APTA has learned that a letter issued by the Centers for Medicare and Medicaid Services (CMS) about the therapy cap has caused some beneficiaries to panic and cancel appointments. 

CMS recently began issuing letters to Medicare beneficiaries who have received $1,700 or more in outpatient therapy services in calendar 2012. The letter informs beneficiaries that if services are furnished above the therapy cap of $1,880 in 2012, and the requirements for an exception are not met, then the beneficiary would be financially responsibility for these services.

To help ease beneficiaries' concerns, APTA has developed a frequently-asked-questions (FAQs) document that physical therapists can download and distribute to patients. Additionally, the document can be accessed by patients directly from APTA's Move Forward consumer website. 

The Centers for Medicare and Medicaid Services (CMS) has released 2 transmittals regarding the manual medical review process for outpatient therapy services that exceed $3,700. The manual medical review process, which approves or denies requests for therapy services in advance, goes into effect October 1.

Transmittal 1117 provides a list of the documentation and information that physical therapists must submit to their Medicare Administrative Contractors (MACs) to get approval for therapy services when patients exceed $3,700. The transmittal also provides guidance on MACs responsibilities in the review process. Specifically, MACs must make a decision (number of days approved and/or denied) and inform the provider and beneficiary (by telephone, fax, or letter; if by letter the letter must be postmarked by the 10th day) within 10 business days of receipt of all requested documentation. Failure to make a decision within 10 business days will lead to an automatic approval of the request.

If the request is denied, the contractor must provide a letter of denial to the provider and beneficiary. The provider letter must have detailed reasons (eg, not enough evidence of skilled care is not sufficient detail).

CMS recently assigned providers to 1 of 3 phases for manual medical review:

• Phase I Providers: Subject to manual medical review October 1 - December 31, 2012
• Phase II Providers: Subject to manual medical review November 1 - December 31, 2012
• Phase III Providers: Subject to manual medical review December 1 - December 31, 2012

No automatic exceptions apply to claims above $3,700 for claims submitted by providers in their respective phase.

A provider education article related to this instruction will be available on CMS' website shortly. 

In addition to providing details on the automatic and manual medical review exception processes, Transmittal 2537 clarifies that therapy evaluations performed after the therapy caps are reached to determine if the patient needs continued services would be exempt from the cap. CPT Codes 97001 97002 are included in this exception for evaluation services. 

In comments sent Tuesday to the Centers for Medicare and Medicaid Services (CMS) on the proposed 2013 Medicare physician fee schedule, APTA recommends multiple revisions to CMS' plan for collecting information on beneficiaries' functional limitations as part of payment reform. "While APTA strongly supports gathering information to develop an alternative to the current arbitrary payment limits (or "caps") on Medicare therapy services," the association says, "… CMS's proposal is overly complex and burdensome and may not result in the collection of meaningful and accurate patient information that could be used to develop an alternative payment system."   

Following the July 6 release of the proposed rule, APTA immediately began communicating with various stakeholder groups, including the American Hospital Association, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, American Stroke Association, and APTA components about CMS' intention to require therapists to report patients' functional limitations. In a meeting with CMS officials on August 27, APTA urged the agency to keep this particular provision as simple as possible to ensure that the requirements are not excessively onerous for physical therapists and do not cause delays in payment for therapy services.    

Specifically, APTA recommends that therapy associations and organizations and CMS collaborate to develop core items in the future that could be used in any tool to standardize data collection. Instead of reporting on primary and secondary functional limitations as described in the rule, APTA recommends that therapists report the information regarding the patient's functional limitation using 1 of 4 specific categories and that CMS establish another G code that would be the "catch all" for functional limitations that do not fit into the 4 categories. Additionally, the association urges against the collection of goal data at this time, comments on the 12-level severity scale, and suggests changes to the proposed frequency of reporting. APTA also provides CMS with a detailed outline of how the agency could implement claims-based therapy data collection in 3 phases that would "decrease provider burden, while still providing CMS with some useful beneficiary information regarding functional limitations." 

APTA also remarks on the proposed 27% percent reduction in the Medicare physician fee schedule conversion factor, prepayment review, and the therapy cap. The association comments extensively on the extension and implementation of the Physician Quality Reporting System (PQRS)—voicing its concern over the use of 2013 data to inform the 2015 payment adjustments given the continued low participation rates and overall lack of awareness of programmatic changes to PQRS. 

This week APTA responded to 4 specific questions posed by the Centers for Medicare and Medicaid Services (CMS) in its proposed rule for Medicare hospital outpatient prospective and ambulatory surgical center payment systems (OPPS) for calendar year 2013.   

The questions are in relation to implementation of the Medicare Part A to Part B Rebilling Demonstration. In this demonstration, participating hospitals are allowed 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. The hospitals can rebill denied Part A claims as Part B services and be paid additional reimbursement when an inpatient admission is found not reasonable and necessary. CMS' questions involve setting parameters regarding the amount of time a patient can remain on observation status, establishing specific clinical criteria for admission and payment, aligning hospital payment rates more closely with the resources used to provide outpatient care, and having case management and utilization review staff available in hospitals outside of regular business hours to improve the accuracy of admission decisions. 

Additionally, APTA notes its support for 3 proposed changes to the IRF Quality Reporting Program. The changes seek to harmonize the processes for the maintenance of technical specifications and measure removal from the IRF quality program with other quality reporting programs such as those in inpatient hospital settings.

Individuals with knee osteoarthritis, regardless of the involvement of 1 or both knees, perform and perceive their functional ability similarly, say authors of an article published online in Arthritis Care & Research. This suggests that clinicians need to consider other factors, such as how long the disease has been progressing or how functional abilities have changed, when treating patients with knee osteoarthritis, the authors add.  

The functional abilities of patients with symptomatic and radiographic diagnosed unilateral (N=84) or bilateral (N=68) knee osteoarthritis were evaluated with self-reports and performance-based tests. Self reports included the Knee Outcome Survey, Global Rating Scale, and Physical Component of Short Form-36; functional tests included Timed Up-and-Go, Stair Climbing Test, and 6-Minute Walk. Separate MANOVAs were performed separately for men and women to determine if perception (self-reports) and performance (functional tests) were dependent on the number of involved knees.

No significant main effects were observed in functional performance between groups for either sex. Similarly, the perception measures did not differ between groups. In general, individuals diagnosed with unilateral and bilateral knee osteoarthritis both performed functional tasks and perceived their functional ability similarly.

APTA members Joseph A. Zeni, PT, PhD, and Lynn Snyder- Mackler, PT, ScD, SCS, FAPTA, coauthored the article.

The National Football League (NFL) will donate $30 million to the Foundation for the National Institutes of Health in support of research on serious medical conditions prominent in athletes and relevant to the general population.

With this contribution, NFL becomes the founding donor to a new Sports and Health Research Program, which will be conducted in collaboration with institutes and centers at the National Institutes of Health (NIH). Specific plans for the research to be undertaken remain to be developed, but potential areas under discussion include concussion; chronic traumatic encephalopathy; the potential relationship between traumatic brain injury and late life neurodegenerative disorders, especially Alzheimer disease; chronic degenerative joint disease; the transition from acute to chronic pain; sudden cardiac arrest in young athletes; and heat and hydration-related illness and injury.

The announcement of the philanthropic gift, the largest that NFL has given in the league's 92-year history, coincides with the release of a study that found that professional football players are more likely to die from neurological disorders than other men.

The study, published online in Neurology, looked at death rates for more than 3,400 pros who played for at least 5 years from 1959 to 1988. For players in speed positions, such as quarterback, running back, and linebacker, death rates for Alzheimer disease and amyotrophic lateral sclerosis combined were 4 times higher than for men in the general population, says a HealthDay News  article. The researchers also looked at death rates for Parkinson disease but found no difference from the general population.

While the study appears to support recent research showing an increase of diseases that damage brain cells among football players, it does not prove that playing pro ball is the cause. Other factors, including the football field surface and looser safety guidelines during the study period, may have played a role, experts say.

Also, chronic traumatic encephalopathy, a relatively new diagnosis associated with concussions and repeated blows to the head, might have been the actual or partial cause of death for some, says the article.