medicare cap for hospitals

[Guest guest]

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.