Congress overrides President's Veto: Key Provisions Critical for Physical Therapy Providers: 

Congress overrode President Bush’s veto of the Medicare Improvements for Patients and Providers Act of 2008, which was therefore enacted on July 15, 2008. The following are the key provisions critical to physical therapist practice and those patients needing skilled physical therapy interventions in the outpatient environment:

·         An 18 month extension of the therapy cap exceptions process until December 31, 2009 to ensure access for seniors and persons with disabilities to physical therapy, occupational therapy, and speech-language pathology services.

·         An updated Conversion Factor of .5% for the remainder of 2008 and a 1.1% update for 2009 in the conversion factor to maintain adequate payments to providers under the Medicare program. This provision overrides a scheduled 10.6% reduction in payments under the Medicare physician fee schedule for the reminder of 2008 and an additional 5.0% cut for 2009.

·         An extension of the Medicare Work Geographic Practice Cost Index (GPCI) under the Medicare physician fee schedule to ensure payment equity and access to services in rural America.

·         An increase in the bonus payments for qualified providers that meet the criteria for reporting under the Physician Quality Reporting Initiative (PQRI) from 1.5% to 2.0% for 2009 and 2010 to improve quality in the Medicare program.

·         A delay in the competitive bidding of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) under Medicare for 18 months by voiding Round 1 of the DMEPOS competitive acquisition program. This provision sets a new process for competitive bidding. DMEPOS items included in round 1 will be reduced by 9.5% to off-set the cost of this provision.

·         An improvement in Medicare coverage of prevention services for seniors and persons with disabilities.

·         An expansion in the scope and duration of previously authorized medical home demonstration to improve access to primary health care.

We will provide additional information as things change.

APTA Members can access additional information at www.apta.org

News from CMS: 10 Day Hold on Claims Submitted beginning July 1, 2008

Comprehensive Outpatient Rehabilitation Facility (CORF) Issues
CMS proposes to cross-reference to the new personnel qualification for physical therapy, occupational therapy, and speech-language pathology as delineated in 42 CFR 484.4. and clarifies that alternate premises for the provision of PT, OT, and SLP services may be the patient’s home.

Physician and Nonphysician Practitioner Enrollment Issues
In the proposed Rule, CMS expresses concerns with their current policy that allows physicians and nonphysicians to retroactively bill for services provided prior to the date that they enrolled in the Medicare program. CMS solicits public comments on two approaches for establishing an effective date for Medicare billing privileges for physicians and nonphysician organizations and individual practitioners. The first approach would establish the initial enrollment date as the date of approval of the enrollment application by the Medicare contractor. The date of approval is the date that a Medicare contractor determines that all Federal and State requirements are met. The second approach would establish the initial enrollment date as the later of: 1) the date of filing of Medicare enrollment application that was subsequently approved by a fee-for-service (FFS) contractor; or 2) the date an enrolled supplier first started rendering services at a new practice location. This option would allow a supplier that is already seeing non-Medicare patients to start billing for Medicare patients beginning on the day they submit an enrollment application that can be fully processed. Also, if physicians and NPPs billing privileges have been suspended or they have an existing overpayment, CMS proposed to prohibit them from obtaining additional billing privileges.

Quality Standards for Physicians and Nonphysician Practitioners Providing Diagnostic Testing Services
CMS proposes that physicians and NPPs who furnish diagnostic testing services must enroll as an independent diagnostic testing facility for each practice location furnishing these services. This proposal could impact physical therapists who perform EMGs/NCVs and other diagnostic tests. According to this proposal, physicians and NPPs who are currently enrolled in Medicare would have until September 30, 2009 to comply with these standards.

Physician Certification and Recertification for Medicare-Covered Home Health Services
CMS asks for feedback on a proposal setting new requirements to ensure more active physician involvement in the certification and recertification of the home health plan of care, such as “direct” patient contact with the physician.

Members of the American Physical Therapy Association can find additional information on the APTA website at www.apta.org

For the complete version of the 2009 Medicare Physician Fee Schedule Rule, click here

CMS Publishes May 2008 CERT Report
CMS issued its mid-year May CERT report, dated May 16. Consistent with the November 2007 report, once again CPT codes 97110 (6.3%) and 97140 (9.9%) were in the list of services with the top 20 errors for insufficient documentation. Insufficient documentation means that the provider did not include pertinent patient facts (e.g., the patient’s overall condition, diagnosis, and extent of services performed) in the medical record documentation submitted.  Although physical therapist services were not specifically identified in the top 20 of any of the other areas of error, Skilled Nursing Facilities and Home Health Agencies were included on lists with high error rates.

For the full May 2008 CERT Report, click here

CMS Publishes Transmittal 88, outlining guidance related to the November 27, 2007 Final Rule
The Centers for Medicare and Medicaid Services has published Transmittal 88 (Change Request 5921), which provides the long awaited guidance on key areas for outpatient therapy services, as well as the application of some of these requirements, including personnel qualification standards, to the inpatient environment. Transmittal 88 provides additional clarification to Transmittal 63, which was published on 12/29/06. Much of Transmittal 63 remains unchanged, however the areas of focus of the new Transmittal includes the extension of the Plan of Care recertification time frame from 30 to 90 days, and the documentation requirements related to this. Additional areas of clarification and guidance include:

• Minimum contents of the Plan of Care (POC), to include the diagnosis, long term treatment goals, and the type, amount, frequency, and duration of treatment (unchanged from Transmittal 63)

• Clarification that tapering of the frequency of treatment may be reasonable, and that frequency and duration alone should not be the basis of determining medical necessity

• Clarification that the physician has up to 30 days after development of the POC to provide timely certification, and clarifies the parameters for delayed certifications

• Progress reporting period is clarified to be every 10 visits or 30 calendar days, whichever is less

• Time frames for recertification of POC does not affect the time frames required for completion of the Progress Report

• Clarification of signature requirements, which eliminates the ability to use stamped signatures

• Modification of the use of a swimming pool for Medicare purposes, which now allows the provider/supplier (except Rehabilitation Agencies (OPTs) and CORFs) to rent/lease the pool or a specific portion of the pool, as long as that portion is used exclusively for Medicare patients during the time of use by the provider/supplier

• Qualified physical therapist is defined, and definition of a physical therapist assistant is provided. These qualification standards apply to all settings

• The Transmittal effective date is January 1, 2008, and the implementation date is June 9, 2008

APTA has written a summary of Transmittal 88, which is available to APTA members at www.apta.org. 

To download Transmittal 88, click here

CMS Publishes new data on Therapy Utilization
The Centers for Medicare and Medicaid Services has published a report entitled CY 2006 Outpatient Therapy Services Utilization Report, which identifies that the current Therapy Cap policy with the Exceptions Process has caused the first negative utilization growth since the implementation of the therapy caps in 1999!

CMS Recovery Audit Contractor Program Identifies $371.5 Million in Improper Medicare Payments in Three States: Physical therapists and physical therapy providers need to focus on accuracy of coding, billing, documentation, and medical necessity!

To read more about the Recovery Audit Contractor Program and its expansion to the entire country, read our article, written initially for Impact, the magazine of the Private Practice Section of the American Physical Therapy Association (printed October, 2007). The Article has been updated, and is available by clicking here!!

New Advanced Beneficiary Notice (ABN) now available. Use of new ABN mandated by September 1, 2008!

Beginning March 3, 2008, physical therapists and physical therapy providers may use the revised ABN for all situations where Medicare payment is expected to be denied. The revised ABN replaces the existing ABN-G (Form CMS-R-131G) and NEMB (Form CMS-20007). CMS will allow a 6-month transition period from the date of implementation for use of the revised form and instructions. Thus, all providers and suppliers must begin using the revised ABN (CMS-R-131) no later than September 1, 2008.

The ABN is a notice given to beneficiaries to convey that Medicare is not likely to provide coverage in a specific case. Providers must complete the ABN and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice. The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raise during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice.

While previously the ABN was only required for denial reasons recognized under section 1879 of the Act, the revised version of the ABN may also be used to provide voluntary notification of financial liability. Thus, this version of the ABN should eliminate any widespread need for the Notice of Exclusion from Medicare Benefits (NEMB) in voluntary notification situations.

For more information on the revised ABN, click here

Congress Passes and the President signs the Medicare, Medicaid, and SCHIP Extension Act of 2007!

On December 29, 2007 the President signed into law S 2449, the Medicare, Medicaid, and SCHIP Extension Act of 2007, which postponed the Medicare therapy cap and scheduled cuts to the physician fee schedule, which would have imposed a 10.1% reduction in the Medicare Physician Fee Schedule. The Act contains several provisions important to physical therapists and their patients, including:

Physician Quality Reporting Initiative (PQRI) provides an incentive for physical therapists to report quality measures- Therapists could see up to 1.5% bonus payment!

Medicare began the PQRI incentive program in 2007, with only one measure available to physical therapists, Screening for Future Fall Risk (Measure #4). APTA has been heavily involved with advocating and negotiating for additional measures to be accessible to physical therapists. As a result of these efforts, in 2008 physical therapists have access to 8 Quality Measures which could provide bonus payments when reported consistently:

DON'T LET THIS HAPPEN TO YOU!

The U.S. Dept. of Health & Human Services Office of Inspector General (OIG) issued a report in December 2007, entitled "Review of Texas Physical Therapist's Medicare Claims for Therapy Services Provided during 2002" and recommended that the physical therapist "refund to the Medicare program $281,325 in unallowable payments for therapy services provided in 2002, and develop quality control procedures to ensure that therapy services are provided and  documented in accordance with Medicare reimbursement requirements."

The report went on to say that none of the 100 sampled claims met Medicare's reimbursement requirements. "In total, 688 of the 702 physical therapy services contained in the sampled claims did not meet one or more of the Medicare reimbursement requirements because:

• the physical therapist inappropriately used his provider identification number to bill for services  performed or supervised by someone else,

• the documentation for therapy services did not meet Medicare requirements,

• therapy services provided were not medically necessary and reasonable,

• plans of care did not meet Medicare requirements,

• Medicare was billed instead of the responsible insurer, and

• cardiac rehabilitation services provided did not meet Medicare requirements.

• the physical therapist inappropriately used his provider identification number to bill for services  performed or supervised by someone else,

• the documentation for some therapy services did not meet Medicare requirements,

• some therapy services were miscoded, and

• a plan of care did not meet Medicare requirements.

Both reports clearly identified that the physical therapist did not have a thorough understanding of Medicare requirements and did not have effective policies and procedures in place to ensure that he billed Medicare only for services that met Medicare reimbursement requirements".

Physical therapists and physical therapy providers must ensure that they are aware of and appropriately compliant with Medicare rules and regulations.

Click here to read the August 2007 OIG report.

Click here to read the December 2007 OIG report.