Therapy Cap for Hospital Based OP Summary and Links

[Guest guest]

To view the Medicare Physician Fee Schedule, go to

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

Below is the summary of the therapy cap from CMS along with links to the

transmittal and CMS MedLearn article. In addition, the link for the webinar on

the therapy cap as well as other topics is

https://www.showmyevent.com/events/viewEventDetails.aspx?EventID=1886

CMS released Transmittal 2457 on April 27, 2012 that provides

information on the therapy cap for 2012 and other information that

impacts therapy services in 2012 as a result of the Middle Class Tax

Relief and Job Creation Act of 2012 (MCTRJCA). This Change Request

extends the therapy cap exceptions process through December 31, 2012 and

adds therapy services provided in outpatient hospital settings to the

therapy cap effective October 1, 2012.

MCTRJCA

contains two requirements that become effective on October 1, 2012. The

first of these requires suppliers and providers to report the National

Provider Identifier (NPI) of the physician, or nonphysician practitioner

(NPP) where applicable, responsible for reviewing the therapy plan of care, on

the beneficiary’s claim

for therapy services. For implementation purposes, the physician or NPP

(as applicable) certifying the therapy plan of care is reported.

MCTRJCA

also calls for a manual medical review process for those exceptions

where the beneficiary therapy services for the year reach a threshold of

$3,700. The separate thresholds triggering manual medical reviews build

upon the separate therapy caps -- one for PT and SLP services combined

and one for OT services. Claims with a KX modifier requesting an

exceptions for services above either threshold, per MCTRJCA, are subject

to a manual medical review process. The count of services to which

these thresholds apply begins on January 1, 2012. Absent Congressional

action, manual medical review expires when the exceptions process

expires for dates of service after December 31, 2012.

Claims

for services at or above the therapy caps or thresholds for which an

exception is not granted will be denied as a benefit category denial,

and the beneficiary will be liable. While suppliers and providers are

not required to issue an Advance Beneficiary Notice (ABN) for these

benefit category denials, they are encouraged to issue the voluntary ABN

as a courtesy to their patients requiring services over the therapy cap

amounts ($1,880 for each cap in CY 2012) to alert them of their

possible financial liability.

To view Transmittal 2457, go to

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R245\

7CP.pdf

To access the CMS MedLearn article, go to

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatte\

rsArticles/Downloads/MM7785.pdf

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc

www.gawendaseminars.com

Subject: Re: Therapy Cap for Hospital Based OP

To: PTManager

Date: Friday, May 11, 2012, 11:02 AM

Â

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

>

>

>

[Guest guest]

If the patients are registered patients of the hospital, the billing must be

done through the hospital and not via individual NPI's of a therapist in private

practice, even under arrangements with a therapist in private practice. Read

Section 230.6 of the attached link below. You can also read below for a webinar

on the therapy cap next week.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.\

pdf

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

www.gawendaseminars.com

Follow Gawenda Seminars & Consulting, Inc on Facebook

Register for the June 19, 2012 webinar conference: " ICD-9 Coding, Medicare

Therapy Cap, CCI Edits & Modifiers Used in Outpatient Therapy " at

https://www.showmyevent.com/events/viewEventDetails.aspx?EventID=1886

Subject: Re: Therapy Cap for Hospital Based OP Summary and Links

To: PTManager

Date: Thursday, May 17, 2012, 8:27 AM

 

I am curious if any hospital based therapy clinics have considered moving

toward billing through individual therapist NPIs rather than continuing the

direct hospital relationship? It seems the costs & regulatory issues that come

with being hospital based outweigh the benefits, specifically once the cap is in

place.

I would appreciate any input on pros/cons of moving toward an independent model

rather than hospital based.

Doug Culbert

Director, Rehab Services

>

> > >

>

> > > 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

>

> >

>

> >

>

> >