Today, the House of Representatives and Senate passed legislation to prevent a 27.4% payment cut to Medicare providers scheduled for March 1 and extend several other Medicare policies important to physical therapists. The measure extends the Geographic Practice Cost Index (GPCI) at the current level for the remainder of the year and includes a 10-month extension of the therapy cap exceptions process that will begin to create a path to a reformed therapy payment system.
Physical therapists will continue to use the KX modifier at the $1,880 cap for 2012. However, new provisions have been added to the cap exceptions process. Starting October 1, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to a manual medical review. The legislation designates that this medical review will be similar to the process used following implementation of the Deficit Reduction Act in 2006. The $3,700 threshold will be applied to a combined physical therapy and speech language pathology cap. A separate $3,700 threshold will be applied to the occupational therapy cap. Also beginning October 1, each request for payment must include the national provider identifier of the physician who reviewed the plan of care. In addition, the therapy cap with exceptions will apply to hospital outpatient departments no later than October 1 until the end of 2012. This provision will sunset at the end of 2012 unless Congress extends it into 2013. APTA will work with the Centers for Medicare and Medicaid (CMS) to determine the agency's plans for implementing this and other provisions contained in the legislation.
The bill also calls for the Medicare Payment Advisory Commission to submit recommendations by June 15, 2013, to the House Energy and Commerce Committee, House Ways and Means Committee, and the Senate Finance Committee on ways to reform the payment system to ensure that the benefit is better designed to reflect individual acuity, condition, and therapy needs of the patient. The report will examine private sector initiatives related to outpatient therapy benefits.
The committee's measure also directs the Department of Health and Human Services (HHS) to implement a claims-based data collection strategy to assist in reforming the Medicare payment system for outpatient therapy. The system will be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes. In proposing and implementing such a strategy, HHS will consult with relevant stakeholders.
In addition, the General Accountability Office will issue a report by May 1, 2013, to the House Committee on Energy and Commerce, the House Ways and Means Committee, and the Senate Finance Committee on the implementation of the manual medical review process. The report is to include data on the number of beneficiaries and claims subjected to the process, the number of reviews conducted, and the outcome of the reviews.
The bill will be sent to President Obama for signature. APTA staff will reach out to CMS in the coming weeks to begin a dialogue about implementation of this legislation and will provide further information to membership regarding guidance and timelines for these new provisions.
APTA is analyzing this legislation and will provide more resources as they become available.