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  • CMS Releases Home Health Prospective Payment System Final Rule for CY 2013

    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 therapy discipline.

    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 services.

    Lastly, 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.

    The final rule will be published in the Federal Register on November 8, 2012. APTA will post a summary of the final rule shortly.

    MedPAC Votes on Outpatient Therapy Payment Reform Recommendations

    Yesterday, 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. 

    Overall, 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 conditions.

    To avoid 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.

    Other 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.

    To 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.

    For more 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.  

    CMS Issues Final 2013 Physician Fee Schedule Rule

    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 System (PQRS).

    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 2013. 

    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 comments 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 patients. 

    The final rule with comment period will appear in the November 16 Federal Register. APTA will post a detailed summary of the final rule shortly. 

    [Update as of 5:00 pm: APTA's summary of the rule is available at www.apta.org/Payment/Medicare/CodingBilling/FeeSchedule/.] 

    CMS Releases Calendar Year 2013 Final Rule for Outpatient Hospital Services

    On 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 discharge.

    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 future policymaking.

    APTA will post a summary of the final rule on its website shortly.

    APTA to Match Donations for NY and NJ Relief Efforts

    Following 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.

    In 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.] 

    New Podcast: Physical Therapy Services in Palliative Care

    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. 

    APTA 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.

    Physical Therapy Listed as a 'Best Job' by CNNMoney

    CNNMoney's Best Jobs in America report ranks physical therapy 8th among the top 100 jobs in the United States.