Updated Part B Therapy Claims Processing Instructions - Bipartisan Budget Act of 2018

Dan Ciolek

As AHCA announced in an earlier article, the Centers for Medicare & Medicaid Services (CMS) had begun the process of reprocessing calendar year (CY) 2018 Medicare Part B claims, including those for outpatient physical therapy, occupational therapy, and speech-language pathology services, in order to implement provisions of the Bipartisan Budget Act of 2018. This reprocessing will positively impact affected skilled nursing facility (SNF) providers as it will reverse prior therapy cap related denials across the country, as well as increase Part B payment rates for SNFs in certain geographic locations.

This law, enacted February 9, contained a number of provisions that may have impacted SNF Part B therapy claims, including the Work Government Practice Cost Index (GPCI) Floor, and the permanent repeal of the outpatient therapy caps beginning on January 1, 2018. 

Due to the retroactive effective dates of these provisions, your Medicare Administrative Contractor (MAC) was provided additional instructions to automatically reprocess claims impacted by this legislation from April 1 to no later than six months after this date. For the limited number of SNF providers impacted, you will not need to request any reprocessing unless you believe that the MAC systems did not automatically reprocess your impacted claim(s).     

CMS also posted a more reader-friendly MLN Matters article that provides additional details about these changes impacting SNFs, including the following specifics:

• The MACs will reprocess therapy claims with the KX modifier containing Dates of Service in Calendar Year 2018, which were denied prior to the implementation of the updated legislative effective dates issued on January 25, 2018. NOTE: For institutional claims, these claims will include revenue codes 042x, 043x, or 044x and modifiers GN, GO, or GP.
• The MACs will reprocess therapy claims with the KX modifier which were denied due to an invalid date provided by CMS on February 12, 2018.
• The MACs reprocess MPFS claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY 2018. 
• MACs shall ensure all reprocessing actions have been initiated within 6 months of the issuance of CR10531.
• The MACs will reprocess 2018 therapy claims and claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY 2018 which cannot be automatically reprocessed only if you bring such claims to the attention of your MAC.

AHCA recommends that provider billing staff review these documents.