April 2011
April
29th: CMS published the
2012 Interim Final Rule for SNF and gave the industry a jolt. The
proposal includes changes in payment structure that could result in
just under a $4 billion reduction in payment, also clarification of
the missed 3 days of therapy regulation. Along with that
clarification came another OMRA to be completed in conjunction with
the EOT OMRA when the patient resumes therapy within 5 days of the
EOT.
Now for the biggy as we say in the
UK, the facility will have to review the patient treatment outside
of the observation period and if it is significantly different from
the RUG level they are being paid then a Change of Therapy (COT)
OMRA will be done to create the new payment level. This review is to
be performed weekly and should finally stop the changes in treatment
time and modes of treatment that we know occurs in some facilities.
Documentation will be under scrutiny to support the services being
provided along wit identification on the POT to support group
treatment.
Also changing are the optimal
assessment reference dates to eliminate the "double dipping" of
treatment minutes to create 2 different RUG levels along with the
number of grace days which has been reduced to 4 days for all other
than the 5-day. (Maybe they finally read my comments about reducing
those dates which I entered as comment for the Final Rule about 5
years ago).
Group treatment has been redefined to
make a group to consist of 4 patients and, in the calculation of the
RUG, only 25% of group minutes will be counted along with the
current restriction of 25% of the total minutes coming from group.
Good News is that the direct line-of-sight supervision of students
is being eliminated.
And who do we have to blame? No one
but ourselves. Every time CMS changes payment structure, we changed
how we practiced. Based on the STRIVE report, the calculation RUG IV
were developed. The STRIVE report indicated that there was minimal
use group treatment with most treatment being individual or
concurrent. The data collected from the new system indicates
dramatic reduction in use of concurrent, but significant increase in
group treatment.
We will be preparing a more in-depth
overview of the proposed changes in the next few days. We also will
be updating our Mastering Medicare Seminar to include the changes
once the Final Rule is published at the end of July.
Our news is that our new website is
almost ready to go live and we hope you will enjoy it and find it
easier to negotiate. This, along with some other factors has been
why April has been lacking in updates. With the new website, that
should be resolved, so stay tuned.
March 2011
March
29th: Well, March has been a
quiet month for news!
Unfortunately, it has been a busy month for me and getting to update
the site has been difficult.
I have had several people contact me
to see if I ever heard back from the CMS SNF Open Door team on the
questions I sent them in January about the EOT OMRA when a patient
misses days of therapy, and guess what the answer is! NO. The
questions were also not answered at the March 17th SNF ODF either.
At the March 17th meeting, the topic
was brought up and it was acknowledged that this requirement is NOT
in the RAI Manual. It was brought up that this requirement was in
statute and had been addressed in the FR for 2010 FY. Checking back,
guess what I found. The reference was to section 409 of the Code of
Federal Regulations covering extended care services. This section
identifies that skilled therapy services under Part A SNF must be
provided at a minimum of 5 days a week. The section goes on to state
that " an occasional missed treatment of 1 or 2 days will not
compromise the Part A coverage." and "most SNFs provide 5 days a
week coverage". The interesting fact is that this statute has been
in place for many years and was in place when mentioned in 2009 and
we were using the MDS 2.0. So I guess my question is "Why has the
CMS SNF group decided to implement this regulation after the
training for MDS 3.0 and the publication of the RAI Manual?"
Anyhow, seeing non of them probably
read this column, we will probably never know. So, the best that I
could get out of that audio cast was that they are working on it!
The new RAI updates will "probably" address it and it is something
that is not going to go away.
Based on all the information I have
been able to obtain, the information in the January section still
applies. My recommendation if that, unless you have never provided
services on a weekend, then your facility could get away with the 2
missed days plus Saturday and Sunday. As most facilities have been
able to provide a services on a weekend, either because a holiday
was occurring during the week, or a patient was in an observation
period and the ARD could not be moved, then you may find that this
new interpretation applies to you.
How can it be managed? Well,
if a patient misses days during the week, when the second treatment
is missed then that day, the team need to look at why and if the
patient can be seen the next day. Remember, this only applies when
all disciplines are missing treatments. If it looks as if the 3rd
treatment day is going to be missed, then the EOT OMRA needs to be
done on Day 3 to be in compliance (ARD day 1, 2 or 3 after the last
therapy). Now for the tricky bit, has nursing been providing any
skilled nursing services: if not, then they better be addressing the
reason for the missed therapy. WHY? Well, the EOT OMRA has a look
back of 7 days, same as all others and creates a nursing RUG payment
applicable from the day after the last therapy. If no skills have
been provided then the MDS may not even be able to meet a skilled
level of care. WOW! Then what?
This situation was also discussed as
guess what has not happened; the SNF ABN has not been issued and the
patient has not been informed of the coverage ending and the
nightmare continues. I don't know how many of you reading this
listened to the audio conference, but, at this point, someone made
the comment that if not seeing the patient on the Saturday and
Sunday counts as 2 missed days and then, because something happens
on the Monday so that the patient is not seen and nursing has not
been providing skilled services, should they have given the patient
the ABN on the Friday and should this be done as a matter of course.
The first answer appeared to be yes, and then, as we have come to
expect from these meetings, the speaker said that she wasn't meaning
that this should be done. Well, it sure sounded like that to me.
So here we are, no further forward
and more confused than ever. My recommendation, make sure that
someone can provide a weekend treatment if Friday is missed, and
essential if Thursday and Friday were missed. This situation, unless
clearly resolved, could end up being the RACs favorite new
issue.
Stay Tuned.
February 2011
February 21st: The Department
of HHS announced that a
combined action by the HEAT task forces had made arrests in several
areas including Brooklyn, Los Angeles, Detroit and Miami. The round
up follows investigation of fraud in billing Medicare services and
identified over $240 million in fraudulent claims. Unfortunately
Physical Therapy was one of the Medicare benefits that was under
scrutiny with at least three different schemes. A Physical Therapist
in New York was accused of fraudulently bill over $11.9 million in
claims between January 2005 and June 2010. These claims were either
for services not performed or medically unnecessary.
This round up follows closely on the
heels of the OIG report that identified the two counties of Queens
and Kings as 2 of the 20 counties having massive overutilization of
therapy services. Our latest edition of the e-newsletter contains
our editorial review of these two reports. To access the Part B
report
follow this link and for the SNF
report
follow this link.
February 5th: The
government's fight against the increasing prevalence in Medicare and
Medicaid fraud has taken a new turn which puts a spotlight on PTs in
private practice above other therapy providers! Starting March 25th
2011, additional provisions are being put in place to screen new
providers and suppliers of Medicare services, along with existing
providers and suppliers who are revalidating their Medicare
participation.
The new regulations outlined in the
Final Rule published February 2nd, authorizes 3 levels of additional
screening based on assessed risk. Under the new rule
CMS will require Medicare contractors to
screen all initial applications, including applications
for a new practice location, and any application
received in response to a revalidation request. The three
levels are based on
Limited, Moderate and High
Categorical Risk.
Limited risk
includes amongst others OTs and SLPs in Private practice, Skilled
Nursing Facilities and Rehab Agencies;
the screening
requirements are:
1) verify that the provider or supplier meet the Federal regulations
and State requirements for the provider type prior to enrollment;
2) conduct license verifications;
3) Conduct database checks on pre and post enrollment basis to
ensure that providers and suppliers meet enrollment criteria for
their provider/supplier type.
Moderate risk
includes amongst others
Physical therapists enrolling as individuals or as group practices
and comprehensive outpatient rehabilitation facilities.
The
screening includes the requirements listed above
PLUS
on-site visits.
The
High risk category
includes new HHA and DMEPOS
providers, however!!!!!!! Any therapist in private practice that
wants to provide DME, orthotics or prosthetics to its patients will
have to meet the same screening requirements as the DMEPOS which
are:
1) All of the
requirements for limited and moderate risk level;
2) Submission
of a set of fingerprints for a national background
check from all individuals who maintain a 5 percent or greater
direct or indirect ownership interest in the provider or supplier;
and
3)
Fingerprint-based criminal history record check of the FBI’s
Integration Automated Fingerprint Identification System on all
individuals who maintain a 5 percent or greater direct or indirect
ownership interest in the provider or supplier. This must be done
upon submission of a Medicare enrollment application and within 30
days of the contractor request.
As if this wasn't enough, the rule
also imposes application fees on institutional providers
and gives CMS new authorities to place moratoria and
suspension of payment holds on specific provider types when
fraud, abuse or waste is suspected. (Note: suspected
NOT proven.)
We have known for long enough that
there has been a significant amount of both abuse and fraud being
done through the provision of Part B services, now we are all going
to be paying the price of a few. This rule follows hard on the heels
of the OIG reports indicating over utilization of both Part B
services in 20 counties in the US with Miami/Dade County receiving
special recognition as having 4 times as much utilization than the
National Average.
January 2011
January 31st: Last
Thursday, during the SNF Open Door call, the speaker addressed the
CMS policy for the EOT OMRA when the patient has missed 3 days of
therapy. The result for myself and I'm sure most of the listeners
was more confusion. I have an e-mail in to the speaker with
definitive questions that I hope will clear the confusion. Here is
the non-confused information I got from the call.
When a patient misses 3 days of
therapy then an EOT OMRA must be completed. The 3 days refer to
therapy overall, not each services so if PT misses 3 days
but another therapy misses only 2 days before the patient resumes
care then this would not apply. When the facility provides 7 day
therapy, then the patient would have to miss 3 consecutive days, so
for example. The patient receives no therapy service on Friday,
Saturday and Sunday, then an EOT must be done. Now it gets
interesting! In the regulations for when the ARD of the EOT must
occur, it states that it can be day 1, 2 or 3 after the last day
that therapy was provided, which presumably means that Sunday would
become the ARD. So one would presume that as soon as the therapist
determines that there is no way to provide at least 15 minutes of
therapy that day, the MDS coordinator must be ready to fix that day
as the ARD so that they are not out of compliance with the
regulations.
Now comes the confusion in what
actually defines how many days a week a facility provides therapy.
In previous calls, as well as at conferences, Ellen Berry, the PT
who works for CMS has stated that if you demonstrated the ability to
provide a services on a Saturday or Sunday, that makes you a 6 or 7
day week department. The speaker on Thursday said that a casual
provision of therapy does not make you a 6 or 7 day department.
First confusion! Next she started to provide an example of a five
day clinic but finished up relating back to the 7 day clinic, so a
clear defined answer or example was never given.
One caller provided an example of the
fact that their facility provides Monday thru Friday only coverage,
but, because of the holidays, they provided services on the Saturday
and Sunday before so that the staff could have the Friday holiday
off. The resultant answer was that, because they missed Friday
Saturday and Sunday, then they should have done a EOT because the
patient missed 3 days, even though the patient had received the
therapy required by the POT. Second confusion!
Once I receive the answers to my
questions I will post them on this site and in the meantime, the
moral of this story appears to be, get 15 minutes of any therapy done, if it
looks like the patient is going to miss 3 consecutive days or
never treat on a Saturday or Sunday so you can truly say you
are a 5 times a week clinic. Ah Government, and the interesting
thing is, this policy is not written down in the RAI Manual. I am
presuming that this will be remedied in the updates that are
expected in the spring.
January 10th:
Late last month, the OIG
released two reports on “Questionable Billing Practices”,
one for Medicare Outpatient Therapy Service and the other for SNF
Part A Services. The findings in both of these reports was of high
overutilization of services with both abuse and fraud occurring. The
recommendations for both of these reports were to increase scrutiny
of claims submitted and institute changes to the ways that payment
for these services are created.
What they found: For outpatient therapy
services, 20 counties were identified that, in 2009, had provided 1)
the highest average Medicare payments per beneficiary and 2) had
services that produced more than $1 million in total Medicare
payments, i.e. high utilization counties. For SNF, it was determined
that from 2006 to 2008, 1) billing for high paying RUGs increased
even though beneficiary characteristics remained generally
unchanged, 2) For profit SNFs were more likely to bill higher paying
RUGS than not for profit or government SNFs, and 3) Some hadt
questionable billing practices with high RUGs and long length of
stay (total of 348 of facilities in study).
What does that mean for us?
MORE Medical Reviews!
Who needs to be concerned?
Well, for OPT,
Miami-Dade was analyzed separately from all others as it has a much
higher utilization of all counties. The other 19 counties included 6
counties in Louisiana, 4 in Texas, 3 in Mississippi, 2 in Indiana, 2
in New York, 1 in Georgia and another in Florida.
For SNF, large companies had the
highest utilization of high RUG levels, mainly RU groups, with a
noticeable increase in utilization after they purchased new
facilities.
What are the triggers?
For OPT, the use of the
KX modifier both during treatment and on initial therapy visit,
treatment throughout the year as well as services by multiple
providers; also included is treatment exceeding 8 hours a day. For
SNF, high use of RUG Ultra levels along with longer than average
length of stay and higher than average ADL scores. The report also
identified used of ICD-9 codes with V57, care involving use of rehab
procedures, increasing 4.9% in 2 years and heading their list of
codes.
We will be creating an overview of
both reports and have them posted in the next few days.
December 2010
December 24th:
The APTA
sent updated information to its members on the effect of the MRRP
policy. It indicated that the negative effect of the MPPR is offset
by a combination of the PPIS survey data and the Medicare Economic
Index rebasing. The notice indicated that the net impact of these
changes all combined would be a negative impact of about 5%. They
did not differentiate between whether this was for the 20% or 25%
decrease. Seeing that the APTA predominantly issues information
effecting the private practitioner, we are making, a presumption
that this 5% affects PTPP, so the institutional based practices,
including CORFs (Rehab Agencies) and CORFs would have a negative
impact somewhat higher as had been initially indicated depending on
practice patterns, of 6% to 7% from 2010
December 23rd: CMS issued the
transmittal explaining the MPPR policy.
The policy is effective January 1st
for all providers and suppliers of Part B services, however, the
reduction in the practice expense is different for Therapists in
Private Practice from that of institutional providers. Under the
regulations, "suppliers" of Part B services, i.e. therapists in
private practice, that provide services in an office or
non-institutional setting are subject to a 20% reduction
in the practice expense (PE) as provided in the Physician Payment
and Therapy Relief Act, whereas institutional providers i.e.
ALL Other Providers, will see the 25% reduction
in the PE portion of the billed units as originally announced in the
November Final Rule. The Medicare Economic Index was announced and
provides a negative 2% rebasing of values for the 2011 Fee Schedule.
To read the CMS transmittal,
follow this link and to read
the MLN interpretation,
follow this link.
December 20th:
The on December 15th, the president signed into law the Senate
Amendment to HR4994 which includes the provisions identified below.
This amendment did not address the MPPR scheduled for January 1st
2011. Also what has not been released is the Medicare Economic Index
for 2011. This could have a 7% to 8% negative impact according to
Rick Gawenda, PT, President of the APTA's Health Administration
Section. So while there is overall good news, we still do not know
the exact financial impact on Part B services for 2011.
Do you still have claims for any
services provided in 2009 that you have not filed? If you have, you
better get them submitted before December 31st or they will be
denied. Also, the Patient Protection and Affordable Care Act (PPACA)
instituted a 1 year time limit to file claims. Therefore, effective
January 1st 2011, services will be automatically denied that are
older than 1 calendar year.
In
general, the start date for determining the 1-year timely filing
period is the date of service or “From” date on the claim. For
institutional claims that include span dates of service (i.e., a
“From” and “Through” date on the claim), the “Through” date on the
claim is used for determining the date of service for claims filing
timeliness. For claims submitted by physicians and other
suppliers that include span dates of service, the line item “From”
date is used for determining the date of service for claims filing
timeliness.
To
view the Medicare Learning Network Article follow
this link for SNF
and
this link for Part B Services.
December
10th: WOW! Merry Christmas
from Congress.
Congress passed the Medicare and
Medicaid Extension Act providing therapists with a very welcome 2011
gift. For the first time, therapists under Part B know what to
expect come January 1st 2011.
-
We have the extension of the
therapy cap exception process till 2012
-
We have the same reimbursement
fee schedule as 2010 with continuation of the 2.2% increase
instead of the forecasted 25.5% decrease
-
The proposed 50% decrease in the
practice expense through the MPPR was decreased to 20%, thus
making the decrease in overall revenue a manageable (sort of) 4%
to 5% decrease from 2010.
Congress also gave CMS a present too.
They repealed the delay in implementing RUG IV meaning that CMS does
not have to spend any more time or any more of our money creating
the hybrid RUG III software and SNFs do not have to go through a
period of having their claims recalculated and monies returned.
Therefore, both CMS and SNFs can now focus on getting the MDS 3.0
and RUG IV system to make sense.
December 1st: Yesterday
the President signed PPTRA into law, providing for a continuation of
the present fee schedule till the end of the year. The cost of the 1
month extension is being paid for with the 20% MPPR decrease
effective January 1st 2011. However, during the last weeks of the
present session, the SGR is to be addressed so as to be proactive
regarding the scheduled 25% decrease as of January 1st. It is also
hoped that included will be the therapy caps and the extension of
the exception process. Not sure if we should be holding our breath
on that one! It would be a first.
CMS issued the Final Rule for the
Physician's Fee Schedule on November 29th, and now will have to
address the new changes.
November 2010
November 19th: Well,
the first sort of good news
for a while! Yesterday the US Senate passed the Physician Payment
and Therapy Relief Act (PPTRA) which extends the 2.2% increase in
the fee schedule through the end of the year. This act also reduces
the 25% decrease in the PE reimbursement to 20%. The scheduled
decrease in the fee schedule for 2011 of approximately 25% was not
addressed.
The American Health Care Association
is encouraging Congress to address the implementation of RUG IV, so
as to decrease the disruption that would occur with the payment
system. The house has already passed bills which would implement RUG
IV payments as of October 1st 2010 instead of the current schedule
of 2011. CMS has addressed this in their open door sessions as they
are having to develop a hybrid system that would recalculate the
current payments to a mix of RUG III and the MDS 3.0. Essentially
meaning that there will be a recalculation of payments and very
likely refunds to Medicare. The cost of this along with the
disruption it would cause is just another example of the effects of
the HealthCare legislation which "had to be passed so we would then
know what was in it".
They also addressed the extending the
exception process for Part B therapy caps as the impact of this cap
on the residents of Skilled Nursing Facilities has the most negative
consequences of all Medicare beneficiary groups.
Hopefully. the "lame duck" congress
will get their act together finally all the campaigning is over and
start making sense out of what they are doing!!
November 3rd: It's official,
therapists are in for a decrease in reimbursement starting January
1st. Yesterday, CMS
published the Final Rule for 2011 effecting reimbursement for Part B
services.
Good news:
the Therapy Cap has increased a whopping $10 to 1870 per cap,
Bad News: We still have the caps in place and no exception
process for 2011 unless addressed by Congress. Good News
according to CMS: The cap will go father enabling the
beneficiary to have more therapy before the cap is met!!!!
Bad News: CMS is
implementing the multiple procedure reduction policy (MPPR),
Good News: it's 25% of the practice expense RVU of the fee
schedule, not the 50% initially proposed. CMS indicated that it has
estimated that this will result in a 7% to 9% reduction in payments,
not the 11% to 13% in the proposed rule!!!
Bad News: The MPPR
applies to all "always therapy codes" provided by the
provider/supplier to the beneficiary per day. This means that for
institutional providers it applies to therapy services performed
that day, just like the CCI edits. It is provider specific not
discipline specific, therefore, if a combination of PT, OT and SLP
services are provided on the same day, the most expensive code
billed by any of the disciplines will be paid in full while rest of
the claim will be subject to the MPPR reduction. It also applies to
BID treatments as it is day specific not treatment session or visit.
Also in the FR, CMS continues to
address the options for reimbursement of therapy Part B services.
October 2010
October 28th: SNF Open Door
Forum held today still
reflected the confusion that is MDS 3.0 and RUG IV. Until repealed
by Congress, CMS is continuing to work on the development of the
hybrid RUG III payment system and indicated that the grouper to
recalculate the RUG payments should be ready in the New Year. Talk
about your tax dollars at work. The House passed the repeal of this
requirement before the recess but the Senate still has to vote on it
before it can become official, that is RUG IV payments are valid
from Oct 1st 2010, not 2011.
The speakers frequently mentioned
"listening to comments" made by providers and are working on
updating the RAI Manual, to address concerns raised. This new manual
should be published in Spring 2011.
The next Open Door Forum on the MDS
3.0 is scheduled for November 9th. Hopefully it will throw some
light on the use of the EOT OMRA when the patient misses visits. We
will keep you posted.
October 26th: Everyone is
waiting for the FR for Part B services to be published.
There is no indication of
whether the proposed changes in the Fee schedule will be changed in
the now much awaited publication of the 2011 FR, effective January
1st 2011. To compound the concern, the delay of the implementation
of the 21% plus decrease in payment that was delayed by Congress is
scheduled to expire on November 30th. Whether this will be
addressed by the "lame duck" session prior to the Christmas recess
is anybodies guess.
Having just finished our seminars on
Medicare Part B, we were unfortunately not able to deliver a
positive look for Rehab in 2011.
October 1st: Well, the MDS 3.0
is official. As of
today, therapist are working under a new set of regulations in
Skilled Nursing. Rules so new some of them still have wet ink!
CMS clarified how to code set up
minutes on September 23rd. The minutes spent on set up time,
provided by an aide, therapist or therapist assistant can be counted
and included as skilled services. What CMS clarified was the the
minutes are allocated to the mode of therapy services that is being
prepared for. individual, concurrent or group.
So if the aide is preparing an area
for the therapist to provide group therapy, then the minutes wound
be included under the group therapy time.
Congress adjourned this week without
addressing any of the therapy concerns with regards to the
expiration of the current fee schedule levels set to change
on December 1st, creating a 21% plus decrease for Part B services.
There was no action to combine the 2 bills addressing the rescinding
of the delay in the implementation of RUG IV till next year.
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:
-
Name and therapy degree of
performing therapy professional
-
Name of academic institution
having conferred the degree
-
Date of graduation
-
Name and professional degree of
supervising physician/NPP
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.