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Re: Therapy Cap for Hospital Based OP

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Guest guest

Posted
Posted

It certainly looks that way , and if the CAP is not repealed all together , the

exceptions clause will most likely go away as well, making $1880 a firm CAP.

Last month I went to Capital Hill along with over 250 PT's, PTA's and to once

again lobby for CAP repeal. If you have never taken the time to get involved in

the lobbying efforts of our profession, the time is now.

This election, and the health care bills pending in Congress will impact our

professional future and our collective voice need to be heard.

Ron Barbato PT

Administrative Director, Rehabilitation Services

Program Director, Cancer Support Services

Ephraim McDowell Health

Voice:

Fax:

rbarbato@...

PRIVILEGED AND CONFIDENTIAL: This transmission may contain information that is

privileged subject to attorney-client privilege or attorney work product,

confidential and/or exempt from disclosure under applicable law. If you are not

the intended recipient, then please do not read it and be aware that any

disclosure, copying, distribution, or use of the information contained herein

(including any reliance thereon) is STRICTLY PROHIBITED. If you received this

transmission in error, please immediately advise me, by reply e-mail, and delete

this message and any attachments without retaining a copy in any form. Thank

you.

Re: Therapy Cap for Hospital Based OP

Hi Tom,

Remember we had the Manual Review in 2006?

Back then it was a paper submission and an optional " Justification Statement "

if, for some reason, you thought your notes weren't perfectly clear in their

rationale and support for services exceeding the (then) $1,670 Medicare cap on

outpatient PT/OT services.

Any reason why it should be different this time?

Tim , PT

www.PhysicalTherapyDiagnosis.com<http://www.PhysicalTherapyDiagnosis.com>

> >

> > 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.

> >

> >

> >

> >

> >

> >

> >

> >

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

> >

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Guest guest

Guest guest

Posted
Posted

It certainly looks that way , and if the CAP is not repealed all together , the

exceptions clause will most likely go away as well, making $1880 a firm CAP.

Last month I went to Capital Hill along with over 250 PT's, PTA's and to once

again lobby for CAP repeal. If you have never taken the time to get involved in

the lobbying efforts of our profession, the time is now.

This election, and the health care bills pending in Congress will impact our

professional future and our collective voice need to be heard.

Ron Barbato PT

Administrative Director, Rehabilitation Services

Program Director, Cancer Support Services

Ephraim McDowell Health

Voice:

Fax:

rbarbato@...

PRIVILEGED AND CONFIDENTIAL: This transmission may contain information that is

privileged subject to attorney-client privilege or attorney work product,

confidential and/or exempt from disclosure under applicable law. If you are not

the intended recipient, then please do not read it and be aware that any

disclosure, copying, distribution, or use of the information contained herein

(including any reliance thereon) is STRICTLY PROHIBITED. If you received this

transmission in error, please immediately advise me, by reply e-mail, and delete

this message and any attachments without retaining a copy in any form. Thank

you.

Re: Therapy Cap for Hospital Based OP

Hi Tom,

Remember we had the Manual Review in 2006?

Back then it was a paper submission and an optional " Justification Statement "

if, for some reason, you thought your notes weren't perfectly clear in their

rationale and support for services exceeding the (then) $1,670 Medicare cap on

outpatient PT/OT services.

Any reason why it should be different this time?

Tim , PT

www.PhysicalTherapyDiagnosis.com<http://www.PhysicalTherapyDiagnosis.com>

> >

> > 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.

> >

> >

> >

> >

> >

> >

> >

> >

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

> >

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Guest guest

Guest guest

Posted
Posted

Hi ,

As it reads now the cap for hospital-based OP clinics is just from Oct 1,

2012 - December 31, 2012 and will expire as will the exceptions process.

Without action by Congress, the therapy cap would revert back to one of

the original cap formats where there would be the inflation-adjusted cap,

no exceptions process and hospital-based clinics would be exempt from the

cap. Will make for interesting lobbying. The prevailing opinion, however,

from the APTA is that Congress will act to continue the cap for

hospital-based clinics beyond December 31, 2012. I am sure that the

advice would be for hospital-based clinics to plan for it to be extended

as well.

M Howell, PT, MPT

IPTA Payment Specialist

Meridian, ID

thowell@...>

Since the “lame duck†congress must act before December 31st to

> repeal the caps, does anyone know if OP hospitals go back to being

> exempt from the caps if legislation doesn’t go through? Or will

> everyone be stuck with the $1880/year amount?

> Granato

> Hospital

> Naperville, IL

>

> From: PTManager [mailto:PTManager ] On

> Behalf Of M. Howell PT, MPT

Sent: Wednesday, May 09, 2012 5:51

> PM

> To: PTManager

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

>

>

>

> The reason for concern is that there has to be a report from the GAO to

> Congress by May 1, 2013 on the manual medical review process this time

> which may change the process so that data can be more easily collected

> for that report. Other than that no one really knows yet what or how the

> process will work. I am sure they will look at the metrics from 2006 and

> the process and use that as a starting point but a lot I would speculate

> depend on if that process worked and saved money. If it didn’t I

> don’t think it will be back since now they have to show that the

> manual medical review is saving money, which is what the GAO reports are

> usually focused on.

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

>

> IPTA Payment Specialist

>

> Meridian, Idaho

>

> <mailto:thowell@...<mailto:thowell%40fiberpipe.net>>

> thowell@...<mailto:thowell%40fiberpipe.net>

> This email and any files transmitted with it may contain PRIVILEGED or

> CONFIDENTIAL information and may be read or used only by the intended

> recipient. If you are not the intended recipient of the email or any of

> its attachments, please be advised that you have received this email in

> error and that any use, dissemination, distribution, forwarding,

> printing or copying of this email or any attached files is strictly

> prohibited. If you have received this email in error, please immediately

> purge it and all attachments and notify the sender by reply email.

> From: PTManager <mailto:PTManager%40yahoogroups.com>

> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>]

> On Behalf Of Tim

Sent: Wednesday, May 09, 2012 3:37 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

> Subject: Re: Therapy Cap for Hospital Based OP

>

> Hi Tom,

>

> Remember we had the Manual Review in 2006?

>

> Back then it was a paper submission and an optional " Justification

> Statement " if, for some reason, you thought your notes weren't perfectly

> clear in their rationale and support for services exceeding the (then)

> $1,670 Medicare cap on outpatient PT/OT services.

> Any reason why it should be different this time?

>

> Tim , PT

> www.PhysicalTherapyDiagnosis.com<http://www.PhysicalTherapyDiagnosis.com>

>

>

>> >

>> > 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.

>> >

>> >

>> >

>> >

>> >

>> >

>> >

>> >

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

>> >

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Share on other sites
Guest guest

Guest guest

Posted
Posted

Hi ,

As it reads now the cap for hospital-based OP clinics is just from Oct 1,

2012 - December 31, 2012 and will expire as will the exceptions process.

Without action by Congress, the therapy cap would revert back to one of

the original cap formats where there would be the inflation-adjusted cap,

no exceptions process and hospital-based clinics would be exempt from the

cap. Will make for interesting lobbying. The prevailing opinion, however,

from the APTA is that Congress will act to continue the cap for

hospital-based clinics beyond December 31, 2012. I am sure that the

advice would be for hospital-based clinics to plan for it to be extended

as well.

M Howell, PT, MPT

IPTA Payment Specialist

Meridian, ID

thowell@...>

Since the “lame duck†congress must act before December 31st to

> repeal the caps, does anyone know if OP hospitals go back to being

> exempt from the caps if legislation doesn’t go through? Or will

> everyone be stuck with the $1880/year amount?

> Granato

> Hospital

> Naperville, IL

>

> From: PTManager [mailto:PTManager ] On

> Behalf Of M. Howell PT, MPT

Sent: Wednesday, May 09, 2012 5:51

> PM

> To: PTManager

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

>

>

>

> The reason for concern is that there has to be a report from the GAO to

> Congress by May 1, 2013 on the manual medical review process this time

> which may change the process so that data can be more easily collected

> for that report. Other than that no one really knows yet what or how the

> process will work. I am sure they will look at the metrics from 2006 and

> the process and use that as a starting point but a lot I would speculate

> depend on if that process worked and saved money. If it didn’t I

> don’t think it will be back since now they have to show that the

> manual medical review is saving money, which is what the GAO reports are

> usually focused on.

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

>

> IPTA Payment Specialist

>

> Meridian, Idaho

>

> <mailto:thowell@...<mailto:thowell%40fiberpipe.net>>

> thowell@...<mailto:thowell%40fiberpipe.net>

> This email and any files transmitted with it may contain PRIVILEGED or

> CONFIDENTIAL information and may be read or used only by the intended

> recipient. If you are not the intended recipient of the email or any of

> its attachments, please be advised that you have received this email in

> error and that any use, dissemination, distribution, forwarding,

> printing or copying of this email or any attached files is strictly

> prohibited. If you have received this email in error, please immediately

> purge it and all attachments and notify the sender by reply email.

> From: PTManager <mailto:PTManager%40yahoogroups.com>

> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>]

> On Behalf Of Tim

Sent: Wednesday, May 09, 2012 3:37 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

> Subject: Re: Therapy Cap for Hospital Based OP

>

> Hi Tom,

>

> Remember we had the Manual Review in 2006?

>

> Back then it was a paper submission and an optional " Justification

> Statement " if, for some reason, you thought your notes weren't perfectly

> clear in their rationale and support for services exceeding the (then)

> $1,670 Medicare cap on outpatient PT/OT services.

> Any reason why it should be different this time?

>

> Tim , PT

> www.PhysicalTherapyDiagnosis.com<http://www.PhysicalTherapyDiagnosis.com>

>

>

>> >

>> > 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.

>> >

>> >

>> >

>> >

>> >

>> >

>> >

>> >

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

>> >

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Guest guest

Guest guest

Posted
Posted

If no further legislation is passed, hospitals would be exempt from the therapy

cap beginning January 1, 2013.

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

http://www.gawendaseminars.com

> Since the “lame duck†congress must act before December 31st to repeal the

caps, does anyone know if OP hospitals go back to being exempt from the caps if

legislation doesn’t go through? Or will everyone be stuck with the $1880/year

amount?

>

> Granato

> Hospital

> Naperville, IL

>

> From: PTManager [mailto:PTManager ] On Behalf

Of M. Howell PT, MPT

> Sent: Wednesday, May 09, 2012 5:51 PM

> To: PTManager

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

>

>

>

> The reason for concern is that there has to be a report from the GAO to

Congress by May 1, 2013 on the manual medical review process this time which may

change the process so that data can be more easily collected for that report.

Other than that no one really knows yet what or how the process will work. I am

sure they will look at the metrics from 2006 and the process and use that as a

starting point but a lot I would speculate depend on if that process worked and

saved money. If it didn’t I don’t think it will be back since now they have

to show that the manual medical review is saving money, which is what the GAO

reports are usually focused on.

>

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

>

> IPTA Payment Specialist

>

> Meridian, Idaho

>

> <mailto:thowell@...<mailto:thowell%40fiberpipe.net>>

thowell@...<mailto:thowell%40fiberpipe.net>

>

> This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended recipient.

If you are not the intended recipient of the email or any of its attachments,

please be advised that you have received this email in error and that any use,

dissemination, distribution, forwarding, printing or copying of this email or

any attached files is strictly prohibited. If you have received this email in

error, please immediately purge it and all attachments and notify the sender by

reply email.

>

> From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf

Of Tim

> Sent: Wednesday, May 09, 2012 3:37 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

> Subject: Re: Therapy Cap for Hospital Based OP

>

> Hi Tom,

>

> Remember we had the Manual Review in 2006?

>

> Back then it was a paper submission and an optional " Justification Statement "

if, for some reason, you thought your notes weren't perfectly clear in their

rationale and support for services exceeding the (then) $1,670 Medicare cap on

outpatient PT/OT services.

>

> Any reason why it should be different this time?

>

> Tim , PT

> www.PhysicalTherapyDiagnosis.com<http://www.PhysicalTherapyDiagnosis.com>

>

>

> > >

> > > 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.

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

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

> > >

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Guest guest

Guest guest

Posted
Posted

If no further legislation is passed, hospitals would be exempt from the therapy

cap beginning January 1, 2013.

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

http://www.gawendaseminars.com

> Since the “lame duck†congress must act before December 31st to repeal the

caps, does anyone know if OP hospitals go back to being exempt from the caps if

legislation doesn’t go through? Or will everyone be stuck with the $1880/year

amount?

>

> Granato

> Hospital

> Naperville, IL

>

> From: PTManager [mailto:PTManager ] On Behalf

Of M. Howell PT, MPT

> Sent: Wednesday, May 09, 2012 5:51 PM

> To: PTManager

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

>

>

>

> The reason for concern is that there has to be a report from the GAO to

Congress by May 1, 2013 on the manual medical review process this time which may

change the process so that data can be more easily collected for that report.

Other than that no one really knows yet what or how the process will work. I am

sure they will look at the metrics from 2006 and the process and use that as a

starting point but a lot I would speculate depend on if that process worked and

saved money. If it didn’t I don’t think it will be back since now they have

to show that the manual medical review is saving money, which is what the GAO

reports are usually focused on.

>

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

>

> IPTA Payment Specialist

>

> Meridian, Idaho

>

> <mailto:thowell@...<mailto:thowell%40fiberpipe.net>>

thowell@...<mailto:thowell%40fiberpipe.net>

>

> This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended recipient.

If you are not the intended recipient of the email or any of its attachments,

please be advised that you have received this email in error and that any use,

dissemination, distribution, forwarding, printing or copying of this email or

any attached files is strictly prohibited. If you have received this email in

error, please immediately purge it and all attachments and notify the sender by

reply email.

>

> From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf

Of Tim

> Sent: Wednesday, May 09, 2012 3:37 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

> Subject: Re: Therapy Cap for Hospital Based OP

>

> Hi Tom,

>

> Remember we had the Manual Review in 2006?

>

> Back then it was a paper submission and an optional " Justification Statement "

if, for some reason, you thought your notes weren't perfectly clear in their

rationale and support for services exceeding the (then) $1,670 Medicare cap on

outpatient PT/OT services.

>

> Any reason why it should be different this time?

>

> Tim , PT

> www.PhysicalTherapyDiagnosis.com<http://www.PhysicalTherapyDiagnosis.com>

>

>

> > >

> > > 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.

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

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

> > >

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Guest guest

Guest guest

Posted
Posted

We are a hospital based OP program. One question that staff asked us is what

the $1800.00 is based on. The billed amount or the actual reimbursement by

Medicare.

Thanks,

Nano , PT

Physical Therapy Supervisor

Regional Rehabilitation Institute

Rapid City, S.D.

njohnson@...

(f)

From: PTManager [mailto:PTManager ] On Behalf Of

ez, Joyce

Sent: Wednesday, May 09, 2012 8:42 AM

To: PTManager

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

Thanks for the summary Tom!

We strictly follow Medicare guidelines and have successfully passed

Medicare/JCAHO audits in the past. Every single one of our Medicare and

non-Medicare patient's plan of care (initial eval and re-cert) is signed

by the referring MDs certifying the need for or continuation of skilled

PT,OT or ST services. Our therapists do a great job with documentation,

they write substantial daily SOAP notes, detailed assessment of

objective measurements and goal attainment every 6 visits plus a

progress report written once every 10 treatment days or at least once

every 30 calendar days, whichever is less.

Since we're already doing all that, the only thing added to the process

is using a KX modifier and undergoing a " manual medical review " . I will

contact our MAC to get more details and I'm sure Rick Gawenda will have

a webinar about this as well.

Thanks again and have a great day!

Joyce

Joyce ez, PT

Outpatient Rehab Manager

Provena Saint ph Hospital

Phone: ext. 5177

Email: Joyce.ez@...<mailto:Joyce.ez%40provena.org>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>\

>

Important Notice:

This message and any attachments are confidential and maybe protected by

legal privilege. If you are not the inted recipient, be aware that any

disclosures, copying, distribution, or use of this message or any

attachment is prohibited. If you recieved this in error, please notify

us immediately by returning it to sender and deleting the copy from your

system. Thank you.

________________________________

From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On

Behalf Of M. Howell PT, MPT

Sent: Tuesday, May 08, 2012 6:21 PM

To: PTManager <mailto:PTManager%40yahoogroups.com>

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

Hi Joyce,

I would highly recommend that you look up the information on it on the

CMS

site or at the APTA site for full details on the current regulations.

A short summary is that any Part B Medicare outpatient beneficiary

reaching

the combined PT/ST cap of $1880 has a couple of choices. One is that

they,

in discussion with their PT, can end therapy when the cap is reached.

Second, is that if the PT has determined and documented the medical

necessity to continue and it is approved in the plan of care signed by

the

provider (mostly the referring physician) that PT should continue care.

The

billing of claims once the cap is reached must be submitted with a -KX

modifier to indicate that the therapy is continuing under the

" Exceptions "

process. The continued therapy MUST be justified as reasonable and

necessary in the notes with objective data to support that continued

therapy

is medically necessary. This process continues as long as care is needed

BUT now there is a new added regulation that these claims that continue

under the KX modifier now MUST undergo a " manual medical review " once

the

claim reaches $3700. That " manual medical review " is brand new and no

proposed regulations for it have been released yet so no-one knows how

it

will work.

Basically, this is a process by which you can continue therapy past the

cap

as long as you can justify it based on how Medicare wants it justified

and

as long as the plan of care to continue is approved. The new wrinkle is

that manual medical review.

For the details of how the KX modifier gets on claims and where it goes,

you

need to consult the source. A good place to start is the MAC( Medicare

Administrative Contractor) for your region. Most have online training

courses just for this and I am sure they will have plenty more in

preparation for October.

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

IPTA Payment Specialist

Meridian, Idaho

<mailto:thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net> >

thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended

recipient. If you are not the intended recipient of the email or any of

its

attachments, please be advised that you have received this email in

error

and that any use, dissemination, distribution, forwarding, printing or

copying of this email or any attached files is strictly prohibited. If

you

have received this email in error, please immediately purge it and all

attachments and notify the sender by reply email.

From: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ]

On Behalf

Of ez, Joyce

Sent: Tuesday, May 08, 2012 3:19 PM

To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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

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

to the therapy cap until now. Can somebody please explain what a KX

modifier is?

Joyce ez, PT

Outpatient Rehab Manager

Provena Saint ph Hospital

Phone: ext. 5177

Email: Joyce.ez@...<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org> >

Important Notice:

This message and any attachments are confidential and maybe protected by

legal privilege. If you are not the inted recipient, be aware that any

disclosures, copying, distribution, or use of this message or any

attachment is prohibited. If you recieved this in error, please notify

us immediately by returning it to sender and deleting the copy from your

system. Thank you.

________________________________

From: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ] On

Behalf Of M. Howell PT, MPT

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

To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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.

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 - 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 - we may

lose that KX exceptions process again. I hope everyone is ready to mount

a lobbying campaign - we will need it big time!

I encourage all PT'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 PT's and

PTA's.

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

IPTA Payment Specialist

Meridian, Idaho

<mailto:thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net> >

thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

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recipient. If you are not the intended recipient of the email or any of

its attachments, please be advised that you have received this email in

error and that any use, dissemination, distribution, forwarding,

printing or copying of this email or any attached files is strictly

prohibited. If you have received this email in error, please immediately

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From: PTManager <mailto:PTManager%40yahoogroups.com>

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<mailto:PTManager%40yahoogroups.com>

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On Behalf Of Witt

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

To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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> <mailto:wittpt%40att.net>

<mailto:wittpt%40att.net>

<mailto:wittpt%40att.net>

<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>

<mailto:bperlson%40asante.org>

<mailto:bperlson%40asante.org>

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

A transmittal

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

Transmittals-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.

>

>

>

>

>

>

>

>

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

>

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Posted
Posted

We are a hospital based OP program. One question that staff asked us is what

the $1800.00 is based on. The billed amount or the actual reimbursement by

Medicare.

Thanks,

Nano , PT

Physical Therapy Supervisor

Regional Rehabilitation Institute

Rapid City, S.D.

njohnson@...

(f)

From: PTManager [mailto:PTManager ] On Behalf Of

ez, Joyce

Sent: Wednesday, May 09, 2012 8:42 AM

To: PTManager

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

Thanks for the summary Tom!

We strictly follow Medicare guidelines and have successfully passed

Medicare/JCAHO audits in the past. Every single one of our Medicare and

non-Medicare patient's plan of care (initial eval and re-cert) is signed

by the referring MDs certifying the need for or continuation of skilled

PT,OT or ST services. Our therapists do a great job with documentation,

they write substantial daily SOAP notes, detailed assessment of

objective measurements and goal attainment every 6 visits plus a

progress report written once every 10 treatment days or at least once

every 30 calendar days, whichever is less.

Since we're already doing all that, the only thing added to the process

is using a KX modifier and undergoing a " manual medical review " . I will

contact our MAC to get more details and I'm sure Rick Gawenda will have

a webinar about this as well.

Thanks again and have a great day!

Joyce

Joyce ez, PT

Outpatient Rehab Manager

Provena Saint ph Hospital

Phone: ext. 5177

Email: Joyce.ez@...<mailto:Joyce.ez%40provena.org>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>\

>

Important Notice:

This message and any attachments are confidential and maybe protected by

legal privilege. If you are not the inted recipient, be aware that any

disclosures, copying, distribution, or use of this message or any

attachment is prohibited. If you recieved this in error, please notify

us immediately by returning it to sender and deleting the copy from your

system. Thank you.

________________________________

From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On

Behalf Of M. Howell PT, MPT

Sent: Tuesday, May 08, 2012 6:21 PM

To: PTManager <mailto:PTManager%40yahoogroups.com>

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

Hi Joyce,

I would highly recommend that you look up the information on it on the

CMS

site or at the APTA site for full details on the current regulations.

A short summary is that any Part B Medicare outpatient beneficiary

reaching

the combined PT/ST cap of $1880 has a couple of choices. One is that

they,

in discussion with their PT, can end therapy when the cap is reached.

Second, is that if the PT has determined and documented the medical

necessity to continue and it is approved in the plan of care signed by

the

provider (mostly the referring physician) that PT should continue care.

The

billing of claims once the cap is reached must be submitted with a -KX

modifier to indicate that the therapy is continuing under the

" Exceptions "

process. The continued therapy MUST be justified as reasonable and

necessary in the notes with objective data to support that continued

therapy

is medically necessary. This process continues as long as care is needed

BUT now there is a new added regulation that these claims that continue

under the KX modifier now MUST undergo a " manual medical review " once

the

claim reaches $3700. That " manual medical review " is brand new and no

proposed regulations for it have been released yet so no-one knows how

it

will work.

Basically, this is a process by which you can continue therapy past the

cap

as long as you can justify it based on how Medicare wants it justified

and

as long as the plan of care to continue is approved. The new wrinkle is

that manual medical review.

For the details of how the KX modifier gets on claims and where it goes,

you

need to consult the source. A good place to start is the MAC( Medicare

Administrative Contractor) for your region. Most have online training

courses just for this and I am sure they will have plenty more in

preparation for October.

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

IPTA Payment Specialist

Meridian, Idaho

<mailto:thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net> >

thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended

recipient. If you are not the intended recipient of the email or any of

its

attachments, please be advised that you have received this email in

error

and that any use, dissemination, distribution, forwarding, printing or

copying of this email or any attached files is strictly prohibited. If

you

have received this email in error, please immediately purge it and all

attachments and notify the sender by reply email.

From: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ]

On Behalf

Of ez, Joyce

Sent: Tuesday, May 08, 2012 3:19 PM

To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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

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

to the therapy cap until now. Can somebody please explain what a KX

modifier is?

Joyce ez, PT

Outpatient Rehab Manager

Provena Saint ph Hospital

Phone: ext. 5177

Email: Joyce.ez@...<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org> >

Important Notice:

This message and any attachments are confidential and maybe protected by

legal privilege. If you are not the inted recipient, be aware that any

disclosures, copying, distribution, or use of this message or any

attachment is prohibited. If you recieved this in error, please notify

us immediately by returning it to sender and deleting the copy from your

system. Thank you.

________________________________

From: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ] On

Behalf Of M. Howell PT, MPT

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

To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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.

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 - 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 - we may

lose that KX exceptions process again. I hope everyone is ready to mount

a lobbying campaign - we will need it big time!

I encourage all PT'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 PT's and

PTA's.

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

IPTA Payment Specialist

Meridian, Idaho

<mailto:thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net> >

thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended

recipient. If you are not the intended recipient of the email or any of

its attachments, please be advised that you have received this email in

error and that any use, dissemination, distribution, forwarding,

printing or copying of this email or any attached files is strictly

prohibited. If you have received this email in error, please immediately

purge it and all attachments and notify the sender by reply email.

From: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>

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<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ]

On Behalf Of Witt

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

To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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> <mailto:wittpt%40att.net>

<mailto:wittpt%40att.net>

<mailto:wittpt%40att.net>

<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>

<mailto:bperlson%40asante.org>

<mailto:bperlson%40asante.org>

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

A transmittal

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

Transmittals-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.

>

>

>

>

>

>

>

>

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

>

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Share on other sites
Guest guest

Guest guest

Posted
Posted

Tom makes a good point, nothing is certain, that is the reason behind my post.

Hospital based or not, we all need to get involved as one voice to support

legislation that will be favorable to the entire profession, not tied to work

type or location

Ron Barbato PT

Administrative Director, Rehabilitation Services

Program Director, Cancer Support Services

Ephraim McDowell Health

Voice:

rbarbato@...

PRIVILEGED AND CONFIDENTIAL: This transmission may contain information that is

privileged subject to attorney-client privilege or attorney work product,

confidential and/or exempt from disclosure under applicable law. If you are not

the intended recipient, then please do not read it and be aware that any

disclosure, copying, distribution, or use of the information contained herein

(including any reliance thereon) is STRICTLY PROHIBITED. If you received this

transmission in error, please immediately advise me, by reply e-mail, and delete

this message and any attachments without retaining a copy in any form. Thank

you.

Re: Therapy Cap for Hospital Based OP

>

> Hi Tom,

>

> Remember we had the Manual Review in 2006?

>

> Back then it was a paper submission and an optional " Justification

> Statement " if, for some reason, you thought your notes weren't perfectly

> clear in their rationale and support for services exceeding the (then)

> $1,670 Medicare cap on outpatient PT/OT services.

> Any reason why it should be different this time?

>

> Tim , PT

> www.PhysicalTherapyDiagnosis.com<http://www.PhysicalTherapyDiagnosis.com>

>

>

>> >

>> > 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.

>> >

>> >

>> >

>> >

>> >

>> >

>> >

>> >

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

>> >

Link to comment
Share on other sites
Guest guest

Guest guest

Posted
Posted

Tom makes a good point, nothing is certain, that is the reason behind my post.

Hospital based or not, we all need to get involved as one voice to support

legislation that will be favorable to the entire profession, not tied to work

type or location

Ron Barbato PT

Administrative Director, Rehabilitation Services

Program Director, Cancer Support Services

Ephraim McDowell Health

Voice:

rbarbato@...

PRIVILEGED AND CONFIDENTIAL: This transmission may contain information that is

privileged subject to attorney-client privilege or attorney work product,

confidential and/or exempt from disclosure under applicable law. If you are not

the intended recipient, then please do not read it and be aware that any

disclosure, copying, distribution, or use of the information contained herein

(including any reliance thereon) is STRICTLY PROHIBITED. If you received this

transmission in error, please immediately advise me, by reply e-mail, and delete

this message and any attachments without retaining a copy in any form. Thank

you.

Re: Therapy Cap for Hospital Based OP

>

> Hi Tom,

>

> Remember we had the Manual Review in 2006?

>

> Back then it was a paper submission and an optional " Justification

> Statement " if, for some reason, you thought your notes weren't perfectly

> clear in their rationale and support for services exceeding the (then)

> $1,670 Medicare cap on outpatient PT/OT services.

> Any reason why it should be different this time?

>

> Tim , PT

> www.PhysicalTherapyDiagnosis.com<http://www.PhysicalTherapyDiagnosis.com>

>

>

>> >

>> > 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.

>> >

>> >

>> >

>> >

>> >

>> >

>> >

>> >

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

>> >

Link to comment
Share on other sites
Guest guest

Guest guest

Posted
Posted

Actual reimbursement from your Medicare Physician Fee Schedule rates.

Thanks so much!

Jill

From: PTManager [mailto:PTManager ] On Behalf Of

njohnson@...

Sent: Thursday, May 10, 2012 1:30 PM

To: PTManager

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

We are a hospital based OP program. One question that staff asked us is what the

$1800.00 is based on. The billed amount or the actual reimbursement by Medicare.

Thanks,

Nano , PT

Physical Therapy Supervisor

Regional Rehabilitation Institute

Rapid City, S.D.

njohnson@...<mailto:njohnson%40regionalhealth.com>

(f)

From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf

Of ez, Joyce

Sent: Wednesday, May 09, 2012 8:42 AM

To: PTManager <mailto:PTManager%40yahoogroups.com>

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

Thanks for the summary Tom!

We strictly follow Medicare guidelines and have successfully passed

Medicare/JCAHO audits in the past. Every single one of our Medicare and

non-Medicare patient's plan of care (initial eval and re-cert) is signed

by the referring MDs certifying the need for or continuation of skilled

PT,OT or ST services. Our therapists do a great job with documentation,

they write substantial daily SOAP notes, detailed assessment of

objective measurements and goal attainment every 6 visits plus a

progress report written once every 10 treatment days or at least once

every 30 calendar days, whichever is less.

Since we're already doing all that, the only thing added to the process

is using a KX modifier and undergoing a " manual medical review " . I will

contact our MAC to get more details and I'm sure Rick Gawenda will have

a webinar about this as well.

Thanks again and have a great day!

Joyce

Joyce ez, PT

Outpatient Rehab Manager

Provena Saint ph Hospital

Phone: ext. 5177

Email:

Joyce.ez@...<mailto:Joyce.ez%40provena.org><mailto:Joyce.Mar\

tinez%40provena.org>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>\

<mailto:Joyce.ez%40provena.org>>

Important Notice:

This message and any attachments are confidential and maybe protected by

legal privilege. If you are not the inted recipient, be aware that any

disclosures, copying, distribution, or use of this message or any

attachment is prohibited. If you recieved this in error, please notify

us immediately by returning it to sender and deleting the copy from your

system. Thank you.

________________________________

From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com>] On

Behalf Of M. Howell PT, MPT

Sent: Tuesday, May 08, 2012 6:21 PM

To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com>

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

Hi Joyce,

I would highly recommend that you look up the information on it on the

CMS

site or at the APTA site for full details on the current regulations.

A short summary is that any Part B Medicare outpatient beneficiary

reaching

the combined PT/ST cap of $1880 has a couple of choices. One is that

they,

in discussion with their PT, can end therapy when the cap is reached.

Second, is that if the PT has determined and documented the medical

necessity to continue and it is approved in the plan of care signed by

the

provider (mostly the referring physician) that PT should continue care.

The

billing of claims once the cap is reached must be submitted with a -KX

modifier to indicate that the therapy is continuing under the

" Exceptions "

process. The continued therapy MUST be justified as reasonable and

necessary in the notes with objective data to support that continued

therapy

is medically necessary. This process continues as long as care is needed

BUT now there is a new added regulation that these claims that continue

under the KX modifier now MUST undergo a " manual medical review " once

the

claim reaches $3700. That " manual medical review " is brand new and no

proposed regulations for it have been released yet so no-one knows how

it

will work.

Basically, this is a process by which you can continue therapy past the

cap

as long as you can justify it based on how Medicare wants it justified

and

as long as the plan of care to continue is approved. The new wrinkle is

that manual medical review.

For the details of how the KX modifier gets on claims and where it goes,

you

need to consult the source. A good place to start is the MAC( Medicare

Administrative Contractor) for your region. Most have online training

courses just for this and I am sure they will have plenty more in

preparation for October.

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

IPTA Payment Specialist

Meridian, Idaho

<mailto:thowell@...<mailto:thowell%40fiberpipe.net><mailto:thowell%40f\

iberpipe.net> <mailto:thowell%40fiberpipe.net> >

thowell@...<mailto:thowell%40fiberpipe.net><mailto:thowell%40fiberpipe\

..net> <mailto:thowell%40fiberpipe.net>

This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended

recipient. If you are not the intended recipient of the email or any of

its

attachments, please be advised that you have received this email in

error

and that any use, dissemination, distribution, forwarding, printing or

copying of this email or any attached files is strictly prohibited. If

you

have received this email in error, please immediately purge it and all

attachments and notify the sender by reply email.

From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> ]

On Behalf

Of ez, Joyce

Sent: Tuesday, May 08, 2012 3:19 PM

To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

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

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

to the therapy cap until now. Can somebody please explain what a KX

modifier is?

Joyce ez, PT

Outpatient Rehab Manager

Provena Saint ph Hospital

Phone: ext. 5177

Email:

Joyce.ez@...<mailto:Joyce.ez%40provena.org><mailto:Joyce.Mar\

tinez%40provena.org> <mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>\

<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org> >

Important Notice:

This message and any attachments are confidential and maybe protected by

legal privilege. If you are not the inted recipient, be aware that any

disclosures, copying, distribution, or use of this message or any

attachment is prohibited. If you recieved this in error, please notify

us immediately by returning it to sender and deleting the copy from your

system. Thank you.

________________________________

From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ] On

Behalf Of M. Howell PT, MPT

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

To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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.

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 - 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 - we may

lose that KX exceptions process again. I hope everyone is ready to mount

a lobbying campaign - we will need it big time!

I encourage all PT'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 PT's and

PTA's.

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

IPTA Payment Specialist

Meridian, Idaho

<mailto:thowell@...<mailto:thowell%40fiberpipe.net><mailto:thowell%40f\

iberpipe.net> <mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net> >

thowell@...<mailto:thowell%40fiberpipe.net><mailto:thowell%40fiberpipe\

..net> <mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended

recipient. If you are not the intended recipient of the email or any of

its attachments, please be advised that you have received this email in

error and that any use, dissemination, distribution, forwarding,

printing or copying of this email or any attached files is strictly

prohibited. If you have received this email in error, please immediately

purge it and all attachments and notify the sender by reply email.

From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ]

On Behalf Of Witt

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

To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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><mailto:wittpt%40att.net>

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

<mailto:wittpt%40att.net>

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

<mailto:bperlson%40asante.org>

<mailto:bperlson%40asante.org>

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

A transmittal

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

Transmittals-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.

>

>

>

>

>

>

>

>

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

>

Link to comment
Share on other sites
Guest guest

Guest guest

Posted
Posted

Actual reimbursement from your Medicare Physician Fee Schedule rates.

Thanks so much!

Jill

From: PTManager [mailto:PTManager ] On Behalf Of

njohnson@...

Sent: Thursday, May 10, 2012 1:30 PM

To: PTManager

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

We are a hospital based OP program. One question that staff asked us is what the

$1800.00 is based on. The billed amount or the actual reimbursement by Medicare.

Thanks,

Nano , PT

Physical Therapy Supervisor

Regional Rehabilitation Institute

Rapid City, S.D.

njohnson@...<mailto:njohnson%40regionalhealth.com>

(f)

From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf

Of ez, Joyce

Sent: Wednesday, May 09, 2012 8:42 AM

To: PTManager <mailto:PTManager%40yahoogroups.com>

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

Thanks for the summary Tom!

We strictly follow Medicare guidelines and have successfully passed

Medicare/JCAHO audits in the past. Every single one of our Medicare and

non-Medicare patient's plan of care (initial eval and re-cert) is signed

by the referring MDs certifying the need for or continuation of skilled

PT,OT or ST services. Our therapists do a great job with documentation,

they write substantial daily SOAP notes, detailed assessment of

objective measurements and goal attainment every 6 visits plus a

progress report written once every 10 treatment days or at least once

every 30 calendar days, whichever is less.

Since we're already doing all that, the only thing added to the process

is using a KX modifier and undergoing a " manual medical review " . I will

contact our MAC to get more details and I'm sure Rick Gawenda will have

a webinar about this as well.

Thanks again and have a great day!

Joyce

Joyce ez, PT

Outpatient Rehab Manager

Provena Saint ph Hospital

Phone: ext. 5177

Email:

Joyce.ez@...<mailto:Joyce.ez%40provena.org><mailto:Joyce.Mar\

tinez%40provena.org>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>\

<mailto:Joyce.ez%40provena.org>>

Important Notice:

This message and any attachments are confidential and maybe protected by

legal privilege. If you are not the inted recipient, be aware that any

disclosures, copying, distribution, or use of this message or any

attachment is prohibited. If you recieved this in error, please notify

us immediately by returning it to sender and deleting the copy from your

system. Thank you.

________________________________

From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com>] On

Behalf Of M. Howell PT, MPT

Sent: Tuesday, May 08, 2012 6:21 PM

To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com>

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

Hi Joyce,

I would highly recommend that you look up the information on it on the

CMS

site or at the APTA site for full details on the current regulations.

A short summary is that any Part B Medicare outpatient beneficiary

reaching

the combined PT/ST cap of $1880 has a couple of choices. One is that

they,

in discussion with their PT, can end therapy when the cap is reached.

Second, is that if the PT has determined and documented the medical

necessity to continue and it is approved in the plan of care signed by

the

provider (mostly the referring physician) that PT should continue care.

The

billing of claims once the cap is reached must be submitted with a -KX

modifier to indicate that the therapy is continuing under the

" Exceptions "

process. The continued therapy MUST be justified as reasonable and

necessary in the notes with objective data to support that continued

therapy

is medically necessary. This process continues as long as care is needed

BUT now there is a new added regulation that these claims that continue

under the KX modifier now MUST undergo a " manual medical review " once

the

claim reaches $3700. That " manual medical review " is brand new and no

proposed regulations for it have been released yet so no-one knows how

it

will work.

Basically, this is a process by which you can continue therapy past the

cap

as long as you can justify it based on how Medicare wants it justified

and

as long as the plan of care to continue is approved. The new wrinkle is

that manual medical review.

For the details of how the KX modifier gets on claims and where it goes,

you

need to consult the source. A good place to start is the MAC( Medicare

Administrative Contractor) for your region. Most have online training

courses just for this and I am sure they will have plenty more in

preparation for October.

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

IPTA Payment Specialist

Meridian, Idaho

<mailto:thowell@...<mailto:thowell%40fiberpipe.net><mailto:thowell%40f\

iberpipe.net> <mailto:thowell%40fiberpipe.net> >

thowell@...<mailto:thowell%40fiberpipe.net><mailto:thowell%40fiberpipe\

..net> <mailto:thowell%40fiberpipe.net>

This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended

recipient. If you are not the intended recipient of the email or any of

its

attachments, please be advised that you have received this email in

error

and that any use, dissemination, distribution, forwarding, printing or

copying of this email or any attached files is strictly prohibited. If

you

have received this email in error, please immediately purge it and all

attachments and notify the sender by reply email.

From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> ]

On Behalf

Of ez, Joyce

Sent: Tuesday, May 08, 2012 3:19 PM

To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

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

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

to the therapy cap until now. Can somebody please explain what a KX

modifier is?

Joyce ez, PT

Outpatient Rehab Manager

Provena Saint ph Hospital

Phone: ext. 5177

Email:

Joyce.ez@...<mailto:Joyce.ez%40provena.org><mailto:Joyce.Mar\

tinez%40provena.org> <mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>\

<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org> >

Important Notice:

This message and any attachments are confidential and maybe protected by

legal privilege. If you are not the inted recipient, be aware that any

disclosures, copying, distribution, or use of this message or any

attachment is prohibited. If you recieved this in error, please notify

us immediately by returning it to sender and deleting the copy from your

system. Thank you.

________________________________

From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ] On

Behalf Of M. Howell PT, MPT

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

To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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.

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 - 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 - we may

lose that KX exceptions process again. I hope everyone is ready to mount

a lobbying campaign - we will need it big time!

I encourage all PT'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 PT's and

PTA's.

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

IPTA Payment Specialist

Meridian, Idaho

<mailto:thowell@...<mailto:thowell%40fiberpipe.net><mailto:thowell%40f\

iberpipe.net> <mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net> >

thowell@...<mailto:thowell%40fiberpipe.net><mailto:thowell%40fiberpipe\

..net> <mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended

recipient. If you are not the intended recipient of the email or any of

its attachments, please be advised that you have received this email in

error and that any use, dissemination, distribution, forwarding,

printing or copying of this email or any attached files is strictly

prohibited. If you have received this email in error, please immediately

purge it and all attachments and notify the sender by reply email.

From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ]

On Behalf Of Witt

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

To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com> <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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><mailto:wittpt%40att.net>

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

<mailto:wittpt%40att.net>

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

<mailto:bperlson%40asante.org>

<mailto:bperlson%40asante.org>

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

A transmittal

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

Transmittals-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.

>

>

>

>

>

>

>

>

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

>

Link to comment
Share on other sites
Guest guest

Guest guest

Posted
Posted

Neither. It's based on the Medicare allowed amount. You can also check my

website for a webinar that I'll be presenting on the therapy cap in June.

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

http://www.gawendaseminars.com

> We are a hospital based OP program. One question that staff asked us is what

the $1800.00 is based on. The billed amount or the actual reimbursement by

Medicare.

> Thanks,

>

> Nano , PT

> Physical Therapy Supervisor

> Regional Rehabilitation Institute

> Rapid City, S.D.

> njohnson@...

>

> (f)

>

> From: PTManager [mailto:PTManager ] On Behalf

Of ez, Joyce

> Sent: Wednesday, May 09, 2012 8:42 AM

> To: PTManager

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

>

> Thanks for the summary Tom!

>

> We strictly follow Medicare guidelines and have successfully passed

> Medicare/JCAHO audits in the past. Every single one of our Medicare and

> non-Medicare patient's plan of care (initial eval and re-cert) is signed

> by the referring MDs certifying the need for or continuation of skilled

> PT,OT or ST services. Our therapists do a great job with documentation,

> they write substantial daily SOAP notes, detailed assessment of

> objective measurements and goal attainment every 6 visits plus a

> progress report written once every 10 treatment days or at least once

> every 30 calendar days, whichever is less.

>

> Since we're already doing all that, the only thing added to the process

> is using a KX modifier and undergoing a " manual medical review " . I will

> contact our MAC to get more details and I'm sure Rick Gawenda will have

> a webinar about this as well.

>

> Thanks again and have a great day!

>

> Joyce

>

> Joyce ez, PT

> Outpatient Rehab Manager

> Provena Saint ph Hospital

> Phone: ext. 5177

> Email: Joyce.ez@...<mailto:Joyce.ez%40provena.org>

>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>\

>

>

> Important Notice:

> This message and any attachments are confidential and maybe protected by

> legal privilege. If you are not the inted recipient, be aware that any

> disclosures, copying, distribution, or use of this message or any

> attachment is prohibited. If you recieved this in error, please notify

> us immediately by returning it to sender and deleting the copy from your

> system. Thank you.

>

> ________________________________

>

> From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On

> Behalf Of M. Howell PT, MPT

> Sent: Tuesday, May 08, 2012 6:21 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

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

>

> Hi Joyce,

>

> I would highly recommend that you look up the information on it on the

> CMS

> site or at the APTA site for full details on the current regulations.

>

> A short summary is that any Part B Medicare outpatient beneficiary

> reaching

> the combined PT/ST cap of $1880 has a couple of choices. One is that

> they,

> in discussion with their PT, can end therapy when the cap is reached.

> Second, is that if the PT has determined and documented the medical

> necessity to continue and it is approved in the plan of care signed by

> the

> provider (mostly the referring physician) that PT should continue care.

> The

> billing of claims once the cap is reached must be submitted with a -KX

> modifier to indicate that the therapy is continuing under the

> " Exceptions "

> process. The continued therapy MUST be justified as reasonable and

> necessary in the notes with objective data to support that continued

> therapy

> is medically necessary. This process continues as long as care is needed

> BUT now there is a new added regulation that these claims that continue

> under the KX modifier now MUST undergo a " manual medical review " once

> the

> claim reaches $3700. That " manual medical review " is brand new and no

> proposed regulations for it have been released yet so no-one knows how

> it

> will work.

>

> Basically, this is a process by which you can continue therapy past the

> cap

> as long as you can justify it based on how Medicare wants it justified

> and

> as long as the plan of care to continue is approved. The new wrinkle is

> that manual medical review.

>

> For the details of how the KX modifier gets on claims and where it goes,

> you

> need to consult the source. A good place to start is the MAC( Medicare

> Administrative Contractor) for your region. Most have online training

> courses just for this and I am sure they will have plenty more in

> preparation for October.

>

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

>

> IPTA Payment Specialist

>

> Meridian, Idaho

>

> <mailto:thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net> >

> thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

>

> This email and any files transmitted with it may contain PRIVILEGED or

> CONFIDENTIAL information and may be read or used only by the intended

> recipient. If you are not the intended recipient of the email or any of

> its

> attachments, please be advised that you have received this email in

> error

> and that any use, dissemination, distribution, forwarding, printing or

> copying of this email or any attached files is strictly prohibited. If

> you

> have received this email in error, please immediately purge it and all

> attachments and notify the sender by reply email.

>

> From: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com> ]

> On Behalf

> Of ez, Joyce

> Sent: Tuesday, May 08, 2012 3:19 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

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

>

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

> to the therapy cap until now. Can somebody please explain what a KX

> modifier is?

>

> Joyce ez, PT

> Outpatient Rehab Manager

> Provena Saint ph Hospital

> Phone: ext. 5177

> Email: Joyce.ez@...<mailto:Joyce.ez%40provena.org>

<mailto:Joyce.ez%40provena.org>

> <mailto:Joyce.ez%40provena.org>

>

<blocked::mailto:Joyce.ez@...<mailto:Joyce.ez%40provena.org>

> <mailto:Joyce.ez%40provena.org>

> <mailto:Joyce.ez%40provena.org> >

>

> Important Notice:

> This message and any attachments are confidential and maybe protected by

> legal privilege. If you are not the inted recipient, be aware that any

> disclosures, copying, distribution, or use of this message or any

> attachment is prohibited. If you recieved this in error, please notify

> us immediately by returning it to sender and deleting the copy from your

> system. Thank you.

>

> ________________________________

>

> From: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com>

> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com> ] On

> Behalf Of M. Howell PT, MPT

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

> To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com>

> 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.

>

> 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 - 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 - we may

> lose that KX exceptions process again. I hope everyone is ready to mount

> a lobbying campaign - we will need it big time!

>

> I encourage all PT'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 PT's and

> PTA's.

>

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

>

> IPTA Payment Specialist

>

> Meridian, Idaho

>

> <mailto:thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

> <mailto:thowell%40fiberpipe.net>

> <mailto:thowell%40fiberpipe.net> >

> thowell@...<mailto:thowell%40fiberpipe.net>

<mailto:thowell%40fiberpipe.net>

> <mailto:thowell%40fiberpipe.net>

> <mailto:thowell%40fiberpipe.net>

>

> This email and any files transmitted with it may contain PRIVILEGED or

> CONFIDENTIAL information and may be read or used only by the intended

> recipient. If you are not the intended recipient of the email or any of

> its attachments, please be advised that you have received this email in

> error and that any use, dissemination, distribution, forwarding,

> printing or copying of this email or any attached files is strictly

> prohibited. If you have received this email in error, please immediately

> purge it and all attachments and notify the sender by reply email.

>

> From: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com>

> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com> ]

> On Behalf Of Witt

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

> To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com>

> <mailto:PTManager%40yahoogroups.com>

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

<mailto:wittpt%40att.net>

> <mailto:wittpt%40att.net>

> <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>

> <mailto:bperlson%40asante.org>

> <mailto:bperlson%40asante.org>

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

>

> A transmittal

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

> Transmittals-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

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Guest guest

Guest guest

Posted
Posted

Neither- it is based on the fee schedule.

Marc lacroix

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

<mailto:wittpt%40att.net>;

<mailto:wittpt%40att.net>;

<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>;

<mailto:bperlson%40asante.org>;

<mailto:bperlson%40asante.org>;

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

A transmittal

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

Transmittals-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.

>

>

>

>

>

>

>

>

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

>

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Guest guest

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Posted
Posted

I was wondering where we might find an updated fee schedule manual for current

Medicare allowable amounts? Are these amounts different with hospital based

versus free standing clinics?

> >

> > A transmittal

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

> > Transmittals-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

>

>

>

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Guest guest

Guest guest

Posted
Posted

I was wondering where we might find an updated fee schedule manual for current

Medicare allowable amounts? Are these amounts different with hospital based

versus free standing clinics?

> >

> > A transmittal

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

> > Transmittals-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

>

>

>

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