Yesterday, officials from the Centers for Medicare and Medicaid Services (CMS) held a call with therapy stakeholder groups to describe their plans to implement the manual medical review process for the therapy cap exceptions that exceed $3,700 effective October 1. CMS has provided a fact sheet and question-and-answer document regarding the process and will issue a transmittal in the coming days. The therapy cap is an annual per-beneficiary limitation on services that applies to all outpatient therapy settings except critical-access hospitals.

Highlights regarding manual medical review include these:

• KX modifier requirements still remain in place for therapy services that exceed $1,880.
• For outpatient therapy services that exceed $3,700 an advanced approval process under which providers will be assigned to 1 of 3 distinct phases for manual medical review. CMS will notify providers by letter and contractor websites regarding which phase they are included in.
  * Phase I providers:  Subject to manual medical review October 1-December 31.
  * Phase II providers:  Subject to manual medical review November 1-December 31.
  * Phase III providers:  Subject to manual medical review December 1-December 31.
• Criteria for medical review will be based on current medical review standards. CMS will provide guidance and additional training for providers and Medicare Administrative Contractors (MACs) in the coming weeks.
• MACs will have 10 business days to decide whether or not they will approve services that exceed $3,700. If the MAC does not respond to a provider within 10 business days, claims beyond the $3,700 threshold will be approved.
• Advanced approval will allow an additional 20 treatment days beyond the $3,700 amount. Advanced approval does not guarantee payment. Retrospective review may still be performed.
• If a provider does not request advanced approval prior to providing services over $3,700, payment for the claims will stop, and a request for medical records will be sent to the provider. The provider will be subject to prepayment review for those claims, and the time frame for review will be approximately 60 days.
• Beneficiaries who have received $1,700 or more of therapy services in 2012 will receive letters in September 2012 providing them information about their potential financial liability for services over the therapy cap amount. An advanced beneficiary notice to beneficiaries is not required but is recommended as a way for the provider to convey information about the patient's potential financial responsibility for services above the therapy cap amount.  

A special open door forum (ODF) teleconference on the manual medical review of therapy claims will be held August 7, 2 pm-3:30 pm, ET. Special open door participation instructions are below:

• Dial 800/603-1774, using conference ID: 16032541.
• Participants may submit questions prior to the ODF to therapycapreview@cms.hhs.gov.
• A transcript and audio recording of the ODF will be posted to the special ODF website and will be accessible for downloading.

The Sitting Balance Scale is comparable to the Trunk Impairment Scale for measuring sitting balance in older adults who are nonambulatory or have limited mobility, say authors of an article published in Clinical Rehabilitation.  

The authors conducted this prospective study in acute care, inpatient rehabilitation, skilled nursing facility, and home health settings. Participants included 98 patients, with a mean age of 80.5 (SD 7.9) years, who received physical therapy (n = 20 acute care, n = 18 inpatient rehabilitation, n = 30 skilled nursing facility, n = 30 home setting). Nineteen patients were nonambulatory, and 79 had limited functional mobility with Timed Up and Go scores ≥20 seconds. The main measures were the Sitting Balance Scale, Trunk Impairment Scale, Timed Up and Go, length of stay, and setting-specific clinical measures of sitting balance (OASIS-C M1850; MDS G-3b).

A moderate association between ambulatory status and sitting balance measures was found (Sitting Balance Scale r = 0.67, Trunk Impairment Scale r = 0.61). Moderate to strong relationships between Sitting Balance Scale, Trunk Impairment Scale, and clinical outcomes varied by setting. Multivariate analysis of variance results revealed differences between ambulators and nonambulators and among diagnostic categories for both instruments.

APTA member Mary Thompson, PT, PhD, GCS, is lead author of the article. APTA members Ann Medley, PT, PhD, CEEAA, and Steve Teran, PT, are coauthors.      

Interdisciplinary collaboration and coordination is vital to facilitate early mobility and rehabilitation in the intensive care unit (ICU) setting. A recent stakeholders' conference aimed at improving long-term outcomes for ICU survivors identified important silos among critical care and rehabilitation clinicians working in the ICU, with these silos acting as a barrier to collaboratively advancing the field and improving patient outcomes. While clinical trials support the benefits of early rehabilitation for mechanically ventilated patients, implementing these interventions requires creating a new ICU culture based on proactive rehabilitation and interdisciplinary collaboration between all critical care and rehabilitation clinicians.

Critical Care Rehabilitation Conference 2012: Creating and Sustaining a Physical Rehabilitation Program in the ICU, hosted by Johns Hopkins University School of Medicine September 21-22, will bridge the interdisciplinary gap from research to clinical implementation at the bedside. 

APTA members Jennifer Zanni, PT, Michelle Kho, PT, PhD, and Michael Friedman, PT, MBA, will participate in panel discussions and present several sessions at the conference.

For course objectives and registration information, visit the conference's webpage.

On Monday, the Centers for Medicare and Medicaid Services (CMS) will release a follow-up Comparative Billing Report (CBR) to the 5,000 independent physical therapy providers who received the report in 2010. The CBR shows KX modifier use for 5 codes commonly billed by physical therapists. The report will be the same format as the CBR released in 2010. However, this CBR will use 2011 billing data, intending to inform providers of any change in use since receiving the original CBR.

The CBRs are produced by Safeguard Services under contract with CMS and contain data-driven tables and graphs with an explanation of findings that compare nationally and statewide physical therapist billing and payment patterns with the KX modifier. Safeguard Services has indicated to APTA that these reports are only educational rather than punitive, intending to prevent improper billing and use of the KX modifier.

For more information regarding these Outpatient Physical Therapy Services CBRs, visit CBR Services' website or call the SafeGuard Services' provider help desk, CBR support team, at 530/896-7080.

The Centers for Medicare and Medicaid Services' (CMS) 3-year Medicare Prior Authorization for Power Mobility Device (PMD) demonstration begins September 1. The demonstration is designed to develop and demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services. CMS believes this demonstration will lead to reductions in improper payments for power mobility devices.

CMS will implement a prior authorization process for scooters and power wheelchairs for people with fee-for-service Medicare who reside in 7 states with high populations of fraud- and error-prone providers (California, Illinois Michigan, New York, North Carolina, Florida, and Texas). Additionally, this demonstration will help ensure that a beneficiary's medical condition warrants his or her medical equipment under existing coverage guidelines and assist in preserving a Medicare beneficiary's ability to receive quality products from accredited suppliers.

Based on comments from APTA and other stakeholders, CMS removed the 100% prepayment review phase (formerly Phase 1) from the demonstration earlier this year. Also based on stakeholder feedback, CMS will allow suppliers to perform the administrative function of submitting the prior authorization request on behalf of the physician/treating practitioner.

Additional information is available on CMS' website.

This month's PTJ has a diversity of authorship—with articles by physical therapists, occupational therapists, engineers, basic scientists, and physicians from around the world. Hear Editor in Chief Rebecca Craik, PT, PhD, FAPTA, summarize the issue's 6 research reports and 2 "remarkably interesting" case reports and offer her comments on articles' contribution to the literature in the in the August Craikcast.     

Plan now to make this your best National Physical Therapy Month (NPTM) event yet. Go to www.apta.org/NPTM for this year's tools and resources. Start with the 2012 NPTM Event Planning Guide for specific information about conducting a successful community event. Next, check out the links to tools and resources designed specifically for this year's celebration, such as a sample proclamation for your governor or mayor, sample press release, logos, and web buttons. New tools will be added in the coming weeks, such as an event flyer template and downloadable NPTM bookmarks to give to patients and members of your community. And, learn how you can participate in APTA's public relations initiative, "Fit After 50," kicking off during NPTM.