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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.
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:
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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