Medicare caps, case rate reimbursement and short sightedness

[Guest guest]

I would suggest to all to continue treating patients as is needed and medically

necessary, and not allow the " cap " to factor in on patient care

management.  Then plan on, if needed, using the exceptions process, KX modifier

if your comprehensive care plan will exceed the cap. Even plan on the extra work

of the appeals process. When you set out to manage within the cap, and not on

what the patient will need, you reinforce the cap. When you treat based on the

patient's needs, and exceed the cap, you potential contribute to redefining the

cap. I would speculate that previous utilization of exceptions, KX modifier, and

appeals led to the implementation of the additional higher threshold $3700

per year  Historically, rehabilitation has been poorly compliant with use of the

KX modifier. I see many articles about facilities/groups providing a lot of

ancillary, free services aside from their billed services to manage patients

within the constraints of

the cap and this only serves to provide feedback that the money amount alloted

annually is sufficient. Clinicians should keep in mind, the medicare caps are

not cutoffs, they are thresholds at which Medicare requires more extensive

documentation through the exceptions process for Medicare to review medical

necessity. The caps more favor a " trigger " for Medicare to be alerted to the

need to review a case. This serves to keep Medicare from needing the resources

to review EVERY case.

 

Bisesi MPT, COMT

Winter Haven, FL

[Guest guest]

Good article ,

That has been the problem from the inception in 1999. We initially didn't

let the patient aware that there was a " cap " at that time and regulated our

goals and duration to keep within that limit. Then when we got the exception

process, did not necessarily create a realistic plan but preferred, in some

clinics, to be " safe " from medical review by discharging to the hospital OPT

setting.

In all of my seminars I have emphasized the importance of documentation of

medical need from the inception of treatment, not just only when under the

cap.

I applaud your comment that it isn't a limit, just financial thresholds,

however, under statute it is a limited amount and unless Congress again

allows the exception process or repeals the cap completely, January 1st will

see us capitated at probable not much more than $1890 and therefore, the

Medicare beneficiary denied access to a very important component of their

Part B benefit. Even if the Hospital OPT clinic is exempted, we know that

there is no way they would be able to appropriately care for that many

patients.

ine

ine M. o, PT, MCSP

Owner

Encompass Consulting & Education, LLC

8114 NW 100th Terrace, Tamarac, FL 33321-1259

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From: PTManager [mailto:PTManager ] On Behalf

Of keith bisesi

Sent: Wednesday, August 29, 2012 6:39 PM

To: PTManager

Subject: Medicare caps, case rate reimbursement and short

sightedness

I would suggest to all to continue treating patients as is needed and

medically necessary, and not allow the " cap " to factor in on patient care

management. Then plan on, if needed, using the exceptions process, KX

modifier if your comprehensive care plan will exceed the cap. Even plan on

the extra work of the appeals process. When you set out to manage within the

cap, and not on what the patient will need, you reinforce the cap. When you

treat based on the patient's needs, and exceed the cap, you potential

contribute to redefining the cap. I would speculate that previous

utilization of exceptions, KX modifier, and appeals led to the

implementation of the additional higher threshold $3700 per year

Historically, rehabilitation has been poorly compliant with use of the KX

modifier. I see many articles about facilities/groups providing a lot of

ancillary, free services aside from their billed services to manage patients

within the constraints of

the cap and this only serves to provide feedback that the money amount

alloted annually is sufficient. Clinicians should keep in mind, the medicare

caps are not cutoffs, they are thresholds at which Medicare requires more

extensive documentation through the exceptions process for Medicare to

review medical necessity. The caps more favor a " trigger " for Medicare to be

alerted to the need to review a case. This serves to keep Medicare from

needing the resources to review EVERY case.

Bisesi MPT, COMT

Winter Haven, FL