On April 21, 2016, the Centers for Medicare and Medicaid Services (CMS) released the skilled nursing facility (SNF) proposed rule for FY 2017 for services reimbursed under Medicare Part A benefits. Based on the proposed rule, CMS projects payments for SNF’s will increase by 2.1% in FY 2017 compared to FY 2016. The 2017 proposed rule adds to the list of quality measures that will be required of SNFs beginning in 2018 to include data on discharge to community, Medicare spending per beneficiary, and potentially preventable 30-day readmissions. The proposal also stipulates that by 2020, SNFs will be required to supply reports on drug regimen reviews with follow-up.
On April 21, 2016, the Centers for Medicare and Medicaid Services (CMS) released FY 2017 Inpatient Rehabilitation Facility (IRF) proposed rule. In the proposed rule, CMS is proposing to increase IRF payment by 1.45% in FY 2017 compared to FY 2016.
Beginning in FY 2014, any IRF that does not submit the required data to CMS receives a 2.0 percentage point decrease in its annual increase factor for payments under the IRF PPS. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the continued specification of quality measures, as well as resource use and other measures, for the IRF QRP.
In order to satisfy the requirements of the IMPACT Act, CMS is proposing four claims-based measures for inclusion in the IRF QRP for the FY 2020 and FY 2018 payment determination and subsequent years and one new assessment-based quality measure for inclusion in the IRF QRP for FY 2020 and subsequent years, respectively:
Discharge to Community – Post Acute Care (PAC) IRF QRP (claims-based);
Medicare Spending Per Beneficiary (MSPB) – Post-Acute Care (PAC) IRF QRP (claims-based);
Potentially Preventable 30 Day Post-Discharge Readmission Measure for IRFs (claims-based);
Potentially Preventable Within Stay Readmission Measure for IRFs (claims-based); and
Drug Regimen Review Conducted with Follow-Up for Identified Issues (assessment-based).
Pending final data analysis, CMS is also proposing to add four new measures to IRF QRP public reporting on a CMS website, such as Hospital Compare, by Fall 2017. In addition, we propose to extend the timeline for submission of exception and extension requests for extraordinary circumstances from 30 days to 90 days from the date of the qualifying event.
I often have therapists tell me that they have to do a reevaluation on all of their patient’s every 30 days from the date of the patient’s initial evaluation. I then ask them why they think that is a requirement. Their response is usually along the lines of “Medicare requires we do a reevaluation every 30 days” or “my state practice act requires we do a reevaluation every 30 days” or “my employer or my organization requires we do a reevaluation every 30 days.” In this article, I will address the above 3 responses and explain why it probably is not a reevaluation that you are doing, rather, is a Progress Report they are completing.
First of all, a reevaluation is not appropriate to bill on Medicare patient’s or for that matter, any other patient every 30 days from the start of care. The Medicare program does not require reevaluations be performed at certain intervals. I am also not aware of an insurance carrier that requires reevaluations be performed every 30 days. What the Medicare program does require as do some private insurance carriers is that the therapist complete a progress report every so often during the episode of care and I will address progress reports later in this article. In addition, a reevaluation is not appropriate to bill simply because your state practice act and/or your employer/organization requires a reevaluation every 30 days or other specific time frame.
A reevaluation may be considered reasonable and necessary in the following situations:
The Centers for Medicare and Medicaid Services (CMS) has released Skilled Nursing Facility (SNF) utilization and payment data for 2013. In addition to information on payments and charges, the SNF Payment Public Use File (PUF) contains information on two categories of RUGs for patients who receive a significant amount of therapy: Ultra-High (RU) and Very High (RV) Rehabilitation RUGs. Consistent with prior CMS findings, the SNF PUF shows that for these two RUGs, the amount of therapy provided is often very close to the minimum amount of minutes needed to qualify a patient for these categories. Medicare SNF per diem payment amounts for rehabilitation RUGs are primarily based on therapy minutes and payment amounts for these two RUGs can exceed payments for comparable RUGs with fewer therapy minutes by more than 25 percent. Due to this, CMS has referred this issue to the Recovery Auditor Contractors (RAC) for further investigation.
To view the 2013 payment data, click
Physical therapists bill CPT code 97002 for a reevaluation. Occupational therapists bill CPT code 97004 for a reevaluation. But what CPT code do speech-language pathologists (SLPs) use to bill for a reevaluation? The answer depends on who is the insurance carrier and what is their policy. And did you also know that SLPs do have a reevaluation code that some private insurance carriers list as payable in their speech-language pathology policies? In this article, I will explain how to bill for a reevaluation to Medicare and private insurance carriers, reveal the reevaluation code that SLPs have and list several insurance carriers that state they pay for this unknown reevaluation code.
Lets start with when is a reevaluation warranted to be performed by the speech-language pathologist (SLP). A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.
Indications for a re-evaluation include:
As I speak around the country, I am often surprised how many providers are not aware of CPT codes that speech-language pathologists (SLPs) could and should be using to bill to an insurance carrier for the evaluation of a speech-generating augmentative and alternative communication device (SGD). A SGD is a device that produces digital or synthesized speech. In this week’s article, I will explain how to use the evaluation CPT codes for an evaluation for a SGD as well as how to bill for the programming, modification and patient education and training associated with a SGD.
Lets begin with the evaluation CPT codes. There are 2 CPT codes SLPs should be using when performing an evaluation for a SGD.