Therapy Cap: Exceptions• January 1 - October 1, 2012: an automatic exception

to the therapy cap may be made when documentation supports the medical necessity of the services beyond the cap. Providers should use the KX modifier.

• October 1, 2012 - December 31, 2012: an automatic exception may be made for claims between $1880-$3700 (use KX modifier).

• October 1, 2012 - December 31, 2012: Claims exceeding $3700 in expenditure will be subject to manual medical review to be paid.

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2012 Therapy Cap: Hospitals

• Starting October 1, 2012 the therapy cap with an exceptions process will apply to Part B SNF, CORF, ORF, private practices, Rehabilitation agencies, and Hospital Outpatient Departments (critical access hospitals are exempt).

• Hospitals would no longer be subject to the therapy cap after December 31, 2012 unless Congress extends the provision in future legislation.

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2012 Therapy Cap: Dollars Accrued

• Therapy cap is based on the allowed charges.

• Medicare Part B will pay 80% of the allowed charges ($1504.00) and the beneficiary will be responsible for the remaining 20% ($376.00).

• MPPR reduction is included in the amount of the allowed charges.

2012 Therapy Cap: Dollars Accrued

• C-SNAP uses the Centers for Medicare & Medicaid Services (CMS) beneficiary eligibility system to provide our Real-time Eligibility data.

• http://www.wpsmedicare.com/j5macpartb/resources/claims_elig_tools/csnap/

Therapy Evaluations

• Therapy evaluations after the therapy caps are reached to determine if the patient needs therapy services would be exempt from the cap.  (97001 (PT evaluation) & 97002 (PT re-evaluation). 

Therapy Cap: Manual Medical Review

• Phase I providers: Subject to manual medical review from October 1‐December 31, 2012.

• Phase II providers: Subject to manual medical review from November 1‐December 31, 2012.

• Phase III providers: Subject to manual medical review from December 1‐December 31, 2012.

• List of NPIs and phases to which they are assigned is available at:

https://data.cms.gov/dataset/Therapy-Provider-Phase-Information/ucun-6i4t

Therapy Cap: Manual Medical Review

• PROVIDERS SHOULD NOT SEND IN CLAIMS FOR PRE-APPROVAL BEFORE THE SCHEDULED BEGIN DATE FOR EACH PHASE (see next slide for dates)

PhasePre-approval Start

DateService Start Date

Phase I September 16, 2012 October 1, 2012

Phase II October 17, 2012 November 1, 2012

Phase III November 16, 2012 December 1, 2012

Therapy Cap: Manual Medical Review

• PROVIDERS MUST SUBMIT REQUEST ON CORRECT FORM (wrong form = no review)

• PROVIDERS SHOULD CONTACT THEIR REPSECTIVE MAC OR LEGACY TO DETERMINE THE APPROPRIATE FORM

Therapy CAP Exception Preapproval Request

PART A (BILL ON UB04 FORM)

WPS – Medicare Attention: Medical Review Department

3333 Farnam Street, Suite 600 Omaha, NE 68131

**WPS only accepts paper submissions mailed to the above address.

Beneficiary Last Name ________________First Name _________ Middle initial _____

HIC #_______________________ Beneficiary Date of Birth_____________________

Ordering Provider Name ________________________________________________

Ordering Provider PTAN/NPI # ____________________________________________

Ordering Provider Address ________________________________________________

City _____________________________State ________ Zip Code ________________

Contact Phone # ________________________________________________________

Performing Provider Name _______________________________________________

Performing Provider PTAN/NPI # ___________________________________________

Performing Provider Address______________________________________________

City _____________________________State ________ Zip Code________________

Contact Phone # ________________________________________________________

Number of treatment days requested: PT ________________________ Number of treatment days requested: OT ________________________ Number of treatment days requested: SLP _______________________ Expected date range of services: PT ____________________________ Expected date range of services: OT ____________________________ Expected date range of services: SLP ___________________________ Requestor:_________________________________________________ Date of submission:__________________________________________ Phone # and Email address____________________________________

This Cover Sheet must be submitted to process preapproval request

Therapy CAP Exception Preapproval Request

PART A (BILL ON UB04 FORM)

This Cover Sheet and the following requested information and documentation must be submitted with the preapproval request:

Justification for the extended treatment days

Evaluation/Reevaluation form to include:

o Physician order

o Signed and dated certification by physician

o Date of evaluation o Start of care date

o Medical diagnosis & Treatment diagnosis

o Onset date

o Current level of function

o Prior level of function

o Treatment plan with long and short term goals

Previous Therapy administered to include:

o Date

o Diagnosis for treatment

o Modalities administered

Three months of progress reports and treatment notes detailing service provided for each date of

service billed

Grid reflecting service/HCPCS provided

Actual minutes provided to support each timed service/HCPCS provided

Advance Beneficiary Notice (if applicable)

Request for advance preapproval for therapy services above $3,700

PART B (BILL ON HCFA 1500 FORM)

Please submit the following information to: WPS Medicare

Attention: Medical Review Department 1717 West Broadway Madison, WI 53713

**WPS only accepts paper submissions mailed to the above address.

Beneficiary Last Name ________________First Name_________ Middle initial______

HIC #_______________________ Beneficiary Date of Birth_____________________

Ordering Provider Name ____________________________

Ordering Provider PTAN/NPI #____________________

Ordering Provider Address ________________________________________________

City _____________________________State ________ Zip Code _________________

Contact Phone # __________________

Performing Provider Name ____________________________

Performing Provider PTAN/NPI #____________________

Performing Provider Address ______________________________________________

City _____________________________State ________ Zip Code ________________

Contact Phone # __________________

Number of treatment days requested: PT ____________ Number of treatment days requested: OT ____________ Number of treatment days requested: SLP ____________ Expected date range of services: PT __________________ Expected date range of services: OT __________________ Expected date range of services: SLP __________________ Requestor: _________________________________________________ Date of submission: __________________________________________ Phone # and Email address____________________________________

Request for advance preapproval for therapy services above $3,700

PART B

This Cover Sheet must be submitted to process preapproval request This Cover Sheet and the following requested information and documentation must be submitted with the preapproval request:

Documentation that supports the individual is under the care of a physician (such as an order or referral for additional therapy services).

Initial evaluation and any re-evaluations to support medical necessity.

Initial certification and any subsequent recertification of the Plan of Care.

Any documentation supporting medical necessity for the extended services.

A Plan of Care (signed and dated) established by a physician/nonphysician practitioner (NPP) or by the therapist

providing the services. The plan of care must contain:

o Diagnosis

o Objective and measurable treatment goals; and

o Type, amount, duration and frequency of therapy services

Treatment progress notes for three (3) months prior to the requested dates of extended services which include:

o Date of treatment;

o Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding;

o Total timed code treatment minutes and total treatment time in minutes. Total treatment time

includes the minutes for timed code treatment and untimed code treatment. Total treatment time does not include time for services that are not billable (e.g. rest periods); and

o Signature and professional identification of the qualified professional who furnished or supervised the

services and a list of each person who contributed to that treatment.

Therapy treatment logs.

All flow sheets pertinent to therapy provided.

Qualifications of personnel providing services.

Therapy discharge notes (if applicable).

Information on any special devices being used for therapy services.

Written/telephone physician orders.

Signature key for all flow sheets. A key for non-standard abbreviations.

Therapy Cap: Manual Medical Review

• FORM MUST BE MAILED

• DO NOT FAX FORM

• RECOMMEND CERTIFIED MAIL

• WPS WILL NOT TRACK IF IT WAS RECIEVIED or NOT RECIEVED

Therapy Cap: Manual Medical Review

• Medicare Administrative Contractors (MAC) will have 10 business days to make decisions regarding whether services will be approved over the $3700 amount. If a provider request is not reviewed by MAC within 10 business days, claims beyond the $3700 threshold will be approved.

• Advanced approval will allow an additional 20 treatment days beyond the $3700 amount.

• Provider will use modifier on claim form to indicate advance approval given.

• Advanced approval does not guarantee payment. – Retrospective review may still be performed. – There is an APPEAL PROCESS for “Retrospective Review”– NO APPEAL PROCESS for Manual Review

Therapy Cap: Manual Medical Review

• If a provider does not request advanced approval prior to providing services over $3700, payment for the claims will stop and a request for medical records will be sent to the provider.

• The provider will be subject to prepayment review for those claims and the time frame for review will be approximately 60 days.

Part A (facilities) Mail To: WPS Medicare Attention: MR Department

3333 Farnam St., Suite 600Omaha, NE 68131

J5 / J8 Part B (practitioners) Mail To: WPS Medicare Attention: MR Department

1717 West BroadwayMadison, WI 53713

Legacy Part B (practitioners) Mail To: WPS Medicare Attention: MR Department

8120 Penn Ave S, Suite 200 Bloomington, MN 55431

Therapy Cap: Manual Medical Review

• There is NO APPEAL PROCESS with the Manual Review (must submit another review)

Therapy Cap: Example • Patient A receives therapy services at a SNF (Part B)

from January 15, 2012-April 20, 2012 and accrues $3800.00 toward the therapy cap.

• Patient A is discharged from the SNF and later goes to an outpatient hospital department for therapy on October 15, 2012.

• The hospital would need to request manual medical review to get coverage for these services because the patient has already exceeded the $3700 threshold.

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Therapy Cap: Example• Patient A receives therapy services from an outpatient

hospital from February 15-May 15, 2012 and accrues $3800 in therapy services.

• Patient A goes to a private practice for services on September 20 until November 15. Private practice submits the claim on September 20 for payment and the common working file reflects $0 toward the cap.

• On October 1, the $3800 from the hospital therapy would be added to the common working file; for dates of service provided to patient A after October 1 the provider would need to seek advanced approval (if a phase I provider).

Therapy Cap Example

• Patient A received $4000 of services from a hospital stay from January 15—May 15, 2012.

• From July 22, 2012 –August 25, 2012 patient A received services from a private practice.

• The private practice would not need to submit the KX modifier or submit a request for advanced approval as Patient A was discharged prior to October 1, 2012.

Therapy Cap Example• “A beneficiary was in a skilled nursing facility (SNF) and exhausted

their SNF benefit days under Part A.

• The beneficiary continued to receive therapy services under Part B totaling $3,600 (all dates of service before 10/1/2012).

• The beneficiary was then discharged from the SNF and received therapy services from an independently practicing PT totaling $1,800.

• The independent PT billed in November 2012 for services provided after 10/1/2012.

Therapy Cap Example• The MAC received the claims and processed them. After these

claims were processed the MAC received the SNF Part B claims totaling $3,600 and processed them.

• Had these 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 the example above the contractor is not required to perform post payment review on the $1,800 provided by the independent therapist. “

Notification to Beneficiaries

• Beneficiaries who have received $1700 or more of therapy services in 2012 received letters in September 2012 providing them information about their potential financial liability for services over the therapy cap amount.

• APTA provided a document for beneficiaries to provide info on cap. http://www.moveforwardpt.com/Resources/Advocacy.aspx

Therapy Cap: Collecting Out of Pocket

• If a patient does not qualify for an exception, the provider can collect out of pocket payment from the beneficiary.

• It is advisable to give the beneficiary an Advanced Beneficiary Notice (ABN) if Collecting Out of Pocket. Revised ABN form (Form-R-131) available on the CMS website at: https://www.cms.gov/BNI/02_ABN.asp

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Therapy Cap: Collecting Out of Pocket

• Provider can determine the amount of payment to collect from the patient; it does not have to be the fee schedule amount.

• Providers should avoid deep discounts or providing services for free as that could violate anti-kickback statutes.

Therapy Cap: Collecting Out of Pocket

• If provider would like a denial from Medicare in order to bill a secondary insurer after the therapy cap amount is exceeded, the provider could submit claim with a modifier:

• GX Modifier:• Notice of Liability Issued, Voluntary Under Payer Policy.• Report this modifier only to indicate that a voluntary ABN was

issued for services that are not covered.• Medicare will automatically reject claims that have the –GX

modifier applied to any covered charges.

• GY modifier:• Notice of Liability Not Issued, Not Required Under Payer Policy. 

This modifier is used to obtain a denial on a non covered service.  Use this modifier to notify Medicare that you know this service is excluded.

APTA RESOURCES• APTA has developed a Medicare Therapy Cap

Resources website.  This website compiles relevant information available from APTA and CMS in one place. 

• You can view the website by clicking here or by going to APTA’s homepage and clicking Learn More on the Medicare marquee.  Please share this information with your colleagues and staff

• Questions regarding the therapy cap may also be emailed directly to CMS at therapycapreview@cms.hhs.gov.

On July 6, 2012 the Centers for Medicare and Medicaid Services (CMS) released the proposed 2013 Medicare physician fee schedule rule that updates 2013 payment amounts and revises other payment policies.

◦ http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1590-P.html

CMS will publish a final rule by November 1, 2012 which will become effective for services furnished during calendar year 2013.

KanCare benefit packages outlined (By Dave Ranney; Wednesday, September 26, 2012)

◦ Comparison of benefit packages offered by KanCare MCOs

A brief outline of the AFFORDABLE CARE ACT (ObamaCare) can be accessed at:

◦ http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act

TRICARE WILL NOT reimburse for services furnished by physical therapist assistants that are provided in a:

◦ Physical therapy private practice

◦ Freestanding clinic

◦ Home care agency

◦ Comprehensive outpatient rehabilitation facility (CORF)

TRICARE WILL reimburse for services furnished by a physical therapist assistant in a:

Hospital

Skilled nursing facility

Kansas Department of Labor: Division of Workers' Compensation

Kansas WC contacts: http://www.dol.ks.gov/WorkComp/Default.aspx