PT/OT caps exception process extended to 12/31/2009

When Congress passed The Medicare Improvements for Patients and Providers Act of 2008 on July 15^th not only did it stop a 10.6% pay cut for most medical service providers. There were other provisions as well.

One of the other provisions was to extend the exceptions process of PT and OT therapy caps. Claims for outpatient therapy with dates of service on or after July 1^st that exceed the current cap can be submitted using the KX modifier. The KX modifier indicates that the therapy cap exception has been approved or it meets all the guidelines for an automatic exception. In order for claims to be paid specified required documentation must be on file.

The current caps are $1810 for physical therapy and speech therapy combined and $1810 for occupational therapy, for the 2008 calendar year. Deductible and coinsurance amounts as well as paid amounts count towards the cap. If services meet the exception criteria and are billed using the KX modifier they will be paid beyond the cap.

Prior to Congress passing this new legislation providers were instructed not to submit claims using the KX modifier for any services after July 1^st. Claims that were already submitted for dates of service after July 1^st without the KX modifier that are over the cap will be denied. The claims need to be resubmitted with the KX modifier.

Remember, in order for claims to be paid with the KX modifier they must meet the exception criteria. The exception must either be an automatic exception or be approved by Medicare after the appropriate documentation was submitted for review. The list of ICD-9 codes that qualify for an automatic exception can be found on the CMS website.

If you have a patient who doesn’t qualify for the automatic exception but you feel they need additional therapy you need to submit a request to your Medicare carrier. You should include an evaluation and certified plan of care, Physician approval, clinician signed interval progress reports, treatment encounter notes, and records justifying services over the cap.

The legislation has extended the exceptions process for the therapy caps until December 31, 2009.

What Should Your Billing Service Be Doing For You

Many providers today are choosing to outsource their billing. The billing process has become much more involved over the past few years and for many it makes sense to outsource. Between the software updates, required electronic filing of claims, NPI numbers, and other changes, it has become nearly impossible for providers to keep up.
However, if you've only ever used one biller, or one billing service, then you might not really know what you should be expecting from them. We have providers who use other services ask us sometimes "Should my billing service be doing this for me, or is it something I need to do in my office?"

It is good to clearly know what your billing service should be doing, and what your office will be responsible for. That way you can keep things running smoothly. Not all billing services do things the same way and that's ok, as long as you know what yours is doing and it works for you. We actually provide different services for different accounts depending on the needs of the office. For example, we don't normally get involved with obtaining authorizations, however we have a couple of clients who cannot handle getting them from their office so they pay us extra to take care of that for them.

But there are some things that all billing services should handle. Billing is not just the act of submitting the insurance claims and waiting for payment to come. A good billing service will submit the claims, electronically whenever possible, check electronic reports for denials and bad batches, and follow up on unpaid claims. They should also take care of any denied claims.

If they are not checking electronic reports and doing regular follow up then you are losing money and so are they. Electronic reports will notify you if there are issues with any of your claims or with entire batches. If they are not reading them then they are not fixing those issues. For example, an electronic report will return a claim if the ID number is not right. Maybe it's a simple typo, two numbers got transposed, but if the electronic reports aren't being read it could be a big problem. What if it's a patient that comes in once a week? None of the claims are going thru because the ID number wasn't fixed.

Many insurance carriers today have time filing deadlines. Some are very short, like 60 days from the date of service. If regular follow up is not being done then money can be lost due to timely filing. Follow up reports should be run every 4-6 weeks and all claims over 30 days should be checked on.

There are other things that billing services can do to keep your accounts receivable running smoothly, but those are the basics. If you feel that your accounts receivable is not what it should be you might want to consider meeting with your billing service and asking what can be done to improve the situation. Tell them you would like a report of your accounts receivables. What are your figures over 30 days, over 60 days? They should be willing to provide you with reports of what's outstanding and why and it shouldn't take more than a couple of days for them to make the reports available. If they are unwilling to provide you with this information then you need to consider why.

I'm not trying to rat anybody out. I'm just trying to make us all accountable to providing the best service possible so that billing services don't get a bad name. We hear too many stories of bad services and it makes providers leery of outsourcing when it is a viable option.

The Centers for Medicare and Medicaid Services (CMS) Placed 10 day Hold on All Medicare Claims

On July 2^nd all Medicare Contractors were instructed to hold all Medicare claims for services dates July 1, 2008 or later, for 10 business days. This hold was placed to allow Congress more time to consider legislation related to the Medicare payment cuts that were scheduled to take effect July 1, 2008.

In December 2007 Congress had passed a law to postpone the cuts scheduled for January 1, 2008 for six months which went thru June 30, 2008. The new law contained a formula which reflected an increase of about 0.5 percent from the 2007 reimbursement rates.

This new halt will only last until July 15^th. If Congress fails to come up with a new law before July 15^th health care providers will see about a 10.6 percent cut from the 2007 rates.

There is a law pending called The Medicare Improvements for Patients and Providers Act which would postpone the steep payment cuts for an additional 18 months. This Act includes a 1.1 percent increase for 2009. However the law hasn’t made it out of the House of Representatives yet.

In the meantime there is nothing that we providers/billers can do but sit and wait to see what Congress ends up doing. It is such a huge cut that it greatly affects all health care providers. Rumors are that up to 60 percent of Participating Medicare Providers plan on dropping out of the program if the cuts are put into place.

It is understandable why they would want to drop out. However the problem is that by dropping out they are really only hurting the Medicare patients and the providers who stay in the program. There is no good outcome if the cuts are put into place.

Hopefully Congress will do the right thing for Medicare and come up with an alternative to the 10.6 percent cut in reimbursement rates.

Medicare “Cleaning Up” Providers with Tax ID vs. SS Numbers

Medicare is cracking down on providers who do not have their information recorded properly with Medicare. For example, if a provider signed up with Medicare under his/her social security number, but now uses a tax ID# for claims, his/her claims are being rejected by Medicare stating “NPI/Tax ID number not on crosswalk.” Medicare is requiring that your NPI number, your EIN or Tax ID number, and your LBN (Legal Business Name as registered with the IRS) all match up. If you tax id number is registered to John Smith MD but you call your practice Centertown Medical Office, Medicare must have you on file as John Smith MD. Their name for you must match what is on file with the IRS. Also, your NPI number must also match up with the IRS information. So if you are receiving strange rejections from Medicare, or if you have received a letter from CMS stating that your information doesn’t match, you need to straighten it out.

If you don’t have any idea what part is not matching, your best bet is to call your Medicare carrier and verify your information with them. They usually can direct you as to what information is not matching up.

Congress passes law to halt the 10.6% Provider Reimbursement Cuts in Medicare

Congress voted today, July 15^th, and passed a law that not only stops the 10.6% Medicare cuts, but it also includes a 1.1% increase for 2009. Today also ends the 10 day hold CMS had instructed Medicare carriers to impose on all claims with dates of service after July 1^st. This means that Medicare health care providers will not have to take a substantial pay cut for servicing Medicare providers.

New ABN (Advance Beneficiary Notice) for Medicare

CMS released a revised ABN or Advance Beneficiary Notice of Noncoverage (CMS-R-131) on March 3,2008 but providers and suppliers will be required to begin using it by September 1, 2008. This new form replaces the General Use ABN (CMS-R-131-G) and the Lab ABN (CMS-R-131-1) that were previously available. The new form and the instructions can be found on the cms web site at the following: www.cms.hhs.gov\bni

The ABN is a notice given to Medicare beneficiaries to advise them that Medicare is not likely to pay for a service or supply. Providers and suppliers must complete this form before providing services or products that are subject to this notice to the patient. The ABN must be explained to the patient or the patient’s representative and then the patient must sign the form.

One of the key features of the new form is that the title of the form, “Advance Beneficiary Notice of Noncoverage” more clearly conveys the purpose of the form. The new form replaces the need for two separate forms needed in the past. Also, this new ABN can be used for voluntary notifications instead of having the use the old separate form, the Notice of Exclusion from Medicare Benefits (NEMB).

The new ABN has a mandatory field for cost estimates. The provider or supplier must complete this field with the estimate of the cost of the service or good which may not be covered under Medicare. There is also a new beneficiary option on the new ABN form that allows a patient to choose to receive an item or service, pay for it out of pocket, and not have the claim filed with Medicare.

If you are providing services or supplies to patients that may not be covered by Medicare and are subject to the ABN you must make sure you are using the new ABN form before September 1^st. Make sure that the ABN is explained to the patient and have the patient sign the ABN. The patient should receive a copy of the ABN and a copy should be kept in the patient’s file. It is important that you have followed these steps when providing non covered services to Medicare patients.