During their November 7, 2014 meeting, the Medicare Payment Advisory Commission (MedPAC) provided a presentation on site-neutral payments for select conditions (17 conditions) treated in inpatient rehabilitation facilities and skilled nursing facilities. The 17 conditions were a mix or orthopedic, pulmonary, cardiac and infections. These conditions accounted for 10% of IRF cases and spending. A previous June 2014 report looked at joint replacement and hip and femur procedures and found that the majority of these patients were treated in the SNF setting. IRF outcomes for these conditions compared with SNF outcomes found:  

In a November 6, 2014 meeting, the Medicare Payment Advisory Commission (MedPAC) reported that observation stays should be eliminated as a way of classifying patients. In recent years, hospitals have increased the number of observation stays due to increased audits by RACs for one-day inpatient admissions. This significant rise in observation stays has had a negative impact on a Medicare beneficiaries ability to have a skilled nursing facility (SNF) admission covered by the Medicare program. In order for a SNF admission to be covered under a beneficiaries Part A benefits, they must have had a qualifying 3-day hospital inpatient admission.

When a provider is billing the Medicare program for a reduced service, they are to append modifier-52 to that CPT code on the claim form. When billing for a reduced service, providers should reduce the billed amount by 50% just as providers are to increase a bilateral billing by 50%. Maintaining the same charge for a reduced service is not proper billing. Please make sure that when you submit any CPT code with modifier-52, that you are also reducing the billed amount by 50% prior to submission of the claim to your Medicare contractor. Two examples of when a provider

The Office of the Inspector General (OIG) has released their 2015 work plan and to no surprise, physical therapists in private practice are on their radar. The OIG will review outpatient physical therapy services provided by physical therapists in private practice to determine whether they were in compliance with Medicare reimbursement regulations. Prior OIG work found that claims for therapy services provided by physical therapists in private practice were not reasonable or were not properly documented or that the therapy services were not medically necessary. The OIG focus is on physical therapists in private practice who have a high utilization

On October 31, 2014, the Centers for Medicare and Medicaid Services released the final rule for service reimbursed under the Medicare Physician Fee Schedule that includes outpatient physical, occupational, and speech-language pathology therapy services. The final rule provides information on the 2015 therapy cap dollar amount, manual medical review process for outpatient therapy exceeding $3700 in a calendar year, and significant PQRS changes to the 2015 reporting requirements. In calendar year 2015, the therapy cap dollar amount will be

Health and Human Services Secretary Sylvia M. Burwell has announced an initiative that will fund successful applicants who work directly with medical providers to rethink and redesign their practices, moving from systems driven by quantity of care to ones focused on patients’ health outcomes, and coordinated health care systems. These applicants could include group practices, health care systems, medical provider associations and others. This effort will help clinicians develop strategies to share, adapt and further improve the quality of care they provide, while holding down costs. For the full CMS press release, click HERE.

Effective for Federal District Court requests filed on or after 1/1/2015, the amount in controversy will increase to $1,460. The amount that must remain in controversy for review in Federal District Court requested before 12/31/2014 is $1,430. The amount that must remain in controversy for ALJ hearing requests filed before 12/31/2014 is $140. This amount will increase to $150 for ALJ hearing requests filed on or after 1/1/2015.

The Centers for Medicare and Medicaid Services has published 2 booklets; Reading a Professional Remittance Advice and Reading the Institutional Remittance Advice. Each booklet is designed to provide education to the provider or institution in how to read the remittance advice and includes actual screen shots with an explanation of what you will find on each screen. Private practices will want to read the “Reading a Professional Remittance Advice” booklet and non-private practices (i.e. institutional providers) will want to read “Reading the Institutional Remittance Advice” booklet. To access the booklets, click