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Taking Part B Therapy
Beyond the $3,700 Threshold New Manual Medical Review Process
Effective date October 1, 2012
Presented by:
Leigh Ann Frick, PT, MBA Vice President of Clinical Services
Heritage Healthcare
Agenda
• Therapy Cap Review & History
• Outpatient Hospital-Based Inclusion
• Continued Use of KX Modifier
• Manual Medical Review Process
• National Provider Identifier (NPI)
Requirement
• Next Steps
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History of Therapy Caps
• Statutory Medicare Part B outpatient therapy caps for 2012:
– OT: $1,880
– Combined PT & SLP: $1,880
• Medicare Part B Outpatient Therapy Cap Exceptions Process extended through December 31, 2012
– Middle Class Tax Relief and Job Creation Act of 2012
• Medicare allowable charges counted toward cap
– Includes Medicare payments to providers & beneficiary coinsurance
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Therapy Caps
• Applies to all Part B outpatient therapy settings & providers, including: – Private Practices
– Part B Skilled Nursing Facilities (SNFs)
– Home Health Agencies (TOB 34X)
– Outpatient Rehab Facilities (ORFs)
– Rehabilitation Agencies
– Comprehensive Outpatient Rehabilitation Facilities (CORFs)
– Hospital Outpatient Departments (HOPDs) beginning October 1 through December 31, 2012
• Claims paid for outpatient therapy services since January 1, 2012 will be included in caps’ accrual totals
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Therapy Caps Exceptions Process
• Exceptions process allows cap to be exceeded, IF therapy services:
– Are reasonable & medically necessary
– Require the specialized skills of a medical professional
– Are justified by supporting documentation in the patient’s medical record
• KX modifier MUST be included on the claim once cap is exceeded
– Attests that the requirements for an exception to the therapy cap have been met
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Manual Medical Review Process
• Required per Section 3005 of the Middle Class Tax Relief & Job Creation Act of 2012
• Establishes a pre-approval process for
therapy services that exceed the following
thresholds:
– OT: $3,700
– Combined PT & SLP: $3,700
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New Manual Medical
Review Process • Applies to all Part B outpatient therapy settings &
providers, including: – Private Practices
– Part B Skilled Nursing Facilities (SNFs)
– Home Health Agencies (TOB 34X)
– Outpatient Rehab Facilities (ORFs)
– Rehabilitation Agencies
– Comprehensive Outpatient Rehabilitation Facilities (CORFs)
– Hospital Outpatient Departments (HOPDs) beginning October 1, 2012 until December 31, 2012.
• Thresholds will accrue for claims with dates of service from January 1, 2012 through December 31, 2012
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Phase-In of Review Process
• Review process being phased-in: – Phase I October 1 – December 31, 2012
– Phase II November 1 – December 31, 2012
– Phase III December 1 – December 31, 2012
• Providers assigned to phases based on CMS’ analysis of providers’ billing practices & MAC’s workload
• CMS mailed letters to providers notifying them of the phase to which each had been assigned – Details posted to CMS’ website:
https://data.cms.gov.dataset/Therapy-Provider-Phase- Information/ucum-64-bit
– NPIs listed for providers assigned to either Phase I or II
– Providers are in Phase III if NPI is not listed
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Q & A on Phase-In
Q If I am in Phase III, what happens to my claims during the timeframe of October 1, 2012 to November 30, 2012?
A Phase III is scheduled to begin for services expected to be furnished on or after December 1, 2012. Claims furnished for services furnished before this time will be treated in the same manner as claims for services below the $3,700 threshold.
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Coverage & Policy Guidelines
• MAC will use coverage & payment policy
requirements as outlined in Section 220 of
the Medicare Benefit Policy Manual, as
well as any local coverage decisions (LCDs)
in the decision-making process for
approvals.
– http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/bp1
02c15.pdf
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Manual Medical Review Process
• Requests for OT services exceeding $3,700
threshold or PT/SLP services exceeding
$3,700 need to be approved in advance
– No automatic exceptions
• MAC will not approve more than 20
treatment days at one time
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Information Required in
Pre-Approval Request • Beneficiary Last Name
• Beneficiary First Name
• Beneficiary Middle Initial
• Beneficiary Medicare Claim Number (HICN)
• Beneficiary Date of Birth
• Beneficiary Address & Telephone Number
• Name of Provider Certifying Plan of Care
• Address of Provider Certifying Plan of Care
• Telephone & Fax Number of Provider Certifying Plan of Care
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Information Required in
Pre-Approval Request – continued
• Provider Number of Physician/ non-physician practitioner (NPP) Certifying Plan of Care
• Name of Performing Provider
• Address of Performing Provider
• Performing Provider Number
• Telephone & Fax #s of Performing Provider
• Number of treatment days requested
• Expected date range of services
• Date of Submission
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Information Required in
Pre-Approval Request – continued
• A cover/transmittal sheet containing the following information & documentation: – Cover sheet
– Justification
– Evaluation or reevaluation(s) for Plan(s) of Care
– Certification(s) of the Plan(s) of Care, where available
– Objectives, measurable goals & any other documentation requirements of the Local Coverage Determinations (LCDs)
– Progress reports
– Treatment notes
– Any orders, if applicable, for the additional therapy services
– Any additional information requested by the Medicare contractor
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Exception Approval Process
• Submission by US Mail or fax, according to MAC’s instructions
• MAC has 10 business days from the time it receives all necessary documents to approve or deny the request – Recommend providers retain proof of receipt by MAC
(i.e., fax confirmation & cover sheet that specifies date/time of submission, return receipt or certified mail)
• MAC will inform the provider & beneficiary of the decision by telephone, fax or letter (must be postmarked by the 10th day) – Providers must monitor this closely
• Phase I submissions accepted beginning September 16
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Exception Approval Process – continued
• MACs will inform providers of tracking mechanism being used for preapproval requests & how to submit claims
• If request is denied, provider may submit a new request if it has additional information for consideration
• Each MAC has defined the process it uses for pre-approval
– Check your MAC’s website for specific instructions
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• Providers instructed in the transmittal to
use the HIPAA Eligibility Transaction
System (HETS) to determine whether a
patient is approaching the $3,700
threshold
• As a reminder, the Common Working File
(CWF) does not reflect all of the claims at
any given time
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Exception Approval Process – continued
Out of Sequence Claims
• Medicare has a 12 months claims filing limitation
– Claims may be received and processed in a sequence different than that of the services provided
– Contractor is not required to conduct post payment review on claims that would have been subjected to the $3700 manual medical review threshold had the claims been received & processed in the order provided
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Out of Sequence Claims – continued
• Example: – Beneficiary in SNF receives PT services under Part B totaling
$3600 (all dates of service before October 1, 2012).
– Beneficiary discharged from the SNF & received therapy services from an independently practicing PT totaling $1,800.
– The independent PT bills in November 2012 for services provided after October 1, 2012. The MAC receives the claims & processes them.
– After these claims are processed the MAC receives the SNF Part B claims totaling $3,600 & processes them.
– Had the SNF Part B claims been received in advance of the independent PT services, the independent PT would have been required to have the services approved in advance.
– In circumstances such as this example, the contractor is not required to perform post-payment review on the $1,800 provided by the independent therapist.
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Pre-approval…
What does that mean?
• Pre-authorization is not a guarantee of
payment
• Claims receiving pre-approval still subject
to retrospective review
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Therapy Cap Determination
• In applying the caps after October 1, 2012, claims paid for outpatient therapy services since January 1, 2012 will be included in the caps accrual totals.
• The threshold is determined by the Part B totals billed from January 1, 2012, including hospital outpatient therapy that was provided.
• If an exception is not requested in advance of any treatment beyond the $3,700, payment will stop & a request for medical records will be sent to the provider for a prepayment review.
CMS Communication with
Beneficiaries
• In September, CMS sent letters to beneficiaries for whom Medicare has paid at least $1,700 for therapy services in 2012
• Letters described beneficiary’s financial liability for services provided above the $1,880 cap if the exception requirements are not met
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CMS Communication with
Beneficiaries – continued • Letter stated:
“Even if your therapist or doctor asks for an exception, this isn’t a guarantee that you won’t have to pay for costs above the $1,880 therapy cap amounts. If Medicare decides at any time that your therapist or doctor didn’t show enough proof that your therapy services were medically necessary, you may have to pay for the total cost of the services above the $1,880 therapy cap amounts.”
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• Letters to
beneficiaries do not
mention the $3,700
threshold or potential
beneficiary liability if
the services are not
pre-approved
through the manual
medical review
process
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CMS Communication with
Beneficiaries – continued
Information & Education
• Use of the voluntary
Advanced Beneficiary
Notice of Non-
coverage (ABN) is not
required, but CMS
strongly recommends
using it when the
provider believes
Medicare may not
cover the services.
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Additional Changes – NPI
• Beginning October 1, 2012, the National
Provider Identifier (NPI) of the physician
(or non-physician practitioner (NPP),
where applicable) certifying the therapy
plan of care is to be reported on all claims
for therapy services
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Next Steps? • Communication/dialogue with residents/ members?
• Use of Voluntary ABN?
• Communicate your phase –in date with
Rehab Manager/Director of Rehab
• Review your MAC’s website for further
instructions
• Establish tracking mechanisms & procedures
to integrate this process into current systems
• Ensure business office has NPIs for all
physicians & NPPs
• Communicate with business office on Part B dollars for patients near $3,700
threshold
• Run a therapy cap report & determine who will need an exception submitted
• Business Office Manager to check the CWF to see where patients are in
regard to the caps…this does not yet show the total dollars paid or the
amount compared to the threshold.
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PHASE I
• MACs were able to begin
conducting pre-approval
request reviews on
September 16, 2012.
• Providers that have not
submitted pre-approval
requests should submit
pre-approval requests
ASAP and contact their
MACs
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Summary
• What phase were you assigned to for implementation of the manual medical review process?
• What are your MAC’s requirements?
• Who is responsible for what task?
• Communicate: Make certain that the entire team (including the beneficiary) knows and understands the rules.
• Re-evaluate systems and processes in light of new requirements.
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Source Documents
• Middle Class Tax Relief & Job Creation Act of 2012 • CMS Manual System Change Request 8036/
Transmittal 1117
• MLN Matters Number MM8036, August 31, 2012
• CMS Requests for Exceptions to the Therapy Threshold: Manual Medical Review Process
• CMS Therapy Cap Sheet
• CMS Medicare Claims Processing Change Request 7785/Transmittal #2457
• CMS Special Open Door Forum August 7, 2012 Transcript
• www.cms.gov
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Thank you for joining us.
NASL & AHCA/NCAL thanks today’s presenter:
Leigh Ann Frick, PT, MBA
Heritage Healthcare, Inc.
Webinar sponsored by: National Association for the Support of Long Term Care (NASL)
www.nasl.org
American Health Care Association & National Center for Assisted Living (AHCA/NCAL)
www.ahca/ncal.org
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