coverage and use of such drugs by Medicare beneficiaries in 2022. While the outcome of the coverage determination is unknown, our projection in no way implies what the coverage determination will be, however, we must plan for the possibility of coverage for this high cost Alzheimer’s drug which could, if covered, result in significantly higher expenditures for the Medicare program.

Medicare Part B Income-Related Monthly Adjustment Amounts

Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 7 percent of people with Medicare Part B. The 2022 Part B total premiums for high-income beneficiaries are shown in the following table:

Beneficiaries who file individual tax returns with modified adjusted gross income:	Beneficiaries who file joint tax returns with modified adjusted gross income:	Income-related monthly adjustment amount	Total monthly premium amount
Less than or equal to $91,000	Less than or equal to $182,000	$0.00	$170.10
Greater than $91,000 and less than or equal to $114,000	Greater than $182,000 and less than or equal to $228,000	$68.00	$238.10
Greater than $114,000 and less than or equal to $142,000	Greater than $228,000 and less than or equal to $284,000	$170.10	$340.20
Greater than $142,000 and less than or equal to $170,000	Greater than $284,000 and less than or equal to $340,000	$272.20	$442.30
Greater than $170,000 and less than $500,000	Greater than $340,000 and less than $750,000	$374.20	$544.30
Greater than or equal to $500,000	Greater than or equal to $750,000	$408.20	$578.30

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses, with modified adjusted gross income:	Income-related monthly adjustment amount	Total monthly premium amount
Less than or equal to $91,000	$0.00	$170.10
Greater than $91,000 and less than $409,000	$374.20	$544.30
Greater than or equal to $409,000	$408.20	$578.30

Medicare Part A Premium and Deductible

Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, inpatient rehabilitation, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A inpatient hospital deductible that beneficiaries pay if admitted to the hospital will be $1,556 in 2022, an increase of $72 from $1,484 in 2021. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2022, beneficiaries must pay a coinsurance amount of $389 per day for the 61^st through 90^th day of a hospitalization ($371 in 2021) in a benefit period and $778 per day for lifetime reserve days ($742 in 2021). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $194.50 in 2022 ($185.50 in 2021).

Part A Deductible and Coinsurance Amounts for Calendar Years 2021 and 2022 by Type of Cost Sharing
	2021	2022
Inpatient hospital deductible	$1,484	$1,556
Daily coinsurance for 61^st-90^th Day	$371	$389
Daily coinsurance for lifetime reserve days	$742	$778
Skilled Nursing Facility coinsurance	$185.50	$194.50

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $274 in 2022, a $15 increase from 2021. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $499 a month in 2022, a $28 increase from 2021.

Medicare Part D Income-Related Monthly Adjustment Amounts

Since 2011, a beneficiary’s Part D monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 8 percent of people with Medicare Part D. These individuals will pay the income-related monthly adjustment amount in addition to their Part D premium. Part D premiums vary from plan to plan and roughly two-thirds are paid directly to the plan, with the remaining deducted from Social Security benefit checks. The Part D income-related monthly adjustment amounts are all deducted from Social Security benefit checks. The 2022 Part D income-related monthly adjustment amounts for high-income beneficiaries are shown in the following table:

Beneficiaries who file individual tax returns with modified adjusted gross income	Beneficiaries who file joint tax returns with modified adjusted gross income	Income-related monthly adjustment amount
Less than or equal to $91,000	Less than or equal to $182,000	$0.00
Greater than $91,000 and less than or equal to $114,000	Greater than $182,000 and less than or equal to $228,000	$12.40
Greater than $114,000 and less than or equal to $142,000	Greater than $228,000 and less than or equal to $284,000	$32.10
Greater than $142,000 and less than or equal to $170,000	Greater than $284,000 and less than or equal to $340,000	$51.70
Greater than $170,000 and less than $500,000	Greater than $340,000 and less than $750,000	$71.30
Greater than or equal to $500,000	Greater than or equal to $750,000	$77.90

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Beneficiaries who are married and lived with their spouses at any time during the year, but file separate tax returns from their spouses, with modified adjusted gross income:	Income-related monthly adjustment amount
Less than or equal to $91,000	$0.00
Greater than $91,000 and less than $409,000	$71.30
Greater than or equal to $409,000	$77.90

Reference

Centers for Medicare and Medicare. 2022 Medicare Parts A & B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts.

https://www.cms.gov/newsroom/fact-sheets/2022-medicare-parts-b-premiums-and-deductibles2022-medicare-part-d-income-related-monthly-adjustment

2022 Annual Update to the Therapy Code List

Zachary Edgar — Wed, 10 Nov 2021 20:03:06 GMT

Issue Date: 11/10/2021

Effective Date: 1/3/2022

CMS is adding 5 CPT codes and long descriptors as “sometimes therapy” codes effective for dates of service on or after January 1, 2022. The 5 CPT added codes are:

• CPT code 98975 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment

• CPT code 98976 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days

• CPT code 98977 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days

• CPT code 98980 ─ Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes

• CPT code 98981 ─ Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)

We designated these CPT codes as “sometimes therapy” to allow physicians and certain Nonphysician Practitioners (NPPs), including nurse practitioners, physician assistants, and clinical nurse specialists to provide these services outside a therapy plan of care when appropriate. When therapists provide these "sometimes therapy" services, they’re “always therapy.” This means you must use the appropriate therapy modifier – GP, GO or GN -- to reflect that it’s under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.

We consider these 5 CPT codes to be remote therapeutic monitoring (RTM) services that physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists can provide, when appropriate. The RTM treatment management services described by CPT codes 98980 and 98981 are provided remotely to patients in their homes by therapists in private practice (TPPs) and facility-based therapists. For example, therapists who work in rehabilitation agencies and comprehensive outpatient rehabilitation facilities would provide these services. You would do the RTM service for the initial set-up and patient education on use of equipment (CPT code 98975) in the office or in the patient’s home.

When physicians, NPPs, or therapists don’t directly perform the services, they must be done under direct supervision. While you must always provide therapists’ services under therapy plans of care, RTM services related to a RTM device that’s specific to therapy services, such as the ARIA Physical Therapy supply device in CPT code 98977 that includes therapeutic exercises, must also be provided under a therapy plan of care when provided by physicians and NPPs. If PTs and OTs delegate the RTM services to physical therapist assistants and occupational therapy assistants, respectively, they’re subject to the de minimis standard (with the exception of the 2 CPT codes for the RTM devices).

Reference

Centers for Medicare and Medicaid

MLN Matters Number: MM12446

Low Utilization Payment Adjustment (LUPA) Add-on Amounts for Home Health (HH) Occupational Therapy Visits and Corrections to Payment Grouping Processes

Zachary Edgar — Fri, 06 Aug 2021 20:04:33 GMT

Issue Date: 8/6/2021

Effective Date: 1/32/2022

This change request makes changes to Original Medicare systems to allow for LUPA add-on payments to apply if an occupational therapy visit is the first visit in a period of care.

Background

Under the Consolidated Appropriations Act, 2021 (CAA 2021), the regulations at §§ 484.55(a)(2) and 484.55(b)(3) were revised to allow Occupational Therapists (OTs) to conduct initial and comprehensive assessments for all Medicare beneficiaries under the home health benefit when the plan of care does not initially include skilled nursing care. That is, occupational therapists may conduct the initial assessment and complete the comprehensive assessment, but only when occupational therapy is on the home health plan of care with either physical therapy and/or speech therapy and skilled nursing services are not initially on the plan of care. Because of this change, CMS must establish a LUPA add-on factor in calculating the LUPA add-on payment amount for the first skilled occupational therapy visit in LUPA periods that occur as the only period of care or the initial 30-day period of care in a sequence of adjacent 30- day periods of care.

This change request also contains requirements to ensure consistent and accurate processing of HH claims under the Patient-Driven Groupings Model.

All HH claims are matched to their associated Outcomes and Assessment Information System (OASIS) assessment during processing and use certain OASIS items to determine the Health Insurance Prospective Payment System (HIPPS) code used for payment. Medicare Administrative Contractors (MACs) have reported intermittent failures in the claims-OASIS matching process. When MACs observe unusually high volumes of HH claims in suspense locations awaiting a match, they may recycle the claims to the assessment system a second time. Per instructions in publication 100-04, chapter 10, section 10.1.10.1, MACs may take this action at their discretion or when notified by CMS. Requirements four and five ensure the recycled claims process correctly in all cases.

Similarly, on all HH claims, the HH Grouper program must calculate the HIPPS code used for payment. MACs have reported intermittent cases where HH claims bypass the HH Grouper and have paid using the provider-submitted HIPPS code. Requirement six creates a safeguard to prevent this.

Policy

Currently, there are no sufficient data regarding the average excess of minutes for the first visit in LUPA periods where the initial and comprehensive assessments are conducted by OTs. Therefore, in the Calendar Year (CY) 2020 HH Prospective Payment System (PPS) final rule, CMS finalized to utilize the Physical Therapy (PT) LUPA add-on factor of 1.6700 as a proxy for the OT LUPA add-on factor for CY 2022 until we have CY 2022 data to establish the OT add-on factor for the LUPA add-on payment amounts in future years. The similarity in the per-visit payment rates for both PT and OT make the PT LUPA add-on factor the most appropriate proxy until CMS has sufficient data to establish the OT LUPA add-on factor.

Reference

Centers for Medicare & Medicaid Services

Transmittal 10919

Changes to Medicare Enrollment of PTs, OTs, and SLPs

Zachary Edgar — Tue, 22 Jun 2021 20:34:06 GMT

Visit our Medicare Enrollment Page for updated criteria for physical, occupational, and speech therapists to enroll in Medicare as private practitioners.

Reason Code Updates for the 2020 Annual Therapy Current Procedural Terminology (CPT) Codes in Change Request (CR) 11501

Zachary Edgar — Fri, 31 Jul 2020 18:34:46 GMT

Background: On January 6, 2020, CR11501 titled, 2020 Annual Update to the Therapy Code was implemented to prepare the Medicare systems to accept the updated CPT therapy code changes. CMS was made aware that there was an issue where claims were receiving reason codes for the updates to the 2020 therapy codes. This CR allows the Fiscal Intermediary Shared System (FISS) to update any necessary logic or reason codes needed for the CPT therapy codes, which were previously implemented in CR11501.

Policy: The policies implemented in this notification were discussed in CY 2020 Medicare Physician Fee Schedule (MPFS) rulemaking. This CR updates the therapy code list and associated policies for CY 2020, as follows:

For CY 2020, the CPT Editorial Panel created two new biofeedback codes to replace CPT code 90911. CMS designated them as “sometimes therapy” to permit physicians and Non-Physician Practitioners (NPPs), including nurse practitioners, physicians assistants, and certified nurse specialist to furnish these services outside a therapy plan of care when appropriate. The two new “sometimes therapy” codes using their CPT long descriptors, are as follows:

• CPT code 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including electromyography (EMG) and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient

• CPT code 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)

The CPT Editorial Panel also created, for CY 2020, CPT code 97129 and 97130 to replace CPT code 97127, which CMS did not recognize. These new codes will effectively replace Healthcare Common Procedure Coding System (HCPCS) code G0515 which is deleted, effective January 1, 2020. These codes are designated “sometimes therapy” in order to permit physicians, NPPs, and psychologists to furnish these services outside a therapy plan of care when appropriate. The CPT long descriptors for the two new “sometimes therapy” codes, are as follows:

• CPT 97129 - Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes

• CPT 97130 - Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure)

The CPT Editorial Panel also deleted the following codes for manual muscle testing for CY 2020: CPT codes 95831, 95832, 95833, and 95834.

The following 42 HCPCS Level II G-codes are deleted for dates of service after December 31, 2019:

• HCPCS codes G8978 through G8999, G9158 through G9176, and G9186

These codes were used for Functional Reporting of therapy services for CY 2013 through 2018, but were retained for CY 2019 as discussed in CY 2019 MPFS final rule at 83 FR 59661.

CPT codes 0019T and 64550 are being removed from prior years, 2017 and 2019, respectively.

Reference

Centers for Medicare & Medicaid Services

Transmittal 10241

Therapy Codes Update

Zachary Edgar — Tue, 26 May 2020 18:49:02 GMT

Issue Date: 5/26/2020

Effective Date: 6/16/2020

This article informs you of updates to the list of codes that sometimes or always describe therapy services. The additions to the therapy code list reflect those made in the Calendar Year (CY) 2020 for the COVID-19 Public Health Emergency (PHE). Please make sure your billing staffs are aware of these changes.

CMS is designating the below listed codes we’ve collectively termed as Communications Technology-Based Services (CTBS) as “sometimes therapy,” to permit physicians and NonPhysician Practitioners (NPPs), including nurse practitioners, physician assistants, and clinical nurse specialists to provide these services outside a therapy plan of care when appropriate. When provided by psychologists, licensed clinical social workers, or other practitioners, these CTBS codes are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier. When provided by therapists in private practice or therapists in institutional providers of therapy services, the CTBS codes are always provided under a physical therapy, occupational therapy, or speech-language pathology plan of care and must be reported with the associated GP, GO, or GN therapy modifier.

These three CPT codes, with their short descriptors, are added for telephone assessment and management services:

• CPT code 98966 (Hc pro phone call 5-10 min)

• CPT code 98967 (Hc pro phone call 11-20 min)

• CPT code 98968 (Hc pro phone call 21-30 min)

These five HCPCS codes, with their short descriptors, are added for remote evaluation of patient images/video, virtual check-ins, and online assessments (e-visits):

• HCPCS code G2010 (Remot image submit by pt)

• HCPCS code G2012 (Brief check in by MD/QHP)

• HCPCS code G2061 (Qual nonMD est pt 5-10 min)

• HCPCS code G2062 (Qual nonMD est pt 11-20 min) • HCPCS code G2063 (Qual nonMD est pt 21 min)

Reference

Centers for Medicare and Medicaid

MLN Matters Number: MM11791

The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM)

Zachary Edgar — Mon, 10 Feb 2020 18:35:49 GMT

Issue Date: 2/10/2020

Effective Date: January 1, 2020

This special edition MLN Matters article is for home health agencies (HHAs) that furnish therapy services (physical therapy, occupational therapy, and speech-language pathology therapy) under a physician-established Medicare home health plan of care.

Background

The Bipartisan Budget Act of 2018 (BBA of 2018) included several requirements for home health payment reform, effective January 1, 2020. These requirements include the elimination of the use of therapy thresholds for case-mix adjustment and a change from a 60-day unit of payment to a 30-day unit of payment. The mandated home health payment reform resulted in the Patient-Driven Groupings Model, or PDGM. The PDGM is designed to emphasize clinical characteristics and other patient information to better align Medicare payments with patients’ care needs.

The Continued Role of Therapy Under the PDGM

The need for therapy services under PDGM remains unchanged. Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits. The number of needed visits to achieve the goals outlined on the plan of care is determined through the therapist’s assessment of the patient in collaboration with the physician responsible for the home health plan of care. The home health Conditions of Participation (CoPs) (42 CFR 484.60) require that each patient must receive an individualized written plan of care. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s); the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care, and the patient and caregiver education and training. All services must be furnished in accordance with physician orders and accepted standards of practice. Therefore, the visit patterns of therapists should not be altered without consultation and agreement from the physician responsible for the home health plan of care. Any changes to the frequency or duration of therapy visits must be in accordance with the home health CoPs at 42 CFR 484.60.

Additionally, beneficiaries must receive proper written notice in advance of the HHA reducing or terminating on-going care in accordance with the home health CoPs regarding patient rights at 42 CFR 484.50. These rights also include that the patient must be advised of the name, address, and telephone number of the Quality Improvement Organization (QIO) in the beneficiary’s service area if the beneficiary has a complaint about the quality of care he/she has received, or if the beneficiary needs to appeal a health care provider’s decision to discontinue services.

Even though therapy thresholds are no longer a factor in adjusting home health payment, there are two clinical groups under the PDGM where the primary reason for home health services is for therapy (musculoskeletal rehabilitation and neuro/stroke rehabilitation). Furthermore, therapy should be provided regardless of the clinical group when included under the plan of care. While the principal diagnosis helps define the primary reason for home health services, it does not in any way direct what services should be included in the plan of care. Additionally, there is no improvement standard under the Medicare home health benefit and therapy services can be provided for restorative or maintenance purposes. The physician who establishes and periodically reviews the home health plan of care must determine the therapy the patient needs regardless of the patient’s diagnoses or PDGM clinical group.

Therapists play an instrumental role in assessing and documenting patients’ functional Therapists play an instrumental role in assessing and documenting patients’ functional impairments. This information is captured through responses to OASIS items measuring functional ability, including walking, dressing and bathing and assists therapists in developing an individualized home health therapy plan of care in collaboration with the certifying physician. A comprehensive assessment conducted by a skilled therapist can help to ensure that patient needs are identified, an individualized therapy plan of care is established, therapy services are provided, and goals of care are met.

Finally, the quality scores on Home Health Compare incorporate the use of therapy services in patient outcomes. Home Health Compare is a website for patients and their families where they can compare HHAs to help them choose a quality HHA that has the skilled home health services they need. In addition to general information about HHAs, Home Health Compare includes information on:

Services offered (like nursing care, physical therapy, occupational therapy, speech therapy, medical/social services, and home health aide services )
A Quality of Patient Care star rating that summarizes selected information about the performance of each home health agency compared to other agencies
Information about each home health agency’s quality of care (quality measures) and information from patients about experiences with the home health agency (patient survey results)

Reference

Centers for Medicare and Medicaid

MLN Matters Number: SE20005

2020 Annual Update to the Therapy Code List

Zachary Edgar — Tue, 28 Jan 2020 20:45:23 GMT

Effective Date: January 1, 2020

Applicable Providers

Physicians, therapists, and suppliers billing Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries.

Coding Changes

CR 11501 updates the list of codes that sometimes or always describe therapy services. The additions, changes, and deletions to the therapy code list reflect those made in the Calendar Year (CY) 2020 Current Procedural Terminology (CPT) and Level II HCPCS.

Biofeedback

The CPT Editorial Panel created two new biofeedback codes to replace CPT code 90911. The Centers for Medicare & Medicaid Services (CMS) designated these new codes as “sometimes therapy” to permit physicians and Non-Physician Practitioners (NPPs), including nurse practitioners, physician assistants, and certified nurse specialists to furnish these services outside a therapy plan of care when appropriate. The two new “sometimes therapy” codes with their CPT long descriptors, are as follows:

CPT code 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including electromyography (EMG) and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
CPT code 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)

Therapeutic Interventions

The CPT Editorial Panel also created, for CY 2020; CPT codes 97129 and 97130 to replace CPT code 97127, which CMS did not recognize. These new codes will effectively replace HCPCS code G0515, which will be deleted, effective January 1, 2020. These codes are designated “sometimes therapy” to permit physicians, NPPs, and psychologists to furnish these services outside a therapy plan of care when appropriate. The CPT long descriptors for the two new “sometimes therapy” codes are:

CPT code 97129 - Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes
CPT code 97130 - Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure)

Deleted Codes

The CPT Editorial Panel also deleted the following codes for manual muscle testing for CY 2020: CPT codes 95831, 95832, 95833, and 95834.

The following 42 HCPCS Level II G-codes are deleted for dates of service after December 31, 2019:

HCPCS codes G8978 through G8999; G9158 through G9176; and G9186

These codes were used for Functional Reporting of therapy services for CY 2013 through 2018 but were retained for CY 2019 as discussed in the CY 2019 MPFS final rule at 83 FR 59661.

Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, Maintenance Therapy, and Remote Patient Monitoring

Zachary Edgar — Fri, 10 Jan 2020 18:50:35 GMT

Issue Date: 1/10/2020

Effective Date: 2/11/2020

Provider Action Needed

CR11577 updates Chapter 7 of the Medicare Benefit Policy Manual to reflect policy changes finalized in the Calendar Year (CY) 2019 and 2020 Home Health Prospective Payment System (HH PPS) Final Rules with comment period (83 FR 56406 and 84 FR 60478). Specifically, these manual updates reflect policies related to:

The implementation of the Patient-Driven Groupings Model (PDGM)
A change to a 30-day unit of payment
Changes to split-percentage payments
Changes to the provision of maintenance therapy
The definition of remote patient monitoring.

Background

Regulations at 42 Code of Federal Regulations (CFR) 484.205 set forth the basis of home health payment under the HH PPS. Currently, Home Health Agencies (HHAs) are paid a prospective payment for a 60-day episode of care, adjusted for case-mix and area wage differences. Based on Section 51001 of the Bipartisan Budget Act of 2018, the Centers for Medicare & Medicaid Services (CMS) finalized policy changes to the home health unit of payment and the case-mix adjustment methodology in the CY 2019 HH PPS final rule with comment period (83 FR 56406), effective for home health periods of care beginning on and after January 1, 2020.

Also, in the CY 2019 HH PPS final rule with comment period, CMS finalized a change in the unit of payment from 60-day episodes to 30-day periods for periods beginning on or after January 1, 2020. This 30-day payment amount is adjusted by a new case-mix adjustment methodology, the Patient-Driven Groupings Model (PDGM), also finalized in the CY 2019 HH PPS final rule. Payment under the PDGM is adjusted by patient characteristics and other information obtained from home health claims, other Medicare claims, and certain items from the Outcome and Assessment Information Item Set (OASIS). Specifically, home health 30-day payments will be adjusted by the principal and secondary diagnoses, timing of the period of care, admission source and level of functional impairment.

In the CY 2020 HH PPS final rule with comment period (84 FR 60578), CMS finalized a change to the split-percentage payment approach, reducing the up-front payment amount to 20 percent in CY 2020 for all 30-day periods of care for HHAs certified for participation in Medicare on or before December 31, 2018. HHAs will submit a Request for Anticipated Payment (RAP) at the beginning of each 30-day period and a final claim at the end of each 30-day period.

As finalized in the CY 2019 HH PPS final rule (83 FR 56406), newly enrolled HHAs (that is, HHAs certified for participation in Medicare on and after January 1, 2019) will not receive splitpercentage payments for 30-day periods beginning on or after January 1, 2020. Newly enrolled HHAs will submit a “no-pay” RAP at the beginning of each 30-day period to establish the home health period of care and trigger consolidated billing edits in the Medicare claims processing system. Newly enrolled HHAs will receive a full 30-day period payment rate (minus any adjustments) after submission of a final claim at the end of each 30-day period.

The manual revisions related to these changes are in Section 10 of the revised Chapter 7 as included in CR11577.

In the CY 2020 HH PPS final rule with comment period (84 FR 60578), CMS finalized changes to the regulations at 42 CFR 409.44(c)(2)(iii)(C) regarding the provision of maintenance therapy services. Beginning in CY 2020, therapist assistants, and not just qualified therapists, can perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements.

The manual revisions related to these therapy services are in Section 40.2.1 of the revised Chapter 7.

Section 1895(e)(1)(A) of the Social Security Act (the Act) prohibits payments for services furnished via a telecommunications system if such services substitute for in-person home health services ordered as part of a plan of care. However, the statute does not define the term, “telecommunications system” as it relates to the provision of home health care. In CY 2019 HH PPS final rule with comment period (83 FR 56406), CMS defined “remote patient monitoring,” and finalized associated changes regarding allowed administrative costs on Medicare cost reports.

CMS defined remote patient monitoring under the Medicare home health benefit as, “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency.” This definition is in Section 80.10 of the revised Chapter 7. Visits to a beneficiary’s home for the sole purpose of supplying, connecting, and/or training the patient on the remote patient monitoring equipment, without the provision of another skilled service, are not separately billable. CMS also finalized to amend the regulations at 42 CFR 409.46 to include the costs of remote patient monitoring as an allowable administrative cost (that is, operating expense), if remote patient monitoring is used by the HHA to augment the care planning process. These remote monitoring changes are also in the revised Section 80.10.

Reference

Centers for Medicare and Medicaid

MLN Matters MM11577

New Modifiers to Identify Occupational Therapy (OT) and Physical Therapy (PT) Services Provided by a Therapy Assistant

Zachary Edgar — Fri, 01 Nov 2019 20:40:54 GMT

Effective Date: January 1, 2020

Applicable Providers

Physical and occupational therapists and assistants.

Compliance Change

CMS has established two modifiers, CQ and CO, for services furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs). The modifiers are defined as follows:

CQ modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
CO modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

Effective for claims with dates of service on and after January 1, 2020, the CQ and CO modifiers are required to be used, when applicable, for services furnished in whole or in part by PTAs and OTAs on the claim line of the service alongside the respective GP or GO therapy modifier, to identify those PTA and OTA services furnished under a PT or OT plan of care.

For those practitioners submitting professional claims who are paid under the PFS, the CQ/CO modifiers apply only to services of physical and occupational therapists in private practice (PTPPs and OTPPs); and not to the therapy services furnished by or incident to the services of physicians or nonphysician practitioners (NPPs) ‒ including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) ‒ because PTAs and OTAs do not meet the qualifications and standards of physical or occupational therapists, as required by §§ 410.60 and 410.59, respectively.

For providers submitting institutional claims and paid at PFS rates for their outpatient PT and OT services, the CQ and CO modifiers apply to the following providers: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and CORFs. However, the CQ and CO modifiers are not applicable to claims from critical access hospitals because they are paid on a reasonable cost basis, or from other providers for which payment for OT services is not made under the PFS rates. The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy modifier. Claims not so paired will be rejected/returned as unprocessable.

Policies for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device

Zachary Edgar — Tue, 11 Jun 2019 20:42:51 GMT

Article Release Date: June 11, 2019

Applicable Providers

Therapists and Home Health Agencies (HHAs) submitting claims to Home Health & Hospice Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Reporting NPWT Services using a Disposable Device

Effective January 1, 2017, Medicare makes a separate payment amount for a disposable Negative Pressure Wound Therapy (NPWT) device for a patient under a home health plan of care. Payment is equal to the amount of the payment that would otherwise be made under the Outpatient Prospective Payment System (OPPS).

Disposable NPWT services are billed using the following Current Procedural Terminology® (CPT) codes:

97607 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.
97608 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters.

The HHA reports the CPT code with one of three revenue codes, depending on the practitioner that provided the service:

Skilled nurse – 0559
Physical therapist – 042x
Occupational therapy – 043x.

When using revenue codes 042x or 043x, the HHA should not use the therapy plan of care modifiers (GO or GP) for NPWT services.

There are no additional documentation requirements for the provision of NPWT using a disposable device. The HHA documentation (and any supporting documentation leading to the order for home health and NPWT using a disposable device) should support that the patient needs wound care using NPWT. The medical necessity and documentation requirements would be no different than what is currently required when patients receive wound care from a home health nurse when the patient is receiving conventional NPWT. HHAs may also follow their own internal policies and procedures for documenting clinical information in the patient’s medical record beyond those required by regulation.

Billing for NPWT Services:

The (CPT) codes for furnishing NPWT using a disposable device include both performing the service and the disposable NPWT device, which is defined as an integrated system comprised of a non-manual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy. Services related to the furnishing NPWT using a disposable device that do not encompass the placement or replacement of the entire integrated system should be billed per existing HH PPS guidelines.

When furnishing NPWT using a disposable device, both the device and the services associated with furnishing the device are paid for separately based on the OPPS amount.

When a HHA furnishes NPWT using a disposable device, the HHA is furnishing a new disposable NPWT device.

This means the HHA provider is either initially applying an entirely new disposable NPWT device, or removing a disposable NPWT device and replacing it with an entirely new one.
In both cases, all the services associated with NPWT—for example, conducting a wound assessment, changing dressings, and providing instructions for ongoing care—must be reported on TOB 34x with the corresponding CPT code (that is, CPT® code 97607 or 97608); they may not be reported on the home health claim (TOB 32x).
The reimbursement for all of these services is included in the OPPS reimbursement amount for those two CPT codes.

Any follow-up visits for wound assessment, wound management, and dressing changes where a new disposable NPWT device is not applied must be included on the home health claim (TOB 32x).

Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

Zachary Edgar — Fri, 25 Jan 2019 21:53:16 GMT

Effective Date: 2/26/2019

This update is intended for therapists, physicians, certain nonphysician practitioners and other providers of therapy services – including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services − who submit professional or institutional claims to Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries.

CR 11120 updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent changes in outpatient therapy services billing instructions and payment policies related to the Bipartisan Budget Act of 2018 and the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule. These policy revisions include:

The repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and,
The discontinuation of the functional reporting requirements.

Background

Section 50202 of the Bipartisan Budget Act of 2018 (BBA of 2018) repeals application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold of incurred expenses above which claims must include a KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.

After a consideration of stakeholders’ requests for burden reduction and a review of the Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA) requirements, the Centers for Medicare & Medicaid Services (CMS) concluded in the CY 2019 MPFS final rule that continued collection of functional reporting data through the same format would not yield additional information to inform future analyses. The rule ended the functional reporting requirements to reduce burden of reporting for providers of therapy services.

CR 11120 updates Chapters 12 and 15 of the Medicare Benefit Policy Manual and Chapter 5 of the Medicare Claims Policy Manual to reflect these changes to law and regulation. Note: The relevant manual chapters are attached to CR 11120 for your review.

Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.

Reference

MLN Matters MM11120

Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

Zachary Edgar — Fri, 25 Jan 2019 20:38:57 GMT

Effective Date: January 1, 2019

Applicable Providers

Therapists, physicians, certain non-physician practitioners and other providers of therapy services – including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services − who submit professional or institutional claims to Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries

Compliance Change

These policy revisions include:

The repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and,
The discontinuation of the functional reporting requirements. Please make sure your billing staffs are aware of these changes.

Effective for dates of service on or after January 1, 2018, providers of therapy services shall continue to report the KX modifier on claims as applicable. The modifier no longer represents an exception request but serves as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record after the beneficiary has exceeded the threshold of incurred expenses. Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.

Background Information

Annual Update to the Per-Beneficiary Therapy Amounts

Zachary Edgar — Fri, 30 Nov 2018 19:12:07 GMT

Effective Date: 1/7/2019

This update is intended for physicians, therapists, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

CR 11055 describes the annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 (BBA of 2018) was signed into law. Another provision of the BBA of 2018 lowers the threshold of the targeted medical review process as explained in the Background section below.

For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040. Make sure that your billing staffs are aware of these updates.

Background

Effective for January 1, 2018, section 50202 of the Bipartisan Budget Act of 2018, P.L. 115-123 (BBA of 2018) amended section 1833(g) of the Social Security Act (the Act) to repeal the application of the therapy caps and the therapy caps exceptions process while also retaining and adding limitations to ensure appropriate therapy. The therapy caps or financial limitations originally applied through section 4541(c) of the Balanced Budget Act of 1997, P.L. 105-33 (1997 BBA) are no longer applicable to beneficiaries.

A separate provision of section 50202 of the BBA of 2018 adds section 1833(g)(7)(A) of the Act to preserve the former therapy cap amounts as thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. Claims from suppliers or providers for therapy services above these amounts without the KX modifier are denied. These amounts are now known as the KX modifier thresholds.

Just as with the incurred expenses for the therapy cap amounts, there is one KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined and a separate amount for occupational therapy (OT) services. These perbeneficiary amounts under section 1833(g) of the Act (as amended by 1997 BBA) are updated each year by the Medicare Economic Index (MEI).

For CY 2019, the KX modifier threshold amounts are: (a) $2,040 for PT and SLP services combined, and (b) $2,040 for OT services.

Another provision of section 50202 of the BBA of 2018 adds section 1833(g)(7)(B) of the Act which maintains the targeted medical review process (first established through section 202 of the Medicare Access and CHIP Reauthorization Act of 2015), but at a lower threshold than the $3,700 amount established as part of the therapy caps exceptions process via section 3005 of the Middle Class Tax Relief and Jobs Creation Act of 2012. For CY 2018 (and each successive calendar year until 2028, at which time it is indexed annually by the MEI), this now-termed Medical Review (MR) threshold amount is $3,000 for PT and SLP services combined and $3,000 for OT services.

Reference

MLN Matters Number: MM11055

2019 Update to the Per-Beneficiary Therapy Amounts

Zachary Edgar — Fri, 30 Nov 2018 17:57:16 GMT

Effective Date: January 1, 2019

Applicable Providers

Physicians, therapists, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

Compliance Change

The annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 (BBA of 2018) was signed into law.

Reference

MLN Matters Number: MM11055

Modifications Within Common Working File (CWF) to Adjustment Claims Exceeding Annual Therapy Threshold

Zachary Edgar — Fri, 10 Aug 2018 19:10:05 GMT

Effective Date: 1/7/2019

The purpose of this Change Request (CR) is for CWF to modify the process to set CWF edits correctly on adjustment claims when the therapy threshold is exceeded.

Background: Currently, when CWF receives an adjustment to a therapy (physical-PT, speech-SP, or occupational-OT) claim which had been paid prior to the therapy cap being reached, CWF searches to see if the beneficiary exceeded the threshold. If the beneficiary exceeds the threshold then CWF subjects the adjustment claim(s) to the normal therapy threshold processing, and if no 'KX' modifier is present, rejects the adjustment claim(s) and generates an edit which ultimately results in the original claim being treated as an overpayment.

The CMS request CWF to review CR 8938 and ensure that the system is in compliance with the therapy adjustment requirements and modify/revise the software if when necessary.

The contractor shall ensure that the adjustments to therapy claims for PT/SP and/or OT service(s) are excluded from therapy edits and threshold limits

Reference

Transmittal # R2111OTN

Clarification of Instructions Regarding the Intensive Level of Rehabilitation Therapy Services Requirements

Zachary Edgar — Fri, 23 Feb 2018 18:59:01 GMT

Effective Date: 3/23/2018

The purpose of this Change Request (CR) is to clarify the instructions for conducting medical review of Inpatient Rehabilitation Facility (IRF) claims when reviewing the requirements for the intensive level of rehabilitation therapy services.

Contractors shall verify that the IRF documentation requirements are met in accordance with Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.

Contractors shall not make denials based solely on any threshold of therapy time.

Contractors shall use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case.

Contractors shall not make denials solely because the situation/rationale that justifies group therapy is not specified in the patient’s medical records at the IRF.

Reference

Transmittal #R771PI

2018 Annual Update to the Therapy Code List

Zachary Edgar — Thu, 16 Nov 2017 18:40:15 GMT

Effective Date: 1/2/2018

This update is intended for physicians, therapists, and other providers, including Comprehensive Outpatient Rehabilitation Facilities (CORFs), submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

Change Request (CR) 10303 updates the list of codes that sometimes or always describe therapy services and their associated policies. The additions, changes, and deletions to the therapy code list reflect those made in the Calendar Year (CY) 2018 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT4). The therapy code listing is available at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html

Background

The Social Security Act (Section 1834(k)(5)) requires that all claims for outpatient rehabilitation therapy services and all Comprehensive Outpatient Rehabilitation Facility (CORF) services be reported using a uniform coding system. The Calendar Year (CY) 2018 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4) is the coding system used for the reporting of these services.

The policies implemented in CR10303 were discussed in CY 2018 Medicare Physician Fee Schedule (MPFS) rulemaking. CR10303 updates the therapy code list and associated policies for CY 2018, as follows:

The Current Procedural Terminology (CPT) Editorial Panel revised the set of codes physical and occupational therapists use to report orthotic and prosthetic management and training services by differentiating between initial and subsequent encounters through the: (a) addition of the term “initial encounter” to the code descriptors for CPT codes 97760 and 97761, (b) creation of CPT code 97763 to describe all subsequent encounters for orthotics and/or prosthetics management and training services, and (c) deletion of CPT code 97762. The new long descriptors for CPT codes 97760 and 97761 – now intended only to be reported for the initial encounter with the patient – are:

CPT code 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes)
CPT code 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes)

The Centers for Medicare & Medicaid Services (CMS) will add CPT code 97763 to the therapy code list and CPT code 97762 will be deleted.

The panel also created, for CY 2018, CPT code 97127 to replace/delete CPT code 97532. CMS will recognize HCPCS code G0515, instead of CPT code 97127, and add HCPCS code G0515 to the therapy code list. CPT code 97127 will be assigned a Medicare Physician Fee Schedule (MPFS) payment status indicator of “I” to indicate that it is “invalid” for Medicare purposes and that another code is used for reporting and payment for these services.

Just as its predecessor code was, CPT code 97763 is designated as “always therapy” and must always be reported with the appropriate therapy modifier, GN, GO or GP, to indicate whether it’s under a Speech-language pathology (SLP), Occupational Therapy (OT) or Physical Therapy (PT) plan of care, respectively.

HCPCS code G0515 is designated as a “sometimes therapy” code, which means that an appropriate therapy modifier − GN, GO or GP, to reflect it’s under an SLP, OT, or PT plan of care – is always required when this service is furnished by therapists; and, when it’s furnished by or incident to physicians and certain Nonphysician Practitioners (NPPs), that is, nurse practitioners, physician assistants, and clinical nurse specialists when the services are integral to an SLP, OT, or PT plan of care. Accordingly, HCPCS code G0515 is sometimes appropriately reported by physicians, NPPs, and psychologists without a therapy modifier when it is appropriately furnished outside an SLP, OT, or PT plan of care. When furnished by psychologists, the services of HCPCS code G0515 are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier.

The therapy code list is updated with one new “always therapy” code and one new “sometimes therapy” code, using their HCPCS/CPT long descriptors, as follows:

CPT code 97763 – This “always therapy” code replaces/deletes CPT code 97762. o CPT code 97763: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
HCPCS code G0515 – This “sometimes therapy” code replaces/deletes CPT code 97532.
HCPCS code G0515: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

Reference

MLN Matters MM10303

Therapy Cap Values for Calendar Year (CY) 2018

Zachary Edgar — Thu, 09 Nov 2017 18:39:09 GMT

Effective Date: 1/2/2018

Change Request (CR) 10341 provides the amounts for outpatient therapy caps for Calendar Year (CY) 2018. For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010. Make sure that your billing staffs are aware of these therapy cap value updates.

Background

The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “therapy caps.” The therapy caps are updated each year based on the Medicare Economic Index.

Section 5107 of the Deficit Reduction Act of 2005 required an exceptions process to the therapy caps for reasonable and medically necessary services. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy caps exceptions process through December 31, 2017.

Reference

MLN Matters MM10341

2018 Update to the Per-Beneficiary Therapy Amounts

Zachary Edgar — Thu, 09 Nov 2017 17:56:28 GMT

Effective Date: January 1, 2018

Applicable Providers

Therapists, physicians, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

Compliance Change

For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010. Make sure that your billing staffs are aware of these therapy cap value updates.

Reference

MLN Matters Number: MM10341

Updated Editing of Always Therapy Services – MCS

Zachary Edgar — Thu, 27 Jul 2017 18:34:35 GMT

Effective Date: 1/2/2018

CR 10176 implements revised editing of Part B “Always Therapy” services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap. CR10176 contains no new policy. Instead, the guidelines presented in the CR improve the enforcement of longstanding, existing instructions. Make sure your billing staffs are aware of these revisions.

Services furnished under the Outpatient Therapy (OPT) services benefit – including Speech Language Pathology (SLP), Occupational Therapy (OT), and Physical Therapy (PT) – are subject to the financial limitations, known as therapy caps, originally required under Section 4541 of the Balanced Budget Act (1997).

There are two such caps. One cap is for PT and SLP services combined and another cap is for OT services. In order to accrue incurred expenses to the correct therapy cap; the use of one of the three therapy modifiers (GN, GO, or GP) is required on a certain set of Healthcare Common Procedure Coding System (HCPCS) codes in order to identify when each OPT service is furnished under an SLP, OT, or PT plan of care, respectively.

Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy and publishes this list as an Annual Update on the Therapy Services Billing page at https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.

On professional claims, each code designated as “always therapy”:

Must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such,
Must always be accompanied by one of the GN, GO, or GP therapy modifiers.

In addition, several “always therapy” codes have been identified as discipline-specific – requiring the GN modifier for six codes, the GO modifier for four codes, and the GP modifier for four codes, as illustrated in Tables 1-3.

Table 1: Codes Requiring the “GN” Therapy Modifier

Code	Description	Modifier
92521	Evaluation of speech fluency	GN
92522	Evaluate speech production	GN
92523	Speech sound lang comprehend	GN
92524	Behavral quality analys voice	GN
92597	Oral speech device eval	GN
92607	Ex for speech device rx 1hr	GN

Table 2: Codes Requiring the “GO” Therapy Modifier

Code	Description	Modifier
97165	Ot eval low complex 30 min	GO
97166	Ot eval mod complex 45 min	GO
97167	Ot eval high complex 60 min	GO
97168	Ot re-eval est plan care	GO

Table 3: Codes Requiring the “GP” Therapy Modifier

Code	Description	Modifier
97161	Pt eval low complex 20 min	GP
97162	Pt eval mod complex 30 min	GP
97163	Pt eval high complex 45 min	GP
97164	Pt re-eval est plan care	GP

The following “Always Therapy” HCPCS codes require a GN, GO, or GP modifier, as appropriate. Descriptors for these codes are included as an attachment to CR 10176.

92507 92508 92526 92608 92609 96125 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97530 97533 97535 97537 97542 97750 97755 97760 97761 97762 97799 G0281 G0283 G0329

In addition to Therapists in Private Practice (TPPs) – including physical therapists, occupational therapists, and speech-language pathologists – professional claims for OPT services may be furnished by physicians and certain Non-Physician Practitioners (NPPs) – specifically, physician assistants, nurse practitioners, and certified nurse specialists.

All OPT services furnished by TPPs are always considered therapy services, regardless of whether they are designated as “always therapy” or “sometimes therapy.” As such, the appropriate therapy modifier must be included on the claim. However, it may be clinically appropriate for physicians and NPPs to furnish OPT services that have been designated “sometimes therapy” codes outside a therapy plan of care - in these cases, therapy modifiers are not required and claims may be processed without them.

During analyses of Medicare claims data for OPT services, the Centers for Medicare & Medicaid Services (CMS) found that these “always therapy” codes and modifiers are not always used in a correct and consistent manner. CMS found OPT professional claims for “always therapy” codes without the required modifiers. Also, CMS found claims that reported more than one therapy modifier for the same therapy service; for example, both a GP and GO modifier, when only one modifier was allowed.

These claims represent non-compliant billing by TPPs, physicians, and NPPs, and hamper CMS’ ability to properly track the therapy caps and analyze claims data for purposes of Medicare program improvements. The requirements in CR10176 will create new edits for Medicare professional claims processing systems to return claims when “always therapy” codes and the associated therapy modifiers are improperly reported.

Providers should expect the following:

MACs will return/reject claims which contain an “always therapy” procedure code, but do not also contain the appropriate discipline-specific therapy modifier of GN, GO, or GP.
MACs will also return/reject claims if any service line on the claim contains more than one occurrence of a GN, GO, or GP therapy modifier.
MACs who are returning/rejecting such claims will use Group Code CO and Claim Adjustment Reason Code (CARC) 4 on the related remittance advice.

Reference

MLN Matters MM10176

Clarification of Payment Policy Changes for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device and the Outlier Payment Methodology for Home Health Services

Zachary Edgar — Fri, 24 Feb 2017 18:33:03 GMT

Effective Date: 3/27/2017

In the CY 2017 HH PPS Final Rule, CMS finalized clarifications and revisions to policies related to payment for furnishing of NPWT using a disposable device, as well as change to the methodology used to calculate outlier payments to HHAs.

Negative Pressure Wound Therapy Using a Disposable Device

The Consolidated Appropriations Act of 2016 (Pub. L. 114-113) requires a separate payment to a HHA for an applicable disposable device when furnished on or after January 1, 2017, to an individual who receives Home Health Services for which payment is made under the Medicare home health benefit. The legislation defines an applicable device as a disposable NPWT device that is an integrated system comprised of a non-manual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy used in lieu of a conventional NPWT DME system. The separate payment amount for a disposable NPWT device is to be set equal to the amount of the payment that would be made under the Medicare Hospital Outpatient Prospective Payment System (OPPS) using the Level I HCPCS code, otherwise referred to as Current Procedural Terminology (CPT® 4) codes, for which the description for a professional service includes the furnishing of such a device.

Payment for HH visits related to wound care, but not requiring the furnishing of an entirely new disposable NPWT device, will be covered by the HH PPS episode payment and must be billed using the HH claim. Where a HH visit is exclusively for the purpose of furnishing NPWT using a disposable device, the HHA will submit only a type of claim that will be paid for separately outside the HH PPS (Type of Bill (TOB) 34x). Where, however, the home health visit includes the provision of other home health services in addition to, and separate from, furnishing NPWT using a disposable device, the HHA will submit both a home health claim and a TOB 34x—the home health claim covering the other home health services, and the TOB 34x capturing the furnishing of NPWT using a disposable device.

EXAMPLE: A patient requires NPWT for the treatment of a wound. On Monday, a nurse assesses a patient’s wound, applies a new disposable NPWT device, and provides wound care education to the patient and family. The nurse returns on Thursday for wound assessment and replaces the fluid management system (or dressing) for the existing disposable NPWT, but does not replace the entire device. The nurse returns the following Monday, assesses the patient’s condition and the wound, and replaces the device that had been applied on the previous Monday with a new disposable NPWT device. In this scenario, the billing procedures are as follows:

For both Monday visits, all the services provided by the nurse were associated with furnishing NPWT using a disposable device. The nurse did not provide any services that were not associated with furnishing NPWT using a disposable device. Therefore, all the nursing services for both Monday visits should be reported on TOB 34x with CPT code 97607 or 97608. None of the services should be reported on the HH claim.

For the Thursday visit, the nurse checked the wound, but did not apply a new disposable NPWT device. Thus, even though the nurse provided care related to the wound, those services would not be considered furnishing NPWT using a disposable device.

Therefore, the services should be reported on TOB 32x and no services should be reported on TOB 34x.

Outlier Payments

The Centers for Medicare & Medicaid Services (CMS) finalized the proposal to change the methodology used to calculate outlier payments, moving from a cost-per-visit approach to a cost-per-unit approach (1 unit = 15 minutes). This approach more accurately reflects the cost of an outlier episode of care and thus better aligns outlier payments with episode costs than the cost-per-visit approach.

Reference

MLN Matters Number: MM9898

Updated Editing of Professional Therapy Services

Zachary Edgar — Fri, 27 Jan 2017 18:20:31 GMT

Effective Date: 7/3/2017

CR9933 implements the following payment policies related to professional claims for therapy services for the new CPT codes for PT and OT evaluative procedures – claims without the required information will be returned/rejected:

Therapy Modifiers

The new PT and OT codes are added to the current list of evaluative procedures that require a specific therapy modifier to identify the plan of care under which the services are delivered to be on the claim for therapy services. Therapy modifiers GP, GO, or GN are required to report the type of therapy plan of care – PT, OT, or speech-language pathology, respectively. This payment policy requires that each new PT evaluative procedure code – 97161, 97162, 97163 or 97164 – to be accompanied by the GP modifier; and, (b) each new code for an OT evaluative procedure – 97165, 97166, 97167 or 97168 – be reported with the GO modifier.

Functional Reporting

In addition to other Functional Reporting requirements, Medicare payment policy requires Functional Reporting, using G-codes and severity modifiers, when an evaluative procedure is furnished and billed. This notification adds the eight new codes for PT and OT evaluations and re-evaluations – 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168 – to the procedure code list of evaluative procedures that necessitate Functional Reporting. A severity modifier (CH – CN) is required to accompany each functional G-code (G8978-G8999, G9158-9176, and G9186) on the same line of service.

For each evaluative procedure code, Functional Reporting requires either two or three functional G-codes and related severity modifiers be on the same claim. Two G-codes are typically reported on specified claims throughout the therapy episode. However, when an evaluative service is furnished that represents a one-time therapy visit, the therapy clinician reports all three G-codes in the functional limitation set – G-codes for Current Status, Goal Status and Discharge Status.

CMS coding requirements for Functional Reporting applied through CR9933 ensure that at least two G-codes in a functional set and their corresponding severity modifiers are present on the same claim with any one of the codes on this evaluative procedure code list. The required reporting of G-codes includes: (a) G-codes for Current Status and Goal Status; or, (b) G-codes for Discharge Status and Goal Status.

For the documentation requirements related to Functional Reporting, please refer to the “Medicare Benefits Policy Manual,” Chapter 15, Section 220.4, which is available at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf.

Claims Coding Requirements

Therapy Modifiers. Your MAC will return/reject professional claims when:

Reporting codes 97161, 97162, 97163, or 97164 without the GP modifier.
Reporting codes 97165, 97166, 97167, or 97168 without the GO modifier.
Reporting an “always therapy” code without a therapy modifier

For these returned/rejected claims, your MAC will supply the following messages:

Group code CO
CARC – 4: The procedure code is inconsistent with the modifier used or a required modifier is missing.

Functional Reporting. Your MAC will return/reject claims when:

The professional claims you submit for the new therapy evaluative procedures, codes 97161- 97168, without including one of the following pairs of G-codes/severity modifiers required for Functional Reporting: (a) A Current Status G-code/severity modifier paired with a Goal Status G-code/severity modifier; or, (b) A Goal Status G-code/severity modifier paired with a Discharge Status G-code/severity modifier.

Your MAC will provide the following remittance messages when returning such submissions:

Group code of CO (contractual obligation)
Claim Adjustment Reason Code (CARC) – 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
Remittance Advice Remarks Code (RARC) – N572: This procedure is not payable unless non-payable reporting codes and appropriate modifiers are submitted.

Reference

MLN Matters Number: MM9933

Update to Editing of Therapy Services to Reflect Coding Changes

Zachary Edgar — Thu, 01 Dec 2016 20:43:47 GMT

December 1, 2016

This change request instructs contractors to add new Common Procedure Terminology (CPT) codes to report physical and occupational therapy evaluations.

A. Background: Original Medicare claims processing systems contain edits to ensure claims for the evaluative procedures furnished by rehabilitative therapy clinicians – including physical therapists, occupational therapists and speech-language pathologists – are coded correctly. These edits ensure that when the codes for evaluative services are submitted, the therapy modifier (GP, GO or GN) that reports the type of therapy plan of care is consistent with the discipline described by the evaluation or re-evaluation code. The edits also ensure that Functional Reporting occurs, i.e., that functional G-codes, along with severity modifiers, always accompany codes for therapy evaluative services.

For calendar year (CY) 2017, eight new CPT codes (97161-97168) were created to replace existing codes (97001-97004) to report physical therapy (PT) and occupational therapy (OT) evaluations and reevaluations. The new CPT code descriptors include specific components that are required for reporting as well as the typical face-to-face times. In another recent issuance, Change Request (CR) 9782, we described the new PT and OT code sets, each comprised of three new codes for evaluation – stratified by low, moderate, and high complexity – and one code for re-evaluation. CR 9782 designated all eight new codes as “always therapy” (always require a therapy modifier) and added them to the 2017 therapy code list located on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html. For a complete listing of the new codes, their CPT long descriptors, and related policies, please refer to CR 9782.

This notification applies the coding requirements for certain evaluative procedures that are currently outlined in Pub. 100-04, Medicare Claims Processing Manual (MCPM), Chapter 5 to the new codes for PT and OT evaluations and re-evaluations. These coding requirements include the payment policies for evaluative procedures that (a) require the application of discipline-specific therapy modifiers and (b) necessitate Functional Reporting using G-codes and severity modifiers. The new codes are also added to the list of evaluation codes that CMS will except from the caps after the therapy caps are reached when an evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services.

In addition, this Change Request (CR) updates and clarifies information in MCPM, Pub. 100-04, Chapter 5.

B. Policy: This notification implements the following payment policies related to claims for therapy services for the new codes for PT and OT evaluative procedures – claims without the required information will be returned as unprocessable:

Therapy modifiers. The new PT and OT codes are added to the current list of evaluative procedures that require a specific therapy modifier to identify the plan of care under which the services are delivered to be on the claim for therapy services. Therapy modifiers GP, GO or GN are required to report the type of therapy plan of care – PT, OT, or speech language pathology (SLP), respectively. This payment policy requires that each new PT evaluative procedure code – 97161, 97162, 97163 or 97164 – to be accompanied by the GP modifier; and, (b) each new code for an OT evaluative procedure – 97165, 97166, 97167 or 97168 – be reported with the GO modifier.

Functional Reporting (FR). In addition to other Functional Reporting requirements, current payment policy requires Functional Reporting, using G-codes and severity modifiers, when an evaluative procedure is furnished and billed. This notification adds the eight new codes for PT and OT evaluations and reevaluations – 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168 – to the procedure code list of evaluative procedures that necessitate Functional Reporting. A severity modifier (CH – CN) is required to accompany each functional G-code (G8978-G8999, G9158-9176, and G9186) on the same line of service.

CMS coding requirements for Functional Reporting applied through this notification ensure that at least two G-codes in a functional set and their corresponding severity modifiers are present on the same claim with any one of the codes on this evaluative procedure code list. The required reporting of G-codes includes: (a) G-codes for Current Status and Goal Status; or, (b) G-codes for Discharge Status and Goal Status.

Reference

Medicare Transmittal # R3670CP

December 1, 2016

2017 Annual Update to the Therapy Code List

Zachary Edgar — Thu, 10 Nov 2016 20:45:40 GMT

November 10, 2016

SUMMARY OF CHANGES: This Change Request updates the list of codes that sometimes or always describe therapy services. The additions, changes, and deletions to the therapy code list reflect those made in the CY 2017 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4). The attached Recurring Update Notification applies to Chapter 5, Section 10.6

A. Background: Section 1834(k)(5) of the Act requires that all claims for outpatient rehabilitation therapy services and all comprehensive outpatient rehabilitation facility services be reported using a uniform coding system. The CY 2017 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4) is the coding system used for the reporting of these services.

This change request (CR) updates the list of codes that sometimes or always describe therapy services. The additions, changes, and deletions to the therapy code list reflect those made in the CY 2017 HCPCS/CPT-4. The therapy code listing can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html.

B. Policy:The policies implemented in this notification were discussed in CY 2017 Medicare Physician Fee Schedule (MPFS) rulemaking. This CR updates the therapy code list and associated policies for CY 2017, as follows:

For CY 2017, the Current Procedural Terminology (CPT) Editorial Panel created eight new codes (97161- 97168) to replace the 4-code set (97001-97004) for physical therapy (PT) and occupational therapy (OT) evaluative procedures. The new CPT code descriptors for PT and OT evaluative procedures include specific components that are required for reporting as well as the corresponding typical face-to-face times for each service. Refer to Tables 1 and 2 in the Attachment for a complete listing of the new CPT codes for PT and OT evaluative procedures and their long descriptors.

PT and OT evaluation codes. The CPT Editorial Panel created three new codes to replace each existing PT and OT evaluation code, 97001 and 97003, respectively. These new evaluation codes are based on patient complexity and the level of clinical decision-making – low, moderate and high complexity: for PT, codes 97161, 97162 and 97163; and for OT, codes 97165, 97166 and 97167.

PT and OT re-evaluation codes. One new PT code, 97164, and one new OT code, 97168, were created to replace the existing codes – 97002 and 97004, respectively. The re-evaluation codes are reported for an established patient’s when a revised plan of care is indicated.

Just as their predecessor codes were, the new codes are “always therapy” and must be reported with the appropriate therapy modifier, GP or GO, to indicate that the services are furnished under a PT or OT plan of care, respectively.

The therapy code list is updated with eight new “always therapy” codes, using their CPT short descriptors, as follows:

The new codes for PT Evaluative procedures (97161-97164):

The three new PT evaluation codes 97161, 97162, and 97163 replace code 97001
Add: 97161 - PT EVAL LOW COMPLEX 20 MIN
Add: 97162 - PT EVAL MOD COMPLEX 30 MIN
Add: 97163 - PT EVAL HIGH COMPLEX 45 MIN
Delete: 97001 - PT EVALUATION
The new PT re-evaluation code 97164 replaces code 97002
Add: 97164 - PT RE-EVAL EST PLAN CARE
Delete: 97002 - PT RE-EVALUATION

The new codes for OT Evaluative procedures (97165-97168):

The three new OT evaluation codes 97165, 97166, and 97167 replace code 97003
Add: 97165 - OT EVAL LOW COMPLEX 30 MIN
Add: 97166 - OT EVAL MOD COMPLEX 45 MIN
Add: 97167 - OT EVAL HIGH COMPLEX 60 MIN
Delete: 97003 – OT EVALUATION
The new OT re-evaluation code 97168 replaces 97004
Add: 97168 - OT RE-EVAL EST PLAN CARE
Delete: 97004 – OT RE-EVALUATION

For CY 2017 - New CPT Codes and Long Descriptors for PT Evaluative Procedures

97161 - Physical therapy evaluation: low complexity, requiring these components:

A history with no personal factors and/or comorbidities that impact the plan of care;
An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
A clinical presentation with stable and/or uncomplicated characteristics; and
Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.

Typically, 20 minutes are spent face-to-face with the patient and/or family.

97162 - Physical therapy evaluation: moderate complexity, requiring these components:

A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
An evolving clinical presentation with changing characteristics; and
Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.

Typically, 30 minutes are spent face-to-face with the patient and/or family.

97163 - Physical therapy evaluation: high complexity, requiring these components:

A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;
An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
A clinical presentation with unstable and unpredictable characteristics; and
Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.

Typically, 45 minutes are spent face-to-face with the patient and/or family.

97164 - Re-evaluation of physical therapy established plan of care, requiring these components:

An examination including a review of history and use of standardized tests and measures is required; and
Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

Typically, 20 minutes are spent face-to-face with the patient and/or family.

For CY 2017: New CPT Codes and Long Descriptors for OT Evaluative Procedures

97165 - Occupational therapy evaluation, low complexity, requiring these components:

An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;
An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.

Typically, 30 minutes are spent face-to-face with the patient and/or family.

97166 - Occupational therapy evaluation, moderate complexity, requiring these components:

An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.

Typically, 45 minutes are spent face-to-face with the patient and/or family.

97167 - Occupational therapy evaluation, high complexity, requiring these components:

An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;
An assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.

Typically, 60 minutes are spent face-to-face with the patient and/or family.

97168 - Re-evaluation of occupational therapy established plan of care, requiring these components:

An assessment of changes in patient functional or medical status with revised plan of care;
An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.

Typically, 30 minutes are spent face-to-face with the patient and/or family.

Reference

Medicare Transmittal # R3654CP

November 10, 2016

Therapy Cap Values for Calendar Year (CY) 2017

Zachary Edgar — Fri, 04 Nov 2016 20:55:11 GMT

November 4, 2016

Effective Date: January 1, 2017

Background: The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “therapy caps.” The therapy caps are updated each year based on the Medicare Economic Index. An exceptions process to the therapy caps for reasonable and medically necessary services was required by section 5107 of the Deficit Reduction Act of 2005. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy caps exceptions process through December 31, 2017.

Policy: Contractors shall update the allowed dollar amount for CY 2017 outpatient therapy limits to $1,980 for physical therapy and speech-language pathology combined and $1,980 for occupational therapy

Reference

Medicare Transmittal # R3644CP

November 4, 2016

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

Zachary Edgar — Thu, 04 Feb 2016 20:56:04 GMT

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

Therapy Cap Values for Calendar Year (CY) 2016

Zachary Edgar — Wed, 25 Nov 2015 19:30:39 GMT

November 25, 2015

Background: The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “ therapy caps”. The therapy caps are updated each year based on the Medicare Economic Index. An exceptions process to the therapy caps for reasonable and medically necessary services was required by section 5107 of the Deficit Reduction Act of 2005. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 extended the therapy caps exceptions process through December 31, 2017.

Policy: Therapy caps for CY 2016 will be $1,960.

Contractors shall update the allowed dollar amount for CY 2016 outpatient therapy limits to $1,960 for physical therapy and speech-language pathology combined and $1,960 for occupational therapy.

Reference

Medicare Transmittal # R3417CP

November 25, 2015

Revisions to State Operations Manual (SOM), Chapter 2, Clarification of Requirements for Off-Premises Activities and Approval of Extension Locations for Providers of Outpatient Physical Therapy and Speech-Language Pathology Services

Zachary Edgar — Fri, 30 Oct 2015 19:32:56 GMT

2292B – Rehabilitation Agency, Clinic and Public Health Agency (Rev. 150, Issued: 10-30-15, Effective: 10-30-15, Implementation: 10-30-15)

Two person duty requirement: Organizations must always have at least two persons (either of its own personnel or its contracted personnel) on duty on the premises anytime rehabilitation treatment is being provided to a patient. The two person requirement does not specify which staff must be on duty (in other words, professional staff or a combination of professional staff and support staff), but the organizations must consider the supervision required of support staff.

This duty requirement can be verified by requesting staff or personnel time cards. The staff time cards can be compared against patient sign-in sheets if there are concerns regarding the two person duty requirement.

Services provided in a patient’s residence are exempt from the two person duty requirement. Additionally, services provided in a patient’s room within an assisted living facility (ALF) or independent living facility (ILF) may be considered to be a patient’s residence and therefore also exempt from the two person on duty requirement. A common or general use area of the facility, such as a hallway, may be considered to be an extension of the patient’s room and residence and also exempt from the two person on duty requirement.

This requirement is for the safety of the patients. It is not a new requirement, but is sometimes overlooked, particularly at a rehabilitation agency’s extension location(s). Refer to Interpretive Guidance Tag I-118 in Appendix E of the SOM.

Supervision: A physical therapist may not supervise an occupational therapy assistant, nor, may an occupational therapist supervise a physical therapist assistant. Nonprofessional personnel (generally physical and occupational therapy aides) cannot be supervised by anyone other than the qualified physical or occupational therapist while performing patient care activities.

Clinical records: The regulations at § 485.721 require clinical records be maintained on all patients served by the organization. A copy of the patient’s current clinical record should be kept at the practice location and readily accessible for prompt retrieval. Electronic records are acceptable but should be password or other method protected to maintain security and patient privacy.

Administrator: The administrator (§ 485.709) is given internal control of the clinic or rehabilitation agency by the governing body. The administrator must assume overall administrative responsibility for the entirety of the organization’s operation including extension locations and/or off-premises activities. Furthermore, the administrator must serve as a full time administrator, meaning he can only be responsible for a single Medicare certified organization. It is important to determine whether the administrator can efficiently and effectively serve as administrator if the agency has several extension locations. Also, a competent individual must be available at each extension location to manage the day to day operations of that location on the days when the administrator is not onsite. That individual is responsible for reporting to the administrator.

Governing body: The governing body (§ 485.709) (or designated person so functioning) has the legal responsibility for the overall clinic or rehabilitation agency operations (including conduct and compliance of the clinic or rehabilitation agency) and may be legally responsible for more than one clinic or rehabilitation agency. The governing body’s legal responsibility for the overall conduct of the clinic or rehabilitation agency cannot be delegated to any other entity (for example, a parent corporation). The number of individuals who serve on the governing body is determined by the organization/individuals who own the clinic or rehabilitation agency. The name of the owner(s) or corporate officer(s) (for a corporate entity) is fully disclosed to the State Agency. The governing body is expected to meet periodically, consistent with its by-laws.

Contracts: An organization may provide services with direct hire employees (i.e., salaried personnel) and with those employees under arrangement (or contract) (§ 485.719). The employees hired under contract may provide services wherever the organization provides therapy services.

Rehabilitation agencies may contract to provide outpatient therapy services at assisted living facilities (ALFs). In this instance, the rehabilitation agency has the administrative responsibility and supervisory oversight for the delivery of services in these facilities. In addition, the rehabilitation agency is responsible for maintaining clinical records for therapy services provided to the ALF patients.

In situations when the OPT is seeing patients in an ALF or ILF, where there is no ongoing or permanent presence of the OPT, common areas do not need to be closed off when an individual therapy session extends beyond the patient’s room. However, OPTs must afford patients the opportunity for privacy at the patient’s request or when clinical situations warrant privacy.

Any space leased, rented, or dedicated for the provision of OPT services, including space within an ALF or ILF that is designated for therapy service, must meet the two person on duty requirement and become a separately certified OPT or become approved as an extension location of a currently certified OPT. Leased or rented space that is dedicated to therapy services must be closed to non-therapy participants when services are being provided. See Section 3100 for additional guidance for situations and when a location must be approved as an extension site or separately certified.

2298A - Criteria for Extension Location Approval

It is the CMS RO (not the SA or AO) that has the final authority for approving the request for an extension location. The following criteria should be reviewed and assessed in a decision regarding the approval or denial of extension locations:

• The extension location must have equipment and modalities appropriate for the needs of the patients it accepts for service.

• The administrator and other supervisors at the primary site must be capable of adequate supervision of the staff at all extension locations to include management and overseeing operations of the extension location. The administrator may delegate aspects of administrative operations at extension locations provided the agency has internal policies and procedures ensuring coordinated oversight of all locations. The administrator or his/her designee should be available by telephone, at a minimum, and be able to arrive at the extension location in a reasonable amount of travel time.

• Primary sites are generally able to meet the requirements for supervision and oversight when the extension location being requested is within 30 miles of the primary site. Requests for approval of extension locations beyond 30 miles must include adequate documentation to support the OPT’s ability to maintain supervision and oversight of these locations and that the services are being provided to a portion of the total geographic area served by the primary site. An example of evidence supporting this would include, but is not limited to, policies and procedures describing a structured program for supervision and oversight of activities at extension locations. This may include items such as scheduled teleconferences, videoconferencing, and site visits to facilitate administrative and personnel management. Additionally, OPTs may provide a written narrative to the CMS RO further describing their supervision and oversight of extension locations. The oversight program must ensure that the extension locations maintain compliance with all applicable aspects of the CoPs, even though they are not required to independently meet all the CoPs as a rehabilitation agency.

• The extension location must provide the same level of privacy and dignity for its patients as the primary site does.

• For a rehabilitation agency to establish an extension location across State lines, the affected State Survey Agencies must have a signed reciprocal agreement allowing approval of the extension location.

2300 – Outpatient Physical Therapy and/or Speech-Language Pathology Services at Other Locations such as a Patient’s Private Residence, Assisted Living or Independent Living Facility

In addition to the primary site and any extension locations, the organization may provide therapy services in the patient’s private residence or in a patient’s room in a SNF/NF, in an assisted living facility, or in an independent living facility. These are services that are provided on an intermittent basis where there is no ongoing or permanent presence of the OPT. Examples of an ongoing or permanent presence may be indicated by a dedicated therapy gym; storing of equipment, supplies, or medical records at the facility; or having OPT staff regularly assigned to work at that facility directing a coordinated and ongoing rehabilitation program at the facility. These situations are examples that would require the OPT to have the other location become separately certified or become approved as an extension location.

The agency must provide an adequate therapy program whenever and wherever it provides services at locations away from the primary site. The agency must have adequate equipment and modalities available, at any location, to treat the patients accepted for service. If the agency is providing services at more than one location each day, the agency must have infection control policies in place that set forth the techniques the agency employees will use at all locations.

The agency is responsible for providing any modality that is designated on the plan of care or requested by the physician. It is not acceptable for agencies to ask patients to sign waivers for modalities that are not available. The agency should refer the patient to another agency if needed services are not available at the agency practice location. The surveyor should see evidence of the referral in the patient’s clinical record.

The current plan of care and progress notes must be accessible to service providers anytime that the patient is receiving care in order to promote continuity of care.

Periodically, an organization may wish to use a community facility to provide certain therapeutic services. For example, the organization may want to use a community pool to provide aquatic therapy. The SA or AO shall verify that the community pool meets all applicable State laws (i.e., health and safety, infection control requirements, etc.) governing the use of the community facility. Also the SA or AO shall review the organization’s policies and procedures regarding the type of therapy being provided, training for staff, supervision, etc. The pool must be closed to public use during the time the organization is providing therapy to protect the privacy and safety of the patients being treated. The hours of operation and days of the week during which the facility will be used for therapy services, supervision, etc. must be clearly stated in the organization’s policies and procedures as well as the contractual agreement between the community pool and the organization. Verify that the organization has a carefully detailed policy regarding specific arrangements for emergency services in the event of a medical emergency at the community location (i.e., is a telephone in close proximity to the qualified professional providing the service, is there a second organization staff person on site, etc.

Reference
Medicare Transmittal # R150SOMA

October 30, 2015

Applying Therapy Caps to Maryland Hospitals and Manual Information for Therapy Caps in all Outpatient Settings

Zachary Edgar — Thu, 06 Aug 2015 19:35:29 GMT

August 6, 2015

This Change Request (CR) revises Original Medicare systems to ensure therapy services provided in Maryland hospitals are subject to the outpatient therapy per-beneficiary caps.

Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services – General

(Rev. 3309, Issued: 08-06-2015, Effective: 01-01-2016, Implementation:01-04-2016)

Language in this section is defined or described in Pub. 100-02, chapter 15, sections 220 and 230.

Section §1834(k)(5) to the Social Security Act (the Act), requires that all claims for outpatient rehabilitation services and comprehensive outpatient rehabilitation facility (CORF) services, be reported using a uniform coding system. The CMS chose HCPCS (Healthcare Common Procedure Coding System) as the coding system to be used for the reporting of these services. This coding requirement is effective for all claims for outpatient rehabilitation services and CORF services submitted on or after April 1, 1998.

The Act also requires payment under a prospective payment system for outpatient rehabilitation services including CORF services. Effective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for outpatient therapy services furnished by:

• Comprehensive outpatient rehabilitation facilities (CORFs);
• Outpatient physical therapy providers (OPTs), also known as rehabilitation agencies;
• Hospitals (to outpatients and inpatients who are not in a covered Part A stay);
• Skilled nursing facilities (SNFs) (to residents not in a covered Part A stay and to nonresidents who receive outpatient rehabilitation services from the SNF); and
• Home health agencies (HHAs) (to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC)).

NOTE: No provider or supplier other than the SNF will be paid for therapy services during the time the beneficiary is in a covered SNF Part A stay. For information regarding SNF consolidated billing see chapter 6, section 10 of this manual.

Similarly, under the HH prospective payment system, HHAs are responsible to provide, either directly or under arrangements, all outpatient rehabilitation therapy services to beneficiaries receiving services under a home health POC. No other provider or supplier will be paid for these services during the time the beneficiary is in a covered Part A stay. For information regarding HH consolidated billing see chapter10, section 20 of this manual.

Section 143 of the Medicare Improvements for Patients and Provider’s Act of 2008 (MIPPA) authorizes the Centers for Medicare & Medicaid Services (CMS) to enroll speech-language pathologists (SLP) as suppliers of Medicare services and for SLPs to begin billing Medicare for outpatient speech-language pathology services furnished in private practice beginning July 1, 2009. Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services. Previously, the Medicare program could only pay SLP services if an institution, physician or nonphysician practitioner billed them.

In Chapter 23, as part of the CY 2009 Medicare Physician Fee Schedule Database, the descriptor for PC/TC indicator “7”, as applied to certain HCPCS/CPT codes, is described as specific to the services of privately practicing therapists. Payment may not be made if the service is provided to either a hospital outpatient or a hospital inpatient by a physical therapist, occupational therapist, or speech-language pathologist in private practice.

The MPFS is used as a method of payment for outpatient rehabilitation services furnished under arrangement with any of these providers.

The Medicare allowed charge for the services is the lower of the actual charge or the MPFS amount. The Medicare payment for the services is 80 percent of the allowed charge after the Part B deductible is met. Coinsurance is made at 20 percent of the lower of the actual charge or the MPFS amount. The general coinsurance rule (20 percent of the actual charges) does not apply when making payment under the MPFS. This is a final payment.

The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs) or hospitals in Maryland. CAHs are to be paid on a reasonable cost basis. Maryland hospitals are paid under the Maryland All-Payer Model.

Contractors process outpatient rehabilitation claims from hospitals, including CAHs, SNFs, HHAs, CORFs, outpatient rehabilitation agencies, and outpatient physical therapy providers for which they have received a tie in notice from the Regional Office (RO). These provider types submit their claims to the contractors using the ASC X12 837 institutional claim format or the CMS-1450 paper form when permissible. Contractors also process claims from physicians, certain nonphysician practitioners (NPPs), therapists in private practices (TPPs), (which are limited to physical and occupational therapists, and speech-language pathologists in private practices), and physician-directed clinics that bill for services furnished incident to a physician’s service (see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, for a definition of “incident to”). These provider types submit their claims to the contractor using the ASC X 12 837 professional claim format or the CMS-1500 paper form when permissible.

There are different fee rates for nonfacility and facility services. Chapter 23 describes the differences in these two rates. (See fields 28 and 29 of the record therein described). Facility rates apply to professional services performed in a facility other than the professional’s office. Nonfacility rates apply when the service is performed in the professional’s office. The nonfacility rate (that is paid when the provider performs the services in its own facility) accommodates overhead and indirect expenses the provider incurs by operating its own facility. Thus it is somewhat higher than the facility rate.

Contractors pay the non facility rate on institutional claims for services performed in the provider’s facility. Contractors may pay professional claims using the facility or nonfacility rate depending upon where the service is performed (place of service on the claim), and the provider specialty.

Contractors pay the codes in §20 under the MPFS on professional claims regardless of whether they may be considered rehabilitation services. However, contractors must use this list for institutional claims to determine whether to pay under outpatient rehabilitation rules or whether payment rules for other types of service may apply, e.g., OPPS for hospitals, reasonable costs for CAHs.

Note that because a service is considered an outpatient rehabilitation service does not automatically imply payment for that service. Additional criteria, including coverage, plan of care and physician certification must also be met. These criteria are described in Pub. 100-02, Medicare Benefit Policy Manual, chapters 1 and 15.

Payment for rehabilitation services provided to Part A inpatients of hospitals or SNFs is included in the respective PPS rate. Also, for SNFs (but not hospitals), if the beneficiary has Part B, but not Part A coverage (e.g., Part A benefits are exhausted), the SNF must bill for any rehabilitation service.

Payment for rehabilitation therapy services provided by home health agencies under a home health plan of care is included in the home health PPS rate. HHAs may submit bill type 34X and be paid under the MPFS if there are no home health services billed under a home health plan of care at the same time, and there is a valid rehabilitation POC (e.g., the patient is not homebound).

An institutional employer (other than a SNF) of the TPPs, or physician performing outpatient services, (e.g., hospital, CORF, etc.), or a clinic billing on behalf of the physician or therapist may bill the contractor on a professional claim.

The MPFS is the basis of payment for outpatient rehabilitation services furnished by TPPs, physicians, and certain nonphysician practitioners or for diagnostic tests provided incident to the services of such physicians or nonphysician practitioners. (See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, for a definition of “incident to, therapist, therapy and related instructions.") Such services are billed to the contractor on the professional claim format. Assignment is mandatory.

The following table identifies the provider and supplier types, and identifies which claim format they may use to submit claims for outpatient therapy services to the contractor.

“Provider/Supplier Service” Type	Format	Bill Type	Comment
Inpatient SNF Part A	Institutional	21X	Included in PPS
Inpatient hospital Part B	Institutional	12X	Hospital may obtain services under arrangements and bill, or rendering provider may bill
Inpatient SNF Part B (audiology tests are not included)	Institutional	22X	SNF must provide and bill, or obtain under arrangements and bill
Outpatient hospital	Institutional	13X	Hospital may provide and bill or obtain under arrangements and bill
Outpatient SNF	Institutional	23X	SNF must provide and bill or obtain under arrangements and bill
HHA billing for services not rendered under a Part A or Part B home health plan of care, but rendered under a therapy plan of care	Institutional	34X	Service not under home health plan of care
Outpatient physical therapy providers (OPTs), also known as rehabilitation agencies	Institutional	74X	Paid MPFS for outpatient rehabilitation services
Comprehensive Outpatient Rehabilitation Facility (CORF)	Institutional	75X	Paid MPFS for outpatient rehabilitation services and all other services except drugs. Drugs are paid 95% of the AWP
Physician, NPPs, TPPs, (therapy services in hospital or SNF)	Professional		Payment may not be made for therapy services to Part A inpatients of hospitals or SNFs, or for Part B SNF residents NOTE: Payment may be made to physicians and NPPs for their professional services defined as “sometimes therapy” (not part of a therapy plan) in certain situations; for example, when furnished to a beneficiary registered as an outpatient of a hospital
Physician/NPP/TPPs office, or patient’s home	Professional		Paid via MPFS
Critical Access Hospital - inpatient Part B	Institutional	12X	Rehabilitation services are paid at cost
Critical Access Hospital – outpatient Part B	Institutional	85X	Rehabilitation services are paid at cost

10.3 - Application of Financial Limitations

Financial limitations on outpatient therapy services, as described above, began for therapy services rendered on or after on January 1, 2006. References and polices relevant to the exceptions process in this chapter apply only when exceptions to therapy caps are in effect. For dates of service before October 1, 2012, limits apply to outpatient Part B therapy services furnished in all settings except outpatient hospitals, including hospital emergency departments. These excluded hospital services are reported on types of bill 12x or 13x, or 85x. Effective for dates of service on or after October 1, 2012, the limits also apply to outpatient Part B therapy services furnished in outpatient hospitals other than CAHs and hospitals in Maryland. During this period, only type of bill 12x claims with a CMS certification number in the CAH range, type of bill 12x and 13x claims with a CMS certification number beginning with the State code for Maryland, and type of bill 85x claims are excluded. Effective for dates of service on or after January 1, 2014, the limits also apply to CAHs. Effective for dates of service on or after January 1, 2016, the limits also apply to hospitals in Maryland.

Contractors apply the financial limitations to the MPFS amount (or the amount charged if it is smaller) for therapy services for each beneficiary.

As with any Medicare payment, beneficiaries pay the coinsurance (20 percent) and any deductible that may apply. Medicare will pay the remaining 80 percent of the limit after the deductible is met. These amounts will change each calendar year.

Medicare shall apply these financial limitations in order, according to the dates when the claims were received. When limitations apply, the Common Working File (CWF) tracks the limits. Shared system maintainers are not responsible for tracking the dollar amounts of incurred expenses of rehabilitation services for each therapy limit.

In processing claims where Medicare is the secondary payer, the shared system takes the lowest secondary payment amount from MSPPAY and sends this amount on to CWF as the amount applied to therapy limits.

10.3 1 - Exceptions to Therapy Caps – General

The following policies concerning exceptions to caps due to medical necessity apply only when the exceptions process is in effect. Except for the requirement to use the KX modifier, the guidance in this section concerning medical necessity applies as well to services provided before caps are reached.

Provider and supplier information concerning exceptions is in this chapter and in Pub. 100-02, Chapter 15, section 220.3. Exceptions shall be identified by a modifier on the claim and supported by documentation.

The beneficiary may qualify for use of the cap exceptions process at any time during the episode when documented medically necessary services exceed caps. All covered and medically necessary services qualify for exceptions to caps. All requests for exception are in the form of a KX modifier added to claim lines. (See subsection D. for use of the KX modifier.)

Use of the exception process does not exempt services from manual or other medical review processes as described in Pub. 100-08. Rather, atypical use of the exception process may invite contractor scrutiny, for example, when the KX modifier is applied to all services on claims that are below the therapy caps or when the KX modifier is used for all beneficiaries of a therapy provider. To substantiate the medical necessity of the therapy services, document in the medical record (see Pub. 100-02, Chapter 15, sections 220.2, 220.3, and 230).

The KX modifier, described in subsection D., is added to claim lines to indicate that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.

10.3.2 - Exceptions Process

(Rev. 3309, Issued: 08-06-2015, Effective: 01-01-2016, Implementation:01-04-2016)

An exception may be made when the patient’s condition is justified by documentation indicating that the beneficiary requires continued skilled therapy, i.e., therapy beyond the amount payable under the therapy cap, to achieve their prior functional status or maximum expected functional status within a reasonable amount of time.

No special documentation is submitted to the contractor for exceptions. The clinician is responsible for consulting guidance in the Medicare manuals and in the professional literature to determine if the beneficiary may qualify for the exception because documentation justifies medically necessary services above the caps. The clinician’s opinion is not binding on the Medicare contractor who makes the final determination concerning whether the claim is payable.

Documentation justifying the services shall be submitted in response to any Additional Documentation Request (ADR) for claims that are selected for medical review. Follow the documentation requirements in Pub. 100-02, chapter 15, section 220.3. If medical records are requested for review, clinicians may include, at their discretion, a summary that specifically addresses the justification for therapy cap exception.

In making a decision about whether to utilize the exception, clinicians shall consider, for example, whether services are appropriate to—

• The patient’s condition, including the diagnosis, complexities, and severity;
• The services provided, including their type, frequency, and duration;
• The interaction of current active conditions and complexities that directly and significantly influence the treatment such that it causes services to exceed caps.

In addition, the following should be considered before using the exception process:

1. Exceptions for Evaluation Services

Evaluation. The CMS will except therapy evaluations from caps after the therapy caps are reached when evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services. For example, the following CPT codes for evaluation procedures may be appropriate: 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004.

Other Services. There are a number of sources that suggest the amount of certain services that may be typical, either per service, per episode, per condition, or per discipline. For example, see the CSC - Therapy Cap Report, 3/21/2008, and CSC – Therapy Edits Tables 4/14/2008 at www.cms.hhs.gov/TherapyServices (Studies and Reports), or more recent utilization reports. Professional literature and guidelines from professional associations also provide a basis on which to estimate whether the type, frequency, and intensity of services are appropriate to an individual. Clinicians and contractors should utilize available evidence related to the patient’s condition to justify provision of medically necessary services to individual beneficiaries, especially when they exceed caps. Contractors shall not limit medically necessary services that are justified by scientific research applicable to the beneficiary. Neither contractors nor clinicians shall utilize professional literature and scientific reports to justify payment for continued services after an individual’s goals have been met earlier than is typical. Conversely, professional literature and scientific reports shall not be used as justification to deny payment to patients whose needs are greater than is typical or when the patient’s condition is not represented by the literature.

2. Exceptions for Medically Necessary Services

Clinicians may utilize the process for exception for any diagnosis or condition for which they can justify services exceeding the cap. Regardless of the diagnosis or condition, the patient must also meet other requirements for coverage.

Bill the most relevant diagnosis. As always, when billing for therapy services, the diagnosis code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason to report another diagnosis code. For example, when a patient with diabetes is being treated with therapy for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible in accordance with State and local laws and the contractors’ local coverage determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy diagnosis code in the primary position. In that case, the relevant diagnosis code should, if possible, be on the claim in another position.

Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.

The condition or complexity that caused treatment to exceed caps must be related to the therapy goals and must either be the condition that is being treated or a complexity that directly and significantly impacts the rate of recovery of the condition being treated such that it is appropriate to exceed the caps. Documentation for an exception should indicate how the complexity (or combination of complexities) directly and significantly affects treatment for a therapy condition.

If the contractor has determined that certain codes do not characterize patients who require medically necessary services, providers/suppliers may not use those codes, but must utilize a billable diagnosis code allowed by their contractor to describe the patient’s condition. Contractors shall not apply therapy caps to services based on the patient’s condition, but only on the medical necessity of the service for the condition. If a service would be payable before the cap is reached and is still medically necessary after the cap is reached, that service is excepted.

Contact your contractor for interpretation if you are not sure that a service is applicable for exception.

It is very important to recognize that most conditions would not ordinarily result in services exceeding the cap. Use the KX modifier only in cases where the condition of the individual patient is such that services are APPROPRIATELY provided in an episode that exceeds the cap. Routine use of the KX modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry. Be sure that documentation is sufficiently detailed to support the use of the modifier.

In justifying exceptions for therapy caps, clinicians and contractors should not only consider the medical diagnoses and medical complications that might directly and significantly influence the amount of treatment required. Other variables (such as the availability of a caregiver at home) that affect appropriate treatment shall also be considered. Factors that influence the need for treatment should be supportable by published research, clinical guidelines from professional sources, and/or clinical or common sense. See Pub. 100-02, chapter 15, section 220.3 for information related to documentation of the evaluation, and section 220.2 on medical necessity for some factors that complicate treatment.

NOTE: The patient’s lack of access to outpatient hospital therapy services alone, when outpatient hospital therapy services are excluded from the limitation, does not justify excepted services. Residents of skilled nursing facilities prevented by consolidated billing from accessing hospital services, debilitated patients for whom transportation to the hospital is a physical hardship, or lack of therapy services at hospitals in the beneficiary’s county may or may not qualify as justification for continued services above the caps. The patient’s condition and complexities might justify extended services, but their location does not. For dates of service on or after October 1, 2012, therapy services furnished in an outpatient hospital are not excluded from the limitation.

10.3.3 - Use of the KX Modifier for Therapy Cap Exceptions

(Rev. 3309, Issued: 08-06-2015, Effective: 01-01-2016, Implementation:01-04-2016)

When exceptions are in effect and the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy HCPCS code subject to the cap limits. The KX modifier shall not be added to any line of service that is not a medically necessary service; this applies to services that, according to a local coverage determination by the contractor, are not medically necessary services.

The GN, GO, or GP therapy modifiers are currently required to be appended to therapy services. In addition to the KX modifier, the GN, GP and GO modifiers shall continue to be used. Providers may report the modifiers on claims in any order. If there is insufficient room on a claim line for multiple modifiers, additional modifiers may be reported in the remarks field. Follow the routine procedure for placing HCPCS modifiers on a claim as described below.

For professional claims, sent to the A/B MAC(B), refer to:

o Pub.100-04, Medicare Claims Processing Manual, chapter 26, for more detail regarding completing Form CMS 1500, including the placement of HCPCS modifiers. NOTE: The Form CMS 1500 currently has space for providing four modifiers in block 24D, but, if the provider has more than four to report, he/she can do so by placing the -99 modifier (which indicates multiple modifiers) in block 24D and placing the additional modifiers in block 19.

o The ASC X12N 837 Health Care Claim: Professional Implementation Guide for more detail regarding how to electronically submit a health care claim transaction, including the placement of HCPCS modifiers. The ASC X12N 837 implementation guides are the standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for submitting health care claims electronically. The 837 professional transaction currently permits the placement of up to four modifiers, in the 2400 loop, SV1 segment, and data elements SV101-3, SV101-4, SV101-5, and SV101-6. Copies of the ASC X12N 837 implementation guides may be obtained from the Washington Publishing Company.

o For claims paid by a carrier or an A/B MAC(B), it is only appropriate to append the KX modifier to a service that reasonably may exceed the cap. Use of the KX modifier when there is no indication that the cap is likely to be exceeded is abusive. For example, use of the KX modifier for low cost services early in an episode when there is no evidence of a previous episode that might have exceeded the cap is inappropriate.

For institutional claims, sent to the A/B MAC(A):

o When the cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that institutional claim that refer to the same therapy cap (PT/SLP or OT), regardless of whether the other services exceed the cap. For example, if one PT service line exceeds the cap, use the KX modifier on all the PT and SLP service lines (also identified with the GP or GN modifier) for that claim. When the PT/SLP cap is exceeded by PT services, the SLP lines on the claim may meet the requirements for an exception due to the complexity of two episodes of service.

o Use the KX modifier on either all or none of the SLP lines on the claim, as appropriate. In contrast, if all the OT lines on the claim are below the cap, do not use the KX modifier on any of the OT lines, even when the KX modifier is appropriately used on all of the PT lines. Refer to Pub.100-04, Medicare Claims Processing Manual, chapter 25, for more detail.

By appending the KX modifier, the provider is attesting that the services billed:

• Are reasonable and necessary services that require the skills of a therapist; (See Pub. 100-02, chapter 15, section 220.2); and
• Are justified by appropriate documentation in the medical record, (See Pub. 100-02, chapter 15, section 220.3); and
• Qualify for an exception using the automatic process exception.

If this attestation is determined to be inaccurate, the provider/supplier is subject to sanctions resulting from providing inaccurate information on a claim.

When the KX modifier is appended to a therapy HCPCS code, the contractor will override the CWF system reject for services that exceed the caps and pay the claim if it is otherwise payable.

Providers and suppliers shall continue to append correct coding initiative (CCI) HCPCS modifiers under current instructions.

If a claim is submitted without KX modifiers and the cap is exceeded, those services will be denied. In cases where appending the KX modifier would have been appropriate, contractors may reopen and/or adjust the claim, if it is brought to their attention.

Services billed after the cap has been exceeded which are not eligible for exceptions may be billed for the purpose of obtaining a denial using condition code 21.

10.3.4 - Therapy Cap Manual Review Threshold

(Rev. 3309, Issued: 08-06-2015, Effective: 01-01-2016, Implementation:01-04-2016)

Beginning calendar year 2012, there shall be two total therapy service thresholds of $3700 per year: one annual threshold each for

(1) Occupational therapy services.

(2) Physical therapy services and speech-language pathology services combined.

Services shall accrue annually toward the thresholds beginning with claims with dates of service on and after January 1, 2012. The thresholds shall apply to both services showing the KX modifier and those without the modifier. Contractors shall apply the thresholds to claims exceeding it by suspending the claim for manual review. Instructions regarding the manual review process may be found in Pub. 100-08, Medicare Program Integrity Manual.

10.3.5 - Identifying the Certifying Physician

(Rev. 3309, Issued: 08-06-2015, Effective: 01-01-2016, Implementation:01-04-2016)

Therapy plans of care must be certified by a physician or non-physician practitioner (NPP), per the requirements in the Pub. 100-02,Medicare Benefit Policy Manual, chapter 15, section 220.1.3. Further, the National Provider Identifier (NPI) of the certifying physician/NPP identified for a therapy plan of care must be included on the therapy claim.

For the purposes of processing professional claims, the certifying physician/NPP is considered a referring provider. At the time the certifying physician/NPP is identified for a therapy plan of care, private practice therapists (PPTs), physicians or NPPs, as appropriate, submitting therapy claims, are to treat it as if a referral has occurred for purposes of completing the claim and to follow the instructions in the appropriate ASC X12 837 Professional Health Care Claim Technical Report 3 (TR3) for reporting a referring provider (for paper claims, they are to follow the instructions for identifying referring providers per Chapter 26 of this manual) . These instructions include requirements for reporting NPIs.

Currently, in the 5010 version of the ASC X12 837 Professional Health Care Claim TR3, referring providers are first reported at the claim level; additional referring providers are reported at the line level only when they are different from that identified at the claim level. Therefore, there will be at least one referring provider identified at the claim level on the ASC X12 837 Professional claim for therapy services. However, because of the hierarchical nature of the ASC X12 837 health care claim transaction, and the possibility of other types of referrals applying to the claim, the number of referring providers identified on a professional claim may vary. For example, on a claim where one physician/NPP has certified all the therapy plans of care, and there are no other referrals, there would be only one referring provider identified at the claim level and none at the line levels. Conversely, on a claim also containing a non-therapy referral made by a different physician/NPP than the one certifying the therapy plan of care, the billing provider may elect to identify either the nontherapy or the therapy referral at the claim level, with the other referral(s) at the line levels. Similarly, on a claim having different certifying physician/NPPs for different therapy plans of care, only one of these physician/NPPs will be identified at the claim level, with the remainder identified at the line levels. These scenarios are only examples: there may be other patterns of representing referring providers at the claim and line levels depending upon the circumstances of the care and the manner in which the provider applies the requirements of the ASC X12 837 Professional Health Care Claim TR3.

For situations where the physician/NPP is both the certifier of the plan of care and furnishes the therapy service, he/she supplies his/her own information, including the NPI, in the appropriate referring provider loop (or, appropriate block on Form CMS 1500). This is applicable to those therapy services that are personally furnished by the physician/NPP as well as to those services that are furnished incident to their own and delivered by “qualified personnel” (see section 230.5 of this manual for qualifications for incident to personnel).

Contractors shall edit to ensure that there is at least one claim-level referring provider identified on professional therapy claims, and shall use the presence of the therapy modifiers (GN, GP, GO) to identify those claims subject to this requirement.

For the purposes of processing institutional claims, the certifying physician/NPP and their NPI are reported in the Attending Provider fields on institutional claim formats. Since the physician/NPP is certifying the therapy plan of care for the services on the claim, this is consistent with the National Uniform Billing Committee definition of the Attending Provider as “the individual who has overall responsibility for the patient’s medical care and treatment” that is reported on the claim. In cases where a patient is receiving care under more than one therapy plan of care (OT, PT, or SLP) with different certifying physicians/NPPs, the second certifying physicians/NPP and their NPI are reported in the Referring Physician fields on institutional claim formats.

10.3.6 - MSN Messages Regarding the Therapy Cap

(Rev. 3309, Issued: 08-06-2015, Effective: 01-01-2016, Implementation:01-04-2016)

Existing MSN messages 17.13, 17.18 and 17.19 shall be issued on all claims containing outpatient rehabilitation services. Contractors add the applied amount for individual beneficiaries and the generic limit amount to all MSNs that require them. For details of these MSNs, see: http://www.cms.gov/MSN/02_MSN%20Messages.asp

40.1 - Determining Payment Amounts – Institutional Claims

(Rev. 3309, Issued: 08-06-2015, Effective: 01-01-2016, Implementation:01-04-2016)

Institutional outpatient rehabilitation claims are paid under the Medicare Physician Fee Schedule (MPFS), except for claims from CAHs and hospitals in Maryland. Medicare contractors should see §100.2 for details on obtaining the correct fee amounts.

Reference

Medicare Transmittal # R3309CP

August 6, 2015