Saving the Day the CMS Way
Today’s blog post comes from WebPT cofounder and COO Heidi Jannenga, PT, MPT, ATC/L
To all of our Super Therapists working diligently to improve their patients’ functional level and quality of life, the Center for Medicare and Medicaid Services (CMS) has tossed a chunk of Kryptonite into our clinics.
As you know, CMS has implemented many changes this year and continues to have the Proposed Rule for prospective payment and data collection pending. Keeping up to date with these changes is crucial if you are treating patients with Medicare insurance. As our fellow superhero Spiderman says, “Whatever comes our way…we always have a choice...It's the choices that make us who we are, and we can always choose to do what's right.” As therapists, we want to do what’s right for our patients, and that means producing excellent documentation that aligns with Medicare’s compliance requirements. Our skillset as therapists includes validating the need for our services, and we can only achieve this through thorough documentation and use of tests and measures to help show progress during the episode of care. EMRs can help to enforce Medicare compliance, while improving workflow efficiency, but ultimately you’re the last line of defense.
This week, CMS described their plans for the manual medical review process for therapy cap exceptions that exceed $3,700 starting October 1, 2012. So, for those who thought they could use their cape as a shield or were just not paying attention, CMS changed the cap exceptions process. The 2012 therapy cap amount is $1,880, and if you go over that amount, then you must apply the KX modifier to the CPT codes you bill. If you continue to treat the patient and exceed $3,700, you will enter the manual medical review process. As we approach October 1, CMS is now circulating more details regarding the process. Key points include:
- CMS still requires the KX modifier for therapy services exceeding the therapy cap of $1,880.
- For outpatient therapy services that exceed $3,700, CMS now requires an advanced approval process. CMS will assign providers to one of three distinct phases for manual medical review, notifying them of their placement via letter and contractor websites.
- Phase I providers are subject to manual medical review October 1–December 31.
- Phase II providers are subject to manual medical review November 1–December 31.
- Phase III providers are subject to manual medical review December 1–December 31.
- CMS will base these medical reviews on current medical review standard criteria. They will also provide guidance and additional training for providers and Medicare Administrative Contractors (MACs) in the coming weeks.
- MACs will have ten business days to decide whether or not they will approve services that exceed $3,700. If the MAC does not respond to a provider within ten business days, the provider may consider their claims beyond the $3,700 threshold approved.
- If you receive advanced approval, you’re allowed an additional 20 treatment days beyond the $3,700 amount. However, advanced approval does not guarantee payment as MACs may perform retrospective reviews.
- If you as a provider do not request advanced approval prior to providing services over $3,700, payment for the claims will stop. You will receive a request for medical records as part of a prepayment review, which occurs within approximately 60 days.
- Any of your patients, who have received $3,700 or more of therapy services in 2012, will receive letters in September informing them of their potential financial liability for services provided over the therapy cap amount. An advanced beneficiary notice (ABN form) is not required but is recommended as a way for you to educate your patients about the potential financial responsibility for services above the therapy cap amount.
Fellow citizens of physical therapy land, these may seem like weighty key points but that’s because they’re serious, and detailed, and not to be taken lightly. If you have seen any Medicare patients this year for more than $3,700 worth of treatment then you should be prepared to submit documentation to justify medical necessity—even if you applied the KX Modifier appropriately. If you have Medicare patients who have exceeded this therapy cap, all CMS eyes will be on you—think a Batman beacon shining from your clinic, but instead of calling the Caped Crusader for help, you’re calling CMS for an audit.
The electronic billing requirement has not only improved efficiency, but has also opened the door to data mining and comparative analysis. Now more than ever, it is imperative that you conduct chart reviews and educate your staff on the importance of compliance. Over are the days where you could skimp on your documentation without fear of audits or denied reimbursements. But, if you have been documenting correctly and thoroughly this whole time, have no fear.
Plus, you have WebPT, which provides education, tools, and reports to help you ensure documentation compliance. The APTA has also put out a helpful FAQ page. Want even more? Stay tuned to our blog this month (same bat-time, same bat-channel) as we provide copious amounts of compliance education. And, don’t miss our webinar with compliance guru, Rick Gawenda.