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New Medicare Cards Coming April 2018

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires the Centers for Medicare and Medicaid Services (CMS) to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status.

Beginning in April 2018, CMS will start mailing the new Medicare cards with the MBI to all people with Medicare in phases by geographic location.CMS plans to have a transition period where providers can use either the HICN or the MBI to exchange data with them. The transition period will begin no earlier than April 1, 2018 and run through December 31, 2019. Starting January 1, 2020, providers will have to submit claims using MBIs (with a few exceptions), no matter what date you performed the service.

The MBI will be:

For additional information on the new social security cards such as Medicare plan exceptions, fee-for-service claim exceptions, time line to roll out the new cards to the 50 states, American Samoa, Guam, Northern Mariana Islands, and Puerto Rico, how the MBI will look on the new card, and how claims will cross over to the secondary insurance, click

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Supervised Exercise Therapy Under Medicare Part B

Effective May 25, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD). SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest. SET has been recommended as the initial treatment for patients suffering from IC, the most common symptom experienced by people with PAD.

CMS issued the NCD to cover SET for beneficiaries with IC for the treatment of symptomatic PAD. Up to 36 sessions over a 12-week period are covered if all of the following components of a SET program are met:

The SET program must:

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Medicare Therapy Cap & Use of the ABN

Since passage of the 2018 Bipartisan Budget Act of 2018 that repealed the therapy cap for outpatient therapy services, I have been receiving many questions about the application of the KX modifier for services that exceed either $2010 or $3000 physical therapy and speech therapy combined in 2018 or a separate $2010 or $3000 for occupational therapy. Most of the questions center around should I provide the Medicare beneficiary with an advance beneficiary notice of noncoverage (ABN)  when they exceed either $2010 or $3000 in calendar year 2018?

In this article, I will answer the following questions:

  1. If the therapy cap has been repealed, why do we still have an annual therapy cap dollar threshold and have to use the KX modifier?
  2. If a Medicare beneficiary has exceeded the therapy cap dollar threshold of $2010 in 2018 and I believe therapy is still medically necessary, must I use the KX modifier and bill the Medicare program for those visits and services?
  3. When a Medicare beneficiary reaches the therapy cap dollar threshold of $2010 in calendar year 2018, is an advance beneficiary notice (ABN) required if I feel therapy is still medically necessary and requires the skills of a therapist?
  4. If a Medicare beneficiary has exceeded the targeted medical review dollar threshold of $3000 in 2018 and I believe therapy is still medically necessary, must I use the KX modifier and bill the Medicare program for those visits and services?
  5. When a Medicare beneficiary reaches the targeted medical review dollar threshold of $3000 in calendar year 2018, is an advance beneficiary notice (ABN) required if I feel therapy is still medically necessary and requires the skills of a therapist?
  6. Can we have all Medicare patient’s sign a generic advance beneficiary notice (ABN) on their first visit for outpatient therapy services to protect ourselves from possible lack of payment from the Medicare program?

In addition, if you missed my webinar, Medicare Therapy Cap Repealed & 2018 Payment Updates, you can purchase the playback link and view the webinar as many times as your would like on your computer. The webinar also comes with a handout in pdf format. For additional information on this webinar and to order, click HERE.

For additional frequently asked questions (FAQs) on the ABN, click HERE. For  FAQs on the 2018 therapy cap and therapy cap repeal, click HERE.

Lets now get to the answers!

Question

If the therapy cap has been repealed, why do we still have an annual therapy cap dollar threshold and have to use the KX modifier?

Answer

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Does One-on-One Only Apply to Medicare

I receive many questions at my in-person seminars and via email that begin something like “I know we can’t have 2 Medicare patient’s being treated at the same time, but how about 2 patient’s with private insurance”? Or, “I know I need to be one-on-one with Medicare patient’s, but that does not apply to patient’s with private insurance, right”? Lastly, “I know if I have 2 Medicare patient’s in my facility for one hour during the same time period, I have to split the time between them, but if the 2 patient’s had private insurance, I could bill each for the entire one hour as one-on-one time, correct”?

I think it is finally time to answer the above questions and put a stop to the myth that you can’t have 2 or more Medicare patient’s in your facility at the same time or that it is okay to bill 2 non-Medicare patient’s for 4 time-based units when they were each in your facility during the same one hour time frame being treated by just one physical or occupational therapist, one physical therapist assistant, or one occupational therapy assistant. The answer, or should I say, where the answer comes from, will surprise many of you. The answer does not come from the Medicare program, private insurance carriers, workers compensation programs, auto no-fault insurance carriers or state practice acts and administrative rules. The answer to all of the above questions comes from the American Medical Association (AMA).

Surprised? I bet you are! How is it that the AMA is the one that provides the answer to the above questions? It is because the AMA is the organization that creates and maintains the Current Procedural Terminology (CPT) codes that providers use to submit claims to insurance carriers, workers compensation carriers and auto carriers to be paid for services rendered to their clients.1 The federal government, Medicare program, and insurance carriers do not create and define the CPT codes; rather, they use the CPT codes as created by the AMA to pay us for our services. So since insurance carriers, workers compensation carriers and auto carriers, not just the Medicare program, use the CPT codes developed and defined by the AMA to pay us for our services, the definition of “direct (one-on-one) patient contact” as defined by the AMA in some of the CPT codes apply to the insurance carriers, workers compensation programs and auto carriers as well, not just the Medicare program.

In addition, in 2000, the CPT code set was designated by the Department of Health and Human Services as the national coding standard for physician and other health care professional services and procedures under the Health insurance Portability and Accountability Act. This means that organizations that submit claims or other health information electronically must use the current years CPT codes.2

Lets begin by looking at the “Constant Attendance” modality codes. Prior to listing the constant attendance modalities, the AMA

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Humana Implementing 8 Payment Changes for Outpatient Therapy

Humana has announced 8 payment changes effective March 1, 2018 that will impact providers of outpatient physical, occupational and speech therapy services. While Humana states the effective date is March 1, 2018, it appears that the changes may have already been implemented with dates of service on and after January 1, 2018. Effective with dates of service on and after March 1, 2018, Humana will no longer pay for the following CPT codes:

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