RE: Another CAP question

[Guest guest]

FYI......and additional follow up ....many of our Outpatients are showing up

today in OP Clinic and have received letters from CMS educating the

beneficiaries about the therapy cap and thresholds. See below additional

information for your perusal.

Requests for Exceptions to the Therapy Threshold:

Manual Medical Review Process

Why is CMS doing this?

This process is required by Section 1833(g)(5)© of the Social Security Act, as

added by Section 3005 of the Middle Class Tax Relief and Job Creation Act of

2012 (MCTRJA), which was signed into law on February 22, 2012.

Why has CMS not issued regulations on this process?

Section 3005(d) of the MCTRJA requires implementation in a timely manner and

authorizes implementation of this process via program instruction.

(d) IMPLEMENTATION.-The Secretary of Health and Human Services shall implement

such claims processing edits and issue such guidance as may be necessary to

implement the amendments made by this section in a timely manner.

Notwithstanding any other provision of law, the Secretary may implement the

amendments made by this section by program instruction.

What is the manual medical review threshold?

$3,700

What does the $3,700 threshold represent?

The threshold represents the total allowed charges under Part B for services

furnished by independent practitioners, and institutional services under Part B

(hospital outpatient departments, skilled nursing facilities).

Does therapy provided in a critical access hospital (CAH) count?

No. Services provided in a CAH are not counted and CAHs are not subject to the

manual medical review provision.

What are the Phases?

Phase I October 1, 2012 to December 31, 2012

Phase II November 1, 2012 to December 31, 2012

Phase III December 1, 2012 to December 31, 2012

How do I know what Phase I am in?

Each provider subjected to a phase will be notified via US Mail. There will also

be a posting to www.CMS.gov with the providers in phase I and II.

How did CMS come up with the phases?

The phases were developed taking into account specific provider characteristics

(e.g., claims volume and payment) and then adjusted to distribute workload

evenly at the Medicare Administrative Contractor.

What are the guidelines CMS contractors will use when conducting the review?

The contractors will use the coverage and payment policy requirements contained

within Section 220 of the Medicare Benefit Policy manual and any applicable

local coverage decisions when making decisions as to whether a service shall be

preapproved.

How long will a contractor have to make a decision on a pre-approval request?

10 business days.

What happens if a contractors decision about request for an exception is not

made within 10 business days?

If a manual medical review decision is not made within 10 business days, the

request for exception will be deemed to be approved.

If a decision was made within 10 business days and the request for an exception

was denied, and the the provider furnishes the service to the beneficiary and

submits a claim, what happens?

The claim is not payable under Medicare, the claim will be denied, and the

beneficiary will be liable for the services.

Why is the beneficiary liable?

Medicare only covers therapy services up to $1,880 cap in 2012. For services

between $1,880 and $3,700, if the conditions for an exception are not met, the

beneficiary is financially responsible. For services above the $3,700 threshold,

if a request for an exception to the $3,700 threshold is not met, the

beneficiary is finanancially responsible.

Am I required to provide the beneficiary an Advanced Beneficiary Notice (ABN)

for services above the therapy cap of $1,880?

There is no legal requirement for issuance of an ABN. However, CMS strongly

recommends a voluntary ABN where the provider believes that Medicare may not

cover the services.

How is the $3,700 calculated?

The $3,700 is calculated using all outpatient therapy services provided (except

those provided in Critical Access Hospitals) within the category of physical

therapy/speech language therapy and then a separate category for occupational

therapy services.

If I am in Phase III, what happens to my claims during the timeframe of October

1, 2012 to November 30, 2012?

Phase III is scheduled to begin for services expected to be furnished on or

after December 1, 2012. Claims for services furnished before this time will be

treated in the same manner as claims for services below the $3,700 threshold.

If I am in Phase III would a Medicare contractor conduct review of my claims

from October 1, 2012 to November 30, 2012?

Medicare contractors have the authority to review any claim at any time.

How to I know where to submit my request for exception?

Please check the website of the Medicare contractor to whom you submit your

claims for processing for detailed information on where to submit your request

for exception for therapy services above the $3,700 threshold.

Will claims that are pre-approved be guaranteed payment?

Authorization does not guarantee payment. Retrospective review may still be

performed.

Why would a Medicare contractor review therapy that has been pre-approved?

There are many reasons retrospective review would be needed after a

pre-approval:

clinically inappropriate modalities;

patient's clinical therapy needs do not match what was reported, e.g.

* Patient's functional level is greater than reported,

* Patient reached functional independence more quickly than predicted.

Excessive or inappropriate therapy was furnished, e.g.

* therapy more often or of longer duration than is medically r/n;

* therapy provided to clinical treatment area not reasonable and necessary, e.g.

therapy to shoulder when knee is the issue

What happens if I request pre-approval and gain approval for 20 treatment days

and I actually furnish 30 treatments?

The claim will be subject to prepayment medical review.

What is CMS doing to educate beneficiaries about the therapy cap and the

threshold?

CMS will be conducting a mailing in September to beneficiaries who have received

therapy services at or near the cap. The mailing will inform them of the cap and

of the fact that if services above the cap are denied, that they will be

financially liable.

Therapy Cap Fact Sheet

Medicare Part B Outpatient Therapy Cap and Exceptions Process

The Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630) was signed

into law on February 22, 2012. The law extends the Medicare Part B Outpatient

Therapy Cap Exceptions Process through December 31, 2012.

Background

The statutory Medicare Part B outpatient therapy cap for Occupational Therapy

(OT) is $1,880 for 2012, and the combined cap for Physical Therapy (PT) and

Speech-Language Pathology Services (SLP) is also $1,880 for 2012. This is an

annual per beneficiary therapy cap amount determined for each calendar year.

Medicare allowable charges,which includes both Medicare payments to providers

and beneficiary coinsurance, are counted toward the therapy cap. In outpatient

settings, Medicare will pay for 80 percent of allowable charges and the

beneficiary is responsible for the remaining 20 percent of the amount.

The therapy cap applies to all Part B outpatient therapy settings and providers

including:

private practices,

skilled nursing facilities,

home health agencies,

outpatient rehabilitation facilities, and

comprehensive outpatient rehabilitation facilities.

Beginning this year, the therapy cap will also apply to therapy services

furnished in hospital outpatient departments (HOPDs) until December 31, 2012.

Before 2012, therapy provided in hospital outpatient departments did not count

towards the therapy cap.

The law requires an exceptions process to the therapy cap that allows providers

to receive payment from Medicare for services above of the therapy cap amount.

Therapy furnished by providers must always be reasonable and medically

necessary, require the specialized skills of medical professional, and be

justified by supporting documentation in the patient's medical record. When

these conditions are met for care exceeding the therapy cap in a calendar year,

which is $1,880 for 2012, a provider may submit claims for a beneficiary with a

KX modifier included on the claim form. The KX modifier on the claim indicates

that the requirements for an exception to the therapy cap have been met. Claims

that exceed the cap and do not include the KX modifier will be denied.

Manual Medical Review Process

Beginning on the date of the phase-in indicated below, certain providers will be

required to submit a request for an exception for therapy services above the

threshold of $3,700. Similar to the therapy cap, there is a threshold of $3,700

for PT and SLP services combined and another threshold of $3,700 for OT

services. Such requests for exceptions will be manually medically reviewed.

To ensure a timely and orderly implementation, providers within a Medicare

Administrative Contractor (MAC) jurisdiction will be divided into three Phases.

Each specific provider will be notified of their status in the phase-in process.

Providers will be required to submit requests for exceptions to the threshold in

advance of furnishing therapy services above the threshold. The phases are as

follows:

* Phase I Oct 1, 2012 to December 31, 2012

* Phase II Nov 1, 2012 to December 31, 2012

* Phase III Dec 1, 2012 to December 31, 2012

o The Phase for a provider is based on CMS analysis taking into account the

billing practices of the provider as well as the workload of the MAC.

There will be no automatic exceptions granted for the requests fof exceptions

above the threshold solely on the basis of a specific diagnosis.

The contractors will use the coverage and payment policy requirements in Section

220 of the Medicare Benefit Policy manual and any applicable local coverage

decision policies when making determinations for approving therapy services

above the threshold.

Claims received for therapy services above the threshold which have not been

approved for a provider assigned within a specific phase, shall be subject to

prepayment review upon receipt for payment.

Requests for exceptions can be made in increments of 20 treatment days.

Contractors will have 10 business days to review the request for exception to

the threshold using the manual medical review process. The 10-day timeframe

starts when the contractor has obtained all necessary documentation from the

provider. If a contractor fails to make a decision within 10 business days of

receiving a request containing all the required documentation the request will

be automatically approved.

Each MAC will have detailed instructions posted to their websites on how to

submit a request for an exception to the threshold before September 1, 2012.

Providers will be notified via US Mail before September 1, 2012 about the

process to request an exception to the threshold and manual medical review

process on the CMS website and which Phase the provider is assigned.

Outreach and Education

Letters will be sent to beneficiaries who have received $1,700 or more in

therapy services in CY 2012. The letter will inform them that if services are

furnished above the therapy cap of $1,880 in 2012, and the requirements for an

exception are not met, then the beneficiary would be financially responsibility

for these services.

The letters sent to beneficiaries will also inform that that if services

furnished above the $3,700 threshold have not been approved by the manual

medical review process in response to submission of a request for an exception,

then the beneficiary would also be financially responsible for these services.

Notification letters and other outreach activities will be undertaken to inform

beneficiaries and providers of the manual medical review process for therapy

services above the threshold.

o CMS will host an Open Door Forum on Tuesday, August 7th, 2012 at 2 pm, to

provide additional information and answer any questions had on the

implementation of the medical review of therapy services to begin October

1-December 31, 2012.

Further questions?

You can contact CMS with questions about the therapy cap and new threshold via a

designated email box, at therapycapreview@....

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

Ron Barbato

Sent: Tuesday, September 04, 2012 10:18 AM

To: PTManager

Subject: Another CAP question

Those of use who " drop bills " monthly , any ideas on how you are going

to track the CAP?

I guess we could manually keep track by patient using allowable billing

per CPT code?

Ron Barbato PT

Administrative Director, Rehabilitation Services

Program Director, Cancer Support Services

Ephraim McDowell Health

rbarbato@...<mailto:rbarbato%40emrmc.org>

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