Outpatient Therapy Caps and Manual Medical Reviews:

Outpatient Therapy Caps and Manual Medical
Learn How to Dodge the Bullet Aimed at Your Hospital
Outpatient Therapy Department
Questions and Answers
Presented by:
Nancy J. Beckley, MS, MBA, CHC
Nancy Beckley & Associates LLC
[email protected]
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From the Speaker:
Thank you to all that participated in the November 28th Webcast on current and upcoming
outpatient therapy changes. The response to webcast was overwhelming, and it is clear that
this is a time of not only challenge, but confusion for many hospitals forced to make so many
changes so quickly. Please feel free to contact me. Thank You – Nancy Beckley
([email protected] )
Q: Is cardiac rehab subjected to the Cap?
A: No, Cardiac is not subject to the cap. Only those codes that are therapy codes: always
therapy codes, or sometimes therapy codes will billed by a PT, OT or SLP under a therapy
plan of care. All attendees received the CMS spread sheet with a listing of therapy codes.
Q: Our organization has heard recently directly from CMS that therapy evaluations always
require pre-approval. Is this correct? Without an eval, how would we create the Plan of
A: Therapy evaluations do not need an approval, as they are exempted from the therapy caps
(in other words they are not denied as a benefit category). This was stated in all the CMS
Special Open Door Forums on MMR, as well as in the contractors’ presentations that were
made available from late August to current.
Q: If you get approval for 12 visits in medical review. Do you still have to write progress notes
every 5th visit?
A: Progress notes are required, per the Medicare Benefit Policy Manual (Chapter 15, beginning
at Section 220) every 10 visits or 30 days, whichever occurs first. The only exception would
be a practice act requirement to provide a note more frequently.
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Q: Do we need to do POCS on patients who are enrolled in Medicare Advantage Plans?
A: Medicare documentation requirements as listed in the Medicare Benefits Policy Manual
(Chapter 15, beginning at Section 220) applies only to traditional Medicare. Medicare
Advantage Plans may require documentation requirements that parallel Medicare, but you
should check with each plan to determine documentation requirements.
Q: We have submitted a few requests for MMR and never heard back. Did you say that we
should receive an approval #?
A: Most of the Medicare contractors are providing approval or “tracking” numbers that must
appear on your claim. Check with your contractor to determine if they are issuing a number,
and in where it should appear on your claim form (or electronic version)
Q: Will these codes and modifiers also be required on Medicare Advantage plans that follow all
of the Medicare rules?
A: At this point the G codes are for traditional Medicare. It is entirely likely that Medicare
Advantage programs may require this type of outcome reporting, but it is not linked up to or
required by CMS.
Q: Is it acceptable to report G codes for functional limitation DAILY?
A: The G codes (in final form) as well as the modifiers were published shortly before this
webinar. CMS released transmittals to the Benefits Policy Manual and the Claims
Processing Manual the week following the webinar, and have scheduled an informational
audio conference on this topic for December 12th. While the requirement is reporting at least
every 10 days, I will defer to CMS to provide clarification on therapists who choose to report
more frequently.
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Q: Is it acceptable (in a multi-discipline patient) for PT and OT to report functional limitation on
the same G codes?
A: See the answer above. Keep in mind that there may be additional challenges if it appears
that PT and OT (or any other combination of therapies) are providing duplicate services.
Q: You mentioned the evaluation codes are exempt from the cap (once the $1880 cap is
reached). Does that mean you do not need to apply the KX modifier to that claim?
A: The KX modifier should be appended to the claim, unless otherwise instructed by your
Q: After the Evaluation for the new diagnosis: if the patient is already at the $1880.00 cap
should we do the authorization form to see if it would be approved?
A: On December 1st, all Phases are operative for the $3700 threshold. Unless the patient is
close to the threshold, it is likely that your submission would not be reviewed.
Q: What is Medicare customer service phone number?
A: Each contractor has a customer service number that is posted on their website.
Q: I am unclear about the g codes and how they are to be applied
A: Please refer to previous answer, and stay tuned for more information.
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Q: How does secondary ins affect Medicare cap going forward?
A: It is likely that “supplemental” insurance (that pays the Medicare deductible and co-pays) will
parallel Medicare benefits, whereas “secondary “insurance should be verified for benefits
and coverage. In either instance it is good practice to verify benefits with each supplemental
and secondary plan.