MDS Alert
Ready or Not -- Here Comes the Manual Medical Review of Medicare Outpatient Therapy Claims
PDF
Providers dodge snafus with CMS' NPI assignments. Scrambling to prepare for CMS' new take on therapy caps? You're not alone. Starting Oct. 1, the Centers for Medicare & Medicaid Services begin phasing in outpatient rehab providers to manual medical review. After a patient reaches $3,700 of therapy dollar reimbursement for occupational therapy, or speech and physical therapy combined, the therapy provider must apply to CMS for advanced approval of further claims. Snag:
That means, "we may be implementing a complex process for two months, then it may go away. That is a little disconcerting," comments Meryl Freeman, MS, PT, manager of outpatient rehabilitation for Rex Healthcare in Raleigh, North Carolina.
Beware NPI confusion
CMS used national provider identifier (NPI) numbers to assign rehab providers phase-in dates to manual medical review (either Oct. 1, Nov. 1, or Dec. 1).
Major glitch:
Some providers received more than one phase-in date notification from CMS. The problem stemmed from individual therapists having their own NPI numbers yet working for and reassigning to a group that has a separate NPI number, explains Donna Senft, JD, PT, healthcare attorney with Ober/Kaler in Baltimore, Maryland."We posted a question to CMS about this," Senft continues. "They said to use the NPI number on the claim form used to bill for services. Since there are multiple NPS numbers on the claim form, we asked them to clarify if they were referring to the NPI number that goes on the 1500 form in Box 33A, or the treating therapist NPI number that goes with Box 24J." At press time, CMS confirmed that it is the NPI in Box 33A.
Get savvy with your patient education
CMS recently sent letters to Medicare beneficiaries to inform them if they were reaching the $3,700 limit. These letters have tended "to elicit fear," Nicole Scheiman, OTR/L, MHS, CEES, CKTP, CLT-LANA, CSST, director of rehabilitative and wellness services at Florida Hospital DeLand Sports Medicine and Rehabilitation, reports.
That said, "It is very important to educate patients and therapists that the cap doesn't mean therapy [automatically] stops," Scheiman emphasizes. You want to explain that if additional care is medically necessary, the rehab provider must take further steps to approve continued therapy.
In the past, the Notice of Exclusion of Medicare Benefits (NEMB) form was considered most appropriate to inform patients that services above therapy caps were statutorily non-covered (if there were no exceptions). But for manual medical review cases, CMS and several professional rehab associations suggest using the Advance Beneficiary Notice of Non-coverage (ABN) form.
"The reason for suggesting the ABN may be because the services may still be covered; there simply is no required exclusion of coverage for services beyond the $3,700 limit," Senft explains.
MDS Alert
- Medicare Reimbursement:
Ready or Not -- Here Comes the Manual Medical Review of Medicare Outpatient Therapy Claims
Providers dodge snafus with CMS' NPI assignments.Scrambling to prepare for CMS' new take on therapy [...] - Risk Management:
Reduce Your Facility's Litigation and Liability Exposure
Learn from others' mistakes, successes to stay out of trouble.Time and again providers open themselves [...] - Practice Pointers:
Nail Down Therapy Cap Details With This Q&A
Resolve your queries about therapy evals, appeals and more.More information leads to more questions -- which [...] - Risk Management:
Falls are Inevitable But Losing a Falls Case Doesn't Have to Be
Follow these tips to ward off potential liability following a resident fall.More than half of [...] - Surveyor's Definition of Fall:
"Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, [...] - Compliance:
When Does CMS Consider Bed Rails To Be Restraints?
Check out the SOM definition before coding the MDS.Even though the use of bed rails [...] - Surveyor's Definition of Physical Restraints:
"Any manual method or physical or mechanical device, material or equipment attached or adjacent to [...] - Coding Quizzer:
Do You Know When Wandering Puts Your Residents at Risk?
Test your knowledge of how to code these RAI scenarios.Wandering may be a pursuit of [...] - Coding Quizzer Answers:
How Did You Code The MDS Wandering Examples?
Check your coding skills against the answers in the RAI manual.RAIScenario #1: Wandering that results [...]