Today’s blog post comes from PT and compliance guru Rick Gawenda, founder and President of Gawenda Seminars and Consulting, Inc

The Middle Class Tax Relief and Job Creation Act of 2012 (HR3630) impacted physical therapists in private practice in terms of the Medicare therapy cap. First and foremost, HR3630 extended the therapy cap exception process through the 2012 calendar year. Secondly, it requires that the Centers for Medicare and Medicaid Services (CMS) apply the therapy cap limitations to hospital outpatient departments no later than October 1, 2012. The therapy cap for hospital outpatient departments concludes at the end of 2012 unless Congress passes additional legislation extending it into 2013.

So how does this affect the private practitioner? Currently, any outpatient therapy a Medicare beneficiary receives in a hospital outpatient therapy department between January 1 and September 30, 2012, does not count towards the $1,880 physical therapy and speech-language pathology cap. However, beginning on October 1, 2012, any therapy a Medicare beneficiary receives in a hospital outpatient department will now count toward the cap. Additionally, any outpatient therapy the Medicare beneficiary received in a hospital outpatient department from January 1 to September 30, 2012, will be applied retroactively to the $1,880 therapy cap limitations beginning on October 1, 2012.

For example, a Medicare beneficiary receives therapy in a hospital outpatient department from March 5 through April 11, 2012, and July 20 through August 15, 2012, and uses $2,128 toward the Medicare therapy cap. That same Medicare beneficiary now comes to your private practice for outpatient physical therapy beginning on October 17, 2012. During the intake process, you ask the Medicare patient if they have had therapy at all this year. They answer “yes” and tell you XYZ hospital provided therapy during the aforementioned dates. Because the hospital provided therapy services prior to October 1, 2012, you believe the Medicare patient has not used any of their $1,880 therapy cap. On the contrary, those services ($2,128) will be retroactively applied toward the cap on October 1, 2012. Thus, the patient has already exceeded the allowed amount of therapy for the year. As the private practitioner, you would now need to append the KX modifier to each CPT code on the claim form, beginning with the initial date of service to ensure reimbursement for your services. 

Furthermore, beginning October 1, 2012, you must include the physician’s ‪National Provider Identifier (NPI) or non-physician practitioner (NPP) who certified the plan of care on the claim form. So how does that differ from what you do now? If the physician or NPP who certifies the plan of care is the same one who referred the patient for outpatient physical therapy, then there is no difference. However, there are times when one physician/NPP may refer the Medicare patient for outpatient physical therapy, yet a different physician/NPP signed the plan of care. Beginning October 1, 2012, CMS requires the physician or NPP who certifies the plan of care to include his or her NPI number on every claim form submitted for payment. As of today, we are still waiting for CMS to provide instructions as to where therapists should place this information on the1500-claim form.

It’s a lot to take in, I know. So, join me for the WebPT webinar Keep Your Clinic Compliant on August 21st or 23rd. In this free 60-minute session, I’ll discuss the therapy cap and the manual medical review process effective October 1. 

Physical Therapy Billing Open Forum - Regular BannerPhysical Therapy Billing Open Forum - Small Banner
  • articleAug 28, 2013 | 7 min. read

    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 …

  • 2013 Medicare Therapy Cap FAQ Image

    articleFeb 4, 2013 | 6 min. read

    2013 Medicare Therapy Cap FAQ

    In January, WebPT released the Medicare Allowable Fee Schedule in preparation for the new Medicare Therapy Cap Alerts we’ll launch this month. In short, this new feature will allow you to reproduce your Allowable Fee Schedule within WebPT as published by Medicare. This fee schedule will inform a tracking tool and subsequent alerts so you can see how much of the therapy cap your patients have accrued using your services. As a result of this launch, we’ve …

  • articleFeb 18, 2013 | 4 min. read

    Top 5 Medicare Compliance FAQs

    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 way to get up to speed than with some frequently asked questions. …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • Top 10 Medicare Compliance Strategies for Outpatient Therapy Providers Image

    articleNov 15, 2017 | 16 min. read

    Top 10 Medicare Compliance Strategies for Outpatient Therapy Providers

    These days, almost everyone who works in the outpatient therapy setting has treated a patient with Medicare benefits. We have all encountered the daunting list of rules and regulations we must be follow so that: Medicare considers our documentation sufficient , and We command the highest possible level of reimbursement. From G-codes to POCs and FOMs to LTGs, it’s enough to make anyone’s head spin! With that in mind, here’s a top-10 list of helpful tips for …

  • Technical Diligence: The Key to Stopping Claim Denials Dead in their Tracks Image

    articleJul 9, 2015 | 5 min. read

    Technical Diligence: The Key to Stopping Claim Denials Dead in their Tracks

    Hello, readers. Over the past several weeks, I’ve enjoyed answering a number of your questions regarding billing for PT services, so I’m excited to address the topic right here on the WebPT Blog. On June 19, 2015, the Office of the Inspector General (OIG) released a report involving an outpatient private practice physical therapy provider. In case you weren’t aware, the OIG—which is part of the US Department of Health and Human Services (HHS)—is basically the CMS …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • The Ins and Outs of ABNs Image

    articleOct 18, 2018 | 6 min. read

    The Ins and Outs of ABNs

    If the rules of Advance Beneficiary Notices of Noncoverage (ABNs) make you a bit confused, you’re definitely not alone. In an effort to shed some light on the ins and outs of ABNs and to highlight some recent changes to ABN requirements, Medicare created this set of FAQs clarifying their use. Here’s some info to help bring you up to speed: What is an Advance Beneficiary Notice of Noncoverage (ABN)? An ABN is a form practitioners use …

  • Do You Know Your Modifiers? [Quiz] Image

    articleJul 29, 2015 | 1 min. read

    Do You Know Your Modifiers? [Quiz]

    It’s a mad, mad, mad, mad Medicare world, and unfortunately, just about every regulation requires a modifier. If you apply the wrong modifier—or forget one entirely—then your clinic suffers decreased payments or flat-out denials. Even worse, if you amass enough modifier mistakes, you make your practice vulnerable to an audit. Worried you’re miserable at modifiers or want confirmation that you’re actually a modifier master? Take our 10-question quiz below to test your modifier know-how.    

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.