In the final 2018 outpatient prospective payment system (OPPS) rule released by CMS, total knee arthroplasty, also known as total knee replacement (TKA/TKR), was removed from the Medicare inpatient-only (IPO) list. The IPO list includes procedures that are only paid under the hospital inpatient prospective payment system.
As a member of the Billers’ Association for Long-Term Care, you have access to our talk forum, where billing professionals can ask and answer questions to help each other solve billing and reimbursement challenges. A recent biller brought up a good question: Do you therapists bill the time they participate in the SNF care plan meeting?
CMS announced an update on therapy caps and functional reporting in an MLN Matters article dated January 25, 2019. Effective for dates of service on or after January 1, 2018, providers of therapy services shall continue to report the KX modifier on claims as applicable. The modifier no longer represents an exception request but serves as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record after the beneficiary has exceeded the threshold of incurred expenses
New CMP amounts that have been adjusted for inflation and are effective October 11, 2018 were announced in a final rule published by CMS on January 22, 2019. The adjusted amounts apply to CMPs assessed on or after October 11, 2018. For SNFs, NFs and SNF/NFs, the CMP Analytic Tool instructions and calculations will be updated to reflect these changes. Appendix A of the final rule announcement contains the new rates, which have seen an increase.
CR 11064 (MLN Matters) provides the Calendar Year 2019 annual update for the Medicare DMEPOS fee schedule. The update includes information on the data files, new and deleted HCPCS codes, adjusted fee schedule amounts, and other information related to the update of the fee schedule. Click here to read the full article.
The annual per-beneficiary incurred expense amounts are now known as the KX modifier thresholds. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 (BBA of 2018) was signed into law. CMS recently posted a MLN Matters article with these amounts for CY2019, which were lowered by the BBA of 2018 which are as follows.
The MACs for the J5 (Iowa, Kansas, Missouri, and Nebraska) and J8 (Indiana and Michigan) jurisdictions (WPS Government Health Administrators) announced that CMS has authorized them to conduct a Targeted Probe and Educate (TPE) review of outpatient therapy (CPT code 97110). The announcement was made on October 15 on the WPS website. The webpage states that “This is a required process for providers identified by Medical Review. The TPE review process incudes three rounds of prepayment or post-payment probe review with education. If high denial rates continue after three rounds or review, WPS GHA will refer the provider and results to CMS. CMS will determine any additional action, which may include but is not limited to extrapolation, referral to the Unified Program Integrity Contractor (UPIC), and/or referral to the Recovery Audit Contractor (RAC).”
With the release of the proposed rule on April 27, 2018, the Centers for Medicare & Medicaid Services (CMS) introduced the Patient-Driven Payment Model (PDPM) with a proposed implementation date of October 1, 2019. This model is intended to replace the current prospective payment system reimbursement structure, Resource Utilization Groups, Version IV (RUG-IV), and significantly revises the Resident Classification System, Version I (RCS-I), which was introduced to the industry as a proposed RUG-IV replacement in an Advanced Notice of Proposed Rule Making (ANPRM) in 2017. RCS-I and PDPM were developed in conjunction with Acumen, a consulting group hired by CMS, and an interdisciplinary technical expert panel.
The Patient-Driven Payment Model (PDPM), as proposed, is designed to replace the current SNF payment methodology known as RUG-IV. Unless date changes, etc. are made by CMS post commentary review, the effective date of the change (from resource utilization groups to PDPM) is October 1, 2019. PDPM as an outgrowth of the initially proposed resident classification system (RCS) and received commentary is a simplified payment model designed to be more holistic in patient assessment, capture more clinical complexity, eliminate or greatly reduce the therapy focus by eliminating the minute levels for categorization, and simplifying the assessment process and schedule (reducing to three possible assessments/MDS tasks). Below is a summary of PDPM core attributes/features as proposed. Click here to access the PDPM Calculation Worksheet for SNFs that provides additional details beyond the reference points below.