Home Health & Hospice Week

Background: Many HHAs offer Part B outpatient therapy in the home after patients are no longer homebound. For a new tip sheet on how to bill for such services from HHH Medicare Administrative Contractor CGS, go online to www.cgsmedicare.com/hhh/education/materials/Home_Health_Outpatient_Therapy_Billing.html.

One threat, which has been ongoing, is the Part B therapy cap (which doesn't apply to home health episodes, but does apply to outpatient Part B therapy furnished by HHAs). In April, lawmakers introduced legislation to repeal the cap, says Tim Nanof, federal affairs manager for the American Occupational Therapy Association. While the prospect for repeal is "extremely unlikely," Nanof says, the industry uses the repeal bill "as a rally cry  -- a beacon to draw support on the issue of the therapy  cap and try to get Congress to take action, which it has many, many times since the cap was implemented" by the Balanced Budget Act in 1997.

"Currently, under the exceptions process, which is in effect for the remainder of this year, people can get therapy at levels beyond the cap to meet their needs," Nanof tells Eli. And "we are still optimistic that we will get the [therapy cap] exception process" renewed.

But the chances of getting the cap eliminated altogether, which comes with a price tag, are low. When scoring the change, the Congressional Budget Office doesn't "look at the longer-term consequences of what happens when therapy is not provided," he says.

Upside: "The cap has only been implemented for a few weeks at a time" since it was passed, Nanof points out. And he notes that Congress views the cap "not just as a service provider issue but also a beneficiary issue [in that] it eliminates services rather than just reducing payment for them."

The American Speech-Hearing-Language Association continues to work with other organizations to educate Congress regarding "the need to do something more long term about the Part B cap," says Ingrid Lusis, director of federal and policy advocacy for the trade group. ASHA is also working with Congress to ensure "the exceptions process for the cap remains in place," she adds.

Under the Sustainable Growth Rate (SGR) system, "we are all scheduled to take a 29.5 percent cut, which will require legislative action to remedy," says Chuck Willmarth, director of state affairs and reimbursement and regulatory policy for AOTA.

"There was some discussion that the SGR might have been part of the debt ceiling deal," adds Lusis, "but it wasn't. Even so, we anticipate legislation at the end of the year to fix the SGR again."

Also a problem: "Last year the physician fee schedule rule applied the MPPR [Multiple Procedure Payment Reduction] to the practice expense component of therapy services provided on the same day," says Willmarth.

Quick review: CMS applies "a MPPR to the practice expense payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures," states an MLN Matters article. "Full payment is made for the unit or procedure with the highest PE payment. For subsequent units and procedures, furnished to the same patient on the same day, full payment is made for work and malpractice and 80 percent payment for the PE for services furnished in office settings and other non-institutional settings and at 75 percent payment for the PE services furnished in institutional settings." (The article is at www.cms.gov/MLNMattersArticles/downloads/MM7050.pdf.)

The proposed physician fee schedule rule this year, says Willmarth, "leaves the MPPR for therapy unchanged, but [AOTA] will be commenting again on why CMS should apply the MPPR separately."

"The expenses you incur to practice are completely different," he says. ASHA views the MPPR as a "flawed policy," says Lusis. It has less of an effect on SLP services than it does on OT and PT, however, because "our codes are procedure versus time based. PT and OT codes are based on 15-minute increments." But "the policy does affect SLP when two procedures are done on the same day -- or when PT, OT, and speech are provided on the same day," she adds.

Not just Medicare: "We are seeing some private insurance companies apply MPPR-style cuts to therapy that cut the payments in general rather than just the practice expense portion of the Medicare valuation," Nanof says.