Medicare Physician Fee Schedule Final Rule CY 2013
The Centers for Medicare & Medicaid Services (CMS) has just released its final rule on the Medicare Physician Fee Schedule for calendar year 2013. The rule establishes payment practices for outpatient therapy services billed under Medicare Part B. Under the rule, the therapy cap amount for occupational therapy services will be $1,900, and, among other things, providers will have to report functional data for patients on the claims form.
The Outpatient Therapy Cap
The Medicare Economic Index (MEI) is used to determine the outpatient therapy cap amount for every calendar year. As announced in the final rule, the therapy cap amount for CY 2013 is $1,900 for occupational therapy and $1,900 for physical therapy and speech-language pathology, combined (an increase from the 2012 level of $1,880). Pursuant to the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA), the exceptions process to the therapy cap expires December 31, 2012, but AOTA is working hard to extend the process through next year.
Functional Data Collection
CMS' initial plan for complying with MCTRJCA language and instituting a claims-based functional data collection process was first proposed in July 2012. Under the final rule, practitioners furnishing outpatient therapy services are required to include new, nonpayable "G-codes" and modifiers on claim forms for therapy services beginning in 2013. The G-codes would be used by the provider to identify the primary issue being addressed by therapy, and there are 42 codes from which to choose. A scale of 7 modifiers would indicate the complexity of the patient – i.e., their impairment/limitation/restriction – and would be used to track functional change over time. This final scale is reduced and simplified, as per AOTA request, from the original 12 proposed modifiers.
G-Code Categories
Mobility: Walking & Moving Around
Changing & Maintaining Body Position
Carrying, Moving & Handling Objects
Self Care
Other PT/OT Functional Limitation
Other SLP Functional Limitation
Swallowing
Motor Speech
Spoken Language Comprehension
Spoken Language Expression
Attention
Memory
Voice |
[For the full list, see here (Table 21, page 76)].
Severity/Complexity Modifiers
| Modifier |
Impairment/ Limitation/ Restriction
|
|
CH
|
0%
|
|
CI
|
1-19%
|
|
CJ
|
20-39%
|
|
CK
|
40-59%
|
|
CL
|
60-79%
|
|
CM
|
80-99%
|
|
CN
|
100%
|
While reporting will begin on January 1, 2013, in accordance with the authorizing statute, the first 6 months of the year will be a testing period during which providers can acclimate to the change. After July 1, 2013, CMS will reject claims that do not include the required G-codes and modifiers. The professionals required to report these data on the claim form include occupational therapists; physical therapists; speech-language pathologists; physicians; and certain nonphysician professionals, such as physician assistants, nurse practitioners, and clinical nurse specialists.
We encourage providers to be as well-versed in these codes as possible before the start of the new year and to plan to begin reporting as early in the new year as possible. To help educate providers, CMS is hosting a National Provider Call, "Preparing for Therapy Functional Reporting Implementation in CY 2013" on Wednesday, December 12, 2012 from 1:30-3:00pm ET. The call, which will be led by CMS staffer Pamela R. West, DPT, MPH, will address how providers can comply with the new reporting requirements:
Agenda
- Overview of the new functional reporting requirement, including effective dates
- Professionals and providers affected
- Nonpayable G-codes used to report functional limitations
- Modifiers used to report the severity of functional limitations
- When reporting is required
- Documentation requirements
- Question and answer session
AOTA staff will participate, but in order for providers to individually receive the toll-free call-in number and passcode, you must register for the call here. Registration will close at 12 noon ET on the day of the call or when available space has been filled up; no exceptions will be made, so please register early.
Other Elements of the Fee Schedule Final Rule Important to the Practice of Occupational Therapy
Sustainable Growth Rate (SGR): Across-the-board fee schedule cuts could result in CY 2013 from projected changes to the sustainable growth rate (SGR) conversion factor, but AOTA is also working hard to avoid these cuts (as we have done every year) in what is widely known as a "doc fix."
Multiple Procedure Payment Reduction (MPPR): Medicare's multiple procedure payment reduction (MPPR) policy for outpatient therapy pays in full for the CPT code/unit billed with the highest value, and then applies a 20-25% cut to the practice expense (PE) of any second and subsequent codes/units. The policy applies to all "always therapy" service codes billed by a single Part B provider or institution (as identified by NPI) for a single patient in a single day. CMS confirmed in the final rule that these harmful cuts, instituted in 2011 over objections from AOTA and our coalition partners, will continue.
Physician Quality Reporting System (PQRS): Occupational therapists in private practice have been eligible to participate and receive Medicare incentive payments for meeting quality measure reporting requirements under the Physician Quality Reporting System (PQRS). The incentive phase of the system is nearing an end, and in order to avoid Medicare payment cuts beginning in 2015 occupational therapists in private practice should begin reporting on quality measures in 2013.
With this final rule, CMS has made clear it will continue to pursue data collection efforts and alternative payment mechanisms for outpatient therapy services, with the ultimate aim of fundamentally reforming the payment system. AOTA will continue its active engagement in decision-making and rulemaking processes in order to protect and promote the practice of occupational therapy and the pathways to care for beneficiaries. AOTA has already noted our concerns with the plan to collect functional data (see AOTA's Comment Letter on the Proposed Rule) and we are currently closely reviewing the rule for its implications for practice, and working with coalition partners. CMS and AOTA will also be working on provider education efforts in advance of the implementation date, both independently and in concert. The agency has not yet scheduled any calls for providers, but check back here for updated information.
Please send your questions to Regulatory Affairs at regulatory@aota.org.
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