2012 Outpatient Therapy Cap

Gayle Lee, J.D.APTA Senior Director, Health Finance and Quality

Roshunda Drummond-Dye, J.D.APTA Director, Regulatory Affairs

2012 Therapy Cap

• Congress passed legislation (The Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630) on February 17 making changes to the therapy cap exceptions process & other provisions.

• For 2012, the therapy cap amount is $1880 for PT and SLP combined and a separate $1880 cap for OT.

• Medicare Advantage plans do not have to implement a therapy cap.

• Annual per beneficiary cap (does not reset per diagnosis).

2

2012 Therapy Cap: Dollars Accrued

• Therapy cap is based on the allowed charges.

• Medicare will pay 80% of the allowed charges ($1504.00) and the beneficiary will be responsible for the remaining 20% ($376.00).

• MPPR reduction is included in the amount of the allowed charges.

2012 Therapy Cap: Dollars Accrued

• Providers may access the accrued amount of therapy services from the ELGA screen inquiries into CWF. Providers/suppliers may access the remaining therapy services limitation dollar amount through the 270/271 eligibility inquiry and response transaction. Providers who bill to FIs will find the amount a beneficiary has accrued toward the financial limitations on the HIQA.

• Check with your Medicare Administrative Contractor (MAC) regarding the best way to get this information.

• Beginning October 1, 2012 providers will know the exact dollar amount accrued toward the therapy cap.

2012 Therapy Cap: Hospitals

• The therapy cap has applied in the past to all outpatient therapy settings except hospitals.

• Starting October 1, 2012 the therapy cap with an exceptions process will also apply to hospital outpatient settings (critical access hospitals are exempt).

• Hospitals would no longer be subject to the therapy cap after December 31, 2012 unless Congress extends the provision in future legislation.

5

2012 Therapy Cap: Hospitals

• Therapy services provided in hospitals will be counted toward the dollar amount accrued in the common working file starting October 1, 2012. – Providers should check the status of dollars

accrued for each patient currently being treated on October 1, 2012.

Therapy Cap: Exceptions Process

• Providers may request an exception for therapy services in excess of the cap any time during CY 2012.

• For 2012 there will be two exceptions process: automatic exception and manual medical review.

• The exceptions process expires December 31, 2012. Congress will need to pass legislation to extend it.

7

Therapy Evaluations

• Therapy evaluations after the therapy caps are reached to determine if the patient needs therapy services would be exempt from the cap.  (97001 PT evaluation and 97002 PT reevaluation). 

Therapy Cap: Exceptions

• January 1-October 1, 2012: an automatic exception to the therapy cap may be made when documentation supports the medical necessity of the services beyond the cap. Providers should use the KX modifier.

• October 1, 2012-December 31, 2012: an automatic exception may be made for claims between $1880-$3700 (use KX modifier).

• October 1, 2012-December 31, 2012: Claims exceeding $3700 in expenditure will be subject to manual medical review to be paid.

9

Therapy Cap: Manual Medical Review

• Starting October 1 for claims exceeding $3700.• All therapy services beginning January 1, 2012

count toward the therapy cap amount in calculating the $3700.

• CMS issued guidance on manual medical review in a fact and question and answer document. MACs will issue further guidance soon.

10

Therapy Cap: Manual Medical Review

• For outpatient therapy services that exceed $3700 there will be an advanced approval process that will be implemented in three distinct phases.

• Providers will be assigned to one of three phases for manual medical review and will receive notification from CMS by letter and contractor websites regarding which phase they are included in.

Therapy Cap: Manual Medical Review

• Phase I providers: Subject to manual medical review from October 1‐December 31, 2012.

• Phase II providers: Subject to manual medical review from November 1‐December 31, 2012.

• Phase III providers: Subject to manual medical review from December 1‐December 31, 2012.

• List of NPIs and phases to which they are assigned is available at:

https://data.cms.gov/dataset/Therapy-Provider-Phase-Information/ucun-6i4t

Therapy Cap: Manual Medical Review

• If a provider’s NPI is not included on the list, that provider is in phase III.

• Therapists working in the same practice could be assigned to different phases.

Therapy Cap: Manual Medical Review

• MACs will issue guidance by September 9 regarding forms to submit and information from documentation to send for advanced approval.

• Criteria for medical review will be based on current medical review standards. Guidance and additional training will be provided by CMS for providers and Medicare Administrative Contractors in the coming weeks.

Manual Medical Review

• The request shall contain the following information: • Beneficiary Last Name: • Beneficiary First Name: • Beneficiary Middle Initial: • Beneficiary Medicare Claim Number (HICN): • Beneficiary Date of Birth: • Beneficiary Address and Telephone Number: • Name of Provider Certifying Plan of Care:• Address of Provider Certifying Plan of Care:

Manual Medical Review• Telephone &Fax Number of Provider Certifying Plan of

Care: • Provider Number of Physician/NPP Certifying Plan of

Care: • Name of Performing Provider: • Address of Performing Provider: • Performing Provider Number: • Telephone and Fax Number of Performing Provider: • Number of treatment days requested: • Expected date range of services: • Date of Submission

Manual Medical Review• A cover/transmittal sheet containing the following information

and documentation: • Cover sheet; • Justification; • Evaluation and/or reevaluation(s) for Plan(s) of Care; • Certification(s) of the plan(s) of care, where available; • Objectives and measurable goals and any other documentation

requirements of the LCD; • Progress reports; • Treatment notes; • Any orders, if applicable, for the additional therapy services

requested; and • Any additional information requested by the contractor.

Therapy Cap: Manual Medical Review

• Medicare Administrative Contractors (MAC) will have 10 business days to make decisions regarding whether services will be approved over the $3700 amount. If a provider request is not reviewed by MAC within 10 business days, claims beyond the $3700 threshold will be approved.

• Advanced approval will allow an additional 20 treatment days beyond the $3700 amount.

• Provider will use modifier on claim form to indicate advance approval given.

• Advanced approval does not guarantee payment. Retrospective review may still be performed.

Therapy Cap: Manual Medical Review

• If a provider does not request advanced approval prior to providing services over $3700, payment for the claims will stop and a request for medical records will be sent to the provider.

• The provider will be subject to prepayment review for those claims and the time frame for review will be approximately 60 days.

Therapy Cap: Manual Medical Review

• A transcript of a special open door forum held by CMS on the manual medical review process is available at the link below:

(http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/Downloads/080712TherapyClaimsSODFAnnouncementTranscriptAudio.pdf)

A fact sheet and Question and Answer document from CMS and APTA FAQ are available at the link below: http://www.apta.org/Payment/Medicare/CodingBilling/

• Questions may be emailed to: therapycapreview@cms.hhs.gov.

•  

Contact Information for MACs• Cahaba (AL, GA, TN)• First Coast (FL, PR, VI)• CGS Administrators (KY, OH)• NGS (CT, NY, UN, QN)• NHIC (ME, MA, NH, RI, VT)• Noridian (AZ, MT, ND, UT, WY, SD, ID, AK, WA, OR)• Novitas (AR, LA, DE, DC, MD, NJ, PA, Arlington & Fairfax,

VA)• Palmetto (NF, AS, GU, HI, CNMI, NV, SF, VA, NC, SC, WV,

CA)• Trailblazer (CO, NM, OK, TX)• Wisconsin Physicians Service (IA, KS, MO, EM, NE, MI, IN)

Contact information for your MAC

List of MACs– http://www.cms.gov/medicare-coverage-database/ind

exes/contacts-part-b-medicare-administrative-contractor-index.aspx?bc=AgAAAAAAAAAA&

Local Coverage Determinations – http://www.cms.gov/medicare-coverage-database/sea

rch/advanced-search.aspx– http://www.cms.gov/medicare-coverage-database/ind

exes/contacts-contractor-websites-index.aspx?bc=AgAAAAAgAAAA& (websites)

Resource Info: For Medical Review

• Medicare Benefit Policy Manual– http://www.cms.gov/Regulations-and-Guidance/Guida

nce/Manuals/downloads/bp102c15.pdf

• Medicare Claims Processing Manual, chapter 5– http://www.cms.gov/Regulations-and-Guidance/Guida

nce/Manuals/downloads/clm104c05.pdf

• APTA – http://www.apta.org/Payment/

• Centers for Medicare and Medicaid Services– www.cms.hhs.gov

Resource Info: For Medical Review

Transmittal 2537CR 7881 (August 31, 2012)http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2537CP.html

Transmittal 1117CR 8036http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R1117OTN.html

Therapy Cap: Example

• Patient A receives therapy services at a SNF (Part B) from January 15, 2012-April 20, 2012 and accrues $3800.00 toward the therapy cap. Patient A is discharged from the SNF and later goes to an outpatient hospital department for therapy on October 15, 2012. The hospital would need to request manual medical review to get coverage for these services because the patient has already exceeded the $3700 threshold.

25

Therapy Cap: Example

• Patient A receives therapy services from an outpatient hospital from February 15-May 15, 2012 and accrues $3800 in therapy services.

• Patient A goes to a private practice for services on September 20 until November 15. Private practice submits the claim on September 20 for payment and the common working file reflects $0 toward the cap.

• On October 1, the $3800 from the hospital therapy would be added to the common working file; for dates of service provided to patient A after October 1 the provider would need to seek advanced approval (if a phase I provider).

Therapy Cap Example

• Patient A received $4000 of services from a hospital stay from January 15—May 15, 2012. From July 22, 2012 –August 25, 2012 patient A received services from a private practice. The private practice would not need to submit the KX modifier or submit a request for advanced approval as Patient A was discharged prior to October 1, 2012.

Therapy Cap Example• “A beneficiary was in a skilled nursing facility (SNF) and exhausted

their SNF benefit days under Part A. The beneficiary continued to receive therapy services under Part B totaling $3,600 (all dates of service before 10/1/2012). The beneficiary was then discharged from the SNF and received therapy services from an independently practicing PT totaling $1,800. The independent PT billed in November 2012 for services provided after 10/1/2012. The MAC received the claims and processed them. After these claims were processed the MAC received the SNF Part B claims totaling $3,600 and processed them. Had these claims been received in advance of the independent PT services the independent PT would have been required to have the services approved in advance. In circumstances such as the example above the contractor is not required to perform post payment review on the $1,800 provided by the independent therapist. “

Notification to Beneficiaries

• Beneficiaries who have received $1700 or more of therapy services in 2012 receive letters in September 2012 providing them information about their potential financial liability for services over the therapy cap amount.

• APTA provided a document for beneficiaries to provide info on cap. http://www.moveforwardpt.com/Resources/Advocacy.aspx

Therapy Cap: Collecting Out of Pocket

• If a patient does not qualify for an exception, the provider can collect out of pocket payment from the beneficiary.

• It is advisable to give the beneficiary an Advanced Beneficiary Notice (ABN) if Collecting Out of Pocket. Revised ABN form (Form-R-131) available on the CMS website at: https://www.cms.gov/BNI/02_ABN.asp

30

Therapy Cap: Collecting Out of Pocket

• Provider can determine the amount of payment to collect from the patient; it does not have to be the fee schedule amount.

• Providers should avoid deep discounts or providing services for free as that could violate antikickback statutes.

Therapy Cap: Collecting Out of Pocket

• If provider would like a denial from Medicare in order to bill a secondary insurer after the therapy cap amount is exceeded, the provider could submit claim with a modifier:

• GX Modifier:• Notice of Liability Issued, Voluntary Under Payer Policy.• Report this modifier only to indicate that a voluntary ABN was

issued for services that are not covered.• Medicare will automatically reject claims that have the –GX

modifier applied to any covered charges.

• GY modifier:• Notice of Liability Not Issued, Not Required Under Payer Policy. 

This modifier is used to obtain a denial on a non covered service.  Use this modifier to notify Medicare that you know this service is excluded.

NPI reporting

• NPI - Starting October 1, 2012, each request for payment (i.e. claim form) must include the NPI of the physician who has reviewed the plan of care.

• For the purposes of processing professional claims, the certifying physician/NPP is considered a referring provider.

• Follow instructions in the appropriate ASC X12 837 Professional Health Care Claim Technical Report 3 (TR3) for reporting a referring provider.

• For paper claims, follow the instructions for identifying referring providers per Chapter 26 of this IOM).

NPI reporting

• For the purposes of processing institutional claims, the certifying physician/NPP and their NPI are reported in the Attending Provider fields on institutional claim formats.

• Cases where a patient is receiving care under more than one therapy plan of care (OT, PT, or SLP) with different certifying physicians/NPPs, the second certifying physicians/NPP and their NPI are reported in the Referring Physician fields on institutional claim formats.

NPI

• List of Medicare physician NPIs is available at the following link:– http://www.cms.gov/Medicare/Provider-

Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html

Therapy Cap Resources• CR 6660

http://www.cms.hhs.gov/transmittals/downloads/R1860CP.pdf• CR 5871, Pub. 100-04, Transmittal 1414• CMS Pub 100-02, chapter 15, section 220.2

– http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf • CMS Pub.100-04, chapter 5, section 10.2

– http://www.cms.hhs.gov/manuals/downloads/clm104c05.pdf • APTA website

– apta.org (go to the therapy cap resource center)

36

Therapy Cap Resources• CMS website

– http://www.cms.hhs.gov/TherapyServices/– Transmittal 2537CR 7881 (August 31, 2012) http://www.cms.gov/Regulations-and-Guidance/Guidance/

Transmittals/2012-Transmittals-Items/R2537CP.html -Transmittal 1117CR 8036http://www.cms.gov/Regulations-and-Guidance/Guidance/

Transmittals/2012-Transmittals-Items/R1117OTN.html

Therapy Cap: Legislation

• The Government Accountability Office (GAO) is required to issue a report to Congress no later than May 1, 2013 on the implementation of the manual medical review process.

• The report shall include data on the number of individuals and claims subject to the process, the number of reviews conducted and outcomes of those reviews.

• APTA will be setting up complaint form on our website to report problems with the manual medical review process.

38

Reporting Functional Information on Claim Form

• By 2013 CMS will implement a claims based data collection strategy designed to collect data on the claim form about patient function.

• Proposal included in 2013 physician fee schedule rule.

39

Reporting Functional Information on Claim Form

• Comment deadline: September 4.• APTA submitted extensive comments• Involves reporting of G codes regarding

functional limitation accompanied by a severity modifier.

• CMS proposes the use of tools and translation of the scores from those tools to determine the level of impairment and severity modifier reported.

• Final rule will be published November 1, 2012.

Functional Limitation Reporting

Functional Limitation Reporting

MedPAC report

• MedPAC must submit a report on how to improve the outpatient therapy benefit to Congress by June 15, 2013.

• MedPAC discussed outpatient therapy at March 2012 meeting & September 7 meeting.

Therapy Cap Studies

• Several Studies contracted by CMS to identify alternatives to the therapy cap.

• CMS contracted with RTI to perform 5 year study to collect and analyze date to find a long-term solution to the therapy cap.

• This involves development and testing of an assessment instrument to be used in all outpatient therapy settings to gather more information on the patient.

• After data is gathered, recommendations will be made for alternative payment policies.

• http://optherapy.rti.org/

44

Therapy Cap Studies

• CMS contracted with Computer Sciences Corporation (CSC) to develop short term alternatives to the therapy cap.

• Alternatives may include suggestions for systems changes/edits or code changes (e.g. to services, episode length, or treatment types).

• Modifications to guidance in Manuals• Modifications to the therapy cap exceptions process.• Suggestions would be implemented within 2-3 years.• 3 options were discussed in the proposed and final 2011

physician fee schedule rule.

45

QUESTIONS