Medicare Compliance & Reimbursement

 The answer could mean the world to many facilities

With the July 1 implementation date for therapy caps looming, all eyes will be on Capitol Hill this month. Best-case scenario: Congress will nix the caps, ending rounds of moratoriums and implementation delays.

"It may happen," says Peter Clendenin, executive vice president for the National Association for the Support of Long-Term Care (NASL) in Alexandria, VA, referring to legislation in both the House and the Senate that would kill the caps called for originally in the Balanced Budget Act of 1997.

Without a legislative fix, the caps will put an annual $1,590 limit on occupational therapy and a $1,590 limit on speech language pathology and physical therapy combined.

"Effectively, beyond the cap, the services would no longer be a benefit of Medicare," explains Mark Kander, director of health care regulatory analysis for the Speech-Language-Hearing Association in Rockville, MD.

Drawing on anecdotal reports from an unspecified long-term care chain, NASL estimates that as many as one in four residents will likely exceed the caps.

Though NASL and other stakeholders are hoping Congress comes through with a fix, they're not counting on relief. NASL has hinted it would pursue a temporary restraining order to keep the Centers for Medicare & Medicaid Services from implementing the caps.

Providers are also scrambling to grasp just how to cope with the caps if they do become reality. A CMS program memorandum released May 2 (AB-03-057) outlines one way some Part-B residents would be able to access therapy services beyond the cap (the limitation do not apply to SNF residents in a covered Part-A stay).

The memo notes that since Medicare's consolidated billing policies do not apply to residents who are not in a Medicare-certified bed, those residents will be able to obtain therapy in a hospital outpatient department beyond the capped amount, the American Association of Nurse Assessment Coordinators points out.

Clendenin dismisses the fix. "These [patients] are the sickest of the sick, if you will, and they will need significant amounts of therapy to get back to a restored state where they're functioning again," he says. "Asking them to go to an outpatient hospital setting to get additional therapy, if they're lucky enough to be in a non-certified bed, is just not practical."

In a May 23 program memo (AB-03-073), CMS notes that "for SNF residents in non-Medicare certified portions of the facility and SNF nonresidents who go to the SNF for outpatient treatment (bill type 23x), medically necessary outpatient therapy may be covered at an outpatient hospital facility after the financial limitation has been exceeded." The memo also notes "limitations do not apply to SNF residents in a covered Part-A stay, including swing beds."

For updates on related legislation (S569 and HR1125), go to www.nasl.org/advocacy.htm.