Tuesday, March 6, 2018

CMS Posts Updated Information Immediately Impacting Part B Therapy Coverage and Payment Rates

Dan Ciolek

In a February 28 MLN Connects Special Edition notice, the Centers for Medicare and Medicaid Services (CMS) provided a summary of provisions impacting Medicare Part B outpatient therapy services contained in the February 9 Bipartisan Budget Act of 2018 including the following: 

  • Section 50201 - Extension of Work Geographic Practice Cost Index (GPCI) Floor - The new law extends a provision raising the Work GPCI to 1.000 for all localities that currently have a Work GPCI of less than 1.000. The Work GPCI Floor impacts the fees for all codes paid under the Medicare Physician Fee Schedule (MPFS) for those localities.  The Work GPCI floor is extended through December 31, 2019. No new provider action is necessary for implementation. AHCA will provided updated Medicare Part B Fee Schedule updated tables on our website when they become available.
  • Section 50202 - Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy - The new law requires for services after December 31, 2017:
    • Medicare claims are no longer subject to the therapy caps (one for occupational therapy services and another for physical therapy and speech-language pathology combined);
    • Claims for therapy services above a certain amount of incurred expenses ($2,010), which is the same amount as the previous therapy caps, must include the KX modifier indicating that such services are medically necessary as justified by appropriate medical record documentation; and
    • Claims for therapy services above certain threshold levels of incurred expenses will be subject to targeted medical review. The medical review thresholds for therapy services in a year before 2028 are $3,000.
    • CMS will begin the process of releasing claims that had been held briefly after expiration of the therapy caps exceptions process. CMS will release for processing the held claims based on the date the claim was received, i.e., on a first-in, first-out basis, until no claims are being held. This process will be accomplished as quickly as possible while staying within the requirements for the volume of claims that MACs can release on a given day.

NOTE:  CMS has stated that the Medicare Administrative Contractors (MAC) will implement these changes no later than February 26, 2018, and will provide additional details on timelines for reprocessing or release of held claims impacted by these changes.  We will provide updates as CMS releases additional details.

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