On October 31, 2019, the Centers for Medicare and Medicaid Services (CMS) issued the final rule for Home Health Agencies for calendar year 2020. Highlights of the final rule include: CMS projects that aggregate Medicare payments to HHAs in CY 2020 will increase by 1.3 percent, or $250 million CMS will allow physical therapist assistants and occupational therapy assistants to provide maintenance therapy Home health episode of care will decrease for a 60-day episode to a 30-day episode Beginning in 2021, CMS will require HHAs to submit a notification to CMS within 5 calendar days from the start of care

On June 3, 2019, Blue Cross and Blue Shield (BCBS) of Minnesota removed the prior authorization (PA) requirements for outpatient therapies, including physical, occupational, and speech therapy, and chiropractic services. Self-Insured Groups may have benefits that require a PA for outpatient therapy or chiropractic services. These services may be managed as a PA or a retrospective review. While the above is good news, with the removal of the PA, BCBS of Minnesota will be conducting medical necessity review of services. The number of visits outlined below provides an example of when Blue Cross would typically begin reviewing therapies for medical

Since January 1, 2019, facilities that provide post-acute care inpatient services have been required to request prior authorization and receive a pre-service determination before UnitedHealthcare (UHC) Medicare Advantage Plan members can be admitted to a post-acute care facility or a post-acute care bed in one of the following types of facilities: Acute Inpatient Rehabilitation Skilled Nursing Facilities Long-term Acute Care Hospitals Critical Access Hospitals that provide post-acute services Beginning on October 1, 2019, UHC will

The Medicare Payment Advisory Commission (MedPAC) has released a 3-page document providing data and Medicare spending for outpatient therapy in calendar year 2017. Here is a brief summary of the report. Distribution of Outpatient Therapy by Setting Skilled Nursing Facility: 37% PT in Private Practice: 34% Hospital: 16% ORF, CORF and HHA: 9% OT & SLP Private Practice: 3% Physician & Nonphysician Practitioner: 2% Keep in mind that PT in private practice can include physical therapists who practice in a physician-owned therapy practice, but are submitting claims under the NPI number of the treating physical therapist. Spending by Discipline In

If you submit claims to Anthem Blue Cross, significant changes are occurring beginning with dates of service on and after November 1, 2019. AIM Specialty Health has announced they will relaunch the AIM Rehabilitative program (i.e. prior authorization) for Anthem’s Commercial Membership on November 1, 2019 for the following states: I hope you found this article helpful. Thank you for being a Gold Member!

On December 20, 2018, the Department of Defense (DoD) released the long awaited proposed rule to add physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) as TRICARE authorized providers. TRICARE accepted comments on the proposed rule until February 19, 2019. As of the date of this article being published, we I hope you found this article helpful. Thank you for being a Gold Member!  

This week, I will provide 3 billing scenario’s that can be applicable to either outpatient physical therapy or outpatient occupational therapy services and provide the billing answer for Medicare beneficiaries and those insurance carriers that follow the Medicare Program billing rules (i.e. “8-minute rule) and will also provide the billing answer for those insurance carriers that do not follow the Medicare Program billing rules, rather, follow the definition of a substantial portion of a time-based CPT per the American Medical Association (AMA). Two articles that you may want to read prior to continuing on with this article are “What CPT

A question I am often asked is what are the documentation requirements that the Centers for Medicare and Medicaid Services (CMS) requires to support outpatient physical, occupational and/or speech therapy services above the annual therapy dollar threshold. The answer is there