Some major changes are headed our way in terms of the 2011 Medicare Final Rule on the Physician Fee schedule and Other Policies to be effective January 1, 2011.  The Rule included a number of provisions that have impact on outpatient therapy services. The net effect of the policies could lead to payment reductions of approximately 30%.

If you see Medicare patients and they impact your revenue, there are several things to pay attention to and deal with proactively. These changes pose a significant threat to a growing population of baby boomers and their ability to access PT. Changes to these payment reductions can only be averted through Congressional action. APTA is notifying its members of opportunities to advocate on behalf of the profession to eliminate these payment cuts and any developments associated with the implementation of the Multiple Procedure Payment Reduction (MPPR).  Many believe that an extension of the therapy cap exceptions process and a reprieve for Medicare Fee Schedule cut will be considered and with some heavy lobbying are expected to be passed. Please stay alert to these changes and be pro-active in standing up for our profession and the value of the services that we provide.

Here is a brief summary of these provisions to provide a better understanding of the rulings. For a more comprehensive summary for APTA members, please see the 2011 APTA Fee Schedule Summary.

  • Multiple Procedure Payment Reduction (MPPR) for Therapy Services
  • Therapy Cap & Exeptions Process
  • Medicare Part B Benefit Deductible
  • Physician Quality Reporting Initiative (PQRI) expiration of the therapy cap exceptions process
  • Addition of the canalith repositioning code (95992) as a reimbursable service under Medicare
  • Implementation of numerous provisions under the Patient Protection and Affordable Care Act (PPACA).

Multiple Procedure Payment Reduction (MPPR) policy

CMS estimates the financial impact of the MPPR policy to be a 7 to 9% reduction in payments for therapy services in 2011. CMS asserts that this cut will be mitigated to a 3% reduction in 2013 due to the full transition to the use of the physician practice information survey (PPIS). This is an improvement from the 14-18% reduction in payment in 2011 that was outlined in the proposed rule.

The MPPR reduction is made by paying 100% of the practice expense for the code with the highest practice expense Relative Value Unit (RVU) and reduces the practice expense of the second code and all subsequent codes billed on that day by 25% (not the 50% originally proposed). This reduction will apply to all outpatient therapy services furnished in all settings. Basically, it is a cascading payment plan that will reduce your overall net per visit if you are not maximizing your billing AND if you are billing for multiple codes, specifically modalities. This is just another call for PTs to provide patients with the care they need using skillful practice with less fluff like modalities.

Therapy Cap & Exceptions Process

The Final Rule implements the annual therapy cap at $1870 ($10 increase from 2010) for 2011 with no exceptions process with use of the KX modifier (expires Dec. 31, 2010). The final rule also includes discussion of multiple options for therapy cap alternatives including (which CMS reports the most common are 1 and 3):

Additional submission of clinical information regarding the patient severity and complexity to determine need for medical review. A severity scale (none, mild, moderate, severe, complete) would be used with new related G-codes.Introduction of additional claims edits regarding medical necessity such as limiting the number of services per visit, services per episode, or per diagnosis.Adopt a per-session bundled payment that would vary based on patient characteristics and complexity of the treatment services provided.

Medicare Part B Benefit Deductible

In 2011, the Part B deductible will be $162. The co-insurance remains at 20% of Medicare allowable charges.

Canalith Procedure Reimbursement

Beginning in 2011, Medicare will recognize the CPT Code 95992- Standard Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), as an individual active code. Therefore this service will be separately payable by Medicare when covered.

PQRI: Physician's Quality Reporting Initiative

The Affordable Care Act changes PQRI in many ways:

2011 incentive reduced from 2% to 1%Incentive payments reduced to .5% in 2012-2014Penalties for not participating start in 20158 Measures available for PTs via claims/registry based reporting2011 mandatory percentage of reporting reduced from 80% to 50%CMS will create by January 1, 2011 a "Physician Compare" website to show all providers, including PTs, who satisfactorily participated in PQRI and earned incentive payments.

Please see subsequent posts on this BLOG page for more detailed information on PQRI. WebPT is 1 or only 2 CMS certified registries in the PT industry and will keep you up to date with all the newest information available.

Other Provisions Affected

Telehealth Services Annual Wellness Visits and Prevention Plan Off the Shelf Orthotics Exemption NO limitations on Physician referrals for physical therapy services furnished by physician offices

Webinar: 5 Fast and Cheap Ways to Fix Your Clinic’s Marketing - Regular BannerWebinar: 5 Fast and Cheap Ways to Fix Your Clinic’s Marketing - Small Banner

article Feb 18, 2013

Top 5 Medicare Compliance FAQs

This blog post comes from WebPT writers Charlotte Bohnett and Erica Cohen. Navigating the murky waters of Medicare can be as scary as finding yourself on a lifeboat in the middle of the ocean with a tiger on board —well, maybe not just as scary, especially if you have WebPT to help. We’re filling this month’s blogs with all sorts of valuable and applicable information on everything there is to know about 2013 Medicare. But what better …

article Mar 11, 2013

February Medicare Webinar Q&A

Today's blogs post comes from WebPT Co-Founder and PT Heidi Jannenga, Marketing Manager Mike Manheimer, and Senior Writers Erica Cohen and Charlotte Bohnett.   Last month’s webinar on Medicare was our most highly attended webinar to date. And that’s really not surprising, because wherever Medicare goes, questions follow. But unfortunately, we couldn’t get to them all live. So we thought we’d put together a blog post will all the great questions you asked and our answers. That …

article Aug 28, 2012

Keep Your Clinic Compliant Webinar Recap

Today's post comes from copywriters Erica Cohen and Charlotte Bohnett. Last week WebPT hosted its most heavily attended webinar ever. Why so popular? Perhaps it was the brow-furrowing topic of compliance, or maybe it was our special guest—physical therapist and compliance expert Rick Gawenda of Gawenda Seminars . Together, Rick, moderator Mike Manheimer, and WebPT co-founder Heidi Jannenga, PT, set out to tackle compliance, making it entertaining, informative, and most importantly, understandable. Here’s a brief snapshot of …

article Aug 6, 2012

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 …

article Aug 9, 2012

Top 5 Medicare Compliance FAQs

This blog post comes from WebPT copywriters Charlotte Bohnett and Erica Cohen. Medicare compliance is one very tough nut to crack as is navigating the murky waters of medical insurance billing. We’ve filled this month’s blogs with all sorts of valuable and applicable information on everything from HIPAA to autonomy. But what Medicare obstacles do you grapple with daily? Today, let’s talk the five most frequently asked questions regarding Medicare. 1.) What is the Therapy Cap? According to …

Breakdown of the 2014 Proposed Physician Fee Schedule Rule Image

article Jul 30, 2013

Breakdown of the 2014 Proposed Physician Fee Schedule Rule

Recently, the American Physical Therapy Association (APTA) shared  their highlights of the 2014 Proposed Physician Fee Schedule Rule . This summary boils down the 605-page proposal from the Centers for Medicare and Medicaid Services (CMS) into a 16-page bulleted outline. The breakdown is incredibly helpful, and we definitely recommend you read it. However, we know that not everyone is an APTA Member, and many of you are crunched for time. So, we sat down with our Founder …

article Aug 28, 2013

No Workarounds: Following the Rules of the Therapy Cap and the Importance of Solid Documentation

If you’re like most rehab therapists, finding a letter from Medicare in your mailbox is enough to make your brow sweat and your heart skip a beat. With all of the regulations we have to follow—and the potential penalties associated with noncompliance—it’s no surprise that we have grown to fear Medicare. We’re afraid of doing something wrong. Or in some cases, we’re afraid of not getting paid. Thus, rather than defend our decisions, our expertise, and our …

article Nov 4, 2013

What PQRS Could Look Like in 2014

On July 19, 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Medicare Physician Fee Schedule (MPFS) Notice of Proposed Rulemaking (NPRM) in the Federal Register. According to this summary , most of the policies were open for comment until September 6, 2013 and, pending final decisions (which hopefully will occur this month), will take effect on January 1, 2014. The 605-page document contains proposals for policy changes on everything from reimbursements to the …

article Nov 5, 2013

Founder Letter: PQRS 2014

Well, it’s November already, and that means two things: Thanksgiving and Physician Quality Reporting System (PQRS). Sure, PQRS doesn’t involve mouthwatering roasted turkey, savory stuffing, or creamy mashed potatoes, but it has become quite the November tradition for us here at WebPT. You see, this is the time of year that the Centers for Medicare & Medicaid Services (CMS) typically confirms the details of next year’s reporting requirements, thus allowing us to update our PQRS solution (claims- …

Get exclusive content delivered right to your inbox.