Therapy Cap: Exceptions January 1 - October 1, 2012: an automatic exception to the therapy cap may be made when documentation supports the medical necessity of the services beyond the cap. Providers should use the KX modifier. October 1, 2012 - December 31, 2012: an automatic exception may be made for claims between $1880-$3700 (use KX modifier). October 1, 2012 - December 31, 2012: Claims exceeding $3700 in expenditure will be subject to manual medical review to be paid.
2012 Therapy Cap: Hospitals • Starting October 1, 2012 the therapy cap with an exceptions process will apply to Part B SNF, CORF, ORF, private practices, Rehabilitation agencies, and Hospital Outpatient Departments (critical access hospitals are exempt). • Hospitals would no longer be subject to the therapy cap after December 31, 2012 unless Congress extends the provision in future legislation.
2012 Therapy Cap: Dollars Accrued • Therapy cap is based on the allowed charges. • Medicare Part B will pay 80% of the allowed charges ($1504.00) and the beneficiary will be responsible for the remaining 20% ($376.00). • MPPR reduction is included in the amount of the allowed charges.
2012 Therapy Cap: Dollars Accrued • C-SNAP uses the Centers for Medicare & Medicaid Services (CMS) beneficiary eligibility system to provide our Real-time Eligibility data. • http://www.wpsmedicare.com/j5macpartb/resources/claims_elig_tools/csnap/
Therapy Evaluations • Therapy evaluations after the therapy caps are reached to determine if the patient needs therapy services would be exempt from the cap. (97001 (PT evaluation) & 97002 (PT re-evaluation).
Therapy Cap: Manual Medical Review • Phase I providers: Subject to manual medical review from October 1‐December 31, 2012. • Phase II providers: Subject to manual medical review from November 1‐December 31, 2012. • Phase III providers: Subject to manual medical review from December 1‐December 31, 2012. • List of NPIs and phases to which they are assigned is available at: https://data.cms.gov/dataset/Therapy-Provider-Phase-Information/ucun-6i4t
Therapy Cap: Manual Medical Review • PROVIDERS SHOULD NOT SEND IN CLAIMS FOR PRE-APPROVAL BEFORE THE SCHEDULED BEGIN DATE FOR EACH PHASE (see next slide for dates)
Therapy Cap: Manual Medical Review • PROVIDERS MUST SUBMIT REQUEST ON CORRECT FORM (wrong form = no review) • PROVIDERS SHOULD CONTACT THEIR REPSECTIVE MAC OR LEGACY TO DETERMINE THE APPROPRIATE FORM
Therapy Cap: Manual Medical Review • FORM MUST BE MAILED • DO NOT FAX FORM • RECOMMEND CERTIFIED MAIL • WPS WILL NOT TRACK IF IT WAS RECIEVIED or NOT RECIEVED
Therapy Cap: Manual Medical Review • Medicare Administrative Contractors (MAC) will have 10 business days to make decisions regarding whether services will be approved over the $3700 amount. If a provider request is not reviewed by MAC within 10 business days, claims beyond the $3700 threshold will be approved. • Advanced approval will allow an additional 20 treatment days beyond the $3700 amount. • Provider will use modifier on claim form to indicate advance approval given. • Advanced approval does not guarantee payment. • Retrospective review may still be performed. • There is an APPEAL PROCESS for “Retrospective Review” • NO APPEAL PROCESS for Manual Review
Therapy Cap: Manual Medical Review • If a provider does not request advanced approval prior to providing services over $3700, payment for the claims will stop and a request for medical records will be sent to the provider. • The provider will be subject to prepayment review for those claims and the time frame for review will be approximately 60 days.
Part A (facilities) Mail To: WPS Medicare Attention: MR Department 3333 Farnam St., Suite 600 Omaha, NE 68131 J5 / J8 Part B (practitioners) Mail To: WPS Medicare Attention: MR Department 1717 West Broadway Madison, WI 53713 Legacy Part B (practitioners) Mail To: WPS Medicare Attention: MR Department 8120 Penn Ave S, Suite 200 Bloomington, MN 55431
Therapy Cap: Manual Medical Review • There is NO APPEAL PROCESS with the Manual Review (must submit another review)
Therapy Cap: Example Patient A receives therapy services at a SNF (Part B) from January 15, 2012-April 20, 2012 and accrues $3800.00 toward the therapy cap. Patient A is discharged from the SNF and later goes to an outpatient hospital department for therapy on October 15, 2012. The hospital would need to request manual medical review to get coverage for these services because the patient has already exceeded the $3700 threshold.
Therapy Cap: Example • Patient A receives therapy services from an outpatient hospital from February 15-May 15, 2012 and accrues $3800 in therapy services. • Patient A goes to a private practice for services on September 20 until November 15. Private practice submits the claim on September 20 for payment and the common working file reflects $0 toward the cap. • On October 1, the $3800 from the hospital therapy would be added to the common working file; for dates of service provided to patient A after October 1 the provider would need to seek advanced approval (if a phase I provider).
Therapy Cap Example • Patient A received $4000 of services from a hospital stay from January 15—May 15, 2012. • From July 22, 2012 –August 25, 2012 patient A received services from a private practice. • The private practice would not need to submit the KX modifier or submit a request for advanced approval as Patient A was discharged prior to October 1, 2012.
Therapy Cap Example • “A beneficiary was in a skilled nursing facility (SNF) and exhausted their SNF benefit days under Part A. • The beneficiary continued to receive therapy services under Part B totaling $3,600 (all dates of service before 10/1/2012). • The beneficiary was then discharged from the SNF and received therapy services from an independently practicing PT totaling $1,800. • The independent PT billed in November 2012 for services provided after 10/1/2012.
Therapy Cap Example • The MAC received the claims and processed them. After these claims were processed the MAC received the SNF Part B claims totaling $3,600 and processed them. • Had these claims been received in advance of the independent PT services the independent PT would have been required to have the services approved in advance. • In circumstances such as the example above the contractor is not required to perform post payment review on the $1,800 provided by the independent therapist. “
Notification to Beneficiaries • Beneficiaries who have received $1700 or more of therapy services in 2012 received letters in September 2012 providing them information about their potential financial liability for services over the therapy cap amount. • APTA provided a document for beneficiaries to provide info on cap. http://www.moveforwardpt.com/Resources/Advocacy.aspx
Therapy Cap: Collecting Out of Pocket If a patient does not qualify for an exception, the provider can collect out of pocket payment from the beneficiary. It is advisable to give the beneficiary an Advanced Beneficiary Notice (ABN) if Collecting Out of Pocket. Revised ABN form (Form-R-131) available on the CMS website at: https://www.cms.gov/BNI/02_ABN.asp
Therapy Cap: Collecting Out of Pocket • Provider can determine the amount of payment to collect from the patient; it does not have to be the fee schedule amount. • Providers should avoid deep discounts or providing services for free as that could violate anti-kickback statutes.
Therapy Cap: Collecting Out of Pocket • If provider would like a denial from Medicare in order to bill a secondary insurer after the therapy cap amount is exceeded, the provider could submit claim with a modifier: • GX Modifier: • Notice of Liability Issued, Voluntary Under Payer Policy. • Report this modifier only to indicate that a voluntary ABN was issued for services that are not covered. • Medicare will automatically reject claims that have the –GX modifier applied to any covered charges. • GY modifier: • Notice of Liability Not Issued, Not Required Under Payer Policy. This modifier is used to obtain a denial on a non covered service. Use this modifier to notify Medicare that you know this service is excluded.
APTA RESOURCES • APTA has developed a Medicare Therapy Cap Resources website. This website compiles relevant information available from APTA and CMS in one place. • You can view the website by clicking here or by going to APTA’s homepage and clicking Learn Moreon the Medicare marquee. Please share this information with your colleagues and staff • Questions regarding the therapy cap may also be emailed directly to CMS at firstname.lastname@example.org.
2013 Proposed Physician Fee Schedule Rule • On July 6, 2012 the Centers for Medicare and Medicaid Services (CMS) released the proposed 2013 Medicare physician fee schedule rule that updates 2013 payment amounts and revises other payment policies. • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1590-P.html • CMS will publish a final rule by November 1, 2012 which will become effective for services furnished during calendar year 2013.
MEDICAID • KanCare benefit packages outlined (By Dave Ranney; Wednesday, September 26, 2012) • Comparison of benefit packages offered by KanCare MCOs
AFFORDABLE CARE ACT • A brief outline of the AFFORDABLE CARE ACT (ObamaCare) can be accessed at: • http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act
TRICARE • TRICARE WILL NOT reimburse for services furnished by physical therapist assistants that are provided in a: • Physical therapy private practice • Freestanding clinic • Home care agency • Comprehensive outpatient rehabilitation facility (CORF)
TRICARE • TRICARE WILL reimburse for services furnished by a physical therapist assistant in a: • Hospital • Skilled nursing facility
KANSAS WORKER’S COMPENSATION • Kansas Department of Labor: Division of Workers' Compensation • Kansas WC contacts: http://www.dol.ks.gov/WorkComp/Default.aspx