On November 2, the Centers for
Medicare and Medicaid Services (CMS) released the final rule for the Home Health Prospective Payment System (HH PPS) for Calendar
Year (CY) 2013. The rule finalizes a reduction in rates of 1.32%, which is
approximately a $10 million decrease to payments for the home health 60-day
episode for CY 2013.
Of specific importance to
physical therapy, CMS finalizes 3 revisions regarding the requirement that a
qualified therapist complete a functional reassessment of the patient at the 14th
and the 20th visit, and every 30 days. First, CMS finalized its
proposal that if a qualified therapist missed a reassessment visit, therapy
coverage would resume with the visit during which the qualified therapist
completed the late reassessment, not the visit after the therapist completed
the late reassessment. Second, CMS finalized its proposal that in cases where
multiple therapy disciplines are involved, if the required reassessment visit
was missed for any one of the therapy disciplines for which therapy services
were being provided, therapy coverage would cease only for that particular
Third, CMS clarifies that in
cases where the patient is receiving more than one type of therapy, qualified
therapists must complete their reassessment visits during the 11th, 12th, or
13th visit for the required 13th visit reassessment and the 17th, 18th, or 19th
visit for the required 19th visit reassessment. However, CMS also states in
instances where patients receive more than one type of therapy, if the
frequency of a particular discipline, as ordered by a physician, does not make
it feasible for the reassessment to occur during the specified timeframes
without providing an extra unnecessary visit or delaying a visit, then it will
still be acceptable for the qualified therapist from each discipline to provide
all of the therapy and functionally reassess the patient during the visit
associated with that discipline that is scheduled to occur closest to the 14th
Medicare-covered therapy visit, but no later than the 13th Medicare-covered
therapy visit. Likewise, a qualified therapist from each discipline must
provide all of the therapy and functionally reassess the patient during the
visit associated with that discipline that is scheduled to occur closest to the
20th Medicare-covered therapy visit, but no later than the 19th
Medicare-covered therapy visit. The final rule reflects APTA's comments
urging CMS to maintain the current "close to" language.
In addition to the revision to
the therapy functional reassessment requirements, CMS also finalizes its
proposal to allow a nonphysician practitioner in an acute or post-acute
facility to perform the face-to-face encounter in collaboration with or under
the supervision of the physician who has privileges and cared for the patient
in the acute or post-acute facility, and allow such physician to inform the
certifying physician of the patient's homebound status and need for skilled
the rule includes extensive provisions regarding the Home Health Conditions of
Participation and provides several avenues for home health agencies to meet the
survey and certification requirements and lays out CMS' remedial actions if
violations are found when surveys are conducted.
final rule will be published in the Federal
Register on November 8, 2012. APTA will post a summary of the final rule
the Medicare Payment Advisory Commission (MedPAC) voted to adopt several recommendations
on outpatient therapy payment reform. These recommendations will be included in
a report to Congress that may be used to inform future policy related to
outpatient therapy services. Congress has the discretion to determine whether
or not to pass legislation that incorporates any of these recommendations. The
Centers for Medicare and Medicaid Services also can choose to enact MedPAC's
recommendations. APTA will continue to work diligently over the next couple of
months with Congress to extend the exceptions process for therapy services in
2013 and to avoid any payment cuts.
MedPAC commissioners expressed appreciation of the value of outpatient therapy
services for Medicare beneficiaries and recognized that a "hard cap"
with no exceptions would be detrimental and severely impede access to medically
necessary therapy services. Several commissioners also acknowledged that, if
applied appropriately, therapy presents a beneficial alternative to more costly
services, such as surgery and hospital admissions due to falls and other
capping therapy services without an exceptions process, MedPAC recommends that
Congress reduce the therapy cap for physical therapy/speech-language pathology
combined to $1,270 in 2013 and occupational therapy to $1,270 in 2013, and
permanently include hospital outpatient therapy departments under the cap. The
cap amount would be updated each year by the Medicare Economic Index. MedPAC
also calls for the secretary of the Department of Health and Human Services to
implement an improved a manual review process for requests to exceed cap
amounts. MedPAC's recommendation to improve the manual medical review process
was based on what MedPAC staff described as "constructive feedback"
from stakeholder groups, including APTA.
recommendations include applying a multiple
procedure payment reduction (MPPR) of 50% to the practice expense
component of therapy services provided to the same patient on the same day and
reducing the certification period for the outpatient therapy plan of care from
90 to 45 days. MedPAC also voted to direct HHS' secretary to prohibit the use
of V codes as a principal diagnosis on outpatient claims.
improve management of the benefit in the long term, MedPAC recommends that CMS
collect functional status information about beneficiaries using a streamlined,
standardized assessment tool that reflects factors such as patient demographic
information, diagnosis, medications, surgery, and functional limitations. This
information could be used to measure the impact of therapy on functional status
and provide a basis for future long-term reform of the payment system.
In anticipation of
the release of these recommendations, APTA has been aggressively engaged on
Capitol Hill to
ensure payment reforms do not detrimentally impact access, quality, or the
financial viability of providers and facilities that play an essential role in
the health care delivery system.
information, read APTA's October 9 comments to MedPAC regarding its
recommendation to implement a 50% MPPR policy and reduce the therapy cap
amount. Additionally, APTA's comments submitted in September address MedPAC's various long-
and short-term proposals to reform the Medicare therapy benefit.
On November 1, the Centers for
Medicare and Medicaid Services (CMS) released the final 2013 Medicare physician fee schedule rule, which sets the therapy cap amount on
outpatient therapy services for 2013 at $1,900; updates 2013 payment amounts
for physicians, physical therapists, and other health care professionals; and
revises other payment policies. The therapy cap exceptions process will expire
on December 31 unless Congress acts to extend it. Additional policies that will
impact physical therapists include implementation of new functional status
codes for reporting therapy services and updates to the Physician Quality Reporting
The final rule includes a 26.5%
across-the-board reduction to Medicare payment rates for physicians, physical
therapists, and other professionals due to the flawed sustainable growth rate
(SGR) formula. Since 2003, Congress had enacted legislation preventing the
reduction every year. CMS announces that it is "committed to fixing the
SGR update methodology and ensuring these payment cuts do not take effect."
Excluding the 26.5% projected SGR payment cut, the aggregate impact on payment
of changes in the rule for outpatient physical therapy is a positive 4% in
As required by the Middle Class Tax
Relief Jobs Creation Act of 2012, CMS will begin to collect data on claim forms
about patient functional status for patients receiving outpatient physical
therapy, speech therapy, and occupational therapy beginning January 1,
2013. Therapists will be required to report new G codes accompanied by
modifiers on the claim form that convey information about a patient's
functional limitations and goals at initial evaluation, every 10 visits, and at
discharge. This data is for informational purposes and not linked to
reimbursement. Until July 1, 2013, claims will be processed regardless of the
inclusion of functional limitation codes. Beginning July 1, 2013, all claims
must include the functional limitation codes in order to be paid by Medicare. APTA's
on the proposed fee schedule rule had a significant impact in this area of the
final rule, which reflects many of the association's recommendations.
For 2013 the reporting period for
PQRS will be based on a 12-month reporting time frame. The bonus payment amount
will be .5%. Calendar year 2013 also will be used as the reporting period for
the 2015 PQRS payment adjustment of -1.5%. Successful reporting requirements for the program will remain as they
were in 2012, requiring that participants report a minimum of 3 individual
measures or 1 group measure via claims-based reporting on 50% or more of all
eligible Medicare patients, or report a minimum of 3 individual measures or 1
group measure via registry reporting on 80% or more of all eligible Medicare
The final rule
with comment period will appear in the November 16 Federal Register. APTA will post a detailed summary of the final
[Update as of 5:00 pm: APTA's summary of the rule is available at www.apta.org/Payment/Medicare/CodingBilling/FeeSchedule/.]
November 1, the Centers for Medicare and Medicaid Services (CMS) issued its
Calendar Year (CY) 2013 final rule for the outpatient prospective payment system
(OPPS). In the rule,
CMS clarifies that it was not the intent of the agency in the CY 2012 OPPS
final rule to establish different requirements for critical access hospitals
(CAHs) and for OPPS hospitals for the same services. Therefore, physical
therapy, speech therapy, and occupational therapy services that are paid under the
OPPS are subject to the direct supervision requirements in 42 CFR § 410.27,
whether they are furnished in OPPS hospitals or CAHs. The physical
therapy, speech therapy, and occupational therapy services that are not paid
under the OPPS and are paid instead under the Medicare Physician Fee
Schedule are not subject to the direct supervision requirements in §
410.27, whether they are furnished in OPPS hospitals or in CAHs.
As previously discussed in the
proposed rule CMS has implemented the Medicare Part A to Part B Rebilling (AB
Rebilling) Demonstration, which allows participating hospitals to receive 90%
of the allowable Part B payment for Part A short-stay claims that are denied on
the basis that the inpatient admission was not reasonable and necessary.
Participating hospitals can rebill these denied Part A claims under Part B and
be paid for additional Part B services that would usually be payable when an
inpatient admission is deemed not reasonable and necessary. This demonstration
is slated to last for 3 years, from CY 2012 through CY 2014.
In the proposed rule, CMS
discussed that when a Medicare beneficiary arrives at a hospital in need of
medical or surgical care, the physician or other qualified practitioner must
decide whether to admit the beneficiary for inpatient care or treat him or her
as an outpatient. In some cases, when the physician admits the beneficiary and
the hospital provides inpatient care, a Medicare claims review contractor, such
as the Medicare Administrative Contractor (MAC), the Recovery Audit Contractor
(RAC), or the Comprehensive Error Rate Testing (CERT) Contractor, determines
that inpatient care was not reasonable and necessary and denies the hospital
inpatient claim for payment. In these cases, Medicare allows hospitals to
rebill a separate inpatient claim for only a limited set of Part B services,
referred to as "Inpatient Part B" or "Part B Only" services.
The hospital also may bill Medicare Part B for any outpatient services that
were provided in the 3-day payment window prior to the admission.
Hospitals have expressed concern
that this policy provides inadequate payment for resources that they have expended
to take care of the beneficiary in need of medically necessary hospital care,
although not necessarily at the level of inpatient care. Hospitals have
indicated that often they do not have the necessary staff (for example,
utilization review staff or case managers) on hand after normal business hours
to confirm the physician's decision to admit the beneficiary. Thus, for a
short-stay admission, the hospital may be unable to complete a timely review
and change a beneficiary's patient status from inpatient to outpatient prior to
In the proposed rule, CMS
indicates that hospitals appear to be responding to the financial risk of
admitting Medicare beneficiaries for inpatient stays that may later be denied
upon contractor review by electing to treat beneficiaries as outpatients
receiving observation services, often for longer periods of time, rather than
admitting them as inpatients.
CMS received approximately 350
public comments, including those from APTA, in response to its solicitation in
the proposed rule regarding possible policy alternatives to remedy the issue of
Medicare Part A inpatient admissions and observation stays paid under Medicare
Part B. Stakeholders urged CMS not to adopt a final policy regarding patient
status in this final rule but instead develop an informed course of action in
the upcoming months through a formal, ongoing dialogue with all interested
stakeholders. A few stakeholders recommended immediate action to limit
beneficiary liability for SNF care when the 3-day qualifying hospital stay is
subsequently denied and for the difference in beneficiary cost-sharing between
hospital inpatient and outpatient services.
In the final rule, CMS summarizes
the feedback received in response to the solicitation in the proposed rule but
does not provide responses to the public comments. CMS states that it strictly
solicited public comments, and did not propose any changes in policy. CMS
states that it will consider the feedback received from the public in its
APTA will post a summary of the
final rule on its website shortly.
the devastation of Hurricane Sandy, the New York and New Jersey chapters have
established relief funds to help the physical therapy community affected by the
storm. APTA will match contributions to both of the funds 1:1 up to $5,000. Click here to donate to the New Jersey
Chapter's Hurricane Sandy Disaster Relief Fund. At this time, the New York
Chapter has not posted a donation link on its website. APTA will provide a link
to the fund when it becomes available.
addition to the chapter-specific relief efforts, the association will donate
$1,000 to the American Red Cross.
[November 6 Editor’s Note: Information
about the New York Chapter's relief fund, and an online donation form, now is available
on the chapter's website.]
In the latest installment in a series of podcasts on hospice and palliative care, Stephen Gudas, PT, PhD, describes the
goals of palliative care—to live better with disease and address the symptoms
of illness—and the role physical therapists play in meeting those goals by
helping patients preserve function and dignity. Gudas, who practices physical
therapy in the cancer rehabilitation program of the Massey Cancer Center at the
Medical College of Virginia, also illustrates how a high-functioning palliative
care team can meet the needs of patients and their families.
will hold an audio conference titled Hospice and
Palliative Care: The Collaborative Role of Physical Therapy on Tuesday,
November 13, 1:00-2:00 pm ET. Online registration closes 11:00 pm ET
Thursday, November 8,or as soon as all available spaces are filled.
Best Jobs in America report ranks physical therapy 8th among the top 100 jobs in the
issued yesterday by the Government Accountability Office (GAO) based on Part B
claims data found that self-referred magnetic resonance imaging (MRI) services
increased by approximately 84% from 2004 to 2010, whereas non-self-referred MRI
services only increased by roughly 12%.
computed tomography (CT) over the same time period, the number of services
performed by self-referrers increased by approximately 107%, in contrast to an
increase of roughly 30% by non-self-referrers. GAO also found that in 2010
"providers who self -referred made 400,000 more referrals for advanced
imaging services that they would have if they were not self-referring." As
a result, GAO concluded that "financial incentives for self-referring
providers were likely a major factor driving the increase in referrals."
GAO estimated the fiscal impact of the 400,000 improper referrals on the
Medicare program was "more than $100 million" just in 2010. However,
aside from the monetary cost to the nation, GAO also highlighted the
"unacceptable risks for beneficiaries" resulting from additional
radiation exposure, particularly in the case of CT services, associated with
these unnecessary referrals.
report is the first of a series from GAO on self-referral. Additional reports
are expected on self-referral in physical therapy, anatomic pathology, and
release of the report, the Alliance for Integrity in Medicare (AIM)—a coalition
of provider organizations, including APTA, committed to ending the practice of
inappropriate physician self-referral—applauded the findings. AIM said the
report "substantiates our ongoing concerns with the misapplication of the
in-office ancillary service (IOAS) exception to the physician self-referral
law." The coalition urged Congress to "heed these critical findings
and pass legislation to remove advanced diagnostic imaging, anatomic pathology,
radiation therapy, and physical therapy from the IOAS exception, while
preserving the ability of truly integrated multispecialty practices to continue
providing high-value, high-quality care for Medicare beneficiaries under the
will issue a separate statement, which will be highlighted in an upcoming News Now article, on GAO's report.
physician referral for profit
in physical therapy is one of APTA's public policy priorities. The Foundation for Physical
Therapy recently awarded a $300,000 high-impact research grant to Jean
Mitchell, PhD, to investigate the influence of physical therapy referral characteristics and practices
on quality, cost effectiveness, and utilization.
Walk Test (6MWT) distance may be a good indicator of lower limb muscle
strength, and lower limb strengthening may improve gait capacity in patients
with stroke, say authors of an article published in Journal of Rehabilitation Medicine.
of 24 patients (12 men and 12 women) participated in the study. Muscle strength
(Medical Research Council [MRC] scale) and spasticity (modified Ashworth scale)
were assessed prior to the 6MWT. Heart rate was recorded at rest and during the
6MWT. Participants were divided into 2 groups: (1) those with a high MRC sum
score, and (2) those with a low MRC sum score. The relationship between the
6MWT distance and the other parameters was analyzed using a Spearman's rank
was a significant and positive relationship between 6MWT distance and lower
limb muscle strength, whereas no significant correlations were found between
the 6MWT distance and spasticity, resting heart rate, and heart rate during the
2013, BMJ will publish articles on
drugs and devices only if the clinical trial data is made available for
independent scrutiny—whether industry funded or not.
In an editorial published October 29, BMJ Editor in Chief Fiona Godlee says
the recent "brave and benevolent" decision by GlaxoSmithKline (GSK) to allow access to
anonymous patient level data from its clinical trials "really serves to
highlight the rank absurdity of the current situation. Why aren't all clinical
trial data routinely available for independent scrutiny once a regulatory
decision has been made?"
GSK's new policy, an independent panel will assess all requests and access will
be granted on the basis of a reasonable scientific question, a protocol, and a
commitment from the researchers to publish their results. Godlee says it will
be "particularly important to know how many requests are turned down and
for what reasons."
also writes that BMJ has intensified
its efforts to help resolve a 3-year battle to gain access to full data on
oseltamivir (Tamiflu). Taxpayers in the United Kingdom and around the world "have
spent billions of dollars stockpiling a drug for which no one except the
manufacturer has seen the complete evidence base," she says.
and researchers at the Cleveland Clinic have voted weight-loss surgery
as the top medical innovation for 2013, not for its effectiveness in reducing
obesity but for its ability to control type 2 diabetes.
People who reach 100 pounds or more above their ideal weight are almost
never successful in losing weight and keeping it off for many years, says the
clinic announcement. "Many diabetes experts now believe that weight-loss
surgery should be offered much earlier as a reasonable treatment option for
patients with poorly controlled diabetes—and not as a last resort."
Bariatric surgery was chosen as the top innovation "because Medicare
has broadened its indication for payment, and Medicaid in many states follows
Medicare," says Michael Roizen, MD, Cleveland Clinic chief wellness officer,
in a Reuters News article.
"A lot of the other (private) insurance companies started covering it, so
it's much more accessible."
The clinic's list of the best medical innovations for 2013 also
includes an almond-size device implanted in the
mouth to relieve severe headaches, a handheld scanner resembling a blow dryer
that detects skin cancer, better mammography technology, and new drugs
to treat advanced prostate cancer.
and researchers at the clinic voted for what they thought were the biggest,
most significant innovations from the 250 ideas submitted from their
colleagues. One of the main criteria for getting on the list is the number of
people that the product or procedure can potentially help, says Reuters.