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  • CMS Revises Interpretative Guidelines for Rehabilitation in Outpatient Hospitals

    In response to concerns raised by APTA and other associations, the Centers for Medicare and Medicaid Services (CMS) revised interpretative guidelines (Transmittal 72) to eliminate the requirement that rehabilitation services furnished in outpatient hospital settings be ordered by a practitioner with medical staff privileges. The new guidance issued to the State Survey Agency Directors on February 17 is effective immediately and includes the following language:

    Requirements for Ordering Hospital Outpatient Services: Outpatient services in hospitals may be ordered (and patients may be referred for hospital outpatient services) by a practitioner who is:

    • responsible for the care of the patient;
    • licensed in, or holds a license recognized in the jurisdiction where he/she sees the patient;
    • acting within his/her scope of practice under state law; and
    • authorized by the medical staff to order the applicable outpatient services under a written hospital policy that is approved by the governing body. This includes both practitioners who are on the hospital medical staff and who hold medical staff privileges that include ordering the services, as well as other practitioners who are not on the hospital medical staff, but who satisfy the hospital's policies for ordering applicable outpatient services and for referring patients for hospital outpatient services.

    Previous Guidance Superseded: This guidance supersedes the guidance for ?482.56(b) (Tag A-1132) and ?482.57(b)(3) (Tag A-1163) found in SC-11-28 (May 13, 2011) and State Operations Manual (SOM) Transmittal #72 (November 18, 2011).

    The hospital's medical staff policy for authorizing practitioners to refer patients for outpatient services must address how the hospital verifies that the referring practitioner who is responsible for the patient's care is appropriately licensed and acting within his/her scope of practice.

    Resolving this issue has been a high priority for APTA and its members. APTA believes that this language is a significant improvement. The Survey and Certification Policy Memorandum in its entirety will be available on CMS's Web site next week.

    Legislation Includes Cap Exceptions Process With Provisions, Extends GPCI

    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.

    CMS Issues Guidance and Clarification for Version 5010 Implementation

    In light of concerns about the transition to Version 5010, the Centers for Medicare and Medicaid Services (CMS) has issued guidance to help physical therapists and other providers troubleshoot some of the difficulties they may experience with claims submissions. The guidance includes information on how to handle claims that failed edits during the delivery process and what providers can do if they have difficulty receiving information from clearinghouses and/or billing services.

    Although CMS delayed enforcement of Version 5010 transaction standards used for electronic health care claims until March 31, the official deadline to adopt the standards was January 1.

    APTA is aware that some physical therapists are experiencing cash flow issues related to 5010 implementation. The association will launch a new Web resource shortly to help members navigate the issues surrounding the move to the new standards.   

    Act Fast: Free Health Care Reform Audio Conference Filling Up

    About half of the available spots have been reserved for a free audio conference on the challenges and opportunities that health care reform will bring in 2012. Join Justin Moore, PT, DPT, vice president of the Public Policy, Practice, and Professional Affairs Unit, as he examines how health reform initiatives address fee schedule updates, therapy caps, bundled payments for post-acute care, integrated delivery systems, prevention and wellness, and insurance reforms, in addition to contemporary issues surrounding the upcoming Supreme Court decision on the constitutionality of the law, the pressures on states to implement key provisions, and efforts in Congress to repeal, revise, and redirect funding related to the Affordable Care Act.   

    Register today for the March 22 audio conference.