CHANGES TO OUTPATIENT THERAPY SERVICES UNDER MEDICARE FOR 2013
Functional Data Collection
The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Final Rule for CY 2013 established new payment practices for outpatient therapy services billed under Medicare Part B. Under the rule, outpatient therapy providers billing the Medicare program will have to report functional data for patients on the claim form. Reporting takes the form of new, nonpayable "G-codes," which are used to identify the primary issue being addressed by therapy. G-codes are accompanied by modifiers, which indicate the complexity of the patient (i.e., his or her impairment/limitation/restriction) and will ultimately be used to track functional change over time. Reporting began January 1, 2013, with the first six months of the year constituting a "testing period." Beginning July 1, 2013, CMS contractors will stop accepting claims without the required functional data and will return them for re-submission with the required codes.
Functional Data Collection Requirements for Outpatient Therapy (CY 2013)
Manual Medical Reviews over $3,700
Outpatient therapy services above $3,700 for occupational therapy and $,3700 for physical therapy and speech-language pathology, combined, are subject to manual medical review under Medicare. (As always, the Medicare program and its contractors may still review claims for therapy services below this threshold.) Reviews during the last quarter of 2012 involved a pre-authorization process, but there are changes for the 2013 calendar year. Medicare Administrative Contractors (MACs) will continue to conduct prepayment review of claims above $3,700 until March 31. On April 1, Recovery Audit Contractors (RACs) will take over the process, conducting a prepayment review demonstration for Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri and postpayment review in all other states. Neither the MACs nor the RACs are precluded from reviewing therapy services below the $3,700 threshold.
New CMS Rules on Manual Medical Reviews in Outpatient Therapy
Manual Medical Reviews: Guidance for Outpatient Therapy Providers
Medicare beneficiaries and seven organizations reached a settlement with the Department of Health and Human Services (HHS) and Department of Justice (DOJ) in the nationwide class action lawsuit of Jimmo v. Sebelius. The settlement stipulates that skilled services to maintain an individual’s condition or prevent or slow their decline are covered by Medicare and that the so-called “improvement standard” that Medicare had been employing is illegal.
Jimmo v. Sebelius
The Therapy Cap and Exceptions Process
The statutory Medicare Part B outpatient therapy cap for CY 2013 is $1,900 for occupational therapy and $1,900 for physical therapy and speech-language pathology, combined. The cap continues to be an annual per beneficiary amount for each calendar year and applies to all outpatient settings, including hospital outpatient departments (HOPDs). Services provided in Critical Access Hospitals (CAHs) will be counted toward a patient’s therapy total (as converted fee schedule amounts), but CAHs themselves will not be subject to the cap or to reviews over $3,700. The exceptions process to the therapy cap has been extended through December 31, 2013, meaning that occupational therapists may affix the KX modifier to claims for above-the-cap therapy services that are reasonable and necessary.
Multiple Procedure Payment Reduction
Congress has increased the multiple procedure payment reduction (MPPR) amount to 50% across all settings beginning April 1, 2013. This is an increase from the earlier rate of 20% in office settings and 25% in facilities and is expected to result in an estimated payment reduction to therapy of 7%. Also problematic is the fact that the policy again fails to distinguish the three therapy disciplines and apply the MPPR separately to each.
The Physician Quality Reporting System (PQRS)
PQRS is a federal program established in 2007 that uses Medicare payment to promote quality measure reporting among eligible health care professionals. Occupational therapists who (1) work in private practice, and (2) bill Medicare using an individual-level National Provider Identifier (NPI) are subject to PQRS. Occupational therapists working in hospitals or skilled nursing facilities whose employers bill for their services are not subject to the program rules. Because the program is administered on a two year cycle, incentives paid in CY 2013 and CY 2014 will be based on reporting during CY 2011 and CY 2012, respectively. Payment penalties for unsatisfactory reporting, which take effect CY 2015, will be based on reporting done in CY 2013. Thus, participation is now critical: in order to avoid Medicare payment cuts beginning in 2015, eligible occupational therapists should begin reporting on quality measures this year.
Occupational therapists are able to report quality data on the following 16 measures:
Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Documentation of Current Medications in the Medical Record
Pain Assessment Prior to Initiation of Therapy and Follow-Up
Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Falls: Risk Assessment
Falls: Plan of Care
Preventative Care and Screening: Unhealthy Alcohol Use – Screening
Elder Maltreatment Screen and Follow-Up Plan
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with a Functional Deficit of the Neck, Cranium, Mandible, Thoracic Spine, Ribs or Other General Orthopedic Impairment
* - Registry only
Note: At the time of this writing, PQRS Measure 182 (Functional Outcome Assessment) was not available for use by occupational therapists because the measure developer did not include occupational therapy CPT service codes in the measure specifications. AOTA is working on rectifying this oversight.
AOTA informational materials on PQRS will be available online shortly.