Home Health & Hospice Week

Heed therapy cap law's new provisions.

Therapy cap exceptions now apply through Dec. 31, thanks to the Middle Class Tax Relief and Job Creation Act of 2011 (H.R. 3630) signed into law in February, but Part B therapy providers should stay on their toes -- the law presents a few new twists.

1) Manual medical review. Therapy caps kick in at $1,880, but effective Oct. 1, 2012, any therapy claims above $3,700 will be subject to a manual medical review process. (Reminder: For home care providers, the therapy caps apply only to outpatient therapy furnished under Part B, not to therapy included in a home care plan of care.)

The American Occupational Therapy Association, American Physical Therapy Asso-ciation, and American Speech-Language Hearing Association are arranging meetings with the Cen-ters for Medicare & Medicaid Services to discuss what the review process will entail.

"One of the reasons why $3,700 was picked is because 95 percent of claims never reached that level," explains AOTA's Tim Nanof. Remember: "All therapy claims are still subject to medical review," Nanof tells Eli. "Standards for coverage or medical necessity do not change at $3,700."

"We are also requesting, along with APTA and AOTA, that the manual medical review be performed by like professionals; for example, reviews for speech pathology services should be performed by an SLP," reports ASHA's Lisa Satterfield.

2) Cracking down on details. The new law mandates that the KX modifier is a must. "Previous-ly, when a therapist or an agency would forget a KX modifier, they were still getting paid," Nanof says. "We're expecting that CMS will have some sort of automatic edits to deny those claims, so it's very important that therapists use the KX modifier on all claims over $1,880."

In addition, starting Oct. 1, 2012, all therapy claims -- regardless of whether they are above or below the caps -- must include the referring physician's National Provider Identifier.

3) Premonitions of payment reform. The new legislation requires CMS to begin collecting data from therapy claims, starting Jan. 1, 2013. The Medicare Payment Advisory Commission has already been looking closely at rehab, according to APTA's Gayle Lee.

In a March 9 meeting, MedPAC went public with some stats that scrutinize growing therapy usage under the caps, according to Satterfield, the first being that physical therapy covers 73 percent of the spending under therapy caps. Secondly, Med-PAC revealed an eightfold increase in speech claims between 2009 and 2010. "In 2010, SLPs were able to bill independently for the first time, so we take that into consideration, but we did not expect an 8x increase, and we're investigating that," Satterfield says.

"We'll continue to push to get rid of the cap and replace it with an alternative payment methodology," Lee assures. "We've also been working on our own approach that involves developing per session codes that correct for procedure codes."

4) Hospital participation. For the first time in therapy cap history, hospital outpatient department settings will have to participate -- but not until this October through December of 2012.

"Initially there was some discussion about permanently applying the therapy cap to the hospital outpatient setting as a way to pay for a longer extension of the exceptions process," Nanof says. "We opposed that because the hospital outpatient setting has been a safety net for beneficiaries."

Critical access hospitals tend to have very high-cost patients, Lee reports. "So we're also seeking clarification from CMS on their participation."

Note: For more information about Part B therapy reimbursement and regulations, subscribe to Eli's Rehab Report at www.elihealthcare.com.