Therapy Cap Alternatives: The Short Term Alternatives to the Therapy Cap (STATS) and Developing Outpatient Therapy Payment Alternatives (DOTPA) Projects
AOTA has long advocated for a permanent fix to the Medicare outpatient therapy cap, which is $1,860 for occupational therapy services, and a combined $1,860 for physical therapy and speech language pathology services for 2010. The exceptions process in effect through December 31, 2010.
Those of you following this issue are likely aware that AOTA’s work includes active involvement with two projects run by the Centers for Medicare & Medicaid Services (CMS): the Short Term Alternatives to Therapy Services (STATS) and Developing Outpatient Therapy Payment Alternatives (DOTPA) research projects.
STATS is geared toward controlling therapy utilization in the short term through Medicare policy revisions and changes to coding and billing systems. The STATS project was contracted to Computer Sciences Corporation (CSC) and began in November 2008 with a stakeholder kickoff meeting. Since that time, AOTA has placed experts on three workgroups.
The Clinical Workgroup identiﬁes policies that could be revised to better define medically necessary therapy services, considers the administrative burden of existing and revised policies and determines the extent of need for provider and contractor education.
The mission of the Assessment Instrument Workgroup is to evaluate existing patient assessment instruments and identify common factors that help describe medical necessity for therapy services.
The Policy Workgroup seeks to evaluate existing Medicare therapy payment policy to identify policies that could reduce barriers to the efficient, effective delivery of needed therapy services.
DOTPA is designed to identify patterns in Part B therapy utilization and analyze the effectiveness of outpatient therapy services. The ultimate goal of the project is develop recommendations to CMS on payment method alternatives to the outpatient financial cap.
DOTPA was authorized by section 545 of the Benefits Improvement and Protection Act (BIPA) of 2000, which required the Secretary of the Department of Health and Human Services to report on the development of standardized assessment instruments for outpatient therapy. In accordance with BIPA, CMS awarded the DOTPA contract to RTI International in January 2008. RTI was charged with developing a research project to identify, collect, and analyze therapy-related information tied to beneficiary need and the effectiveness of outpatient therapy services that is currently unavailable to CMS.
RTI has developed two assessment tools (CARE-C and CARE-F) to identify the characteristics and outcomes of Medicare beneficiaries receiving occupational therapy, physical therapy, and speech-language pathology services on an outpatient basis. The CARE-C tool is targeted at those receiving Part B services in community-based settings, and the CARE-F tool is specific to those receiving Part B services in a skilled or other nursing facility.
CMS first published the tools in the October 9, 2009 Federal Register. As both tools would significantly impact payment for the provision of occupational therapy services to older adults, AOTA carefully reviewed them and solicited thoughts from member experts. AOTA responded with comments that endorsed the tools’ use of the International Classification of Functioning, Disability and Health (ICF) and a recommendation that the ICF concept of “participation” be better represented. The first version of the CARE-F tool contained no participation measures at all.
When the revised tools were published along with a request for comments on the data collection plan in the April 23, 2010 Federal Register, it was clear that AOTA had been successful and our comments had been incorporated. The CARE-C tool’s existing participation measures were supplemented, and a participation measure was added to the CARE-F tool. AOTA wrote to CMS with another set of comments incorporating member input.
RTI is in the midst of launching its data collection project and is soliciting Medicare Part B outpatient rehabilitation therapy providers to participate. An Open Door Forum (ODF) on the project was held on August 19, 2010. For more information, see the RTI project page, the PowerPoint presentation from the ODF, and the transcript and audio file from the ODF.
CMS released its proposed 2011 Physician Fee Schedule rule in the July 13, 2010 Federal
Register. Among other things, CMS solicited general comments on short- and long-term alternatives to the therapy cap, as well as specific comments on three short-term options offered by the agency (but not formally proposed).
The first option would modify the current therapy cap exceptions process to capture additional clinical information regarding patient severity and complexity in order to facilitate medical review. This option would require that clinicians submit nonpayable function-related HCPCS codes to replace the KX modifier at the onset of the episode onset and at periodical intervals. These codes would be rated on a yet to be determined severity/complexity scale.
The second option would involve introducing additional claims edits regarding medical necessity in an attempt to reduce perceived overutilization. CMS suggests using existing therapy utilization data to develop annual per beneficiary medical necessity payment edits—such as limits to the number of services per session, per episode, or per diagnostic grouping—for exceptions to the therapy caps which could be set at benchmark payment levels that only a small percentage of beneficiaries would surpass in a single year. Once these levels are reached, additional claims would be denied and practitioners would need to appeal those denials if they wished to challenge Medicare’s nonpayment. CMS estimates that this alternative would require one to two years to implement as an expansion of existing policy.
The third option would be to adopt a per-session bundled payment that would vary based on patient characteristics and the complexity of evaluation and treatment services furnished in the session. This would require the use of new single, bundled, per-session codes. Payment for the code would be based on patient characteristics (as identified through prior CMS contractor analyses) and the complexity of the evaluation/assessment and intervention services furnished during the session.
AOTA solicited expert member input and submitted detailed comments to CMS on these options, as well as a number of other important issues contained in the proposed rule.
AOTA will continue to advocate for an accurate of assessment method and payment policy for Medicare Part B occupational therapy services. In addition, AOTA will encourage CMS and its contractors to recognize practitioners’ clinical judgment as an important part of the patient assessment process and seek a permanent fix to the therapy cap issue.
Updated: September 17, 2010