Summary: The Final Rule is the document that modifies the MPFS for all services paid under the Fee Schedule for Part B Medicare. Relevant to therapy services, the Final Rule does the following for 2013:

• Sets the therapy cap amount on outpatient therapy services for 2013 at $1,900; The therapy cap exceptions process will expire on December 31 unless Congress acts to extend it.
• Updates 2013 payment amounts for physicians, physical therapists, and other health care professionals; and revises other payment policies.
• Includes a 26.5% across-the-board reduction to Medicare payment rates for physicians, physical therapists, and other professionals due to the flawed sustainable growth rate (SGR) formula. Since 2003, Congress had enacted legislation preventing the reduction every year. CMS announces that it is "committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect." Excluding the 26.5% projected SGR payment cut, the aggregate impact on payment of changes in the rule for outpatient physical therapy is a positive 4% in 2013.
• As required by the Middle Class Tax Relief Jobs Creation Act of 2012, CMS will begin to collect data on claim forms about patient functional status for patients receiving outpatient physical therapy, speech therapy, and occupational therapy beginning January 1, 2013. Therapists will be required to report new G codes accompanied by modifiers on the claim form that convey information about a patient's functional limitations and goals at initial evaluation, every 10 visits, and at discharge. This data is for informational purposes and not linked to reimbursement. Until July 1, 2013, claims will be processed regardless of the inclusion of functional limitation codes. Beginning July 1, 2013, all claims must include the functional limitation codes in order to be paid by Medicare. The American Physical Therapy Association (APTA) submitted comments on the proposed fee schedule rule, which had a significant impact in this area of the final rule, which reflects many of the association's recommendations.
• For 2013 the reporting period for PQRS will be based on a 12-month reporting time frame. The bonus payment amount will be .5%. Calendar year 2013 also will be used as the reporting period for the 2015 PQRS payment adjustment of -1.5%. Successful reporting requirements for the program will remain as they were in 2012, requiring that participants report a minimum of 3 individual measures or 1 group measure via claims-based reporting on 50% or more of all eligible Medicare patients, or report a minimum of 3 individual measures or 1 group measure via registry reporting on 80% or more of all eligible Medicare patients.

Pages 219-279 contain the relevant areas for outpatient therapy services. The Final Rule will appear in the November 16 Federal Register.

APTA has provided a document that highlights the key provisions of the Final Rule and its impact on therapy services in 2013 and beyond at the link below.

Summary: Documentation, coding, and compliance experts Steve Levine and Helene Fearon have used their collective expertise and years of research and analysis of the EMR marketplace to provide the most comprehensive information yet published for physical therapists who are making important decisions including determining if and when they will adopt an EMR, assessing current products in the marketplace, looking to increase efficiency and effectiveness of their current EMR and assessing the features of their current EMR to determine the best fit for their clinical practice.

The implementation and use of electronic medical records (EMRs) is now one of the highest priorities for healthcare providers, organizations, and government agencies in the United States. An EMR can provide many benefits for physical therapists and their patients, and can improve care by enabling functions that paper medical records cannot deliver. Currently, a majority of healthcare providers still use medical record systems based on paper, yet this is generally the most inefficient and time-consuming manner in which to document, especially if the required or desired elements are to be documented correctly. With the ongoing political and economic pressure to incorporate health information technology into practice, it is essential for physical therapists, and other healthcare providers, to understand the benefits and barriers to adoption of electronic documentation, the potential effects of introducing point of care (PoC) documentation into the therapist-patient relationship, and key points to consider prior to the lease or purchase of a system in order to effectively prepare for the successful transition to an EMR.

The Chapter details information on the following topics:

• Understanding the Current EMR Environment
• The meaning of "Meaningful Use"
• Defining Key Terms
• Benefits of and Barriers to adopting an EMR
• Physical Therapist Practice and the EMR: Key Points to Consider
• Computers at the Point of Care: Introducing Technology into the Therapist/Patient relationship
• Preparing for the Transition to EMR: Strategic Recommendations for Successful Implementation
• Training and Support
• EMR and Third Party Payment: Minimizing Risk and Improving Communication for Payment
• Determining the Right EMR: Criteria for Consideration, including:
  • ASP vs. Client Server Applications
  • Best of Breed vs. Integrated systems
  • Clinical Decision Support Systems

Most physical therapists recognize the importance, and value, of appropriate coding and documentation of clinical services, yet the process of learning and implementing all of the necessary information to adequately document the clinical care provided to patients, not to mention the time it can take to do so, can be overwhelming. However, if an appropriate and effective EMR system is implemented, the process of documentation can not only efficiently meet the clinical, legal, regulatory, and payment requirements that currently exist, but can also serve to enhance the patient encounter, facilitate improved functional outcomes, and increase a company's bottom line, while at the same time reducing the risk of punitive audits. To achieve these goals, it is critical for therapists to increase their "compliance IQ" as well as improve their "documentation hygiene," and then to embrace, after appropriate education and due diligence, the transition to an EMR. A computerized documentation system will not only assist physical therapists to meet new legislative requirements and become a significant administrative and compliance asset - it will also become a most valuable partner in the provision of efficient, effective, evidence-based physical therapy care.

To purchase this chapter, please click below:

Summary: Medicare Part B provides coverage for many types of therapy services. This website provides valuable information and serves as a guide to direct professionals to additional resources regarding rehabilitation therapy services, coverage requirements, payment systems, and points of contact for further information.

Summary: For outpatient rehabilitation providers, the most pertinent portion of this manual is Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Services. This manual describes policy applicable to Medicare fee-for-service claims, or what is known as the original or traditional Medicare program. The Medicare Managed Care Manual provides claims policy for services to enrollees in managed care plans.

Additionally, Section 10.2 provides detailed information on the Therapy Cap and the Therapy Cap Exceptions Process, and is an excellent reference for therapy providers looking for specific information related to billing for medically necessary services that exceed the therapy cap amounts, and the appropriate use of the KX modifier to indicate an automatic exception should be provided.

Summary: The Program Integrity Manual (PIM) is a critical source of information for Medicare providers. The most pertinent sections for rehabilitation providers in the outpatient setting are:

• Chapter 1: Overview of Medical Review (MR), Benefit Integrity (BI), and Local Provider Education and Training (LPET) Programs;
• Chapter 3: Verifying Potential Errors and Taking Corrective Actions;
• Chapter 4: Benefit Integrity;
• Chapter 10: Health Care Provider/Supplier Enrollment;
• Chapter 13: Local Coverage Determinations (LCDs).

Summary: For outpatient rehabilitation providers, the most pertinent portion of this manual is Chapter 15 – Covered Medical and Other Health Services. The two most pertinent sections in Chapter 15 are Section 220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230 - Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology. Also, Chapter 12 provides information  specific to Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage.

Summary: The Internet-only Manuals (IOMs) are a replica of the Agency's official record copy.  The CMS program components, providers, contractors, Medicare Advantage organizations and state survey agencies use the IOMs to administer CMS programs. They are also a good source of Medicare and Medicaid information for the general public.

Summary: The mission of the American Physical Therapy Association (APTA), the principal membership organization representing and promoting the profession of physical therapy, is to further the profession's role in the prevention, diagnosis, and treatment of movement dysfunctions and the enhancement of the physical health and functional abilities of members of the public.

APTA's Vision Statement:

By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.

Summary: The Federation’s vision is that the organization will achieve a high level of public protection through a strong foundation of laws and regulatory standards in physical therapy, effective tools and systems to assess entry-level and continuing competence, and public and professional awareness of resources for public protection.

The Federation of State Boards of Physical Therapy develops and administers the National Physical Therapy Examination (NPTE) for both physical therapists and physical therapist assistants in 53 jurisdictions – the 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands. These high-stakes exams assess the basic entry-level competence for first time licensure or registration as a PT or PTA within the 53 jurisdictions.

Summary: To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191, included "Administrative Simplification" provisions that required HHS to adopt national standards for electronic health care transactions. At the same time, Congress recognized that advances in electronic technology could erode the privacy of health information. Consequently, Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.

In response to the HIPAA mandate, HHS published a final regulation in the form of the Privacy Rule in December 2000, which became effective on April 14, 2001. This Rule set national standards for the protection of health information, as applied to the three types of covered entities: health plans, health care clearinghouses, and health care providers who conduct certain health care transactions electronically. By the compliance date of April 14, 2003 (April 14, 2004, for small health plans), covered entities must implement standards to protect and guard against the misuse of individually identifiable health information. Failure to timely implement these standards may, under certain circumstances, trigger the imposition of civil or criminal penalties.

The Privacy Rule applies only to covered entities. Individuals, organizations, and agencies that meet the definition of a covered entity under HIPAA must comply with the Privacy Rule's requirements to protect the privacy of health information in multiple formats (written, electronic, and oral) and must provide individuals with certain rights with respect to their health information. If an entity is not a covered entity, it does not have to comply with the Privacy Rule.

Summary: Physical therapists and physical therapist assistants should not underestimate the importance of complete documentation or the implications of deficient documentation. Today's health care system relies on documentation to measure patient outcomes, the need for services, and justification of the plan of care. Insufficient or absent documentation can negatively affect reimbursement, communication among providers, risk management, and most important, the care of the patient/client. In light of the importance of documentation in patient/client care and in response to many of the current issues related to physical therapy documentation, APTA has developed the Defensible Documentation for Patient/Client Management resource as a companion guide to the Association's existing documentation guidelines. The objectives of Defensible Documentation for Patient/Client Management resource include: 1) Raising awareness of physical therapists (PTs) and physical therapists assistants (PTAs) on clinical documentation issues; 2) Providing useable and clinically relevant information about defensible documentation in patient/client care; 3) Identifying legal, regulatory, and payer requirements for clinical documentation; 4) Providing tools and resources PTs and PTAs need to create documentation that will satisfy all the aforementioned requirements.

Summary: CMS has published 11 Part B Billing Scenarios specific to PTs and OTs, and plans to update the Web Page to reflect changes in policy (for example, CCI edits, new codes, new coverage determinations) that impact therapy billing and/or to provide clarification on billing policy for PTs, OTs and/or SLPs.

The Medicare contractor who pays your claims is the best source of answers to specific Medicare questions. Medicare Contractors (Carriers/ Intermediaries/ A/B Medicare Administrative Contractors) interpret Medicare laws, develop local policies, and educate providers. Contractor websites list local policies.