Manual Medical Review Process for Therapy Claims extended through 2017

On April 16, 2015, the President signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (see the entire bill by clicking on the link), which temporarily extends the therapy cap exceptions process and modifies the manual medical review process for therapy services through December 31, 2017.


In the meantime, providers should continue to apply the KX modifier on claims above the therapy cap.


The manual medical review process for Medicare Part B therapy services that exceed a $3,700 threshold was mandated in 2012 and requires reauthorization annually. Under the mandate, claims above $3,700 for physical therapy and speech language pathology services combined, and above $3,700 for occupational therapy services, are subject to manual medical review by recovery audit contractors (RACs). The caps are calculated per beneficiary, per year.
Manual medical reviews of outpatient therapy claims above the cap were put on hold last year, but existing RACs received approval on January 16, 2015 to resume sending additional documentation requests (ADRs) to Part B providers.


Review Process
Under a new post-payment review system introduced by the Centers for Medicare and Medicaid Services, RACs are required to review outpatient therapy claims using a tiered approach to ADRs. The new process, which went into effect in January 2015, permits RACs to review 100% of a provider's eligible claims using a 5-step approach to ADRs:
•    A RAC's first ADR may only review one claim, but …
•    The second ADR may review up to 10% of eligible claims,
•    The third ADR may review up to 25% of eligible claims,
•    Tthe fourth ADR may review up to 50% of eligible claims, and  
•    Finally, a RAC's fifth ADR to a particular provider may review 100% of the provider's total eligible claims. The new tiered approach retains the RAC's cycle of 45 days between ADRs.
The process allows for 100% review of provider claims above the $3,700 therapy caps ("eligible claims"), but prevents the RACs from requesting large and potentially unmanageable amounts of records at one time.


CMS believes the new manual review process meets the congressional mandate of a 100% review rate for outpatient therapy claims above the outpatient therapy cap, but will do so in a more equitable manner.


For now, the review process is limited to claims reviewed by existing RACs for claims made from March 1, 2014 through December 31, 2014. CMS has not yet finalized the process for claims made in 2015. The manual medical review process is also limited to claims made by Part B outpatient therapy providers, including but not limited to therapists' private offices, offices of physicians, Part B skilled nursing facilities, home health agencies, and hospital outpatient departments.


We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!


Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

Resource:

Wachler & Associates Health Care law firm

Therapy Cap and SGR Vote Results

According to the APTA, the Senate voted to approve a permanent fix for the Sustainable Growth Rate (SGR) by a vote of 92 to 8. The bill will now await the President's signature.

As a part of the SGR bill, Senators Cardin (D-MD) and Vitter (R-LA) proposed an amendment to permanently repeal the Medicare therapy caps. The amendment needed 60 votes to pass and failed by a vote of 58 to 42. Under the SGR bill, the therapy cap exceptions process will continue for 2 years until December 31, 2017.

For more information, visit www.apta.org.

Thank you for all your actions in reaching out to Senate in an effort to permanently end therapy caps.  

Our senators need to hear from every one of us in the next few days!

The current Sustainable Growth Rate (SGR) formula patch and therapy cap exceptions process expired on March 31. During the last week of March, the House of Representatives passed H.R. 2, a bill that would permanently repeal that formula, which many claim is flawed, but the Senate adjourned for its April recess on March 27 without voting on the bill.  Therefore, the Centers for Medicare and Medicaid Services are now allowed to hold Medicare claims for physician services up to 10 business days.

When Congress returns from its two-week recess on April 13, the Senate will have one day to deal with the SGR, before CMS will have to resort to holding claims. CMS has reminded providers that, under current law, electronic claims are not paid sooner than 14 calendar days after the date of receipt (29 days for paper claims).  CMS will notify providers on or before April 11, regarding what next steps CMS will take.

Senate leaders have indicated they plan to vote on permanent repeal when they return. We must keep the pressure on the Senate to pass the SGR repeal and replacement bill so that they know how necessary and important this bill is to all of us!

The bill would add about $200 billion to the projected Medicare budget over the next 10 years. It would include replacing the SGR with an increase of 0.5% in Medicare physician reimbursement starting in July 2015 through December 2015, and then annual 0.5% increases lasting through 2019.

The measure would also consolidate various reporting programs, such as the Meaningful Use program for electronic health records and several quality reporting programs, into a new merit-based incentive payment system and would incentivize physicians to participate in alternative payment models such as accountable care organizations (ACOs).

The bill also would extend the Children's Health Insurance Program as well as funding for community health centers and the National Health Service Corps.

House leaders are optimistic about the bill, which in the words of House Minority Leader Nancy Pelosi would “replace the broken SGR formula and transition Medicare away from a volume-based system toward one that rewards value, ensures the accuracy of payments, and improves the quality of care."

The fix has also been endorsed by many medical groups including the American Medical Association and the Association of American Medical Colleges. Now add your voice, by contacting your senator – in Ohio, Sherrod Brown by email or by phoning (202) 224-2315; Rob Portman, by email or by phoning 202-224-3353; in Pennsylvania, Robert Casey Jr. by email or by phone, 202.224.6324 or Pat Toomey by email or by phone, (202) 224-4254.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

Resources

MedPageToday

Let’s work together to end the therapy cap!

On Thursday, March 26, the U.S. House of Representatives passed the Medicare Access and CHIP Reauthorization Act (H.R. 2), to repeal and reform the Sustainable Growth Rate (SGR),   while extending the Medicare therapy cap exception process only until December 31, 2017. The Senate has not yet voted on the legislation and is in recess until April 13.

In the meantime, Senator Ben Cardin, a Maryland Democrat, announced that he is prepared to lead the fight to end 18 years of temporary fixes to the therapy cap by ending the cap completely. The historic change could come through an amendment to H.R. 2. But there’s a challenge: Senators need to agree to allow a vote on Cardin's amendment.

The Centers for Medicare and Medicaid Services (CMS) has advised that they will typically hold claims for 14 calendar days, allowing Congress a short window of time when they return from the recess to come to an agreement and pass legislation to prevent cuts to payments and allow necessary therapy services to continue above the therapy cap amount of $1,940.

What You Can Do:  The American Physical Therapists Association, the American Occupational Therapy Association and American Speech and Hearing Association are asking that you please keep up communication with your legislators; encourage your patients and colleagues to reach out as well to support inclusion of full repeal of the therapy cap.  For Ohio and Pennsylvania partners, the contact information is as follows:

In Ohio, Sherrod Brown by email or by phoning (202) 224-2315; Rob Portman, by email or by phoning 202-224-3353; in Pennsylvania, Robert Casey Jr. by email or by phone, 202-224-6324 or Pat Toomey by email, or by phone, 202-224-4254.

Take just a few minutes to send an email to ask your representative to co-sponsor this important legislation and make sure your voice is heard as an advocate for physical, occupational, and  speech therapy.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcomes.

Resources:

American Physical Therapists Association

American Occupational Therapy Association

Facebook: Stop the Medicare Therapy Cap 

“I need therapy. How much of the cost will Medicare pay?”

To most seniors on fixed incomes, that’s the first question that comes to mind.  Thank goodness we live in the Information Age – most of the answers are at the tips of our fingers!

First, find out how much your specific test, item, or service will cost:  talk to your doctor or other health care provider. The specific amount you’ll owe may depend on whether you have other insurance, how much your doctor charges, whether your doctor accepts assignment, the type of therapy provider, and the location where you get your test, item, or service.

Your doctor may recommend you get services more often than Medicare covers. Or, he or she  may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical and occupational therapy, and speech-language pathology services.  (The government describes “medically necessary” as “Health Care services needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.”)

There are limits on these services when you get them from most providers. These limits are called “therapy caps” or "therapy cap limits."

The therapy cap limits for 2015 are:

  • $1,940 for physical therapy (PT) and speech-language pathology (SLP) services combined;
  • $1,940 for occupational therapy (OT) services.

Everyone with Medicare is covered.  First, though, you must pay the amount of your yearly deductible for Part B.  After that, Medicare will pay its share – 80 percent – of the remaining bill, and you will pay the final 20 percent. The Part B deductible is $147 for 2015.  Medicare will pay its share for therapy services until the total amount paid by both you and Medicare reaches either one of the therapy cap limits.

 (Note that both the United States House and Senate are considering amendments to the Medicare fee schedule.)

You may qualify for an exception to the therapy cap limits so that Medicare will continue to pay its share for your therapy services beyond the therapy cap limits. In this case, your therapy provider must:

  • Establish your need for medically reasonable and necessary services and document this in your medical record; and
  • Indicate on your Medicare claim for services above the therapy cap that your outpatient therapy services are medically reasonable and necessary.

As part of the exceptions process, there are additional limits called “thresholds.”  If you get outpatient therapy services higher than the threshold amounts, a Medicare contractor will review your medical records to check for medical necessity. The threshold amounts for 2015 are: 

  • $3,700 for physical therapy  and speech-language pathology combined; and
  • $3,700 for occupational therapy.

Generally when an exceptions process is in effect, if your therapy provider provides documentation showing that your services were medically reasonable and necessary and indicates this on your claim, Medicare will continue to cover its share above the $1,940 therapy cap limits.

Because Medicare doesn't pay for therapy services that aren't reasonable and necessary, your therapist or therapy provider must give you a written notice, called an Advance Beneficiary Notice of Noncoverage (ABN), before providing generally covered therapy services that aren't medically reasonable and necessary for you at the time. The ABN lets you choose whether you want the therapy services. If you choose to get these services, you agree to pay for them.

To find out of your test, item or service is covered, just go to this page.  It’s the official government site  for Medicare services.  Type in the name of the service you’re considering in the box at the top of the page, and you’ll know right away if it’s a covered procedure.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.

This information only applies if you have Original Medicare. If you have a Medicare Advantage Plan (like an HMO or PPO), check with your plan for information about your plan’s coverage rules.

More resources:

American Physical Therapy Association

 

We’ll serve you at our Outpatient Center, too!

Blue Sky’s outpatient facility on Mahoning Avenue in Champion Township offers spine therapy, physical therapy, aquatic therapy, muscle-loss prevention and wellness classes. Our licensed professionals are experienced therapists with a great passion for re-educating all ages in order to prevent decline and dysfunction.

Here, we treat individuals with musculoskeletal disorders such as back and neck strains or knee injuries, those who have suffered a work-related injury, post-surgical patients, orthopedic patients, and those with neurological deficits such as stroke patients.

Our goal is to restore strength, range of motion, balance and function.

Physical therapy helps clients build strength, endurance, muscle tone, range of motion, hand-eye coordination and balance while decreasing anxiety and boosting energy levels and mood.

To provide these therapies, Blue Sky Outpatient offers on-site aquatics, resistance training, weight-bearing exercise, balance and coordination exercises and orthotic training.

Following a thorough initial evaluation, an individualized treatment program is developed in collaboration with the patient. Programs include education of the patient's diagnosis and self-management strategies. All patients are instructed in a customized Home Exercise Program.

Our staff can assist you with many issues you may be experiencing, including:

    Neurological conditions (Parkinson’s disease, Multiple Sclerosis, strokes, etc.)
    Orthopedic conditions (pain, sprains and strains, fractures, arthritis, etc.)
    Post-Surgical therapy (total joint replacements, fractures, etc.)
    Balance issues (with or without a history of falls)
    Weakness and re-conditioning (as a result of illness or other medical problems)

A prescription from your doctor is all we need to begin scheduling your sessions with physical therapy. Our team, in conjunction with your doctor, will begin designing an individual care plan and home program that's right for you!

 

Speech therapy – helping you to say what you mean

You had a stroke. Fortunately, you seem to have recovered well.  But you have difficulty in understanding what people around you are saying sometimes, or perhaps you can’t seem to find the words you want to say. Your brain seems to have forgotten how to do these things.

Don’t worry, you’re not alone. As people age, normal changes occur in their speech, language, memory, and swallowing. In addition, their chances of having a stroke or developing dementia or Parkinson's disease increase, as do the chances of acquiring a communication or swallowing disorder related to these diseases.

The speech-language pathologists at Blue Sky Therapy play an important role in working with patients who experience this disorder.  Speech-language pathologists — SLPs — can assist in differentiating between normal aging and disordered communication or swallowing function. They provide vital services to those individuals whose communication, cognitive, or swallowing impairments are due to illness, trauma, or disease.  This is what we call “speech therapy.”

Simply put, speech therapy is simply a method to help people with speech and language problems to speak more clearly. In the case of the elderly, therapy often follows a trauma such as stroke or a fall that affects a patient’s ability to use language.

Speech Therapy focuses on receptive language, or the ability to understand words spoken to you, and expressive language, or the ability to use words to express yourself. It also deals with the mechanics of producing words, such as articulation, pitch, fluency, and volume. 

The professional in charge of your speech therapy — variously called a speech-language pathologist or speech therapist or any combination of these words — will work to find activities to strengthen your areas of weakness. Treatment for the elderly after a stroke can include art therapy, singing, group therapy, associating words with pictures and other techniques to stimulate and promote re-establishing neurological connections within the brain for communication.

Blue Sky’s speech-language pathologists work with people who cannot produce speech sounds or cannot produce them clearly, and with those with language disorders — problems understanding and producing language; and those with cognitive communication impairments, such as attention, memory and problem-solving disorders.

A speech disorder refers to a problem with the actual production of sounds; a language disorder refers to difficulty in understanding or putting words together to communicate ideas.

Speech disorders include:

  • Articulation disorders: difficulties producing sounds in syllables or saying words incorrectly to the point that listeners can't understand what's being said.
  • Fluency disorders: problems such as stuttering, in which the flow of speech is interrupted by abnormal stoppages, repetitions (st-st-stuttering), or prolonging sounds and syllables (ssssstuttering).
  • Resonance or voice disorders: problems with the pitch, volume, or quality of the voice that distract listeners from what's being said. These types of disorders may also cause pain or discomfort for the speaker.
  • Dysphagia/oral feeding disorders: these include difficulties with drooling, eating, and swallowing, such as increased coughing while eating and/or drinking, trouble taking medications, runny nose or watery eyes when eating are all signs and symptoms of a swallowing disorder.

With the speech therapist’s skills, and the patient’s determination to improve, there’s no limit to the improvements that can be seen!

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.

Resources

American Speech-Hearing-Language Association

Princeton Review

Redlands College

Healthline

Occupational Therapy: Getting back to the tasks of living

To the uninitiated, physical therapy and occupational therapy may seem to be pretty much the same thing.  So how do you know which one you need after you’ve suffered a health crisis – a fall, perhaps, or a stroke?

Both physical and occupational therapists deal with patients with physical injuries and limitations, but they approach those patients in very different ways.  The difference shows up in how they treat the issues, as well as in what issues those are.

Physical Therapists deal with “the big picture:” the treatment of disease, injury, or deformity by physical methods. They help patients with strength, balance, flexibility – the basics of motion.

Occupational therapists go beyond this. While they, too, deal with the overall issues, they also tend to the finer points of daily life and activities – the “occupation of life,” so to speak. They help clients relearn how to tie their shoes, do up buttons, and manipulate small objects. They can facilitate independence by teaching or re-teaching necessary tasks and skills such as writing, cooking, and even housework.

Both fields focus on the recovery of a functional impairment. The difference may be evident in setting and practice. In the hospital setting, the "occupational functions" that are being recovered include self-care activities such as restoring the ability of the patient to perform bathing, dressing, feeding, etc. Physical therapy will focus on mobility tasks such as getting out of bed, standing, walking etc.

In the outpatient setting, occupational therapists may focus on  "hand therapy,"  as hand injuries are common occupational hazards not only on the job but elsewhere, and on elbow and shoulder therapy.

Clients of occupational therapists may need help in those broader areas that physical therapy covers, as well; some clients of one type of therapist are also clients of the other, as the two go hand in hand in many cases.

Occupational therapy covers much more than physical therapy. Occupational therapists can aid clients in treating developmental and cognitive disorders such as Attention Deficit Disorder (ADD) and learning disabilities; sensory disorders, such as autism; and mental health, including depression, addiction, anxiety and eating disorders.

One of the differences between physical therapists and occupational therapists is the help clients get from an OT with the world around them and the things that affect them in everyday life, not just the limitations caused by their own physical and mental state. An OT can help a client with:

  • Medication management: helping clients keep track of their medications and teaching them about their effects and interactions.
  • Routine and schedules: the OT can help develop an outline for the client to follow, and help them stick to it.
  • Education: an OT can suggest training, groups, and classes tailored to the client’s needs.

Occupational therapy treatments will frequently include manual therapy techniques, stretching, therapeutic exercise, hand strengthening, activities to improve manual dexterity, and caregiver training. Occupational therapists may also recommend appropriate adaptive equipment such as reachers, dressing aids, specialized dishes and utensils, and splints for positioning. Educating patients regarding their condition, accommodations, and proper use of adaptive equipment is an important aspect of occupational therapy. An occupational therapist will also create an individualized home exercise program to encourage a patient’s continued progress.

The PT and OT they will often collaborate to maximize the effectiveness of a session. For example, in a nursing home, the physical therapist may help the patient stand from a wheelchair and maintain standing balance while the occupational therapist assists the patient in hygiene tasks at the sink. At an outpatient clinic, they can work together to help a person resume gardening – the physical therapist would help with walking outdoors on uneven surfaces, using proper body mechanics while lifting and carrying gardening supplies, and practicing squatting; while the occupational therapist would assist with opening packages, using a trowel, and turning on the faucet.

Physical therapy and occupational therapy overlap in some areas, and at times it can be hard to tell which is which. The difference lies in the occupational therapist’s assistance in combining the physical, mental and environmental aspects of the client’s situation to arrive at a plan that will heal as well as re-enable the client to take up the reins in everyday life.  

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.

Resources:

Holsman Physical Therapy

& Rehabilitation P.C.

Occupational Therapy

Schools Guide

Ortho Hips and Knees- Part 7

The recovery period

In our previous blogs, we’ve talked about the alternatives to hip and knee replacement surgery, and what to expect if you’ve chosen total joint replacement.  In this, our final blog on the subject, we’ll talk about the recovery period. As with the previous columns, our information comes from the American Association of Hip and Knee surgeons; this time, the association’s Dr. Stephen J. Kelly, M.D., answers most frequently asked questions: 

Will I need to stay in the hospital?
On average, patients spend two nights in the hospital following surgery. Some patients may spend as little as one night, others may stay as long as three nights.

What is recovery like in the hospital?

Recovery starts right after surgery. You are helped out of bed on the day of or the day after surgery. A physical therapist will help you to walk, and most patients will have one or two sessions of physical therapy per day. The goal of therapy is to assist with strengthening of the muscles and walking. Therapy will also make sure that you are safe when you go home. That’s important when doing things like dressing, using the bathroom, getting up from a chair, and climbing stairs.

Will I be able to walk after surgery?
Most patients use a walker or crutches after surgery but often will be able to progress rapidly to using a cane. Walking soon after surgery helps you get better. It also helps avoid things like bedsores, pneumonia, and blood clots.

Can I go directly home from the hospital?
Many patients are able to leave the hospital and go directly home after surgery. It is important to identify a family member or friend who will be able to help with common household tasks such as preparing meals and doing dishes. Some patients will require a stay at a specialized care facility such as a nursing home or rehab hospital.

Will I be able climb stairs when I leave the hospital?
In general, patients are able to climb stairs after leaving the hospital; however, it is often initially slow and tiring and most patients are happiest if initially they are able to stay on one floor after returning home from surgery.

Will I need Physical Therapy after surgery?
All patients benefit from specific exercises after surgery. These will be directed by your surgeon and often will involve a physical therapist. Most patients need to do their exercises for a minimum of four to six weeks following surgery.

How much will my joint replacement weigh?
Most weigh between one and two pounds.

Are there any activities I will not be able to participate in after I recover from my joint replacement?
Most patients are advised to avoid running, jumping, or impact sports after surgery, so that your joint replacement may last longer.

Will I be in a lot of pain?

Fear of pain from surgery is one of the biggest reasons why people avoid having a hip or knee replacement. Pain control comes from using several medications that affect both the spinal cord and the brain.  With better pain control, you will have mild to moderate pain. There are also medications that help control nausea if it occurs.

When will I be back to normal?

Most people get better from hip or knee replacement in about six weeks. The time it takes to walk without a cane or drive after surgery is different for everyone. You will need physical therapy after going home. The skin incision or cut will heal in two to three weeks, but the process of healing can take up to a year. Once you are without pain, you will notice an improvement in your ability to walk.

We at Blue Sky Therapy are ready to assist you after knee replacement therapy!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

Resources:

American Association of Hip and Knee Surgeons. Developed by the AAHKS Patient Education Committee. Authors: Craig J. Della Valle, MD, Frank R. DiMaio, MD, Marc W. Hungerford, MD.