2/14/2018. Emerging Issues in Medicare: Payment Updates and Hot Topics. Learning Objectives

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1 Emerging Issues in Medicare: Payment Updates and Hot Topics February 23, 2018 Kara R. Gainer, JD, Director of Regulatory Affairs, APTA Alice Bell, PT, DPT, Senior Payment Specialist, APTA Learning Objectives 1. Develop an understanding of Medicare Parts A and B payment updates in 2018 as well as federal government activities related to therapy cap and targeted medical review, program integrity initiatives, and Medicare coverage issues 2. Better understand CPT coding and how to appropriately use modifiers 3. Comprehend Medicare s efforts to address administrative burden 1

2 Disclosure No disclosures to report Medicare Physician Fee Schedule 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. Summary of Medicare Outpatient Therapy Expenditures, 2010 Discipline Outpatient Therapy Users Percent of Users Total paid (thousands) All 4,697, % $5,642,532 PT 4,156, % $4,077,033 OT 1,043, % $1,089,115 SLP 526, % $476,385 2

3 Fee Schedule Payment Outpatient physical therapy services are paid under Medicare Physician Fee Schedule Work PE Malpractice These values are multiplied by a dollar conversion factor to determine payments MPFS Spending Difference in PT spending in 2015 vs ,000, ,000, ,000, ,000,000 1,000,000,0001,200,000,0001,400,000,0001,600,000, allowed charges 2016 allowed charges CY 2018 Medicare Physician Fee Schedule Updates Updated PM&R code values Updates to orthotics/prosthetics training and management code descriptors Continued exclusion of PT services from Medicare covered telehealth services list 3

4 How 2018 PFS Rule May Impact You Some PM&R codes increased in value; other code values decreased How this impacts you is dependent on your billing patterns & patient population To determine payment amounts, CMS offers fee schedule calculator at APTA also offers members a fee schedule calculator that takes into account geography, MPPR, and sequestration. Find it at: You may also check with your local contractor on fee schedule payment amounts Orthotic/Prosthetic Train/Mgmt. Codes CPT code 97760: Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies), and/or trunk, initial orthotic(s) encounter, each 15 minutes CPT code 97761: Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s), encounter, each 15 minutes New CPT code 97763: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes Legislative Updates: Fee Schedule 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. 4

5 NEW: Extension of Work GPCI Floor Congress has extended the current 1.0 physician work GPCI floor through 12/31/2019 NEW: 2019 PFS Payment Update Congress reduced 2019 update to PFS from.50% to.25% Reminder: Updates to Part B Payments : APM: Eligible for 5% bonus MIPS: Eligible for +/- payment adjustment 2026 and beyond: Providers in Advanced APM will receive.75% update MIPS providers will receive.25% update (inflationary adjustment resumes) 5

6 NEW: Therapy Cap Congress permanently extended the outpatient therapy exceptions process/targeted medical review threshold Effective: January 1, 2018 Applies in all Part B settings Hospitals are included NEW: Therapy Cap Details Claims above $2,010 for PT, SLP (adjusted annually) for medically necessary services: Use KX modifier By using KX, PT attests the services are medically necessary and meet Medicare requirements for payment Do not use ABN for medically necessary services Targeted medical review: $3,000 threshold NEW: PTA Pay Differential January 1, 2020: Requires use of modifier to denote when outpatient therapy services are furnished in whole or part by PTA or OTA January 1, 2022: Payment for outpatient therapy services provided by PTA or OTA will be at 85% of PFS 6

7 Legislative and Regulatory Updates: Post-Acute Care 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. CY 2018 HH PPS Payment Medicare payments to HHAs in CY 2018 are reduced by 0.4 percent, or $80 million No HHGM in 2019 NEW: HHA Payment Update Congress: Home health market basket percentage increase will be 1.5% in

8 NEW: Extension of Home Health Rural Add-On Congress extended home health rural add-on 2018: 3% increase : Targeted payments (NOT equal across rural HHAs) NEW: Home Health 30-Day Unit of Service Unit of payment is reduced from 60 days to 30 days beginning in 2020 Budget neutral Eliminates therapy thresholds HHS must finalize revised case-mix system prior to 2020 NEW: Home Health Documentation to Satisfy Eligibility To determine beneficiary eligibility for Medicare coverage of HHA services, CMS may review the entire medical record, including the HHA s patient record In places where physician s record may be insufficient to determine eligibility, the HHA s record could be used as supporting material to attest eligibility 8

9 FY 2018 SNF PPS Unadjusted Federal Rate Per Diem Urban Rate component Nursing CMI Therapy CMI Therapy Non-CMI Non-case mix Per Diem $ $ $17.58 $90.44 FY 2018 SNF PPS Cont. Unadjusted Federal Rate Per Diem Rural Rate component Nursing CMI Therapy CMI Therapy Non-CMI Non-case mix Per Diem $ $ $18.78 $92.11 NEW: FY 2019 SNF Payment Update Special rule for FY 2019: SNF market basket percentage is 2.4% 9

10 FY 2018 IRF PPS Payment FY 2020: CMS replaced current pressure ulcer measure with an updated measure (Changes in Skin Integrity) CMS removed All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from IRF FY 2018 LTCH PPS Payment 1 year moratorium on 25% rule Upcoming changes to FY 2020 LTCH QRP NEW: LTCH PPS Extension of 50/50 payment blend through FY 2019 Blend: Half of IPPS or 100% of estimated cost for services (whichever is lower) and LTCH PPS rate 10

11 Post-Acute Care Reform 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. IMPACT Stages of Implementation Data collection, reporting and analysis MedPAC Reports to Congress Feedback reports Public Reporting Medicare Post-Acute Care Prospective Payment Systems 4 separate payment systems establish different payments for similar patients Belief that current SNF & HHA PAC PPS encourage providers to: Furnish therapy services unrelated to care needs Avoid medically complex patients Solution: Payments based on patient characteristics rather than the site of service 11

12 PAC PPS Reform CMS wants to better align payment with patient care needs Connection between SNF and HHA payment and therapy utilization needs to be eliminated Home Health Groupings Model (HHGM): How we got here 1997: Congress calls for development of HH PPS March 2000: MedPAC identifies low-use therapy threshold creates financial incentive October 2000: HH PPS replaces interim payment system : Growing belief that HH payment tied to therapy visits incentivizes unnecessary utilization July 2017: CMS proposes new HH case-mix system to better align HH payments with patient characteristics 35 HHGM Characteristics Changes from 60-day episode to 30-day period of care 144 different episode payment groups Groupings based upon: Admission source Timing Clinical Groupings Functional Level Comorbidity adjustment (Y/N) 36 12

13 Back to Drawing Board (Sort of) Switch to 30-day unit of service in 2020 Budget neutral Eliminates therapy thresholds HHS must: Convene technical expert panel in 2018 Issue report to Congress by April 2019 Implement new case-mix system by SNF RCS-I Model Advance proposal: May 2017 Eliminates connection b/w therapy and payment Comprised of 4 main case-mix components PT/OT SLP Nursing Non-therapy ancillary 38 What to Do Next BOLO FY 2019 SNF proposed rule Continue to demonstrate your value Advocate for your profession 39 13

14 Unified PAC PPS MedPAC s goal: Increase equity of payments across patient conditions : Use a blend of current settingspecific payment rates with those under the site-neutral (unified) PAC PPS relative weights to establish payments 2021: Full implementation of unified PAC PPS Program Integrity 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. Targeted Probe & Educate MACs focus on providers/suppliers who have highest claim error rates or billing practices that vary significantly from peers Probe claims 1-1 provider specific education to address errors within reviewed claims 3 rounds CMS FAQs: Systems/Monitoring-Programs/Medicare-FFS-Compliance- Programs/Medical-Review/Downloads/TPE-QAs f.pdf 42 14

15 TPE Flow Chart Targeted Medical Review Targeted medical review process for Medicare Part B therapy services that exceed $3,000 threshold Conducted on post-payment basis Claims selected for review based on: High claims denial percentage Aberrant billing patterns compared to peers 44 SMRC Additional Documentation Request If selected for review: SMRC will send you an Additional Documentation Request (ADR) ADR will describe: A description of documentation required by SMRC. Response due date Explanation of consequences of negative determination by SMRC 45 days to respond 15

16 ADR Letter Instructions for Submitting Requested Documentation Review Results Letter SMRC will mail you a review results letter that will share its specific findings for each claim Note: SMRC has no specific timeframe SMRC may offer you an opportunity to request a discussion/education period Must respond within 30 days 16

17 Request for Discussion/Education Period Discussion/Education Findings Letter SMRC may conduct discussion/education teleconference, if necessary Subsequently will mail final letter w/ recommendations for payment determination Payment upheld OR Send recommendation to MACs for processing; appeals rights convey when MAC sends demand for overpayment Medicare Appeals Process CY 2018 amount in controversy requirement: $160 for ALJ hearing $1,600 for judicial review New rules streamline 3 rd level appeals process (ALJ): Allows attorney adjudicators to decide appeals when no hearing required Permit designation of Medicare Appeals Council decisions as precedential 17

18 Low Volume Medicare Appeals Settlement Option Must have fewer than 500 Medicare Part A or Part B claim appeals As of November 3, 2017 Pending at OMHA and/or Medicare Appeals Council Total billed amount of $9,000 or less per appeal CMS will settle eligible appeals at 62% of net allowed amount To learn more: and-grievances/orgmedffsappeals/appeals- Settlement-Initiatives/index.html Medicare Coverage Issues 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. Locum Tenens Policy for PTs Medicare now pays for PT furnished by substitute PT HPSA, MUA, or a rural area Not more than 60 days 18

19 CAHs: 96 Hour Rule Beginning October 1, 2017: Medicare contractors will make CAH 96-hour certification requirement a low priority for medical record reviews CAHs shouldn t receive medical record requests related to 96-hour requirement except when concerns of fraud, abuse, or waste Supervision Requirements of Outpatient Therapy in CAHs/Rural Hospitals : CMS did not enforce requirements in CAHs or rural hospitals : Non-enforcement of requirement extended 2017: Congress extends enforcement instruction providing an exception to requirements in CAHs and small rural hospitals (NEW) : CMS continues non-enforcement of requirement New: Supervised Exercise Therapy CMS announced in May it will cover SET for peripheral artery disease if following requirements are met: minute sessions over a 12 week period; maximum 36 sessions Furnished in physician s office or hospital outpatient setting Delivered by qualified auxiliary personnel (INCLUDES PTs) SET program must be under direct supervision of physician, PA, NP New: Updates to claims processing manual ( Network-MLN/MLNMattersArticles/Downloads/MM10295.pdf) Final NCD is under development 19

20 Maintenance Therapy Jimmo continues to confuse Maintenance therapy determination based on patient s need for skilled care Requires skills of qualified technical or professional health personnel (PT) Use clinical judgment: Do the needed services require the skills of a therapist? Coding 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. CPT Code Cognitive function intervention (97127) replaces CPT code : Per session/untimed code CMS will recognize G0515, not G0515:15 min code Check with your non-medicare payers as to whether they will reimburse or G

21 NCCI PTP Edits When to Use Codes 97760, 97761, and 97761: Only used for initial encounter Do not report with for the same extremity on same date of service Note: Once a patient begins gait training with the prosthesis, it is appropriate to report gait training with CPT (Replaces 97762): Used for subsequent visits, such as ongoing training, status checks on fit, updating instructions, etc. **Report L code for evaluation and fitting; once L code is reported, code 97760, can only be used to report time spent training patient in use of orthotic 59 modifier Proper Use of Modifier 59: Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1 418.pdf 21

22 59 Modifier Key Take-Away s Determine the most appropriate modifier based on specificity 59 versus XE, XP, XS, XU Ensure that the justification for the modifier is explicit and supported in your clinical documentation Review payer policy regarding the use of the 59 and XE, XP, XS, and XU modifiers When to Use 96 and 97 Modifiers Modifier 96: Habilitative Services: When a habilitative or rehabilitative service or procedure is provided for habilitative purposes, the physician or other qualified healthcare professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was habilitative. Such services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep or improve those learned skills. Modifier 97: Rehabilitative Services: When a habilitative or rehabilitative service or procedure is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was rehabilitative. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled. PT Eval Code Utilization: Data Analysis 2017 PT Evaluation Code Distribution 0% 10% 20% 30% 40% 50% 60% EVALUATIONS CODED % EVALUATIONS CODED % EVALUATIONS CODED % 22

23 Patients over Paperwork Effort to reduce administrative burden and improve the customer experience while putting patients first Reduce the number of quality measures Simplify and streamline data submission for quality reporting MIPS program adjustments Appropriate Use Criteria program adjustment Clarified DME Proof of Delivery Requirements Clarified Signature Requirements Clarified Medical Review of IRF claims Long Term Care Requirements of Participation Demonstration Projects Medicaid guidance Meaningful Measures A new approach to meaningful outcomes Next steps: Solicit stakeholder input to improve MM framework Work across CMS components to implement framework Evaluate current measure sets and inform measure development Medicare Advantage 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. 23

24 Medicare Advantage Medicare Advantage includes several different kinds of plans, including coordinated care plans such as HMOs or PPOs, private fee-for-service (PFFS) plans, and medical savings account (MSA) plans Review APTA comments related to proposed 2019 changes ules2019/ Advantage/APTAComments_ContractYear2019MAProgramProp osedrule.pdf Medicare Advantage CMS would like to remind MAOs that they should be transparent and provide adequate notice of any coverage restrictions, such as PA requirements, to providers and enrollees. Plans should specify the existence of any coverage restrictions, including what information is needed when submitting a PA request, in the plan s: Evidence of Coverage (EOC), Contracts with providers and Additional provider communications/materials (e.g., provider manuals). Plans should make PA request forms available and easily accessible and should ensure they are delivering timely decisions on PA requests.» Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2019Part2.pdf QUESTIONS 2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. 24

25 References Regulatory resources: Payment Reform Resources: