Medicare Therapy Cap

January 6 Update: Legislation to Repeal Therapy Caps Introduced

Congressmen Xavier Becerra (D-CA), Mike Ross (D-AR), and Roy Blunt (R-MO), and Senators John Ensign (R-NV) and Blanche Lincoln (D-AR) introduced The Medicare Access to Rehabilitation Services Act (HR 43/S 46). This legislation will repeal the cap on therapy services for Medicare beneficiaries once and for all. If Congress does not take action by December 31, 2009, the therapy cap will again be imposed on Medicare-covered physical therapy, occupational therapy, and speech language pathology services.

A direct link to this information you are reading now: www.apta.org/medicareupdates.

Medicare Physician Fee Schedule

October 30 Update: 2009 Physician Fee Schedule Rule Released

The Centers for Medicare and Medicaid Services released the final rule for Part B services performed in calendar year 2009. This information is expected to be published in the Federal Register November 19, 2008. APTA has prepared for its members a highlights document and a comprehensive summary.

Click here for more Fee Schedule resources.

Palmetto GBA Transition

October 17, 2008

On September 2, 2008, the administrative management of Medicare in the state of California transitioned from National Heritage Insurance, Corp (NHIC) to Palmetto GBA. This is a result of Medicare contracting reform mandated by the Medicare Modernization Act of 2003. This reform would divide the country into 15 regions and one company, called a Medicare Administrative Contractor (MAC), would be responsible for the Part A and Part B operations in that region. More information about the contracting reform process can be found here (under Medicare Contracting Reform) and at the CMS Web site.

The transition process from NHIC to Palmetto has raised a significant amount of serious issues for providers practicing in California, including physical therapists.

Update: Palmetto has released a new LCD that uncoupled the ICD-9 and CPT codes that caused many of the claims denials for providers. In addition, Palmetto has developed an online tool to allow providers to check the status of their Medicare enrollment applications.

Click here to learn more.

HR 6331 - the Medicare Improvements for Patients and Providers Act

July 15 Update: Congress Overrides Presidential Veto (HR 6331)

The House and Senate voted to override the Presidential veto to pass HR 6331 - the Medicare Improvements for Patients and Providers Act. HR 6331 includes critical provisions for physical therapists and their patients, including legislation to avoid the 10.6% cut in payments under the Medicare physician fee schedule and the expiration of the therapy cap exceptions process.

The House passed this legislation by a 383-41 vote and by a 70-26 Senate vote. A two-thirds vote was needed by the House and the Senate to override the Presidential veto. Once the Senate voted to approve HR 6331, it now becomes law immediately.

HR 6331: Provisions Critical to Physical Therapist Practice and the Patients We Serve

• 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.

• Continuation of the .5% update 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.

• 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.

• Increases 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.

• Delays 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.

• Improves Medicare coverage of prevention services for seniors and persons with disabilities.

• Expands scope and duration of previously authorized medical home demonstration to improve access to primary health care.

• Adds hospital-based or critical access hospital-based renal dialysis centers, skilled nursing facilities, and community mental health centers to list of originating sites for payment of telehealth services.

Updates & Resources

CMS: Medicare Physician Fee Schedule Payment Rates: July 1–Dec 31, 2008

CMS: Extension of Therapy Cap Exceptions - Overview

CMS: Delay of DMEPOS Competitive Bidding Program - Overview