Reimbursement Archives - Montero Therapy Services

Coming Soon To A SNF Near You – A New Medicare Part A Payment Model

April 29, 2018 By Montero Therapy Services Leave a Comment

Since the release of the Advanced Notice of Proposed Rulemaking (ANPRM) approximately 1 year ago, the talk in SNF Rehab Departments has been about RCS-1 and the looming potential changes coming down the road that would not only change reimbursement for Medicare Part A , but impact the way therapy is currently provided. Along with the facts about RCS-1, there were many many myths and rumors as to how therapy life in the SNF would forever change. See our last article “RCS-1: To be or not to be.

Therapists nationwide were awaiting the SNF PPS Proposed Rule due to be released this spring, in hopes of getting clarification on the changes to come. {For those new to the process, the Proposed Rule released each year outlines changes for the start of the next FY (Fiscal Year) which starts on October 1st. It is released to allow time for comments from providers before releasing the Final Rule prior to October 1st.}

We knew changes were coming, however, as of last month in an ODF (Open Door Forum), CMS stated they were still analyzing comments and feedback related to the proposed changes…and official policies and a start date had not yet been set.

…and then yesterday, April 27th, CMS released the anticipated 266 page Proposed Rule. Yes, change is coming…but not until October 1, 2019….and it was NOT RCS-1!

This new rule proposes the replacement of the existing case-mix classification methodology, the Resource Utilization Groups, Version IV (RUG-IV) model, with a revised case-mix methodology called the Patient-Driven Payment Model (PDPM) effective October 1, 2019. RCS-1 was essentially revamped in response to comments and additional data analysis….and then renamed.

So What Happened?

Well, CMS has commented in the Final Rule for at least the last 5 years that there was significant concern regarding the therapy trends in the SNF . CMS has cited 2 concerns in particular:

The percentage of residents classifying into the Ultra-High therapy category has increased steadily (reaching >60% of total scores in 2017)
The percentage of residents receiving just enough therapy to surpass the Ultra-High and Very-High therapy thresholds has also increased (some SNF’s achieved 100% of RU and RV RUGS with exact minutes of 720 and 500 respectively…like magic)

In the 2015 SNF PPS Final Rule, CMS stated: “We believe the increase in “thresholding” is a strong indication of service provision predicated on financial considerations rather than resident need.” “….Therefore, services which are not specifically tailored to meet the individualized needs and goals of the resident, based on the resident’s condition and the evaluation and judgment of the resident’s clinicians, may not meet [the] definition for covered SNF care, and we believe that internal provider rules should not seek to circumvent the Medicare statute, regulations and policies, or the professional judgment of clinicians.”

{Did you know CMS said this? Looks like they may have been on “your side” all along….though not all were listening….}

So, after years of recommendations and clear data from the OIG and MedPAC to make a change, CMS took a stand last May, gave fair warning of a new payment system (RCS-1) and allowed comments for an extended period of time. CMS really did listen to all the comments and concerns about RCS-1, took them into account and created a payment model with a new name – PDPM.

For those not paying attention to the multitude of CMS statements over the years reiterating that therapy service provision should be based on the resident’s individual needs, this Proposed Rule would rename the payment model so no one could forget… The Rule states:

To make clear the purpose and intent of replacing the existing RUG-IV system, the model we are proposing in this rule is called the Patient-Driven Payment Model (PDPM).

Ok, got it! Patient-Driven…..not therapy-driven, not minute-driven!

Nuts and Bolts of the new PDPM?

PDPM is a new payment model, very similar to the previously proposed RCS-1, that sets daily Medicare Part A payment rates on factors other than therapy days and minutes. Data from the MDS, starting with the ICD-10 code and category that supports the SNF Part A stay, are used to classify a resident. Additional MDS data including function, cognition, swallowing disorders and other clinical diagnoses also contribute to classifications. Unlike the RUG-IV classification where each resident is only classified into 1 RUG group based on the MDS, PDPM breaks apart therapy and nursing to allow for a separate classification for each.

Here is a breakdown of the contributing components:

Nursing is finally “free” from therapy’s grip. With RUG-IV, Rehab RUG’s often trumped Nursing RUG’s. PDPM will use a similar set up as RUG-IV for nursing, minus the Rehab RUG’s. RCS-1 had the total # of RUGS down from 66 to 43, and now PDPM takes it down even further to a total of 25 by combining existing groups. The method for calculating the ADL score will also change and Section GG items will be added to the mix.

PT case mix and payment will be determined by the ICD-10 code category for SNF admission and the functional score based on MDS questions. There are a total of 16 potential PT case mix groups as show here,

OT case mix and payment are determined exactly like PT, however, case mix scores and payment will differ for each category.

Of note, the daily payment amount for PT and OT will pay the full rate for the first 20 days and then decrease by 2% every 7 days thereafter for the remaining 80 days.

Speech case mix and payment is determined by the ICD-10 code category for SNF admission, as well as factors including swallowing disorders, mechanically altered diets, speech co-morbidities and cognition (all from MDS answers). The daily speech rate does not decrease over time like the PT and OT rates.

Now remember….minutes don’t matter. In fact, these PT, OT and Speech categories/case-mix are not even impacted by the presence or absence of an active therapy program. Each resident will fall into a PT, OT and SLP case mix group regardless of therapy services. Yes….facilities are paid a daily rate for therapy services even if therapy is not active. If therapy is active, the payment rate does not change with the amount of time spent with the resident. Why? CMS expects the SNF to save payment for when therapy services are necessary.

There is also a case mix category called “Non-Therapy Ancillary” that will use MDS questions from Section I, K, M and O to determine a case mix score. This payment is tripled for the first 3 days of the stay to cover any costs upfront.

In addition to the 5 case mix based categories above, there is also a non-case mix payment (flat rate) for “overhead costs” such as room and board, laundry, capital expenses, dietary, etc.

The payment rate for the above 6 categories will be added up to make the total daily per diem payment rate. So with RUG-IV we had 1 category determining daily payment and now with PDPM, the eggs are spread into 6 baskets.

What Can Therapists Do To Prepare?

Read the Proposed Rule! It is only 266 pages. You may not need all the info in there, but it will give you greater perspective on why changes were made and the data that drove the changes. It also gives you insight into Medicare’s thought process for Part A payment.

Education is always the best bet. If you are not familiar with the MDS, now is the time to get your feet wet. The MDS tool is and will continue to be the central point for outcomes, Part A reimbursement, Quality Measures, Star Ratings, State case mix and more.

Oh, and there is so much more info out there if you are interested. Here are a few links to get you started.

SNF PPS Proposed Rule for Oct 1st 2018

Acumen Technical Report – SNF PPS Data for PDPM – April 2018

SNF PPS Payment Driven Payment Model CMS Webpage

*Keep in mind that this is a Proposed Rule…and things may change as the date approaches.

Will SNF Therapy Change When “Minutes Won’t Matter?”

Technically it shouldn’t. But will they? Possibly initially…until the dust settles.

If your facility was providing therapy services based on resident’s need and not financial targets, nothing should change, right? CMS used existing provider data to revamp the payment system, and says that if your facility was not one that provided an “excess” of Rehab Ultra, you may be looking at a significant increase in reimbursement under the new model. However, if your facility was one of those with a super high percentage of Ultra High RUG’s, your facility may see a dip in reimbursement with PDPM.

CMS put out a comparison tool so facilities could look themselves up to see how reimbursement would change under PDPM assuming all other variables stayed the same. Find your facility (you will need to know your CCN number) and see what the difference (+ or -) would be if PDPM was in effect in 2017. You can also see your facility revenue which may be eye opening for you!

PDPM Comparison Tool (It is an excel file that you can download and search for your facility. Compare revenue under RUG-IV with PDPM.)

So….

Don’t fall into the doomsday mode out there! There is plenty of Medicare Part A dollars that will continue to be available in the system. You just need to find a facility or company that is willing to “share” with you! Now is the time to find a facility or company that sees you for your value BEYOND your ability to provide minutes!

A new payment model may be a blessing in disguise for therapists in the SNF setting. Therapists who have been around since pre-PPS {cough} remember what autonomy felt like and remember not only being able to make a difference in each residents life, but the life of the SNF as a whole. Back then, therapists were team players that knew the rules…knew what the DOH was looking for…knew what the big picture looked like . Therapists have always been team players, but let’s be honest here…therapist autonomy was somewhat hijacked when PPS and managed Rehab departments came into play.

If you have questions about PDPM or anything else SNF related, send them to our Just Ask Q&A Forum and our team will help you out.

In Your Corner,

Dolores and the Montero Therapy Team

www.MonteroTherapyServices.com

RCS-1 – To Be Or Not To Be ?

April 1, 2018 By Montero Therapy Services Leave a Comment

Chances are that NO ONE has ever read Hamlet’s famous soliloquy by Shakespeare, “To be or not to be…” and thought…hmmm… this reminds me of Medicare, CMS and the potential new SNF reimbursement system RCS-1. {Right?}

In all honesty, I have not thought about Hamlet since 9th grade English. But what I remember {from the Cliff Notes} was that Hamlet was contemplating whether it was more noble to suffer life’s troubles or escape by ending his life. Heavy stuff!! This made me wonder….is CMS thinking the same thing about PPS these days? Are they thinking they can end the troubles that RUG-IV brought with it by killing it off? Maybe.

Rehab companies and those SNF’s that have reaped the benefits of the PPS and Ultra RUG may be hoping “not to be.” However, even though most therapists don’t yet know the ins and outs of what RCS-1 will be, they are ready to take a chance on “to be.”

Therapists in the SNF setting report their clinical judgement is steamrolled over by aggressive reimbursement targets for extending length of stay, questioning therapist recommended discharge dates and having someone other than the primary therapist determine daily treatment minutes to meet financial targets and not clinical needs. Therapists in some settings feel they have become minute robots, providing the # of minutes assigned to them for each resident on their daily schedule, minutes that allow for the achievements of RUG targets that are either exact or pretty close to the RUG minimum {because we wouldn’t want to waste minutes…uggg}. See our article on why “exact RUG minutes are a no-no.”

What is RCS-1?

RCS-1 is a new payment model that sets daily Medicare Part A payment rates on factors other than therapy days and minutes. RCS stands for Resident Classification System, and as the name implies, uses resident data to classify a resident into a category for payment. Data from the MDS, starting with the ICD-10 code and category that supports the SNF Part A stay, are used to classify a resident. Additional MDS data including cognition, function, swallowing disorders and other clinical diagnoses also contribute to classifications. Unlike the RUG-IV classification where each resident is only classified into 1 RUG group based on the MDS, RCS-1 breaks apart therapy and nursing to allow for a separate classification for each.

Nursing is finally “free” from therapy’s grip. With RUG-IV, Rehab RUG’s often trumped Nursing RUG’s. RCS-1 will use the same RUG-IV set up for nursing, minus the Rehab RUG’s. The 66 total RUGs will dwindle to 43.

PT and OT share a category and both function and cognition (from the MDS answers) determine the category, case mix and payment rate. After 14 days, the daily rate for the PT/OT category decreases by 1% every 3 days for the remainder of the 100 days.

Speech is in a category by itself and factors including swallowing disorders, mechanically altered diets, speech co-morbidities and cognition (all from MDS answers) determine the category, case mix and payment rate.

Now remember….minutes don’t matter. In fact, these PT/OT and Speech categories/case-mix is not even impacted by the presence or absence of an active therapy program. Each resident will fall into a PT/OT and SLP case mix group regardless of therapy services. Yes….facilities are paid a daily rate for therapy services even if therapy is not active. If therapy is active, the payment rate does not change with the amount of time spent with the resident. Why? CMS expects the SNF to save payment for when therapy services are necessary.

In addition to the 4 case mix based categories above, there is also a non-case mix payment (flat rate) for “overhead costs” such as room and board, laundry, capital expenses, dietary, etc.

The payment rate for the above 5 categories will be added up to make the total daily per diem payment rate. So with RUG-IV we had 1 category determining daily payment and now with RCS-1, the eggs are spread into 5 baskets.

What Can Therapists Do To Prepare?

Will SNF Therapy change when “minutes won’t matter?” Technically it shouldn’t. If your facility was providing therapy services based on resident’s need and not financial targets, nothing should change, right? If your facility was not one that provided an excess of Rehab Ultra, you may be looking at a significant increase in reimbursement. However, if your facility was one of those with a super high percentage of Ultra High RUG’s, your facility may see a dip in reimbursement with RCS-1.

CMS put out a comparison tool so facilities could look themselves up to see how reimbursement would change under RCS-1 assuming all other variable stayed the same. Find your facility and see what the difference (+ or -) would be if in FY2014 we used RCS-1 vs RUG-IV. You can also see your facility revenue which may be eye opening for you!

RCS-1 Comparison Tool (It is an excel file that you can download and search for your facility.)

So….

Now is the time to find a facility or company that sees you for your value BEYOND your ability to provide minutes! Robot days are over.

So RCS-1 may be a blessing in disguise for therapists in the SNF setting. Therapists who have been around since pre-PPS {cough} remember what autonomy felt like and remember not only being able to make a difference in each residents life, but the life of the SNF as a whole. Back then, therapists were team players that knew the rules…knew what the DOH was looking for…knew what the big picture looked like . PPS and “managed Rehab departments” took therapists autonomy away to some degree and also did not leave time for anything other than minutes and productivity.

RCS-1 – or ANYTHING but the RUG-IV system we have now that incentivizes all the wrong things – may just the “blessing in disguise” that many therapists were hoping for.

On 3/8/18, CMS held an Open Door Forum call that included a brief discussion on RCS-1. On that call, John Kane from CMS cautiously stated that CMS “has not proposed or finalized any policies.” Kane added that “analysis based on comments received was still in progress” and that CMS did not have a timeline.

RCS-1 is not about IF… but rather, WHEN. That…. is the question.

If you have questions about RCS-1 or anything else SNF related, send them to our Just Ask Q&A Forum and our team will help you out.

In Your Corner,

Dolores

www.MonteroTherapyServices.com

Is a Range in Therapy Frequency Acceptable for Part A or B?

March 11, 2018 By Montero Therapy Services Leave a Comment

A common question from Rehab Departments in skilled nursing facilities:

Can our treatment orders have a range in frequency?

What is acceptable?

Part A: 5-6x per week vs 6x per week
Part B: 2-3x per week vs 3x per week

We can all have our opinion on this topic…but let’s look at Medicare’s opinion…since they are paying {or not paying} the bill!

The answer is split into 2 parts, 1 for Medicare A and 1 for Medicare B.

Let’s start with Medicare Part B since the answer is pretty clear-cut.

1- Medicare Part B: The Medicare Benefit Policy Manual, Chapter 15, the Chapter that contains all the rules for Medicare Part B (in all settings including SNF) clearly states that the frequency should be set to strive for the most efficient and effective treatment. This phrase is repeated at least 3 times in the excerpt below. The Manual goes a step further to acknowledge that a patient’s frequency may change during the course of care, and that these changes should be based on the therapist’s assessment of daily progress. The Manual outlines the practice of “tapering” a frequency as an acceptable practice, and provides specific examples on how/why to do this.

Based on this information, establishing a therapy order as a range could lead to a denial. CMS is acknowledging that a patient’s frequency could change, and the Part B Manual presents a method to accommodate this by using “# of visits over a period of weeks” via tapering. Medicare’s focus is covering “reasonable and necessary” services based on the patient’s need – not staffing or convenience of scheduling. In our auditing services, we have come upon denials for services where a range was used. Medicare Part B would only cover {pay for} the lower end of the range. (ie: Therapy order was for 2-3x/week. Medicare only covered 2 visits per week citing unclear medical necessity for the 3rd visit).

Here is the link to the Part B Manual with the key phrases listed. Ultimately your facility/company will have to set a policy for this and be able to back up their decision on audit.

This excerpt from the Manual will help clarify:

Section 220.1.2 – Plans of Care for Outpatient Physical Therapy, Occupational (Includes SNF Part B)

Therapy, or Speech-Language Pathology Services

Contents of Plan

The plan of care shall contain, at minimum, the following information as required by regulation (42CFR424.24, 410.61, and 410.105(c) (for CORFs)). (See §220.3 for further documentation requirements):

Diagnoses;

Long term treatment goals; and

Type, amount, duration and frequency of therapy services.

The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources. The frequency refers to the number of times in a week the type of treatment is provided. Where frequency is not specified, one treatment is assumed. If a scheduled holiday occurs on a treatment day that is part of the plan, it is appropriate to omit that treatment day unless the clinician who is responsible for writing progress reports determines that a brief, temporary pause in the delivery of therapy services would adversely affect the patient’s condition. The frequency or duration of the treatment may not be used alone to determine medical necessity, but they should be considered with other factors such as condition, progress, and treatment type to provide the most effective and efficient means to achieve the patients’ goals. For example, it may be clinically appropriate, medically necessary, most efficient and effective to provide short term intensive treatment or longer term and less frequent treatment depending on the individuals’ needs. It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward an independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time. For example, treatment may be provided 3 times a week for 2 weeks, then 2 times a week for the next 2 weeks, then once a week for the last 2 weeks. Depending on the individual’s condition, such treatment may result in better outcomes, or may result in earlier discharge than routine treatment 3 times a week for 4 weeks. When tapered frequency is planned, the exact number of treatments per frequency level is not required to be projected in the plan, because the changes should be made based on assessment of daily progress. Instead, the beginning and end frequencies shall be planned. For example, amount, frequency and duration may be documented as “once daily, 3 times a week tapered to once a week over 6 weeks”. Changes to the frequency may be made based on the clinicians clinical judgment and do not require re-certification of the plan unless requested by the physician/NPP.

Medicare Part B would accept a fluctuation in frequency, whether the visits are front-loaded and then tapered, or would accept a frequency of 3x per week for a set number of weeks with a reduction in frequency to 2x per week when the therapist deems this appropriate. Setting your frequency on the initial evaluation and the plan of care with a range sends the message that you are not sure what’s best for your patient as you are stating that an “either / or” scenario will work. Make a solid frequency plan and if it needs to be changed, change it! Don’t write a frequency to cover all the “what ifs.”

Let’s take a look at Medicare Part A:

2- Medicare Part A: For Medicare Part A, you may have to read between the lines in the Manual for therapy specifics about frequency. However, the basic principles of medical necessity and “reasonable and necessary” are clearly stated and have to be proven by the therapist in order to justify coverage.

Here is a link to Chapter 8 of the Medicare Benefit Policy Manual where all the SNF Part A rules are located. Keep in mind that Chapter 8 speaks to “Skilled Part A Coverage,” which can be accomplished via therapy services and/or nursing services, so Chapter 8 does not have a “therapy section” like Chapter 15 does for Part B.

In order to qualify for skilled Part A coverage for therapy in a SNF, the frequency has to be at least 5 calendar days per week. This is a fact spelled out in the Manual. When you add a range to this frequency, similar to the info in Part 1 above, you raise the question of why? Why 5 vs 6 vs 7 days per week and why might the frequency fluctuate? Why would you need a range? Would it be based on the patient’s needs, or staffing needs, or RUG needs?

You have to be very careful with Part A due to the calculation of RUG scores based on total minutes. If you had a frequency range of 5-6 days per week and were able to achieve your RUG in 5 days so you did not use the 6^th day that week (ie: RU) but the following week you needed the 6^thday to achieve the RUG RU, this would pose a problem of potential “unreasonable and unnecessary” therapy. In the multiple lawsuits that have come to light in the last 2 years, this type of practice of misusing the therapy frequency was cited.

Part A audits have resulted in paying for only the lower end of a set frequency. This may not seem like a big deal…but if you understand the payment structure for Part A, you can only begin to imagine the nightmare of a denial for this reason and the snowball effect if may have.

Consider this scenario:

Your therapy frequency is written 5-6x per week for 4 weeks. Upon audit, CMS deems the 6th visit per week unreasonable and unnecessary and therefore eliminates the minutes for each 6th visit per week. This would then recalculate every RUG score for the period. No big deal? What if the recalculation now indicates that COT’s should have been completed? You can not go back and add missed MDS assessments, so now, not only would you be faced with a RUG score reduction for payment of days, you may also have days represented by a missing assessment, which then become “provider liable” days, meaning, payment for those days = 0. The potential 30 days of Part A coverage at RU can result in 14 days at RV and 16 days at a non-RUG/non-billable score.

Setting your Part A therapy evaluation treatment plan with a solid frequency, and then adjusting that frequency based on clinical need, is the way to go.

Summary:

So, does either the Part A or Part B Manual state specifically that a range CAN’T be used? No. Does the language used and examples given in BOTH Manuals lean heavily toward a solid plan provided in the most efficient manner? Yes. Has Medicare actually denied Part A and Part B claims when a range was used? Yes!

If you are “on the fence” with establishing a frequency and are thinking about a range, consider using the higher of the range only. Then once the therapy plan is in progress, the clinician will have a better idea if the frequency needs to be changed after a week or so. Frequencies can be changed as often as needed with documentation to support the change. This change is part of providing reasonable and necessary therapy in the most efficient manner, and something that can only be determined by the therapist directly involved in the care for that resident.

Make a solid plan. Stick to it. If it needs to be modified, modify it. Then stick to the new plan until modification is needed again. Believe it or not, needing to modify the plan requires assessment and shows your skill as a clinician.

Any questions, submit them to our Just Ask Q&A Forum and one of our experts will help you out!

In Your Corner,

Dolores and the Montero Therapy Team

www.RehabManagerTraining.com

Medicare Part B Therapy Cap – 2018

February 26, 2018 By Montero Therapy Services Leave a Comment

Therapists providing Medicare Part B services have been on the edge of their seat these past few weeks…waiting….waiting to see how the Therapy Cap roller coaster would end.

Today a law was passed that puts an end to the cap madness. But is the ride over?

All therapists and assistants providing Part B services should familiarize themselves with the ramifications of this new law as explained here:

1- We now have a permanent fix to the Medicare Part B Therapy Cap or “hard cap”

Do we still have a Therapy Cap? Yes…of sorts. More like a hoodie…

So what’s different? We now have a permanent exceptions process, or in other terms, we have a legitimate way to exceed the “cap” or $ amount assigned yearly, if deemed necessary. The assigned dollar amount will serve as a “marker” to trigger additional steps that need to be taken in order to receive payment.

This has been a long-time coming…20+ years! The law provides a permanent solution to the “hard cap” and prevents the ups and downs we have had over the years of watching the exceptions process expire and then be resurrected…over.and.over.again. We now have a [permanent] exceptions process in place allowing therapists to continue to exceed the cap {hoodie} limits for those services they deem medically necessary.

So it looks like KX is here to stay. We will still have an amount that is adjusted annually (PT/SLP at $2010 for 2018; OT at $2010 for 2018). Remember, the KX modifier is the therapist attestation that the services provided above the cap are medically necessary.

Medical reviews used to be at the $3,700 threshold and will now be lowered to $3,000 through 2027. Will all services over $3,000 be reviewed by CMS? No way…impossible to do in the limited budget they have. This is why CMS initiated a “targeted review process” last year. Are you a target? You are if you provide services that stand out from your peers both nationally and locally. What are your billing practices? Are you an outlier?

2- Services provided by Assistants will be paid out / reimbursed at a lower rate of 85% beginning in 2022

Thrown into the negotiating mix at the last minute was the provision to reduce payment for services provided to Part B patients when provided by a physical therapist assistant [PTA] or occupational therapy assistant [OTA]. Reimbursement for services provided by assistants would be paid at 85% of the [PFS] Physician Fee Schedule, as opposed to the current 100%.

No one saw this coming. At least not now..like this…with this particular legislation. APTA and AOTA were not involved in this negotiation and will likely fight for a reversal or attempt to negotiate further.

Over the next few weeks we will likely receive additional information from the “fine print.” For example, is the 85% reduction for assistant-provided services in all Part B settings? Is it possible the some settings will be carved out, just like hospital outpatient therapy departments were exempt from the cap? More to come on those issues.

As far as the ruling on reimbursement for assistants…nothing with Medicare is ever final. CMS publishes a “Final Rule” every year! How is that for final?!

Hang in there, we are all in this together!

In your corner,

Dolores and The Montero Therapy Team

www.MonteroTherapyServices.com

Providing education, training and support for SNF therapy professionals

Medicare Part B Therapy Caps, Codes and More: 2018 Changes

November 19, 2017 By Montero Therapy Services 2 Comments

What is changing for Medicare Part B services in the skilled nursing facility setting effective January 1st, 2018?

On Wednesday, November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018.

Just in case you haven’t had a chance to read the 1250 page document yet, we have summarized the changes for you below:

What Will Change on January 1st?

1- Therapy Cap:

The Therapy cap for 2018 will increase from $1980 to $2010 for 2018….but…*

*There may be some light at the end of this 20+ year tunnel….and we are very close to learning the outcome. The Therapy Cap may be gone for good! We are currently in limbo… Read the MLN Matters update here.

In October, lawmakers from the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee announced a bipartisan agreement to end the therapy cap. On November 15th, a press release from the Ways and Means Committee announced a “Medicare Extenders Package,” citing a permanent extension of exceptions process for Medicare with the repeal of the therapy caps. Read the press release here.

So..the Therapy Cap was going to increase to $2010 per year and now may remain at $1980 with a permanent exceptions process [so it won’t really be a hard cap] meaning the KX modifier can and will need to be used above the $1980 threshold [likely for tracking purposes]. Stay tuned…

2- Therapy Exceptions Process:

The current exceptions process expires as of December 31, 2017, unless congressional action extends it or otherwise revises the law. This means that the Cap would be firm and any overage would be the patient’s responsibility…no KX modifiers!

As stated above, legislation is pending for a permanent exceptions process, meaning the KX modifier will still need to be used above the current $1980 threshold. It is possible that this will become a reality for therapists after 20 years of the back and forth legislation!

As a reminder…the KX Modifier on the billing claim indicates services above the cap are reasonable and necessary and that there is documentation of medical necessity for the extended services. By using the KX modifier, the therapist is attesting that the services above the therapy caps are reasonable and necessary and that there is documentation of medical necessity for the services in the beneficiary’s medical record.

{Do you know when your residents are over the cap? Did you know that the billing person applying the KX code is doing so on your behalf, indicating that you attest to the necessity of these services?}

3- Manual Medical Review Process:

The current exceptions process, which includes the Manual Medical Review, expires as of December 31, 2017, unless congressional action extends it or otherwise revises the law. This would put an end to the Manual Medical Review process, though this is not likely going to happen.

The pending legislation discussed above will also impact the Manual Medical Review Process. If passed, as of January 1, 2018, claims above the $3,000 threshold will be targeted for medical review, a decrease from the current $3,700 threshold. This would be in effect for 10 years, through 2027.

However, not all claims exceeding the therapy threshold will be reviewed. In 2017, targeted reviews occurred for therapy providers with a high claims denial rate and/or those with aberrant billing practices as compared to peers. This will continue in 2018 as no changes have been made to this process, and it is impossible to review all claims above $3000.

{Do you know when your resident hits the $3700 mark in a calendar year? Do you know if your billing department is getting denials? Do you think your billing practices (# of units billed per session, days per week, etc. ) match your peers? Or are you an outlier?}

4- New Therapy CPT Codes:

We don’t see CPT code changes every year that pertain to PT, OT and Speech. Last year, PT and OT were graced with the new Evaluation and Re-Evaluation Codes. [How’s that going?]

For 2018, therapy will ~again ~ see a few CPT code changes.

Orthotics / Prosthetics : What’s Different?

For CY 2018, the Current Procedural Terminology (CPT) Editorial Panel revised the set of codes physical and occupational therapists use to report orthotic and prosthetic management and training services by differentiating between initial and subsequent encounters. [Bold words identify new words added to descriptions below]

97760: Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes
97761: Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes
97762: Code has been DELETED for 2018. This code was used for “Checkout for orthotic/prosthetic use, established patient, each 15 minutes”
97763: NEW Code: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes; This “always therapy” code replaces CPT code 97762.

Cognitive Skills Development: What’s Different?

We will see changes to the Cognitive Skills Development code for 2018. There was some flip-flopping with the coding, but the final outcome is this:

97532: The current CPT code used by PT, OT and SLP to report “Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes” will be DELETED

G0515: This NEW code has been added to the therapy code list and is designated as a “sometimes therapy” code [meaning it is not used exclusively by therapists]. This code will REPLACE 97532. The official descriptor for G0515 is: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

Initially, the code 97127 was set to replace 97532; however, the end result for the replacement code was G0515, and 97127 has been made inactive.

In Summary

Change and anticipation of more change is the new normal.

We will be on the edge of our seats to see the final outcome of the Therapy Cap and Exceptions Process. Stay tuned…

In the meantime, we can prepare for the upcoming CPT Code deletions and additions as noted above.

If you need help or have any questions about the above, please visit our Just Ask Q&A Forum – and get your questions answered!

In Your Corner,

Dolores

Coming Soon To A SNF Near You – A New Medicare Part A Payment Model

So What Happened?

Nuts and Bolts of the new PDPM?

What Can Therapists Do To Prepare?

Will SNF Therapy Change When “Minutes Won’t Matter?”

So….

RCS-1 – To Be Or Not To Be ?

What is RCS-1?

What Can Therapists Do To Prepare?

So….

Is a Range in Therapy Frequency Acceptable for Part A or B?

Let’s start with Medicare Part B since the answer is pretty clear-cut.

Let’s take a look at Medicare Part A:

Medicare Part B Therapy Cap – 2018

Medicare Part B Therapy Caps, Codes and More: 2018 Changes

What Will Change on January 1st?

In Summary

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