Billing Certainty in Rehab Guidelines

By Lynn Berry, PT, CPC

Section 3134 of the Affordable Care Act (ARA) added Section 1848(c) (2) (K) of the Social Security Act, which specifies the identification of potentially misvalued codes, with reductions applied accordingly. The calendar year (CY) 2011 Proposed Rule stipulated a 50 percent reduction to the Practice Expense Component of every unit billed above one, regardless of discipline, for a single date of service for rehab, in both facility and non-facility settings. This was changed to 25 percent in the CY 2011 Final Rule. The Medicare and Medicaid Extenders Act of 2010 made another change, so that practice expense above one unit would be reduced by 20 percent for non-facility charges and by 25 percent for facility charges.

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What this means for the independent occupational, physical, and speech language pathology therapist when billing by the same billing National Provider Identifier (NPI) on the same date of service, is that the first unit of the code with the highest practice expense relative value unit (RVU) will be paid at 100 percent, with a 20 percent reduction of the practice component for services above the first unit for non-facility providers.

How will a non-facility billing department know what the practice will be paid for that date? Easily, says the Centers for Medicare & Medicaid Services (CMS). Find the practice expense RVU for each applicable component of service for that date (listed as a “5” under multiple procedures on the Medicare Physician Multiple Procedure File Data Base). Then look up the code for that service on the fee schedule. You will be paid full value for the service with the highest practice expense RVU. For all other codes, no matter what the discipline, you will be paid 80 percent of the practice component RVU amount.

Although CMS has provided Medicare Administrative Contractors (MACs) with a column in their database that designates the payment amount for fully valued services (per Change Request 7050, Transmittal 826), no such columns are available to providers on the published fee schedule.

For help, turn to professional association membership, such as the American Physical Therapy Association (APTA). On the APTA website, there is a multiple procedural payment reduction rule (MPPR) calculator, as well as a Medicare Outpatient Fee Schedule Pricer. Input all the codes and applicable units of service used by the patient on that date of service from every discipline covered by your billing NPI, as well as your location, and the calculator will tell you the amount payable for each code, which codes have reduced payments, and your total payable amount for the day.

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