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Audio Conference Scheduled for May 4, 2010
Gawenda Seminars will be providing a 1.5 hour audio conference focused on documentation for initial evaluations and re-evaluations. For further information and to register for this important audio conference, please click on the link below.
Documentation to Support Skilled PT, OT, & Speech Therapy Services, Part 1
Senate Passes HR 4691
The Senate passed HR 4691 on March 2, 2010 by a vote of 78-19. This bill extends the Medicare therapy cap exception process until March 31, 2010 and stops the scheduled 21.2% decrease in the Medicare conversion factor that is used to calculate payment for the CPT codes under the Medicare Physician Fee Schedule. Congress now has the rest of the month to work on a longer term solution for both of these important issues .
Changes to the Medicare Appeals Process
CMS released the final rule for changes in the Medicare appeals process on December 9, 2009 in the Federal Register. To access the final rule, click on the link below.
2010 Outpatient Therapy Update
As of January 1, 2010, there is no longer a therapy cap exception process. In the Senate and House versions of healthcare reform, both have addressed extending the therapy cap process either for 1 or 2 years. The House and Senate must merge the 2 bills into one bill, pass it in the House and Senate, and then have it signed by President Obama. Stay tuned for more information as it becomes available. The 21.9% reduction in the Medicare Physician Fee Schedule conversion factor has been put on hold through February 28, 2010. Providers will continue to be reimbursed at the 2009 rates. Congress must act prior to March 1, 2010 or else the 21.9% reduction will go into effect.
CMS Releases Final Rule for Services Reimbursed under the MPFS
The Centers for Medicare and Medicaid Services released the final rule for services reimbursed under the Medicare Physician Fee Schedule on October 30, 2009. The therapy cap dollar amount for 2010 will be $1,860 for occupational therapy and $1,860 for physical therapy and speech-language pathology services combined. Please click on the link below or copy and paste the link in your web browser. The therapy cap information begins on page 1021.
In addition, CMS also discusses Canalith Repositioning (CPT code 95992) and has decided to make that code not valid for Medicare purposes. Therapists who perform Canalith Repositioning (Epply and Semont manuvuer) are instructed to bill for that time under neuromuscular re-educatio This discussion begins on page 154.
The Final Rule will be published in the Federal Register on November 25, 2009
CMS Releases SNF Part A 2010 Final Rule
CMS released the skilled nursing facility (SNF) fiscal year final rule in the Federal Register on August 11, 2009. To view the final rule, click on the link below.
CMS Releases IRF FY 2010 Final Rule
CMS released the Inpatient Rehabilitation Facility (IRF) fiscal year 2010 final rule in the Federal Register on August 7, 2009. There are many changes that become effective October 1, 2009 or January 1, 2010. To view the final rule, click on the link below.
CMS Issues Updated Appeals Process Information
CMS released Transmittal 1762 on July 2, 2009 updating changes to the Medicare claims appeals procedures. To view the transmittal, click on the link below.
CMS Seeking Comments on Proposed IRF Revisions
CMS released the FY 2010 proposed Inpatient Rehabilitaiton Facility (IRF) proposed rule on May 6, 2009 in the Federal Register. Comments will be accepted by CMS until June 29, 2009. In addition, CMS has proposed revisions to Section 110 of the Medicare Benefit Policy Manual (MBPM) pertaining to IRF coverage guidelines. CMS will be accepting comments until June 30, 2009.
Proposed Revisions to Section 110 of the MBPM
CMS to Reimburse for Canalith Repositioning
CMS released Transmittal 1691 on March 4, 2009. In this transmittal, CMS states that CPT code 95992 describing canalith repositioning procedures and that this code would be bundled for payment under the Medicare Physician Fee Schedule. Since physical and occupational therapists also perform this procedure and therapists can't bill the evaluation and management codes, they should continue to bill CPT code 97112 for this procedure. This transmittal is effective January 1, 2009. To read the transmittal, click on the link below and begin reading on page 2.
CMS Selects Final Five Medicare Contractors
The Centers for Medicare and Medicaid Services announced the final five contractors that will process and pay Medicare claims for Part A and Part B services in 14 states on January 7, 2009.
Noridian Administrative Services, LLC (NAS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 6 comprised of Illinois, Minnesota and Wisconsin. The MAC will complete the transfer of the claims and information from FIs and carriers and be fully operational no later than January 2010.
National Government Services (NGS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 8 comprised of Indiana and Michigan. The MAC will complete the transfer of the claims and information from FIs and carriers and be fully operational no later than November 2009.
Cahaba Government Benefit Administrators, LLC (Cahaba GBA) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 10 comprised of Alabama, Georgia and Tennessee. The MAC will complete the transfer of the claims and information from FIs and carriers and be fully operational no later than May 2009.
Palmetto Government Benefits Administrators, LLC (Palmetto GBA) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 11 comprised of North Carolina, South Carolina, Virginia and West Virginia. Jurisdiction 11 excludes the Counties of Arlington and Fairfax in Virginia along with the City of Alexandria in Virginia. Services for these areas of Virginia will be covered under A/B MAC Jurisdiction 12 which was awarded to Highmark Medicare Services. The MAC will complete the transfer of the claims and information from FIs and carriers and be fully operational no later than March 2010.
Highmark Medicare Services (HMS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 15 comprised of Kentucky and Ohio. The MAC will complete the transfer of the claims and information from FIs and carriers and be fully operational no later than March 2010.
More information will be posted to this site when transition dates are announced. For more information on Medicare Contracting Reform, click on the link below.
To view the January CMS Press release, click on the link below.
CMS Selects Final Five Medicare Contractors
To view Q&A's for each Jurisdiction, click on the link below.
A/B MAC Procurement and Implementation
CMS Releases 2009 Medicare Physician Fee Schedule Final Rule
The Centers for Medicare and Medicaid Services released the 2009 final rule for services reimbursed under the Medicare Physician Fee Schedule in the Federal Register on November 19, 2008. If you practice in a CORF setting, pages 64-69, 203, 207, and 217 will be of interest to you. If you practice in an outpatient rehabilitation facility (Rehab Agency), pages 64, 68, 69, 96, and 217 will be of interest to you. On page 69, CMS notes that the plan of care must be reviewed by the physician or the individual who establishes the plan of care at least every 30 days and by meeting this condition of participation, rehabilitation agencies would automatically meet the CMS payment policy requiring review at least every 90 days.
In 2008, the conversion factor was $38.0870 and in 2009 will be $36.0666. This may cause a decrease in reimbursement of some CPT codes in 2009 compared to 2008. There is one new CPT code for PT and OT and that is 95992 - Canalith repositioning procedure(s) (eg. Epley manuever, Semont maneuver), per day. CMS, at this time, is considering this code bundled and will not be separately reimbursed. For further information on the final rule, please click on the link below.
Protest of RAC Awards and Automatic Stay
The Centers for Medicare and Medicaid Services is required to impose an automatic stay in the contract work of the four Recovery Audit Contractors program as a result of protests filed by two unsuccessful bidders. The Government Accountability Office has 100 calendar days from November 4, 2008 to issue it decision. This means a decision is due in early February 2009. Until that time, all RAC contracts and any work under those contracts are on hold.
CMS Announces RAC Medical Record Request Limits
On October 29, 2008, the Centers for Medicare and Medicaid Services announced medical record request limits for the Recovery Audit Contractors. To view the limits and see examples, please click on the link below.
RAC Medical Record Request Limits
CMS Awards Four RAC Contracts & Announces Contingency Fees
On October 6, 2008, the Centers for Medicare and Medicaid Services (CMS) announced the names of the four new national Recovery Audit Contractors (RACs). They are Diversified Collection Services, Inc., CGIÂ Technologies and Solutions, Inc., Connolly Consulting Associates, Inc., and HealthDataInsights, Inc.
On October 10, 2008, CMS announced the contingency fee (i.e. payment) each RAC will receive for the correction of both overpayments and underpayments. Diversified Collection Services, Inc. will receive 12.45%, CGIÂ Technologies and Solutions, Inc. will receive 12.50%, Connolly Consulting Associates, Inc. will receive 9.00%, and HealthDataInsights, Inc. will receive 9.49%.
RAC Contingency Fee Percentages
Congress Overrides Presidential Veto
The United States Senate voted 70-26 and the United States House of Representatives voted 383-41 to override President Bush's veto of HR 6331 - the Medicare Improvements for Patients and Providers Act. This legislation will stop the 10.6% reduction in payment for services reimbursed under the Medicare Physician Fee Schedule and the expiration of therapy cap exception process. HR 6331 becomes law immediately. For further information, visit the APTA website.
CMS Releases Transmittal 88
The Centers for Medicare & Medicaid Services released Transmittal 88 on May 7, 2008. This transmittal includes many important changes and clarifications to outpatient therapy services provided by physical therapists, occupational therapists, and speech-language pathologists. One important item is the official change of the certification time period from 30 calendar days to the duration established in the plan of care and certified by the physician/NPP or 90 calendar days, whichever occurs first. The implementation date of the transmittal is June 9, 2008 with an effective date of January 1, 2008. To view the transmittal, click on the link below.
CMS RELEASES UPDATE ON OUTPATIENT THERAPY CAPS EXCEPTION PROCESS
The Centers for Medicare & Medicaid Services (CMS) issued Transmittal 1414 on January 17, 2008 adjusting the dollar amount for the therapy cap for 2008 along with clarifications to the manual concerning exceptions to outpatient therapy services. This transmittal replaces Transmittal 1407 that was released on January 10, 2008
CMS RELEASES DRAFT FINAL VERSION OF MDS 3.0
The Centers for Medicare & Medicaid Services released the draft final version of MDS 3.0 on January 15, 2008 along with the draft final MDS 3.0 introduction. To view the draft final version as well as additional information on MDS 3.0, please click on the link below.
CONGRESS PASSES THE MEDICARE, MEDICAID AND SCHIP EXTENSION ACT OF 2007
Congress has approved legislation postponing the Medicare therapy cap and scheduled cuts to the physician fee schedule. Lawmakers on Wednesday sent to the president legislation extending the therapy cap exceptions process and implementing a 0.5% positive update in the fee-schedule conversion factor until June 30, 2008. President Bush is expected to sign this legislation into law.
In addition, this legislation permanently freezes the inpatient rehabilitation services compliance threshold at 60%, effective for cost reporting periods starting July 1, 2006, and allows comorbid conditions to count toward this threshold. Sets the market basket update factor at 0% from April 1, 2008 through FY09. Requires the Secretary to study beneficiary access to inpatient rehabilitation services and care at IRFs and to make recommendations for classifying inpatient rehabilitation facility hospitals and units.
CMS Releases 2008 Medicare Physicain Fee Schedule Final Rule
The Centers for Medicare & Medicaid Services (CMS) releaed the final rule for services reimbursed under the Medicare Physician Fee Schedule on November 1, 2007 and it was published in the Federal Register on November 27, 2007. Highlights for therapy include changing the outpatient recertification requirement from once every 30 days to once every 90 days in all settings, including CORF's. This becomes effective January 1, 2008. In addition, CMS will provide manual clarification in mid-2008 regarding the implementation of applicable outpatient policies to the inpatient hospital setting. CMS will also implement the qualification standards of who can provide and be reimbursed for skilled therapy services from the outpatient setting to all settings. The standards will be phased in over a 2 year period. Pages of interest include 73-83 regarding CORF issues, 108-113 regarding qualification standards, students, and recertifications, and a summary from pages 177-188. To view the final rule, please click on the link below.
National Government Services Releases IRF LCD
National Government Services (NGS), Medicare Contractor for the states of IN, IL, KY, ME, MA, NH, VT, CT, DE, NY, OH, WI, MI, VA, WV, AS, CA, CNMI, GU, HI, and NV, has released the IRF LCD on October 1, 2007 for the Notice Period with an effective date of the LCD of December 1, 2007. In addition, NGS released the comments they received regarding the LCD and their response. For more information, please click on the appropriate link below.
NGS IRF LCD Comments & Responses
CMS Releases Fiscal Year 2008 IRF Final Rule
The Centers for Medicare & Medicaid Services released the fiscal year 2008 IRF final rule in the Federal Register on August 7, 2007. The effective date is October 1, 2007. There are no changes to the 75% rule in terms of diagnoses that count towards the 75% rule and co-morbidities will no longer count towards the 75% rule beginning with cost reporting periods on and after July 1, 2008. To read the entire final rule, click on the link below.
IRF Fiscal Year 2008 Final Rule
CMS Releases Transmittal Regarding Charging for Missed Appointments
The Centers for Medicare & Medicaid Services released Transmittal 1279 on June 29, 2007 clarifying that they do not prohibit physicians, suppliers, and hospitals for charging Medicare patient's for missed appointments as long as they do not discriminate against Medicare beneficiaries and also charge non-Medicare patient's for missed appointments. Effective date is October 1, 2007.
CMS Releases Transmittal Clarifying Therapy Evaluations in SNF Setting
The Centers for Medicare & Medicaid Services released Transmittal 73 on JUne 29, 2007 clarifying that a PT, OT, and/or SLP evaluaiton must be performed during the beneficiary's stay in the SNF setting. It is not acceptable to use an evaluation that was performed, for instance, in the acute care hosiptal or IRF setting because the beneficiary's status must be evaluated in the SNF setting. To view the transmittal, click on the link below.
Therapy Evaluations in SNF Setting
CMS rescinds Transmittal 65
The Centers for Medicare & Medicaid Services has rescinded Transmittal 65 concerning the application of the outpatient documentation requirements to the inpatient setting and defining who are qualified professionals to provide and bill for therapy services. Please click on the link below to see that Transmittal 65 has been rescinded. Future information will be posted when it becomes available.
CMS Issues Infrared Decision Memo
CMS released Transmittal 1127 and Transmittal 62 on December 15, 2006 providing further information on Infrared devices that supplements the national coverage decision that went into effect on October 24, 2006. Transmittal 1127 was rescinded and replaced by Transmittal 1183 on February 9, 2007. This new Transmittal provides ICD-9 codes that do not support the medical necessity of infrared devices. The transmittal may be accessed by clicking on the below links.
The CMS issued a decision memo regarding infrared devices on October 24, 2006. CMS has determined that there is sufficient evidence to conclude that the use of infrared devices is not reasonable and necessary for treatment of Medicare beneficiaries for diabetic and non-diabetic peripheral sensory neuropathy, wounds and ulcers, and similar related conditions, including symptoms such as pain arising from these conditions. Therefore, we are issuing the following National Coverage Determination.
The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE), is not covered for the treatment, including symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of skin and/or subcutaneous tissues in Medicare beneficiaries.
To read the entire CMS decision memo, click on the link below.
CMS issues UB-04 Claim Form Instructions
The Centers for Medicare & Medicaid Services issued Transmittal 1018 on July 28, 2006 that contains instructions for the completion of the UB-04 claim form. This transmittal was rescinded and replaced with Transmittal 1104 that was released on November 3, 2006. The UB-04 claim form will be used by all providers of therapy services who are not a private practice and will replace the UB-92 claim form that is currently being used by institutional providers. The UB-04 can be used by providers beginning on March 1, 2007, but will not be mandated for use until May 23, 2007. To learn more about the UB-04 claim form, click on the link below.
Instructions for the Completion of the UB-04 Claim Form
CMS issues Revised 1500 Claim Form Instructions
The Centers for Medicare & Medicaid Services issued Transmittal 1058 on September 15, 2006 that contained revised instructions for the completion of the new 1500 claim form that can begin to be used on January 1, 2007, but will not be mandated for use until April 2, 2007. Transmittal 1058 replaces previous transmittals that contained information and instructions regarding the new Form CMS-1500 (08/05)
CMS Releases Information On Therapy Cap Exception Process
The Centers for Medicare & Medicaid Services released 3 transmittals on February 13, 2006 outlining the therapy cap exception process. The first transmittal contains information that will be included in the Medicare Benefit Policy Manual, Chapter 15. The second transmittal contains information that will be included in the Medicare Program Integrity Manual, Chapter 3. The third transmittal contains information that will be included in the Medicare Claims Processing Manual, Chapter 5. The exception process must be implemented no later than March 13, 2006. To access the transmittals, please click on the links below:
Transmittal 47: Medicare Benefit Policy Manual
Transmittal 140: Medicare Program Integrity Manual
Transmittal 855: Medicare Claims Processing Manual
Therapy Cap Exception Process Fact Sheet
CCI Edits To Apply To Rehab Agencies, SNF Part B, CORF's, and HHA's
Effective January 1, 2006, the Medicare CCI edits will be applied to Rehab Agencies, Skilled Nursing Facilities (SNF) providing outpatient therapy under Medicare Part B, Comprehensive Outpatient Rehabilitation Facilities (CORF), and Home Health Agencies (HHA) providing home health services not under a home health plan of treatment. Currently, the CCI edits are only being applied to rehabilitation therapy services provided by physical and occupational therapists in private practice, physician owned physical and occupational therapy practices, and in hospital outpatient departments. This is not applicable to Critical Access Hospitals. For further information on this very important topic, please click on the Medlearn Matter link below.
