UnitedHealthcare (UHC) Community Plan has revised their speech-language pathology (SLP) coverage determination guideline with an effective date of August 1, 2015. To view the revised SLP coverage determination guideline, click
With the transition to ICD-10 less than 2 months away, providers still have questions concerning ICD-10 and how to use the codes in their outpatient therapy practice and/or department. Worse yet, some providers have yet to start their ICD-10 training and education as they were hoping for a delay in the implementation date. For those that waited, start your training and education now. The Centers for Medicare and Medicaid Services (CMS) has no plans to delay the implementation date and you must be ready to begin using ICD-10 codes for dates of service on or after October 1, 2015.
To help you prepare, CMS has a webpage dedicated to ICD-10 with lots of information available to practices, organizations, billing companies, and clearinghouses. In addition, CMS has been publishing weekly bulletins to assist providers in preparing for the October 1, 2015 implementation date.
In their most recent publication, CMS discussed the following topics concerning ICD-10:
- List of Valid ICD-10-CM Codes
- Use of Unspecified Codes in ICD-10-CM
- Transition of ICD-10 for Home Health
- Claims that Span the ICD-10 Implementation Date
- Coding for ICD-10-CM Regarding Laterality
- Questions and Answers Regarding ICD-10 Coding Flexibilities
Over the next 2 months, Gawenda Seminars and Consulting (GSC) will be providing webinars on ICD-10 for outpatient physical, occupational and speech therapy services related to pediatrics, adults, and geriatrics covering a wide range of conditions and diagnoses’. GSC will also be publishing questions and answers concerning ICD-10 on our ICD-10 FAQ page that is available to our Gold Members. Questions that Rick has answered that are available right now to our Gold Members are:
- What is the implementation date for ICD-10?
- Will all insurances mandate we report ICD-10 codes instead of ICD-9 codes?
- After the implementation of ICD-10, is it possible that we could use ICD-10 codes with some insurance carriers and ICD-9 codes with other insurance carriers?
- What are benefits of switching to ICD-10-CM for outpatient therapy services?
- What is the difference between ICD-10-CM and ICD-10-PCS?
To view the most recent CMS Publication on ICD-10 implementation and to gain access to the answers for the above 5 questions, click
Effective June 4, 2015, The Centers for Medicare and Medicaid Services (CMS) has withdrawn the Requests for Quotes for the next round of Recovery Auditor contracts. CMS plans to update the Statement of Work and release new Requests for Proposals shortly. In the meantime, the current Recovery Auditors will continue active recovery auditing through at least December 31, 2015.
In addition, in mid-January 2015, CMS approved the Recovery Auditors to begin reviewing Outpatient Therapy Threshold claims (those over the $3700 threshold) that were paid March 1, 2014 through December 31, 2014. In an effort to minimize provider burden, CMS set restrictions on the number of Additional Documentation Requests (ADRs) that could be sent related to these claims, as shown below.
On July 15, 2015, the Centers for Medicare and Medicaid Services (CMS) released the 2016 proposed rule for services reimbursed under the Medicare Physician Fee Schedule (MPFS). This proposed rule does impact outpatient therapy services provided in the following settings:
- Private Practice
- Skilled Nursing Facilities
- Outpatient Rehabilitation Facilities
- Comprehensive Outpatient Rehabilitation Facilities
- Home Health Agencies providing Part B Therapy Services
- Hospital Outpatient Departments (excludes critical access hospitals)
Highlights of the proposed rule include the 2016 payment rate, 2016 PQRS program, and CPT codes used by PT and OT that CMS wants to review to see if they are “misvalued” and need to be updated.
In 2016, the proposed conversion factor would be
With less than three months remaining until the nation switches from ICD-9 to ICD-10 coding for medical diagnoses and inpatient hospital procedures, The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) are announcing efforts to continue to help physicians get ready ahead of the October 1 deadline. In response to requests from the provider community, CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set. To read the additional guidance that does include an advanced payment option if problems arise, click
The Centers for Medicare and Medicaid Services (CMS) has issued a proposed new payment model that would bundle payment to acute care hospitals for hip and knee replacement surgery. Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehabilitation periods. In 2013, there were more than 400,000 inpatient primary procedures costing more than $7 billion for hospitalization alone. The average Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas.
Under this proposed model, the hospital in which the hip or knee replacement takes place would be accountable for the costs and quality of care from the time of the surgery through 90 days after—what’s called an “episode” of care. This model would be in 75 geographic areas throughout the country and most hospitals in those regions would be required participate. To view the fact sheet, click HERE.