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September 2010 September 3rd: The special open door on the MDS 3.0 was definitely the best information provided yet. Ellen Berry, PT, a member of the CMS staff presented information on the use of the short stay assessment, the start of therapy (SOT) OMRA and the end of therapy (EOT) OMRA that will come into effect October 1st. The presentation dispelled some of the confusion but revealed the importance of understanding how the MDS grouper will work and that, due to the reimbursement for some of the nursing RUGs, it may be financially beneficial for the facility not to do a short stay assessment as the payment may be better for the nursing RUG. The EOT OMRA is a mandatory assessment that must be completed if the resident is staying in the Part A stay being skilled by nursing. THE SOT and the short stay assessments are voluntary assessments that the facility team will decide to use or not. We will be incorporating all of this into our Made Easy Seminar along with some assessment tools/cheat sheets for the MDS coordinator and therapy to work with. A topic brought up in the Q&A was about the way the grouper would trigger an EOT OMRA when the resident misses more than 3 days of therapy. The question was asked how this was to be handled, as, the flu season is coming and residents may miss some treatment days and the timing of the EOT, then doing a SOT which technically is not a new start of care and therefore would generally not necessitate a new eval and POT. The CMS panel indicated that they would look into this and give guidance at the next ODF. August 2010 August 29th: Last weeks special open door forum on the MDS 3.0 was mainly focused on the transitional period from the last few days of September and the first few days of October for the patients who were in an observation period. The days in September would be covered by the MDS 2.0 and the days in October by the MDS 3.0. Talk about confusing!!! CMS has a produced several excel files that are available on the MDS website for MDS Coordinators to locate the different days accounted for in the observation period. One of the options was just to accept the default rate for one or 2 days and then submit the 3.0 for the balance. The slides are available and a recording of the audioconference will be published on their site. Unfortunately, some of us had a break in contact with the conference call and lost about 20 minutes of information. By the time it was resolved the Q&A was already in session. The last call in this series is this coming Wednesday so hopefully some of the questions about the short stay assessment will be clarified. In the meantime, CMS launched its demonstration to develop an alternative payment system to the current Medicare cap and fee schedule. The program will run for 6 months and data will be collected from a wide cross section of Part B providers. It will utilize the assessments developed by the RTI in conjunction with many other stakeholders that were presented last year. CMS emphasized that the purpose of these assessments were to identify the various needs of the beneficiaries with differing clinical conditions and co-morbidities that effect treatment, including intensity and duration. The study will use an admission and discharge assessment to compare treatment and outcomes. The project will end in Spring 2011. CMS updated reporting requirements for therapy services provided by persons other than licensed therapy professional, also know as "Incident to". The updated requirements were effective as of July 1st 2010 and required the identification of the person providing the therapy services being billed. The notice reiterated who is "qualified" to provide therapy services and that services that were provided by others were not covered and must not be reported for Medicare payment. The new requirements instruct that the following information should be included in the comment field of the electronic claim (1500 form) or included as an attachment in a paper claim. The required information includes:
Do you think that CMS might finally be coming down on incident to services? We know it is still going on, utilizing non-therapy trained professionals. August 15th: CMS completed its Train the Trainer for MDS 3.0 and RUGs IV in Las Vegas on Friday with little news for therapy. The two main items were that transportation to therapy could not be counted as preparation time and neither could getting the patient ready for therapy. This has come about because of the information in the RAI Manual that indicates that the time an aide spends in preparing an area for the therapist to provide individual therapy can be included in the minutes as can other set up time once treatment has begun. It never ceases to amazes me what people think up in order to add those minutes. CMS has made it very clear that SKILLED THERAPY is what they will be paying for, and if you don't know what that is, you're in trouble. It was also explained that the End of Therapy (EOT) OMRA Assessment Reference Date (ARD) must be one to three days after last day that therapy would normally be provided in facility and that the ARD should be based on the facility’s schedule for therapy services (i.e., therapy is available Monday-Friday or seven days a week), not based on the therapy schedule of a particular resident. This has no direct impact on therapy as the Nursing RUG will still be paid from the day after the last therapy has been provided. There's no free ride anymore, what you do is what you get paid for, well almost. The next SNF audio conference on the 3.0 will be on August 24th. Hopefully we will get a little bit more of an explanation of the Short Stay Assessment. I'll keep you posted. CMS announced that they will have a special open door forum for all Part B therapy providers on August 19th to discuss Developing Outpatient Therapy Payment Alternatives (DOTPA)- Data Collection and solicit volunteers to work with these assessments This is a Conference Call only and will be held from 2:00 to 3:30. The research project known as DOTPA, for "Developing Outpatient Therapy Payment Alternatives." was announced last year and two assessments were posted on the RTI International website CMS and its data collection contractor, RTI International, will explain the critical role of providers in this research. Medicare is now actively seeking providers to participate as data collection sites. This call is intended for ALL providers of outpatient physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) who are reimbursed under Medicare Part B. There is one assessment that is for all providers and suppliers with the exception of SNF which has their own specific assessment. More information about the project can be found at http://optherapy.rti.org and on CMS's website. We will be listening to the conference and will post relevant information.
July 2010 July 26th: The SNF open door forum held on July 22nd didn't tell us very much! Although both houses of congress have passed bills indicating the repeal of the delay in the implementation of RUGs IV, CMS is still looking at the hybrid versions until the president actually signs it into law. The scheduled training calls have been rescheduled for later in August with the final one coming on September 1st, just one month before the MDS 3.0 implementation. Talk about last minute learning! In working through some examples of the Short Stay Assessment during our RUG$ to Riche$ seminars, it appears that, although told that the patient who is unexpectedly discharged before obtaining a Rehab RUG can still obtain one through the short stay assessment process, it will probably not occur as easily as anticipated. This again may make some providers change policy to ensure the Rehab RUG level which could have the impact of pushing for therapy provision on day one or over weekend. As usual, we will have to wait and see. July 17th: CMS posted the SNF 2010 Final Rule for FY 2011. The Final Rule for SNF is on the information website of the Federal Register; it will be published in the register on July 22nd. The major change has been in the anticipated wage index and that has had a surprise of an increase in the RUG rates averaging 1.7 to 1.9 percent. Unlike the spread sheet that CMS posted with anticipated rates based on the 2010 numbers, there has been an increase in the therapy wage index which has caused the financial improvement. All of the rehab RUGS have increased over last year, thanks to the change from $116.93 to $137.08 in the Urban therapy index. Nursing wage index decreased from last year but the Nursing index increased considerably in some categories. The surprising change has been in the reimbursement for Rehab Low. Due to the new ADL scoring and the change in the end-splits, RLB has a federal urban rate of $431.05, compare that to the present $294.04. I guess the RLB will take the place of the RMX (almost the same reimbursement!!!! Don't have a restorative program, well I guess you will now. Don't know how to set one up that doesn't get the aides pulled to the floor, we can help you there. We'll keep you posted. Although we do not normally comment on Home Health Agency Regulations, CMS issued it's Final Rule at the same time as the SNF and there are some noticeable changes occurring. The documentation guidelines have been updated and will require justification of continuing services by the therapist at the 13th and 19th treatment if services are to continue. There will also be the requirement by the agency to differentiate between treatment provided by the therapist and the assistant. A lot of the guidelines sound like the updates to the Part B therapy documentation requirements published in 2007. July 1st: CMS revealed the Interim Final Rule for Part B services on June 25th and it doesn't look good! The interim rule which will be officially published in the Federal Register bodes ill for providers and suppliers of Part B therapy services. The proposed rule, which has an open comment period till August 24th proposes a 6.1% cut in the fee schedule along with the reduction caused by the SGR reduction of 21+% delayed till December 1st through the recent Congressional action. This isn't all; CMS is also proposing a "multiple procedure payment reduction" MPPR which will pay the CPT code with the highest practice expense in full and then all other procedures provided that day to the patient will have their practice component reduced by 50%, the malpractice and work components will not be affected. It is anticipated that this will lead to a further 13% overall reduction in the CPT code payment on services provided that day. It is not surprising that Secretary Sibelius was so adamant in her web broadcast to seniors concerned about the changes to their Medicare Benefits under PPACA (or Obamacare as it is fondly known.) During the broadcast, the secretary was insistent that Medicare beneficiary benefits would not be affected by the Act and they would retain all of their current benefits. This is true, however, what good is have Part B Medicare when you can't find a physician or therapist that can afford to take you! Just my thought and editorial. Get reading and writing your comments to CMS. As soon as the Final Rule is published we will have it available for you on the website in an edited version that will only contain information that has relevance to therapy services. If you can't wait, you can download the rule in a pdf word format from www.federalregister.gov/inspection.aspx#special June 2010 June 25th: The President signed the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 today, which includes a 2.2% increase in the PFS valid from June 1st to November 30th 2010. CMS will pay claims for services provided prior to June 1st as normal; payment paid for June 1st and later claims that have been paid at the negative rate will be reprocessed according to Pinnacle Medicare Services, one of the MAC contractors. June 24th: The House has passed the Senate Amendment to H.R. 3962, the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010. This Act was passed the Senate with unanimous consent on Friday, June 18. The legislation provides for a 2.2 percent payment increase to those paid under the Medicare physician fee schedule for a six month time frame ending on Nov 30, 2010. As the language reads, it does appear that the bill will be retroactive back to June 1. The bill will now be sent to the President's desk to be signed into law. June 18th: Congress, specifically the Senate, failed to agree on a resolution to the scheduled decrease in the Fee Schedule, and, despite CMS's optimism, the 21% decrease went in to effect June 1st for services provided by physicians and therapists. The Senate version delayed the decrease but only till November 30th, making further action necessary after the November elections. June 11th: Congress working on bill for PFS and RUGs IV. Congress started work after the Memorial Day recess and produce action on the looming 21% decrease in fee schedule payments. As part of the American Jobs and Closing Tax Loopholes Act (HR4213) there is a proposal to have a 2.2% increase in the fee schedule for 2010 and a 1% increase in 2011 - yet another stop gap fix, although it is extremely welcome. It will also overturn the proposed delay in implementation of RUG IV. giving CMS the green light for its scheduled rollover on October 1st this year. CMS also released the final updates to the RAI Manual for the MDS 3.0 and announced further training sessions in August to try and ease the transition. We're addressing that very topic in our RUG$ to Riche$ workshop coming up in Illinois and Missouri this month and Ohio in July. June 2nd: We still have no interim rule for SNF PPS as of this date. CMS is scheduled to have its Open Door meeting tomorrow, so hopefully we will have a little more to go on. We will keep you updated as changes are announced. May 2010 May 28th: CMS has issued a 2 week hold on Part B claims starting June 1st. In anticipation of Congress passing a bill that will stop the reduction in the fee schedule, CMS has told its contractors to hold payment on claims billed for services starting on June 1st for 15 consecutive days. This will prevent them having to adjust claims when the bill is eventually passed, probably sometime next week. The current version before Congress prevents the scheduled decrease from taking effect while the flawed calculation of the sustainable growth rate is corrected. This bill would put a moratorium on this reduction for the next three and a half years. In the meantime providers can look forward to a slight increase, instead of the planned 21% reduction. May 24th: Well, we FINALLY have news about the changes in the SNF PPS system effective October 1st! Today, CMS issued an update on the progress being made. We have been waiting for the Interim Final Rule which is normally published the end of April to the beginning of May, without success, so this update has been long in coming. The outcome of this update is that the implementation of the MDS 3.0 and RUG IV will go on as planned. There is a measure before Congress to have the requirement for the delay in the RUG IV implementation repealed and CMS is optimistic that this will occur. However, if not, CMS will develop a hybrid RUG III system, which will include the specific new regulations for concurrent and the hospital look-back period within the existing 53 RUG system and will retroactively adjust rates. This system should cause the least disruption to payments for the providers. Also in the pipeline from Congress is an agreement between Congress and the Physicians to place a moratorium on the 21% plus decrease in the PFS rates for 3 and a half years while the flawed calculation of these rates is addresses. Unless Congress acts NOW, the decrease will come into effect on June 1st. Lets keep our fingers crossed that Congress realizes the importance of both of these 2 changes. As always, keep watching, we will post any changes as they occur.
April 2010 April 22nd: In the CMS SNF open door today, the speakers announced that the implementation of RUG IV has been delayed in the healthcare bill passed last month by Congress. However, the plan is to implement two of the provision of RUG IV on October 1st, these being the concurrent therapy provision and the look-back into the hospital stay. They stated that they are also working with the leadership to see if this hold on full implementation can be changed. Presently, there is no grouper to handle this amendment to RUG IV. Obviously from the tone of the speakers, they are hoping that this hold will be changed and the transition from RUG III to RUG IV as originally planned. April 14th: Congress does another quick fix! Yesterday Congress passed the Continuing Extension Act which extended the hold on the implementation of the decrease in the fee schedule for Part B. The hold is in place until May 31st. CMS released the transmittal informing the contractors to release the hold on claims. March 2010 March 28th: CMS issues instructions to hold claims for 14 days after April 1st. CMS has issued instructions to its contractors to hold all Part B claims for services performed after April 1st for 14 days. This indicates that CMS believes that Congress will address the 21%+ decrease in payment for Part B scheduled to hit on April 1st. Due to the Easter recession, lawmakers will probably not address this decrease before it goes into effect in 34 days time. March 24th: How the New HealthCare Bill affects you. Good News! We have the exception process back till the end of the year. Bad News! We will be subject to the 21% plus decrease in the reimbursement for our services unless Congress adds the measure to its next round of bills. Effective April 1st (April Fools Day - boy is that appropriate) all therapy CPT codes will be decreased in reimbursement. The APTA and I'm sure the AOTA and ASHA are working with Congress to try to get this changed. However, the Physician lobby is strong so all we can do is wait and see. We're getting good at that. March 12th: In yesterdays CMS "SNF Open Door Forum" it was announced that the RACs had been informed that they were not to go after the SNF stay when they had denied the qualifying hospital stay. This question had been brought up at a previous open door, and at that time, the speakers said that this topic was covered in the current Benefit Manual relating to a skilled stay. They also announced that they had informed hospitals that they could not arbitrary change an "inpatient stay" after the fact. The hospitals have been also been informed that it is the physician's responsibility to determine the appropriate payment system for the stay. This practice had been cause for concern because of the focus of the RACs on Appropriateness of DRG payments. Some hospitals had determined after discharge that the patient may not have qualified for the level billed and therefore made that change. So why is that important to the SNF? Well, the qualifying hospital stay is a technical requirement for payment of the SNF stay. IF a technical requirement is not met, then the whole stay is denied and their is no appeal rights. This leave the SNF responsible for the cost of the stay. March 11th: Yesterday, the Senate passed a bill extending the exception process for the rest of the year, freezing the PFS payments at the 2009 level, thus preventing the 21% plus decrease until September 30th and re-instating the Geographical Practice Cost Indices (GPCI) floor at 1.0 until the end of the year. The bill now goes to the House and then on to the President for signature before becoming final. March 4th: Yesterday President Obama signed into law, under the Extension to Therapy Act, the extension to the 0% change in the fee schedule and the extension of the exception process till March 31st. CMS lifted it its hold on payment of March claims. The exception process is now in place until the end of the month and made retroactive to January 1st. Claims can now be submitted with the KX modifier and the 2009 guidelines are in place. March 3rd: Late last night Congress passed the Jobs Bill which contained a 30 day extension to the hold on implementing the 21% reduction in the Fee Schedule as well as a Therapy Caps. What does that mean? Well, for now, therapists will still be paid at the 2009 levels for the CPT codes under Part B. However, as for the Caps, all it means is that we are still under the caps but there is a hold on their implementation and the exception process is in place and retroactive to January 1st. This stop gap effort will expire on March 31st. In the meantime, therapists are in limbo. It is widely anticipated that eventually there will be, at a minimum, a 1 year extension of the exception process that will be made retrospective to January 1st. So stay tuned and contact your Representatives and Senators in order to emphasize just what this is doing to the Rehab profession. The freeze in the decrease in payment keeps the physicians happy for another month, however, without the exception process, lots of beneficiaries are going to have problems getting appropriate care. Although the outpatient hospital setting is not under the caps, they would certainly have extreme difficulty in handling the patients who could be without care. March 1st: Well we were in a hurry and wait mode last week waiting for Congress to do something about the therapy caps and the reduction in the fee schedule. Unfortunately, politics got in the way and nothing was done. However, CMS believes that it will be addressed soon and issued instructions to it claims contractors to hold all claims beginning with March 1st for 10 business days. So they obviously expect some action within the next two weeks. We'll post whatever happens on the website so stay tuned. RAC info: As of this time, the RACs are still focusing on DRGs and physician's services. CERT info: The CERT contractor issued its National Error Rate Report for November 2009. The error rate had increased from 3.6$ in May 2008 to over 7% in November. The reason for this is the more stringent processes that had been introduced by CMS which they had not been following. The number of denials increased predominantly for DMEs and physician charges, guess why? Illegible signatures. This is becoming a huge issue for physicians, and therapists are also not excluded for that one. We have addressed these issues in our latest Newsletter. Follow this link to access our latest edition. Latest Medicare News and Rules For Therapists Newsletter
February 2010 February 10th: The APTA announced yesterday the Senate released a draft version of the "Jobs Bill" and included in are provisions addressing the caps and the conversion factor. The proposal is to extend the exception process for one more year and make it retroactive to January 1st. They also propose keeping the 2009 conversion factor in place until September 30th. There were hopes that this would get passed this week but because of the "climate change" going on in Washington, all votes have been postponed for this week. Next week will see no action as it is a "work week at home" due to the Presidents Day Holiday. Sounds like a good time to get hold of your representatives and relate your concerns. We still are waiting on Congress to see if we are going to have the exception process extended or not! There have been moves on the Hill with Senator Baucus indicating that he is drafting a bill to address the caps and the exception process along with other items that expired January 1st. In the meantime, CMS has stated that providers could hold up billing until this problem has been resolved. Well! that works as long as the exception process is allowed, otherwise both patients and providers may be in trouble. January 2010 Happy New Year to Everyone. Well, what a start to the New Year and what a difference a day makes! It appears that the huge changes in Health Care may be delayed somewhat. However, as we stand, things are not looking good for rehab services. The cap is back in place and the new amount is $1860 per cap, the exception has expired and we are still scheduled for the 21% decrease in reimbursement as of March 1st. We can look at that with perverse "British Humour" and say, well, at least the patient is going to get "More Bang for their Cap Buck". No doubt sanity will prevail and we will get both of those big problems resolved. CMS held their SNF open door on Thursday the 21st and announced that everything is on schedule for the MDS 3.0 and RUG IV implementation on October 1st. They have published more of the RAI Manual on their website and the final sections should be there by the end of the month. |
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