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  • House Bill Includes SGR Fix, Extends Cap Exceptions Process

    Today, the House of Representatives released language of the health care provisions in the Middle Class Tax Relief and Job Creation Act. The bill updates the Medicare Physician Fee Schedule Sustainable Growth Rate (SGR) for 2012 and 2013 by 1% -- negating a scheduled 27.4% reduction in payments to providers, including physical therapists who bill under the fee schedule. The bill also provides a 2-year extension of the therapy cap exceptions process with modifications. As currently written, the bill creates a 2-stage exceptions process. In this 2-stage process, physical therapists would submit claims using the KX modifier when the $1,880 cap is reached. At $3,700 a manual review would be required to ensure that the plan of care is medically necessary. APTA is reviewing this and other provisions of the bill, including the application of these provisions in the outpatient hospital setting and federal agency reporting on the new process.

    The House is expected to vote on the bill next week. Early next week the Senate is expected to release its version of the bill. Both chambers need to pass their respective bills and send them to conference for a final bill to be drafted and sent back to both the House and Senate for full votes. Thus, today's action by the House is just the beginning of what promises to be a long and uncertain week on Capitol Hill.


    • Does review @ the $3700 mark mean during one POC or anytime after the $3700 mark is reached?

      Posted by giselle werner on 12/9/2011 3:48 PM

    • The 2 -stage exception process is really NOT a bad idea, only ensures credibility of our practice, which we should be proud to demonstrate. I believe Physical Therapists should be up for embracing accountability and efficiency as keywords for the delivery of our services. This way we will be a positive force and partner in the national debate on health care reformation. A little more paper work and correspondence though, but on the flip side it will facilitate our drive towards evidenced practice. The withdrawal of the exception process with reinstatement of the capitation, is ominous to our prospects and legitimacy as an obligatory and emerging profession. The "cap" is an absurd if not crass irresponsible reasoning, if it is used to stem down health care spending. There are too many reasons to advocate robust physical therapy care for the achievement of the "healthy state" and as necessity in the clinical management of individual cases. Physical Therapy is a natural health care service, it needs steady/continuous scientific growth to keep the pace for enhanced efficiency of the national health care delivery and beneficence intervention in individual cases. Physical Therapists as individuals and through our organization/s cannot be complacent or be a silent accessory to the uninformed curtailment of our best efforts in the face of growing need of our services. There is no rational reason for a gross therapy cap, there is however room for sustaining a rigorous exception process, much akin to the authorization process of private insurances. Wisely operated,it should be devoid of the time wasting and convoluted process of private insurances care-paths and decision point review processes. More often these are deliberate stone-walling, which are myopic economics, precludes the evolution and development of novelty in physical therapy care. "Our Rome is burning", we should engage this issue with wisdom.

      Posted by Popoola, Adeola on 12/9/2011 6:44 PM

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