Re: Therapy Cap for Hospital Based OP

May 7, 2012

A transmittal

(http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmit\

tals-Items/R2457CP.html)

was released to MACs two weeks ago. Presumably instructions to providers will

follow before too long.

The caps pertain to Medicare allowable charges, not hospital charges. And as

you probably know, the implementation starts on October 1, but the limits apply

to all charges incurred since January 1. Beyond that, stay tuned.

bob perlson

Director, Rehabilitation Services

Rogue Valley Medical Center

Medford, OR

>

> Being in a hospital based OP therapy department, we have not paid

> attention to the OP Therapy Cap. Now that it is going to apply to the

> hospital based departments, is there a simple breakdown of OP therapy

> Cap process? It would be helpful to know:

>

> 1. Does the benefit amount refer to billed charges?

>

> 2. What is KX modifier?

>

> 3. Process used by private clinics to ensure compliance with this

> provision?

>

> I appreciate any information.

>

> Thanks.

>

> -----------------------------------------

>

May 7, 2012

Is it correct to say that MC beneficiaries now have $1880 of PT/ST per yr non

hospital AND $1880 of PT/ST per yr in a hospital (outpt) setting?

Witt, PT

Certified Golf Fitness Instructor

Titleist Performance Institute

Segal & Witt Physical Therapy

5162 Linton Boulevard, Suite 105

Delray Beach, FL 33484

C

O

F

wittpt@...

American Physical Therapy Association

Vestibular Disorders Association

A transmittal

(http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmit\

tals-Items/R2457CP.html)

was released to MACs two weeks ago. Presumably instructions to providers will

follow before too long.

The caps pertain to Medicare allowable charges, not hospital charges. And as you

probably know, the implementation starts on October 1, but the limits apply to

all charges incurred since January 1. Beyond that, stay tuned.

bob perlson

Director, Rehabilitation Services

Rogue Valley Medical Center

Medford, OR

>

> Being in a hospital based OP therapy department, we have not paid

> attention to the OP Therapy Cap. Now that it is going to apply to the

> hospital based departments, is there a simple breakdown of OP therapy

> Cap process? It would be helpful to know:

>

> 1. Does the benefit amount refer to billed charges?

>

> 2. What is KX modifier?

>

> 3. Process used by private clinics to ensure compliance with this

> provision?

>

> I appreciate any information.

>

> Thanks.

>

> -----------------------------------------

>

May 7, 2012

No, it is $1880.00 for the entire calendar year.

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

http://www.gawendaseminars.com

> Is it correct to say that MC beneficiaries now have $1880 of PT/ST per yr non

hospital AND $1880 of PT/ST per yr in a hospital (outpt) setting?

>

> Witt, PT

> Certified Golf Fitness Instructor

> Titleist Performance Institute

> Segal & Witt Physical Therapy

> 5162 Linton Boulevard, Suite 105

> Delray Beach, FL 33484

> C

> O

> F

> wittpt@...

> American Physical Therapy Association

> Vestibular Disorders Association

>

> A transmittal

(http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmit\

tals-Items/R2457CP.html)

> was released to MACs two weeks ago. Presumably instructions to providers will

follow before too long.

>

> The caps pertain to Medicare allowable charges, not hospital charges. And as

you probably know, the implementation starts on October 1, but the limits apply

to all charges incurred since January 1. Beyond that, stay tuned.

>

> bob perlson

> Director, Rehabilitation Services

> Rogue Valley Medical Center

> Medford, OR

>

> >

> > Being in a hospital based OP therapy department, we have not paid

> > attention to the OP Therapy Cap. Now that it is going to apply to the

> > hospital based departments, is there a simple breakdown of OP therapy

> > Cap process? It would be helpful to know:

> >

> > 1. Does the benefit amount refer to billed charges?

> >

> > 2. What is KX modifier?

> >

> > 3. Process used by private clinics to ensure compliance with this

> > provision?

> >

> > I appreciate any information.

> >

> > Thanks.

> >

> > -----------------------------------------

> >

May 7, 2012

Hi ,

To the best of my knowledge, that is incorrect. A Medicare beneficiary has an

$1880/year PT/ST cap, period. The difference is that as of Oct 1, 2012,

hospital-based outpatient practices are no longer exempt from the cap. As of

Oct 1, 2012 any outpatient part therapy done from Jan 1, 2012 to Oct 1, 2012, no

matter where it was done will apply towards the cap, even if it was being done

in the exempt outpatient center all along. That is my understanding of it and

why it is causing a concern. But also remember that you can use the KX

modifier, technically up to $3699, then the manual medical review will kick in.

I suspect what hospital-based departments may do is append the KX modifier for

most patients that have had prior therapy and have reached the cap but are below

$3700. If on October 1 a patient goes to the hospital outpatient department and

has greater than $3699 in prior therapy, the department MUST request a manual

medical review first. Unfortunately we still do not know how the manual medical

review will operate. Bottom line, hospital outpatient departments must do a lot

of education between now and October so their staff is ready and they must make

sure that their billing departments and/or front office know how to check to see

if the patient has any prior therapy and how much. Plus all staff must be clear

on when and how to use the correct ABN form.

This is an ingenious plan to ration therapy services and reduce costs. We must

accept that the cost of providing outpatient PT through Medicare has continued

to climb at a very high rate. Nothing has stopped that growth except severe

austerity measures which is what this October is about.

Unfortunately those that will be hurt the most are those that need it the most

â€“ the severely involved long term rehab patients needed PT,OT, ST. The only

hope is that the manual medical review will recognize the need and keep

authorizing PT for these folks.

The trick will be for clinics to use the KX modifier enough to keep seeing

patients but not so much that they trigger an audit.

And just when you get the hang of it, remember that the exceptions process

expires December 31, 2012 and with a lame-duck Congress â€“ we may lose that KX

exceptions process again. I hope everyone is ready to mount a lobbying campaign

â€“ we will need it big time!

I encourage all PTâ€™s to review the alternative payment system for outpatient

PT that the APTA is proposing and releasing to the rank and file soon. The

faster we get this system to its most useable form, the faster we can try to

make the caps go away with a system that will mean less regulation, less rules

and more indication of our value as PTâ€™s and PTAâ€™s.

M.Howell, P.T., M.P.T.

IPTA Payment Specialist

Meridian, Idaho

thowell@...

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reply email.

From: PTManager [mailto:PTManager ] On Behalf Of

Witt

Sent: Monday, May 07, 2012 12:02 PM

To: PTManager

Subject: Re: Re: Therapy Cap for Hospital Based OP

Is it correct to say that MC beneficiaries now have $1880 of PT/ST per yr non

hospital AND $1880 of PT/ST per yr in a hospital (outpt) setting?

Witt, PT

Certified Golf Fitness Instructor

Titleist Performance Institute

Segal & Witt Physical Therapy

5162 Linton Boulevard, Suite 105

Delray Beach, FL 33484

C

O

F

wittpt@... <mailto:wittpt%40att.net>

American Physical Therapy Association

Vestibular Disorders Association

On May 7, 2012, at 11:48 AM, " R " <bperlson@...

<mailto:bperlson%40asante.org> > wrote:

A transmittal

(http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmit\

tals-Items/R2457CP.html)

was released to MACs two weeks ago. Presumably instructions to providers will

follow before too long.

The caps pertain to Medicare allowable charges, not hospital charges. And as you

probably know, the implementation starts on October 1, but the limits apply to

all charges incurred since January 1. Beyond that, stay tuned.

bob perlson

Director, Rehabilitation Services

Rogue Valley Medical Center

Medford, OR

>

> Being in a hospital based OP therapy department, we have not paid

> attention to the OP Therapy Cap. Now that it is going to apply to the

> hospital based departments, is there a simple breakdown of OP therapy

> Cap process? It would be helpful to know:

>

> 1. Does the benefit amount refer to billed charges?

>

> 2. What is KX modifier?

>

> 3. Process used by private clinics to ensure compliance with this

> provision?

>

> I appreciate any information.

>

> Thanks.

>

> -----------------------------------------

>

May 8, 2012

Just and FYI for some rural providers,

CAH facilities, (Critical Access) continue to be exempt from the cap on hospital

based outpatient services. This was clarified in a more recent transmittal from

CMS.

Dan , PT

PT Manager

Vernon Memorial Hospital

Viroqua, WI 54665

dnelson@...

From: PTManager [mailto:PTManager ] On Behalf Of

M. Howell PT, MPT

Sent: Monday, May 07, 2012 10:20 PM

To: PTManager

Subject: RE: Re: Therapy Cap for Hospital Based OP

Hi ,

To the best of my knowledge, that is incorrect. A Medicare beneficiary has an

$1880/year PT/ST cap, period. The difference is that as of Oct 1, 2012,

hospital-based outpatient practices are no longer exempt from the cap. As of Oct

1, 2012 any outpatient part therapy done from Jan 1, 2012 to Oct 1, 2012, no

matter where it was done will apply towards the cap, even if it was being done

in the exempt outpatient center all along. That is my understanding of it and

why it is causing a concern. But also remember that you can use the KX modifier,

technically up to $3699, then the manual medical review will kick in.