Outpatient Therapy Services
Medicare Learning Network® publication: "Comprehensive Outpatient Rehabilitation Facility" (October 2010). This fact sheet provides information about basic, core and optional Comprehensive Outpatient Rehabilitation Facility (CORF) services; place of treatment requirements; rehabilitation plan of care requirements; and CORF payments.
CMS Special Open Door Forum on August 19: Developing Outpatient Therapy Payment Alternatives (DOTPA)
CMS and its data collection contractor, RTI International, explained the critical role of providers in this research. Medicare is now actively seeking providers to participate as data collection sites. An audio recording and transcript of this Special ODF will be posted to the Special ODF website.
Therapy Caps
Extension of Moratorium That Allows Independent Laboratories to Bill for the Technical Component (TC) of Physician Pathology Services Furnished to Hospital Patients
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, which extends the moratorium that allows independent laboratories to bill for the TC of physician pathology services furnished to patients in hospitals, effective for claims with dates of service on and after January 1, 2010, through December 31, 2010.
In the final physician fee schedule regulation published in the Federal Register on November 2, 1999, CMS stated that it would implement a policy to pay only the hospital for the TC of physician pathology services furnished to hospital patients. At the request of industry, to allow independent laboratories and hospitals sufficient time to negotiate arrangements, the implementation of this rule was administratively delayed. Subsequent legislation formalized a moratorium on the implementation of the rule.
Although the previous extension of the moratorium expired at the end of 2009, Section 3104 of the Patient Protection and Affordable Care Act restored the moratorium retroactive to January 1, 2010. Therefore, independent laboratories may now submit claims to Medicare for the TC of physician pathology services furnished to patients of a hospital, regardless of the beneficiary's hospitalization status (inpatient or outpatient) on the date that the service was performed. This policy is effective for claims with dates of service on or after January 1, 2010, through December 31, 2010. If an independent laboratory previously submitted a claim for services covered by this provision and the claim was denied, the laboratory may contact its Medicare contractor for further instructions.
Extension of Therapy Cap Exceptions Process
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, which extends the exceptions process for outpatient therapy caps (see Section 3103). Outpatient therapy service providers may continue to submit claims with the KX modifier, when an exception is appropriate, for services furnished on or after January 1, 2010, through December 31, 2010.
The therapy caps are determined on a calendar year basis, so all patients began a new cap year on January 1, 2010. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,860. For occupational therapy services, the limit is $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.
An educational “MedLearn Matters” article is available which explains things in simple terms: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4364.pdf (02/16/06)
- The Medicare Benefit Policy Manual revision
- The Medicare Claims Processing Manual revision
- The Medicare Program Integrity Manual revision
The ICD-9 codes that qualify for the automatic process therapy cap exception based upon clinical condition or complexity (scroll down to page 22 of the transmittal): http://www.cms.hhs.gov/transmittals/downloads/R855CP.pdf
OIG Audits
OIG Audits Outpatient Therapy Services Practice (12/14/06)
The U.S. Department of Health & Human Services Office of the Inspector General issued a summary of findings indicating that the audited company submitted certain Medicare claims for physical, speech, and occupational therapy that did not meet reimbursement requirements and is therefore subject to recoupment by the Medicare program. Click on the title to access the full report.