On October 31, 2016, the Centers for Medicare and Medicaid Services (CMS) awarded the next round of Recovery Auditor Contractor contracts. The contracts along with the regions are as follows:
The Centers for Medicare and Medicaid Services (CMS) has released the final rule for calendar year 2017 for services paid under the Medicare Physician Fee Schedule. The final rule addresses several important issues relevant to outpatient therapy services including, but not limited to:
- 2017 therapy cap dollar threshold
- Therapy cap exceptions process
- Manual medical review for services above $3700
- Implementation on new PT and OT evaluation and reevaluation CPT codes
- Payment of the new PT and OT evaluation and reevaluation CPT codes
- New PT and OT evaluation and reevaluation codes and their impact on MPPR and therapy cap
- Documentation changes in CMS Publication 100-02, Chapter 15
- 2017 conversion factor
Below, I will provide a brief summary of the items listed above.
The amount that must remain in controversy to request an Administrative Law Judge (ALJ) hearing is increasing to $160 for hearing requests received on or after January 1, 2017. This is an increase of $10 from requests made prior to January 1, 2017.
The amount that must remain in controversy for reviews in Federal District Court requested on or after January 1, 2017 will increase to $1,560.00. This is an increase of $60.00 from requests made prior to January 1, 2017.
As I speak around the country, I often have people tell me they have Medicare beneficiaries sign an Advance Beneficiary Notice of Noncoverage (ABN) when they exceed $3700 in a calendar year physical and speech therapy combined or a separate $3700 for occupational therapy even though the therapist feels therapy is still medically necessary and requires their unique skills to provide. Actually what the provider is doing is not correct.
Before addressing today’s question, you may want to check out some of my other articles I have written on the use of the ABN for outpatient therapy services:
The Centers for Medicare and Medicaid Services (CMS) states an “ABN is
A question I often receive about CPT code 97750 – Physical performance testing or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes is “Can a physical therapist assistant (PTA) or occupational therapy assistant (OTA) bill for 97750 or can only a physical therapist (PT) or occupational therapist (OT) bill for it”? In this article, I will answer who can bill for CPT code 97750 and what component(s) the PTA or OTA can perform and what the PT or OT must perform.
In addition, did you see my article “CPT Code 97750: When Do I Use This Code” where I answered the following questions:
- When can I bill CPT code 97750?
- Can we use CPT code 97750 in place of a reevaluation if an insurance carrier does not pay for a reevaluation?
- Can we use this code for the time it takes us to take range of motion measurements and perform manual muscle testing?
- Can we bill this CPT code for the time a patient completes a questionnaire and we review it with the patient?
- How often can we bill CPT code 97750?
- Can we bill CPT code 97750 for writing a Progress Report?
- Can we bill CPT code 97750 every 10th visit on Medicare patient’s when completing functional limitation reporting?
- What time counts towards “the each 15 minutes” when determining how many units to bill?
A PTA and/or OTA can administer the physical performance testing and measurement
One of the most common questions I receive, either via email or at my live seminars, is “What insurance carriers follow the 8-minute rule for outpatient therapy? Well, we all know the Medicare program follows the 8-minute rule for outpatient therapy services. This is true for all outpatient therapy services provided to Medicare beneficiaries in the following settings:
- Private Practice
- Skilled Nursing Facilities
- Comprehensive Outpatient Rehabilitation Facilities
- Rehabilitation Agencies
- Home Health Agencies providing Part B therapy in the beneficiaries home
- Hospital Outpatient Departments
- Medicare patient’s seen for therapy while they are in the emergency department or under observation status in a hospital setting and do not get admitted
But did you know the 8-minute rule also applies to other insurance carriers besides traditional Medicare? The 8-minute rule applies to all insurance carriers who