Re: medicare cap for hospitals

June 4, 2012

Our MAC has an automated phone line that you can call to verify dollars

remaining. It is really the best estimate though, as patients who had recent

rehab at another facility may have charges that have not been billed to Medicare

yet, and thus not reflected on the phone line.

You can also ask the patient the last time they had outpatient PT and that can

help, though you're relying solely on their word.

So, I'd suggest calling your MAC.

Jill Piazza, PT, DPT

> We are struggling with finding a tool that will allow us to pull up the

> beneficiary annual use --- if as it appears - hospitals will come under

> cap effective October 1 - I am assuming we will have to be aware of all

> beneficiary use of PT OT and ST services since beneficiary year

> beginning January 1. That to me makes it critical we be able to

> readily access the common working files or something... so far we have

> not been able to find a tool to access this info easily.... Can anyone

> make a suggestion?

>

> Laurie , Sr Director Rehabiliation Services

>

> Beaufort Memorial Hospital

>

> From: PTManager [mailto:PTManager ] On

> Behalf Of M. Howell PT, MPT

> Sent: Friday, June 01, 2012 6:15 PM

> To: PTManager

> Subject: RE: medicare cap

>

> Hi Jeff,

>

> The answer to your question lies in what services are received in a

> nursing

> home setting. Many SNF have an outpatient clinic at the facility or have

> the ability to bill Medicare Part B outpatient services. This should and

> can only be done if the resident does not qualify for rehabilitation

> under

> Part A. It would be something worth investigating, though. There has to

> be

> a medical record of outpatient PT being performed that can be copied if

> requested for the employee's father, so he and the employee can verify

> that

> Part B services were done and recorded.

>

> It doesn't matter what setting, as long as it is an allowable Part B

> charge

> and an allowable location then it counts towards the cap.

>

> Home health service do not count towards the cap HOWEVER, part B

> services

> will be denied payment if the person has not been recorded in the system

> as

> discharged from home health. An outpatient clinic needs to find out if a

> Medicare patient has been receiving home health and if they have been

> discharged at the time they are admitted to/evaluated for outpatient

> Part B

> services.

>

> That being said, home health agencies also sometimes contract or employ

> therapists that are Part B eligible and provide Part B services in the

> home.

> This may confuse the patient because the same agency that provided home

> health is now providing outpatient services in the person's home. This

> is

> done when the patient no longer qualifies for home health but still

> needs

> services in the home. Smart home health agencies have capitalized on

> this

> by having therapists that are Part B eligible contracted or on staff.

>

> It takes a good and educated office staff to track down online and by

> the

> patient what Medicare services the patient/client has actually had prior

> to

> starting a new Part B outpatient case to avoid cap problems and denials.

> If you really have concerns about the cap, use the KX modifier early to

> make

> sure that you don't get a denial for going past the cap AND make sure

> you

> document why in case you are audited in the future.

>

> 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 JEFF BROWN

> Sent: Friday, June 01, 2012 2:41 PM

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

> Subject: medicare cap

>

> I was hoping to get some clarification regarding the hospital outpatient

> Medicare cap. Specifically will the physical, occupational, and speech

> pathology services a resident receives

> while in a nursing home count against the cap allowance? This question

> was

> brought to my attention after an employee in our system got a Medicare

> EOB

> statement for her father, after his discharge from a nursing home,

> stating

> that $800 of the $1880 cap allowance had been utilized by the therapy

> services provided in the NH.

>

> One further question, is it correct that the cap does not apply to Home

> Health therapy services and therefore would not count against the cap

> once a

> patient transitions into outpatient services?

>

> Thanks,

>

> Jeff Brown PT

> Director of Rehabilitation

> Decatur Memorial Hospital

> 2300 N. St.

> Decatur, IL 62526

>

> CONFIDENTIAL: This email message and any attachments are for the sole

> use of

> the intended recipient(s) and may contain HIGHLY CONFIDENTIAL PERSONAL

> HEALTH INFORMATION. It is to be used only to aid in providing specific

> healthcare services to this patient. Any unauthorized review,use,

> disclosure, or distribution is a violation of Federal Law (HIPAA)

> and will be reported as such.

>

> If you are not the intended recipient or a person responsible for

> delivering this message to an intended recipient, please contact the

> sender

> by reply email and destroy all copies of the original message

> immediately.

>

June 4, 2012

Our MAC has an automated phone line that you can call to verify dollars

remaining. It is really the best estimate though, as patients who had recent

rehab at another facility may have charges that have not been billed to Medicare

yet, and thus not reflected on the phone line.

You can also ask the patient the last time they had outpatient PT and that can

help, though you're relying solely on their word.

So, I'd suggest calling your MAC.

Jill Piazza, PT, DPT

> We are struggling with finding a tool that will allow us to pull up the

> beneficiary annual use --- if as it appears - hospitals will come under

> cap effective October 1 - I am assuming we will have to be aware of all

> beneficiary use of PT OT and ST services since beneficiary year

> beginning January 1. That to me makes it critical we be able to

> readily access the common working files or something... so far we have

> not been able to find a tool to access this info easily.... Can anyone

> make a suggestion?

>

> Laurie , Sr Director Rehabiliation Services

>

> Beaufort Memorial Hospital

>

> From: PTManager [mailto:PTManager ] On

> Behalf Of M. Howell PT, MPT

> Sent: Friday, June 01, 2012 6:15 PM

> To: PTManager

> Subject: RE: medicare cap

>

> Hi Jeff,

>

> The answer to your question lies in what services are received in a

> nursing

> home setting. Many SNF have an outpatient clinic at the facility or have

> the ability to bill Medicare Part B outpatient services. This should and

> can only be done if the resident does not qualify for rehabilitation

> under

> Part A. It would be something worth investigating, though. There has to

> be

> a medical record of outpatient PT being performed that can be copied if

> requested for the employee's father, so he and the employee can verify

> that

> Part B services were done and recorded.

>

> It doesn't matter what setting, as long as it is an allowable Part B

> charge

> and an allowable location then it counts towards the cap.

>

> Home health service do not count towards the cap HOWEVER, part B

> services

> will be denied payment if the person has not been recorded in the system

> as

> discharged from home health. An outpatient clinic needs to find out if a

> Medicare patient has been receiving home health and if they have been

> discharged at the time they are admitted to/evaluated for outpatient

> Part B

> services.

>

> That being said, home health agencies also sometimes contract or employ

> therapists that are Part B eligible and provide Part B services in the

> home.

> This may confuse the patient because the same agency that provided home

> health is now providing outpatient services in the person's home. This

> is

> done when the patient no longer qualifies for home health but still

> needs

> services in the home. Smart home health agencies have capitalized on

> this

> by having therapists that are Part B eligible contracted or on staff.

>

> It takes a good and educated office staff to track down online and by

> the

> patient what Medicare services the patient/client has actually had prior

> to

> starting a new Part B outpatient case to avoid cap problems and denials.

> If you really have concerns about the cap, use the KX modifier early to

> make

> sure that you don't get a denial for going past the cap AND make sure

> you

> document why in case you are audited in the future.

>

> 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 JEFF BROWN

> Sent: Friday, June 01, 2012 2:41 PM

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

> Subject: medicare cap

>

> I was hoping to get some clarification regarding the hospital outpatient

> Medicare cap. Specifically will the physical, occupational, and speech

> pathology services a resident receives

> while in a nursing home count against the cap allowance? This question

> was

> brought to my attention after an employee in our system got a Medicare

> EOB

> statement for her father, after his discharge from a nursing home,

> stating

> that $800 of the $1880 cap allowance had been utilized by the therapy

> services provided in the NH.

>

> One further question, is it correct that the cap does not apply to Home

> Health therapy services and therefore would not count against the cap

> once a

> patient transitions into outpatient services?

>

> Thanks,

>

> Jeff Brown PT

> Director of Rehabilitation

> Decatur Memorial Hospital

> 2300 N. St.

> Decatur, IL 62526

>

> CONFIDENTIAL: This email message and any attachments are for the sole

> use of

> the intended recipient(s) and may contain HIGHLY CONFIDENTIAL PERSONAL

> HEALTH INFORMATION. It is to be used only to aid in providing specific

> healthcare services to this patient. Any unauthorized review,use,

> disclosure, or distribution is a violation of Federal Law (HIPAA)

> and will be reported as such.

>

> If you are not the intended recipient or a person responsible for

> delivering this message to an intended recipient, please contact the

> sender

> by reply email and destroy all copies of the original message

> immediately.

>

June 5, 2012

Your billing department would have access to the CWF. Ask if someone from your

department can be set up on your Medicare contractors system so they will be

able to view this information.

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

http://www.gawendaseminars.com

> We are struggling with finding a tool that will allow us to pull up the

> beneficiary annual use --- if as it appears - hospitals will come under

> cap effective October 1 - I am assuming we will have to be aware of all

> beneficiary use of PT OT and ST services since beneficiary year

> beginning January 1. That to me makes it critical we be able to

> readily access the common working files or something... so far we have

> not been able to find a tool to access this info easily.... Can anyone

> make a suggestion?

>

> Laurie , Sr Director Rehabiliation Services

>

> Beaufort Memorial Hospital

>

> From: PTManager [mailto:PTManager ] On

> Behalf Of M. Howell PT, MPT

> Sent: Friday, June 01, 2012 6:15 PM

> To: PTManager

> Subject: RE: medicare cap

>

> Hi Jeff,

>

> The answer to your question lies in what services are received in a

> nursing

> home setting. Many SNF have an outpatient clinic at the facility or have

> the ability to bill Medicare Part B outpatient services. This should and

> can only be done if the resident does not qualify for rehabilitation

> under

> Part A. It would be something worth investigating, though. There has to

> be

> a medical record of outpatient PT being performed that can be copied if

> requested for the employee's father, so he and the employee can verify

> that

> Part B services were done and recorded.

>

> It doesn't matter what setting, as long as it is an allowable Part B

> charge

> and an allowable location then it counts towards the cap.

>

> Home health service do not count towards the cap HOWEVER, part B

> services

> will be denied payment if the person has not been recorded in the system

> as

> discharged from home health. An outpatient clinic needs to find out if a

> Medicare patient has been receiving home health and if they have been

> discharged at the time they are admitted to/evaluated for outpatient

> Part B

> services.

>

> That being said, home health agencies also sometimes contract or employ

> therapists that are Part B eligible and provide Part B services in the

> home.

> This may confuse the patient because the same agency that provided home

> health is now providing outpatient services in the person's home. This

> is

> done when the patient no longer qualifies for home health but still

> needs

> services in the home. Smart home health agencies have capitalized on

> this

> by having therapists that are Part B eligible contracted or on staff.

>

> It takes a good and educated office staff to track down online and by

> the

> patient what Medicare services the patient/client has actually had prior

> to

> starting a new Part B outpatient case to avoid cap problems and denials.

> If you really have concerns about the cap, use the KX modifier early to

> make

> sure that you don't get a denial for going past the cap AND make sure

> you

> document why in case you are audited in the future.

>

> 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 JEFF BROWN

> Sent: Friday, June 01, 2012 2:41 PM

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

> Subject: medicare cap

>

> I was hoping to get some clarification regarding the hospital outpatient

> Medicare cap. Specifically will the physical, occupational, and speech

> pathology services a resident receives

> while in a nursing home count against the cap allowance? This question

> was

> brought to my attention after an employee in our system got a Medicare

> EOB

> statement for her father, after his discharge from a nursing home,

> stating

> that $800 of the $1880 cap allowance had been utilized by the therapy

> services provided in the NH.

>

> One further question, is it correct that the cap does not apply to Home

> Health therapy services and therefore would not count against the cap

> once a

> patient transitions into outpatient services?

>

> Thanks,

>

> Jeff Brown PT

> Director of Rehabilitation

> Decatur Memorial Hospital

> 2300 N. St.

> Decatur, IL 62526

>

> CONFIDENTIAL: This email message and any attachments are for the sole

> use of

> the intended recipient(s) and may contain HIGHLY CONFIDENTIAL PERSONAL

> HEALTH INFORMATION. It is to be used only to aid in providing specific

> healthcare services to this patient. Any unauthorized review,use,

> disclosure, or distribution is a violation of Federal Law (HIPAA)

> and will be reported as such.

>

> If you are not the intended recipient or a person responsible for

> delivering this message to an intended recipient, please contact the

> sender

> by reply email and destroy all copies of the original message

> immediately.

>

June 5, 2012

Good Luck with this one! Any site is only as up to date as bills entered to the

patient.

In other words, if the patient hops through various clinics for Rehab care, and

these clinics have not billed yet, when they arrive to see your hospital

clinic, the cap monies are not accurate. Let's hope more info is forthcoming

prior to Oct 1st.

E. Lynn MS PT

Director of Rehabilitation

Marlton Rehabilitation Hospital

92 Brick Rd.

Marlton, NJ 08055

ext 4204

From: PTManager [mailto:PTManager ] On Behalf Of

Laurie

Sent: Monday, June 04, 2012 6:49 PM

To: PTManager

Subject: medicare cap for hospitals

We are struggling with finding a tool that will allow us to pull up the

beneficiary annual use --- if as it appears - hospitals will come under

cap effective October 1 - I am assuming we will have to be aware of all

beneficiary use of PT OT and ST services since beneficiary year

beginning January 1. That to me makes it critical we be able to

readily access the common working files or something... so far we have

not been able to find a tool to access this info easily.... Can anyone

make a suggestion?

Laurie , Sr Director Rehabiliation Services

Beaufort Memorial Hospital

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

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

Behalf Of M. Howell PT, MPT

Sent: Friday, June 01, 2012 6:15 PM

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

Subject: RE: medicare cap

Hi Jeff,

The answer to your question lies in what services are received in a

nursing

home setting. Many SNF have an outpatient clinic at the facility or have

the ability to bill Medicare Part B outpatient services. This should and

can only be done if the resident does not qualify for rehabilitation

under

Part A. It would be something worth investigating, though. There has to

be

a medical record of outpatient PT being performed that can be copied if

requested for the employee's father, so he and the employee can verify

that

Part B services were done and recorded.

It doesn't matter what setting, as long as it is an allowable Part B

charge

and an allowable location then it counts towards the cap.

Home health service do not count towards the cap HOWEVER, part B

services

will be denied payment if the person has not been recorded in the system

as

discharged from home health. An outpatient clinic needs to find out if a

Medicare patient has been receiving home health and if they have been

discharged at the time they are admitted to/evaluated for outpatient

Part B

services.

That being said, home health agencies also sometimes contract or employ

therapists that are Part B eligible and provide Part B services in the

home.

This may confuse the patient because the same agency that provided home

health is now providing outpatient services in the person's home. This

is

done when the patient no longer qualifies for home health but still

needs

services in the home. Smart home health agencies have capitalized on

this

by having therapists that are Part B eligible contracted or on staff.

It takes a good and educated office staff to track down online and by

the

patient what Medicare services the patient/client has actually had prior

to

starting a new Part B outpatient case to avoid cap problems and denials.

If you really have concerns about the cap, use the KX modifier early to

make

sure that you don't get a denial for going past the cap AND make sure

you

document why in case you are audited in the future.

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 JEFF BROWN

Sent: Friday, June 01, 2012 2:41 PM

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

<mailto:PTManager%40yahoogroups.com>

Subject: medicare cap

I was hoping to get some clarification regarding the hospital outpatient

Medicare cap. Specifically will the physical, occupational, and speech

pathology services a resident receives

while in a nursing home count against the cap allowance? This question

was

brought to my attention after an employee in our system got a Medicare

EOB

statement for her father, after his discharge from a nursing home,

stating

that $800 of the $1880 cap allowance had been utilized by the therapy

services provided in the NH.

One further question, is it correct that the cap does not apply to Home

Health therapy services and therefore would not count against the cap

once a

patient transitions into outpatient services?

Thanks,

Jeff Brown PT

Director of Rehabilitation

Decatur Memorial Hospital

2300 N. St.

Decatur, IL 62526

CONFIDENTIAL: This email message and any attachments are for the sole

use of

the intended recipient(s) and may contain HIGHLY CONFIDENTIAL PERSONAL

HEALTH INFORMATION. It is to be used only to aid in providing specific

healthcare services to this patient. Any unauthorized review,use,

disclosure, or distribution is a violation of Federal Law (HIPAA)

and will be reported as such.

If you are not the intended recipient or a person responsible for

delivering this message to an intended recipient, please contact the

sender

by reply email and destroy all copies of the original message

immediately.

June 5, 2012

Good Luck with this one! Any site is only as up to date as bills entered to the

patient.

In other words, if the patient hops through various clinics for Rehab care, and

these clinics have not billed yet, when they arrive to see your hospital

clinic, the cap monies are not accurate. Let's hope more info is forthcoming

prior to Oct 1st.

E. Lynn MS PT

Director of Rehabilitation

Marlton Rehabilitation Hospital

92 Brick Rd.

Marlton, NJ 08055

ext 4204

From: PTManager [mailto:PTManager ] On Behalf Of

Laurie

Sent: Monday, June 04, 2012 6:49 PM

To: PTManager

Subject: medicare cap for hospitals

We are struggling with finding a tool that will allow us to pull up the

beneficiary annual use --- if as it appears - hospitals will come under

cap effective October 1 - I am assuming we will have to be aware of all

beneficiary use of PT OT and ST services since beneficiary year

beginning January 1. That to me makes it critical we be able to

readily access the common working files or something... so far we have

not been able to find a tool to access this info easily.... Can anyone

make a suggestion?

Laurie , Sr Director Rehabiliation Services

Beaufort Memorial Hospital

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

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

Behalf Of M. Howell PT, MPT

Sent: Friday, June 01, 2012 6:15 PM

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

Subject: RE: medicare cap

Hi Jeff,

The answer to your question lies in what services are received in a

nursing

home setting. Many SNF have an outpatient clinic at the facility or have

the ability to bill Medicare Part B outpatient services. This should and

can only be done if the resident does not qualify for rehabilitation

under

Part A. It would be something worth investigating, though. There has to

be

a medical record of outpatient PT being performed that can be copied if

requested for the employee's father, so he and the employee can verify

that

Part B services were done and recorded.

It doesn't matter what setting, as long as it is an allowable Part B

charge

and an allowable location then it counts towards the cap.

Home health service do not count towards the cap HOWEVER, part B

services

will be denied payment if the person has not been recorded in the system

as

discharged from home health. An outpatient clinic needs to find out if a

Medicare patient has been receiving home health and if they have been

discharged at the time they are admitted to/evaluated for outpatient

Part B

services.

That being said, home health agencies also sometimes contract or employ

therapists that are Part B eligible and provide Part B services in the

home.

This may confuse the patient because the same agency that provided home

health is now providing outpatient services in the person's home. This

is

done when the patient no longer qualifies for home health but still

needs

services in the home. Smart home health agencies have capitalized on

this

by having therapists that are Part B eligible contracted or on staff.

It takes a good and educated office staff to track down online and by

the

patient what Medicare services the patient/client has actually had prior

to

starting a new Part B outpatient case to avoid cap problems and denials.

If you really have concerns about the cap, use the KX modifier early to

make

sure that you don't get a denial for going past the cap AND make sure

you

document why in case you are audited in the future.

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 JEFF BROWN

Sent: Friday, June 01, 2012 2:41 PM

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

<mailto:PTManager%40yahoogroups.com>

Subject: medicare cap

I was hoping to get some clarification regarding the hospital outpatient

Medicare cap. Specifically will the physical, occupational, and speech

pathology services a resident receives

while in a nursing home count against the cap allowance? This question

was

brought to my attention after an employee in our system got a Medicare

EOB

statement for her father, after his discharge from a nursing home,

stating

that $800 of the $1880 cap allowance had been utilized by the therapy

services provided in the NH.

One further question, is it correct that the cap does not apply to Home

Health therapy services and therefore would not count against the cap

once a

patient transitions into outpatient services?

Thanks,

Jeff Brown PT

Director of Rehabilitation

Decatur Memorial Hospital

2300 N. St.

Decatur, IL 62526

CONFIDENTIAL: This email message and any attachments are for the sole

use of

the intended recipient(s) and may contain HIGHLY CONFIDENTIAL PERSONAL

HEALTH INFORMATION. It is to be used only to aid in providing specific

healthcare services to this patient. Any unauthorized review,use,

disclosure, or distribution is a violation of Federal Law (HIPAA)

and will be reported as such.

If you are not the intended recipient or a person responsible for

delivering this message to an intended recipient, please contact the

sender

by reply email and destroy all copies of the original message

immediately.

June 5, 2012

Laurie,

Check out eSolutions MedicareMVP live. It is a web-based verification tool that

allows both Medicare Part A and B providers to verify eligibility real time. We

are just starting to look into this " service " so I don't know all the

particulars or agility as of yet. There is a relatively small monthly fee ($95

I believe but I don't know the license restrictions) and so far the feedback

I've been getting has been positive.

Good luck,

Jeff Brown PT

Director of Rehabilitation

Decatur Memorial Hospital

2300 N. St.

Decatur, IL 62526

>>> " Laurie " 6/4/2012 5:48 PM >>>

We are struggling with finding a tool that will allow us to pull up the

beneficiary annual use --- if as it appears - hospitals will come under

cap effective October 1 - I am assuming we will have to be aware of all

beneficiary use of PT OT and ST services since beneficiary year

beginning January 1. That to me makes it critical we be able to

readily access the common working files or something... so far we have

not been able to find a tool to access this info easily.... Can anyone

make a suggestion?

Laurie , Sr Director Rehabiliation Services

Beaufort Memorial Hospital

From: PTManager [mailto:PTManager ] On

Behalf Of M. Howell PT, MPT

Sent: Friday, June 01, 2012 6:15 PM

To: PTManager

Subject: RE: medicare cap

Hi Jeff,

The answer to your question lies in what services are received in a

nursing

home setting. Many SNF have an outpatient clinic at the facility or have

the ability to bill Medicare Part B outpatient services. This should and

can only be done if the resident does not qualify for rehabilitation

under

Part A. It would be something worth investigating, though. There has to

be

a medical record of outpatient PT being performed that can be copied if

requested for the employee's father, so he and the employee can verify

that

Part B services were done and recorded.

It doesn't matter what setting, as long as it is an allowable Part B

charge

and an allowable location then it counts towards the cap.

Home health service do not count towards the cap HOWEVER, part B

services

will be denied payment if the person has not been recorded in the system

as

discharged from home health. An outpatient clinic needs to find out if a

Medicare patient has been receiving home health and if they have been

discharged at the time they are admitted to/evaluated for outpatient

Part B

services.

That being said, home health agencies also sometimes contract or employ

therapists that are Part B eligible and provide Part B services in the

home.

This may confuse the patient because the same agency that provided home

health is now providing outpatient services in the person's home. This

is

done when the patient no longer qualifies for home health but still

needs

services in the home. Smart home health agencies have capitalized on

this

by having therapists that are Part B eligible contracted or on staff.

It takes a good and educated office staff to track down online and by

the

patient what Medicare services the patient/client has actually had prior

to

starting a new Part B outpatient case to avoid cap problems and denials.

If you really have concerns about the cap, use the KX modifier early to

make

sure that you don't get a denial for going past the cap AND make sure

you

document why in case you are audited in the future.

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 JEFF BROWN

Sent: Friday, June 01, 2012 2:41 PM

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

Subject: medicare cap

I was hoping to get some clarification regarding the hospital outpatient

Medicare cap. Specifically will the physical, occupational, and speech

pathology services a resident receives

while in a nursing home count against the cap allowance? This question

was

brought to my attention after an employee in our system got a Medicare

EOB

statement for her father, after his discharge from a nursing home,

stating

that $800 of the $1880 cap allowance had been utilized by the therapy

services provided in the NH.

One further question, is it correct that the cap does not apply to Home

Health therapy services and therefore would not count against the cap

once a

patient transitions into outpatient services?

Thanks,

Jeff Brown PT

Director of Rehabilitation

Decatur Memorial Hospital

2300 N. St.

Decatur, IL 62526

CONFIDENTIAL: This email message and any attachments are for the sole

use of

the intended recipient(s) and may contain HIGHLY CONFIDENTIAL PERSONAL

HEALTH INFORMATION. It is to be used only to aid in providing specific

healthcare services to this patient. Any unauthorized review,use,

disclosure, or distribution is a violation of Federal Law (HIPAA)

and will be reported as such.

If you are not the intended recipient or a person responsible for

delivering this message to an intended recipient, please contact the

sender

by reply email and destroy all copies of the original message

immediately.

June 5, 2012

Laurie,

Check out eSolutions MedicareMVP live. It is a web-based verification tool that

allows both Medicare Part A and B providers to verify eligibility real time. We

are just starting to look into this " service " so I don't know all the

particulars or agility as of yet. There is a relatively small monthly fee ($95

I believe but I don't know the license restrictions) and so far the feedback

I've been getting has been positive.

Good luck,

Jeff Brown PT

Director of Rehabilitation

Decatur Memorial Hospital

2300 N. St.

Decatur, IL 62526

>>> " Laurie " 6/4/2012 5:48 PM >>>

We are struggling with finding a tool that will allow us to pull up the

beneficiary annual use --- if as it appears - hospitals will come under

cap effective October 1 - I am assuming we will have to be aware of all

beneficiary use of PT OT and ST services since beneficiary year

beginning January 1. That to me makes it critical we be able to

readily access the common working files or something... so far we have

not been able to find a tool to access this info easily.... Can anyone

make a suggestion?

Laurie , Sr Director Rehabiliation Services

Beaufort Memorial Hospital

From: PTManager [mailto:PTManager ] On

Behalf Of M. Howell PT, MPT

Sent: Friday, June 01, 2012 6:15 PM

To: PTManager

Subject: RE: medicare cap

Hi Jeff,

The answer to your question lies in what services are received in a

nursing

home setting. Many SNF have an outpatient clinic at the facility or have

the ability to bill Medicare Part B outpatient services. This should and

can only be done if the resident does not qualify for rehabilitation

under

Part A. It would be something worth investigating, though. There has to

be

a medical record of outpatient PT being performed that can be copied if

requested for the employee's father, so he and the employee can verify

that

Part B services were done and recorded.

It doesn't matter what setting, as long as it is an allowable Part B

charge

and an allowable location then it counts towards the cap.

Home health service do not count towards the cap HOWEVER, part B

services

will be denied payment if the person has not been recorded in the system

as

discharged from home health. An outpatient clinic needs to find out if a

Medicare patient has been receiving home health and if they have been

discharged at the time they are admitted to/evaluated for outpatient

Part B

services.

That being said, home health agencies also sometimes contract or employ

therapists that are Part B eligible and provide Part B services in the

home.

This may confuse the patient because the same agency that provided home

health is now providing outpatient services in the person's home. This

is

done when the patient no longer qualifies for home health but still

needs

services in the home. Smart home health agencies have capitalized on

this

by having therapists that are Part B eligible contracted or on staff.

It takes a good and educated office staff to track down online and by

the

patient what Medicare services the patient/client has actually had prior

to

starting a new Part B outpatient case to avoid cap problems and denials.

If you really have concerns about the cap, use the KX modifier early to

make

sure that you don't get a denial for going past the cap AND make sure

you

document why in case you are audited in the future.

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 JEFF BROWN

Sent: Friday, June 01, 2012 2:41 PM

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

Subject: medicare cap

I was hoping to get some clarification regarding the hospital outpatient

Medicare cap. Specifically will the physical, occupational, and speech

pathology services a resident receives

while in a nursing home count against the cap allowance? This question

was

brought to my attention after an employee in our system got a Medicare

EOB

statement for her father, after his discharge from a nursing home,

stating

that $800 of the $1880 cap allowance had been utilized by the therapy

services provided in the NH.

One further question, is it correct that the cap does not apply to Home

Health therapy services and therefore would not count against the cap

once a

patient transitions into outpatient services?

Thanks,

Jeff Brown PT

Director of Rehabilitation

Decatur Memorial Hospital

2300 N. St.

Decatur, IL 62526

CONFIDENTIAL: This email message and any attachments are for the sole

use of

the intended recipient(s) and may contain HIGHLY CONFIDENTIAL PERSONAL

HEALTH INFORMATION. It is to be used only to aid in providing specific

healthcare services to this patient. Any unauthorized review,use,

disclosure, or distribution is a violation of Federal Law (HIPAA)

and will be reported as such.

If you are not the intended recipient or a person responsible for

delivering this message to an intended recipient, please contact the

sender

by reply email and destroy all copies of the original message

immediately.

June 5, 2012

I concur with Rick but since I just answered this for a few hospital folks this

week, I have the reference handy from Transmittal 2457:

B. Access to Accrued Amount

All providers and contractors may access the accrued amount of therapy services

from the ELGA screen inquiries into CWF. Provider/suppliers may access remaining

therapy services limitation dollar amount through the 270/271 eligibility

inquiry and response transaction. Providers who bill to FIs or A/B MACs will

also find the amount a beneficiary has accrued toward the financial limitations

on the HIQA. Some suppliers and providers billing to carriers or A/B MACs may,

in addition, have access to the accrued amount of therapy services from the ELGB

screen inquiries into CWF. Suppliers who do not have access to these inquiries

may call the contractor to obtain the amount accrued.

Beneficiaries are provided with the most current amount accrued toward their

caps on each MSN.

J. Beckley, MS, MBA, CHC | President

Beckley & Associates LLC

P | F

<http://nancybeckley.com/> nancybeckley.com |

<http://rehabcomplianceblog.com/> rehabcomplianceblog.com

<http://nancybeckley.com/> Description: Description: Description: Logo for

email signature3

<http://www.linkedin.com/in/nancybeckley> Description: Description: ZA102637857

Linked In Icon <http://www.twitter.com/nancybeckley> Description: Description:

ZA102637858 Twitter Icon

From: PTManager [mailto:PTManager ] On Behalf Of

Rick Gawenda

Sent: Tuesday, June 05, 2012 7:06 AM

To: PTManager

Subject: Re: medicare cap for hospitals

Your billing department would have access to the CWF. Ask if someone from your

department can be set up on your Medicare contractors system so they will be

able to view this information.

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

http://www.gawendaseminars.com

On Jun 4, 2012, at 6:48 PM, " Laurie " <Lmartin@...

<mailto:Lmartin%40bmhsc.org> > wrote:

> We are struggling with finding a tool that will allow us to pull up the

> beneficiary annual use --- if as it appears - hospitals will come under

> cap effective October 1 - I am assuming we will have to be aware of all

> beneficiary use of PT OT and ST services since beneficiary year

> beginning January 1. That to me makes it critical we be able to

> readily access the common working files or something... so far we have

> not been able to find a tool to access this info easily.... Can anyone

> make a suggestion?

>

> Laurie , Sr Director Rehabiliation Services

>

> Beaufort Memorial Hospital

>

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

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

> Behalf Of M. Howell PT, MPT

> Sent: Friday, June 01, 2012 6:15 PM

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

> Subject: RE: medicare cap

>

> Hi Jeff,

>

> The answer to your question lies in what services are received in a

> nursing

> home setting. Many SNF have an outpatient clinic at the facility or have

> the ability to bill Medicare Part B outpatient services. This should and

> can only be done if the resident does not qualify for rehabilitation

> under

> Part A. It would be something worth investigating, though. There has to

> be

> a medical record of outpatient PT being performed that can be copied if

> requested for the employee's father, so he and the employee can verify

> that

> Part B services were done and recorded.

>

> It doesn't matter what setting, as long as it is an allowable Part B

> charge

> and an allowable location then it counts towards the cap.

>

> Home health service do not count towards the cap HOWEVER, part B

> services

> will be denied payment if the person has not been recorded in the system

> as

> discharged from home health. An outpatient clinic needs to find out if a

> Medicare patient has been receiving home health and if they have been

> discharged at the time they are admitted to/evaluated for outpatient

> Part B

> services.

>

> That being said, home health agencies also sometimes contract or employ

> therapists that are Part B eligible and provide Part B services in the

> home.

> This may confuse the patient because the same agency that provided home

> health is now providing outpatient services in the person's home. This

> is

> done when the patient no longer qualifies for home health but still

> needs

> services in the home. Smart home health agencies have capitalized on

> this

> by having therapists that are Part B eligible contracted or on staff.

>

> It takes a good and educated office staff to track down online and by

> the

> patient what Medicare services the patient/client has actually had prior

> to

> starting a new Part B outpatient case to avoid cap problems and denials.

> If you really have concerns about the cap, use the KX modifier early to

> make

> sure that you don't get a denial for going past the cap AND make sure

> you

> document why in case you are audited in the future.

>

> 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 JEFF BROWN

> Sent: Friday, June 01, 2012 2:41 PM

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

<mailto:PTManager%40yahoogroups.com>

> Subject: medicare cap

>

> I was hoping to get some clarification regarding the hospital outpatient

> Medicare cap. Specifically will the physical, occupational, and speech

> pathology services a resident receives

> while in a nursing home count against the cap allowance? This question

> was

> brought to my attention after an employee in our system got a Medicare

> EOB

> statement for her father, after his discharge from a nursing home,

> stating

> that $800 of the $1880 cap allowance had been utilized by the therapy

> services provided in the NH.

>

> One further question, is it correct that the cap does not apply to Home

> Health therapy services and therefore would not count against the cap

> once a

> patient transitions into outpatient services?

>

> Thanks,

>

> Jeff Brown PT

> Director of Rehabilitation

> Decatur Memorial Hospital

> 2300 N. St.

> Decatur, IL 62526

>

> CONFIDENTIAL: This email message and any attachments are for the sole

> use of

> the intended recipient(s) and may contain HIGHLY CONFIDENTIAL PERSONAL

> HEALTH INFORMATION. It is to be used only to aid in providing specific

> healthcare services to this patient. Any unauthorized review,use,

> disclosure, or distribution is a violation of Federal Law (HIPAA)

> and will be reported as such.

>

> If you are not the intended recipient or a person responsible for

> delivering this message to an intended recipient, please contact the

> sender

> by reply email and destroy all copies of the original message

> immediately.

>

June 5, 2012