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  • CMS Clarifies That PTs Must Use ABN for Services not 'Reasonable and Necessary' That Exceed Therapy Cap

    Guidance issued by the Centers for Medicare and Medicaid Services (CMS) clarifies that in 2013 physical therapists (PTs) must issue a valid Advanced Beneficiary Notice (ABN) to patients to collect out-of-pocket payment from Medicare beneficiaries when Medicare deems services "not reasonable and necessary" after the therapy cap is exceeded.

    CMS added a frequently asked questions (FAQ) document to its therapy resources page that describes in further detail the rules for using an ABN for services that exceed the therapy cap on or after January 1, 2013, as a result of the Taxpayer Relief Act of 2012. The FAQ reinforces that "If the ABN isn't issued when it is required and Medicare doesn't pay the claim, the provider/supplier will be liable for the charges."

    This is a significant change in Medicare policy regarding the use of the ABN when the therapy cap is exceeded. Before 2013, the provider was not required to provide the beneficiary with an ABN when the therapy cap is exceeded for the beneficiary to be liable for denied charges.

    The FAQ clarifies that a PT must issue a valid ABN to the beneficiary before providing services when the PT believes that Medicare will deny a service because it is "not reasonable and necessary," such as when the patient has exceeded the therapy cap and continued services don't qualify under the exceptions process. CMS further clarifies that PTs must not issue the ABN to all beneficiaries who receive services that exceed the cap amount, only to those whose services the PT believes do not meet the Medicare definition of "reasonable or necessary." If the PT submits a claim with the KX modifier for an exception to the therapy cap, he or she is attesting that the services are reasonable and necessary.

    PTs with further questions on using ABNs can contact CMS at RevisedABN_ODF@cms.hhs.gov.

    CMS Proposes 2% Increase for Inpatient Rehab Facilities for 2014

    The Centers for Medicare and Medicaid Services' (CMS) proposed inpatient rehabilitation facility (IRF) prospective payment system (PPS) rule for fiscal year 2014 includes a 2% increase. The increase is based on a marketbasket update to payments of 1.8% and a 0.2% increase to the outlier threshold. CMS estimates the fiscal impact to be $150 million.

    The proposed rule, issued May 2, would further restrict which facilities qualify for the higher IRF PPS rates, as opposed to the lower the hospital inpatient PPS rates. To qualify, an inpatient hospital must demonstrate that at least 60 percent of its patients meet the criteria specified in the regulations, including the need for intensive inpatient rehabilitation services for 1 or more of 13 listed conditions that presume the need for intensive inpatient rehabilitation. CMS proposes to drop several diagnostic codes from the "presumptive compliance" list, saying these conditions "would not prove compliance in the absence of additional facts that would have to be pulled from a patient's medical record."

    Elsewhere in the proposed ruling, CMS plans to continue to use the catheter-associated urinary tract infection (CAUTI) outcome measure endorsed by NQF, which recently was updated from a non-endorsed measure; and to adopt a risk-adjusted pressure ulcer measure, dropping a non-risk adjusted version. In addition, CMS proposes to add 3 new quality measures to the IRF Quality Reporting Program, 2 related to flu vaccine and 1 to readmissions.

    CMS will accept comments regarding the provisions of the proposed rule until July 1, 2013. APTA will provide a comprehensive summary of the proposed rule in the coming days and will submit comments on behalf of the membership.

    New in the Literature: Exercise May Delay Physical Decline in Alzheimer Patients (JAMA Intern Med. 2013 Apr 15:1-8. [Epub ahead of print])

    Finnish researchers reported that an intensive, long-term exercise program was beneficial to the physical functioning of patients with Alzheimer disease (AD) without increasing total costs of health and social services or causing any significant adverse effects. The implications are promising, if increased, targeted exercise would allow more patients to remain at home or delay a move to a care facility.

    The study included 210 home-dwelling patients with AD living with their spousal caregivers, divided into 3 groups: group-based exercise, tailored home-based exercise, and "usual community care." Both exercise groups were led by physical therapists who tailored the exercise to the patients' needs. The group-based exercise group attended twice-a-week classes, while a physical therapist visited the home-based group for 1 hour twice a week.

    After 1 year, the home-exercise and group-exercise subjects had significantly less deterioration in function and significantly fewer falls than the control subjects, with the home-exercise group faring the best. The main outcome measures used included the Functional Independence Measure, Short Physical Performance Battery, and information on the use and costs of social and health care services.