On January 12, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule which would specify the qualifications needed for qualified practitioners to furnish and fabricate, and qualified suppliers to fabricate prosthetics and custom- fabricated orthotics; accreditation requirements that qualified suppliers must meet in order to bill for prosthetics and custom-fabricated orthotics; requirements that an organization must meet in order to accredit qualified suppliers to bill for prosthetics and custom-fabricated orthotics; and a timeframe by which qualified practitioners and qualified suppliers must meet the applicable licensure, certification, and accreditation requirements. In addition, this rule would remove the

The 2018 CPT codes have been officially released by the American Medical Association (AMA) and there are several changes that will impact outpatient physical and occupational therapy services. CPT codes, description, and material are copyright 2017 AMA. CPT is a trademark of the AMA. 2018 CPT code changes impact the following CPT codes:  Multi-layer compression system CPT codes 29582 and 29583 Orthotic and management training (CPT code 97760) Prosthetic management and training (CPT code 97761) Orthotic/prosthetic checkout (CPT Code 97762) Development of cognitive skills (CPT code 97532) Lets begin with the multi-layer compression system CPT codes. For dates of service

The Centers for Medicare and Medicaid (CMS) had initiated a pilot program called Targeted Probe and Educate (TPE) where the Medicare Administrative Contractors focus on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service. TPE involves the review of 20-40 claims per provider, per item or service, per round, for a total of up to three rounds of review. Each round of 20-40 claim reviews is referred to as a probe. After each round, providers are offered individualized education based on the results of their reviews. Providers/suppliers with continued high error rates after three rounds of

The Military Health System (MHS) is modernizing TRICARE to better serve its members and respond to changes in law and policy. Most provisions will go into effect on January 1, 2018, with full implementation occurring on January 1, 2019. Changes will impact TRICARE health plans, changes to the 3 TRICARE Regions and new regional contractors that will process claims. These changes will impact practices and organizations that provide therapy services to TRICARE beneficiaries. I will address all these changes in this article. Changes to TRICARE health plans include the following:

The Centers for Medicare and Medicaid Services (CMS) has released the 2018 proposed rule for services paid under the outpatient prospective payment system. In the proposed rule, CMS is proposing to remove the total knee arthroplasty (TKA) from the Inpatient Procedure Only (IPO) List and allow Medicare beneficiaries to have a TKA on an outpatient basis beginning on January 1, 2018. If CMS does finalize this proposal and removes the TKA from the IPO list, it does not mean

Did you know that the Medicare program covers skilled maintenance therapy services under the Medicare home health benefit, skilled nursing facility benefit and outpatient therapy benefit? The goal of a maintenance therapy program is to maintain the patient’s current condition or to prevent or slow further deterioration in their condition. The Centers for Medicare and Medicaid Services (CMS) states “skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such

I am often asked must physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) in private practice enroll in the Medicare program if they want to treat Medicare beneficiaries for outpatient therapy services that are covered by the Medicare program? This then leads to a second question I am often asked. If PTs, OT’s and SLPs must enroll in the Medicare program, what is this non-participating provider status? Doesn’t this mean I don’t participate with Medicare, hence, I can charge the Medicare beneficiary cash for outpatient therapy services? How about services that are statutorily non-covered by the Medicare program;

When providers of therapy services have medical records audited by their Medicare Administrative Contractor (MAC) and one or more services are denied, the MAC will determine the providers error rate and this error rate could determine whether additional medical records will be requested for review. So how does the MAC determine the error rate? The error rate is determine 1 of 2 ways dependent upon if it is a prepayment medical review or postpayment medical review. For a prepayment review, the error rate is determined by