Back to School season means it is CMS change season as well.
It must be a busy time to work at CMS. Over the next 12 months several changes included in the Middle Class Tax Relief and Job Creation Act of 2012 will begin to impact providers of outpatient rehab services. Some changes will cause significant effort by all involved; others are minor refinements to the existing Therapy Cap process.
In a few linked articles, I outline Clinicient’s approach to some of the more complicated provisions, but it seems like a good time to review the major points:
1) Extension of the Medicare Cap:
- Modifier Use: Claims exceeding the $1,880 cap must include the KX modifier. The exempt and non-exempt dx code distinction ceases to exist.
- Manual Medical Review: Therapy claims exceeding $3,700 per year will trigger mandatory medical review. (This is per discipline, so $3,700 combined speech/PT and $3,700 OT.) The medical review policy will be phased in from October 1, 2012 forward.
- NPI: All claims must contain the ordering physician’s NPI or the NPI of the physician who reviews and certifies the plan of care beginning October 1, 2012.
- Temporary Application of the Therapy Cap to Outpatient Hospital Settings: The therapy cap (with exceptions) will temporarily be applied to hospital outpatient departments beginning no later than October 1, 2012. This provision will sunset at the end of 2012 unless Congress extends it into 2013.
(Read Medicare Therapy Cap adds a new wrinkle to see how Clinicient supports this.)
2) Data Collection:
Beginning January 1, 2013, CMS will implement a claims based data collection strategy designed to assist in reforming the Medicare payment system for outpatient therapy. The system is designed to collect data on patient function during the course of therapy services in order to better understand patient condition and outcomes. This is part of a five year data collection project called DOTPA. (In a future article I will cover why this won’t be hard)
3) MedPAC:
Not later than June 15, 2013, MedPAC will submit to the House Energy and Commerce Committee, House Ways and Means Committee and the Senate Finance Committee a report on how to improve the outpatient therapy benefit. The report will include recommendations on how to reform the payment system so the benefit is better designed to reflect individual acuity, condition and therapy needs of the patient. The report will examine private sector initiatives relating to outpatient therapy benefits.
4) GAO Report on Manual Medical Review:
Not later than May 1, 2013, the Comptroller General will issue a report to the House Committee on Energy and Commerce, the House Ways and Means Committee and the Senate Finance Committee on the implementation of the manual medical review process. The report shall include data on the number of individuals and claims subject to the process, the number of reviews conducted and the outcome of the reviews.
This is quite an agenda. Ultimately, CMS and Congress’s search for alternate payment models is driving a concerted effort to collect outcome oriented data. Whether manually reviewing the most costly conditions or reporting progress on functional limitations, the next 12 months promise lots change for practitioners and even more change for their EMR and Practice Management partners.
One Comment
Like your article. Hope you can point me in the right direction.
Lots of rule changes with physical and occupational reimbursement.
Need to understand:
• if MEDICARE requires different application/approval/operational processes if a facility is operated as a:
o Hospital outpatient department (offsite)
o Independent, non hospital facility
o Within the physician office
• Within these areas:
o Does Medicare reimburse at different levels. If yes, which is higher?
o Are there more advanced certifications required for the Physical or Occupational Therapist in the independent environment
o Are there different physician supervisory requirements in independent versus hospital OP environments
o Do commercial insurance companies attempt to direct patients to one type of facility over another? Which?
o Does Medicaid pay for PT/OT in either setting? Which ones?
• Within an independent facility, are there limitations on use of physical facility for other purposes?
• The social security limits for PT and OT are 1,880 EACH in 2012? These are separate cumulative totals?
o What services are covered under these limits? Possibilities could include IP PT/OT within hospital, IP stays within Rehab hospital, Hospital OP only, Physicians office, independent OP?
Thanks!
Rich Klass