Share

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

Social Media for PTs: Is it Worth it? - Regular BannerSocial Media for PTs: Is it Worth it? - Small Banner
Heidi Jannenga PT

Subscribe to our blog.

  • articleMar 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 …

  • articleAug 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 …

  • articleAug 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 …

  • articleAug 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 …

  • articleFeb 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 …

  • articleNov 7, 2012

    CMS: 2013 Final Rule for Medicare Physician Fee Schedule

    Today’s blog post comes from WebPT Senior Copywriters Erica Cohen and Charlotte Bohnett. We do this every year: waiting and wondering what Medicare is going to do. As the news trickles in—and details are still coming—it all seems as expected so far. So what are the big takeaways? Here is WebPT Co-Founder and COO Heidi Jannenga’s take on what these CMS changes mean for you and your clinic. First of all, CMS increased the therapy cap by …

  • articleNov 20, 2010

    Temporary Reprieve to some Final Rule Changes Passed by Senate but the Fight is NOT Over!

    Last night the Senate passed a bill  by unanimous vote called The Physician Payment and Therapy Relief Act of 2010 (PPTRA) that allows a 30 day reprieve from the Medicare Final Rule and continue the existing 2.2% Medicare payment update that expires November 30. The PPTRA also changes  the multiple payment procedure reduction (MPPR) finalized by the Centers for Medicare & Medicaid Services (CMS) this month, by applying a 20% reduction, rather than the 25% reduction in the …

  • articleFeb 12, 2013

    PQRS in a Nutshell

    What is PQRS?  Created by Center for Medicare and Medicaid Services (CMS), Physician Quality Reporting System (PQRS) mandates that physical therapists, occupational therapists, and qualified speech-language therapists meet the standards for satisfactory reporting. If you are not PQRS compliant in 2013, CMS will assess penalties of 1.5% of your Medicare payments as fines in 2015. However, if you are compliant, you will earn a 0.5% incentive payment on your total allowed charges during the reporting period. Why …

  • This Week in PT News, March 28 Image

    articleMar 28, 2014

    This Week in PT News, March 28

    S. 2110 Vote The Senate is scheduled to vote on the Medicare cap this week, so it’s your last chance to contact your local representatives and ask them to vote “yes” for the Medicare SGR Repeal and Beneficiary Access Improvement Act (S. 2110). Find your senator’s contact information here . HR 4302 Vote Yesterday, the House of Representatives passed by voice vote a proposal (HR 4302) to delay for 12 months a scheduled 24% cut to Medicare …

Get exclusive content delivered right to your inbox.