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.

Physical Therapy Billing Open Forum - Regular BannerPhysical Therapy Billing Open Forum - Small Banner
  • 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 …

  • articleAug 9, 2012 | 5 min. read

    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 …

  • 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 …

  • CMS’s Final Bow: The 2019 Final Rule Image

    articleNov 5, 2018 | 8 min. read

    CMS’s Final Bow: The 2019 Final Rule

    Last week, the Centers for Medicare and Medicaid Services (CMS) published its 2019 final rule . Clocking in at just over 2,300 pages, the final rule isn't exactly a light read—especially because the legal lingo can be harder to interpret than Shakespearean verse. Luckily, we have the script—with all its twists and turns—decoded and ready for you to review. Here's the synopsis of all the physical therapy, occupational therapy, and speech-language pathology Medicare changes for 2019: Out, …

  • articleNov 19, 2013 | 4 min. read

    Therapy Cap Recap

    If you’re a rehab therapist who treats Medicare patients, you’ve got a bevy of rules and regulations to follow and knowing all of them inside and out is a tall order, to say the least. If decoding government legalese isn’t really your thing, don’t worry—we’ve dedicated this entire month to serving up a smorgasbord of digestible, easy-to-understand guides on the important Medicare policies that apply to you. On today’s menu: the therapy cap. As part of the …

  • Common Questions from Our PT Billing Open Forum Image

    articleAug 18, 2018 | 34 min. read

    Common Questions from Our PT Billing Open Forum

    Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing . Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on …

  • articleNov 18, 2010 | 4 min. read

    What PTs Should Know About 2011 Final Rule Medicare Changes

    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 …

  • 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 …

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