Outpatient Therapy. Addendum

Transcription

1 Outpatient Therapy Addendum

2 Change Request 8129 Therapy Cap Values for Calendar Year (CY) 2013 Effective Date: January 1, 2013 Implementation Date: January 7, 2013 Summary of changes: Occupational Therapy (OT) cap $1900 Physical Therapy (PT) and Speech Language Pathology (SLP) combined cap $1900 Note: Only applies to home health outpatient therapy billed under Type of Bill (TOB) 34X MM8129 June 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 1 Outpatient Therapy Caps The American Taxpayer Relief Act of Section 601- Medicare Physician Payment Update Zero percent update of Medicare Physician Fee Schedule (MPFS) THROUGH December 31, Section 603 Extension Related to Payment for Medicare Outpatient Therapy Services Extends exceptions process Append KX modifier Therapy Cap Fact Sheet June 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 2 Outpatient Therapy Caps Section 603 Extension Related to Payment for Medicare Outpatient Therapy Services Mandatory Manual Medical Review for: Therapy claims above the $3700 threshold with dates of service October 1,, through December 31, Therapy claims above the $3700 threshold with dates of service on or after January 1, 2013, through December 31, 2013 Manual medical review will be done on a prepayment basis Therapy Cap Fact Sheet June 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 3 June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 1

3 Manual Medical Review (MMR) of Outpatient Therapy Claims by Recovery Auditors (RAs) Effective: April 1, 2013 All outpatient therapy claims at or above the $3,700 threshold cap will need to be reviewed Medical review will be conducted separately by discipline Questions: Regarding the review of the claim shall be directed to the RA Questions concerning the adjustment of the claim, denial and/or appeal shall be addressed by the MAC Reference: CMS FAQs RA Outpatient Therapy April 17, 2013: Systems/Monitoring-Programs/Medical- Review/Downloads/FAQ_OutpatientTherapy_ pdf May 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 4 Two types of review: Prepayment review For the eleven states participating in the RA Prepayment Review Demonstration (FL, CA, MI, TX, NY, LA, IL, PA, OH, NC and MO) The claim will be reviewed before the claim is processed for payment The RAs will conduct prepayment review within 10 business days of receiving the medical record The ADR will be sent to the provider by the MAC with instructions to send the records to the RA If an improper claim has been submitted, a review results letter will be sent to the provider, which clearly documents the rationale for the determination May 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 5 Two types of review: Prepayment review For the eleven states participating in the RA Prepayment Review Demonstration (FL, CA, MI, TX, NY, LA, IL, PA, OH, NC and MO) The claim will be reviewed before the claim is processed for payment The RAs will conduct prepayment review within 10 business days of receiving the medical record The ADR will be sent to the provider by the MAC with instructions to send the records to the RA If an improper claim has been submitted, a review results letter will be sent to the provider, which clearly documents the rationale for the determination May 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 6 June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 2

4 Post-payment review For all remaining states The claim will be reviewed after the claim has been processed for payment The ADR will be sent to the provider immediately after the claim is paid by the MAC to the with instructions to send the records to the RA If an improper payment has resulted, a demand letter will be sent to the provider, which clearly documents the rationale for the determination May 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 7 Therapy Caps and Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 Prior to the ATRA, Medicare claims for outpatient therapy services at or above therapy caps that did not qualify for a coverage exception, were denied as a benefit category denial, and the beneficiary was financially liable for the non-covered services Issuance of an ABN wasn t required for the beneficiary to be held financially liable Now, the provider/supplier must issue a valid, mandatory ABN to the beneficiary before providing services above the cap when the therapy coverage exceptions process isn t applicable If the ABN isn t issued when it is required and Medicare doesn t pay the claim, the provider/supplier will be liable for the charges Reference: CMS FAQs ABN and Therapy Cap April 2013: ds/abn-noncoverage-faq.pdf May 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 8 Section 603(c) of the American Taxpayer Relief Act of (ATRA) Change to Payment Liability for Therapy Cap Denials Effective: January 1, 2013 From beneficiaries liability to provider liability Medicare systems were not updated in time to accurately represent this change on provider remittance advices (RAs) MACs may have already processed therapy cap denials for services provided in 2013 These denials incorrectly report on RAs beneficiary liability (Group Code PR ) when liability legally rests with the provider (Group Code CO ) Institutional claims will correct the inaccurate RA reporting beginning on June 24, 2013 May 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 9 June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 3

5 Section 603(c) of the American Taxpayer Relief Act of (ATRA) Since Medicare s payment amount for these claims is correct, the claims will NOT be adjusted to correct the Group Code Providers should review any therapy cap denials for dates of service on or after January 1, 2013, to determine whether any payments have been collected from beneficiaries Refund any beneficiary payments they find for these services Cease collecting payments for therapy cap denials Unless the beneficiary was appropriately notified via an Advanced Beneficiary Notice of Non-coverage (ABN) May 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 10 Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services Effective for therapy services with dates of service (DOS) on/after January 1, 2013 Effective Testing period January 1 June 30, 2013 Claims will be returned/rejected for date of DOS on/after July 1, 2013 MM8005 June 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 11 Summary of changes: Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Social Security Act implements a new claimsbased data collection requirement for outpatient therapy services requiring reporting with: 42 new non-payable functional G-codes and Seven new modifiers on claims for PT, OT and SLP services June 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 12 June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 4

6 Functional reporting applies: Home Health (Part B only) TOB 34X on Part A MAC Claims June 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 13 Documentation Requirements: Documentation must be included in the beneficiary s medical record of therapy services for each required reporting Documentation must be completed by: The qualified therapist furnishing the therapy services The physician/npp personally furnishing the therapy services The qualified therapist furnishing services incident to the physician/npp The physician/npp for incident to services furnished by qualified personnel who are not qualified therapists The qualified therapist furnishing the PT, OT, or SLP services in a CORF June 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 14 New Progress Report Requirement: Progress reporting required on or before every 10th treatment day Previously, the progress report was due every 10th treatment day or 30 calendar days, whichever was less June 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 15 June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 5