Here are the latest E-notes from APTA Payment Policy & Advocacy Unit…

Industry Updates

House Passes Important Therapy Cap and Medicare Physician Fee Payment Provisions, While Senator Bunning Defeats Senate Attempt to Pass the Measure
On Feb 25 2010, the U.S. House of Representatives passed H.R. 4691, The Temporary Extension Act of 2010 by a voice vote. This bill delays the scheduled 21.2% cut in Medicare physician fee payments, which was to occur March 1st and extends the Medicare therapy cap exceptions process through March 31, 2010. In addition to these very important APTA provisions, the bill also provides a one month extension for other vital issues like unemployment insurance and COBRA. Click here for a summary of the bill. The one month extension legislation was developed to allow Congress to work during March on a larger jobs bill, which could contain a longer-term extension to the therapy caps exception process and prevention of Medicare physician fee payments cuts.

After the House passed H.R. 4691, it was sent immediately to the Senate. Senate Majority Leader Reid, for the second night in a row, sought a unanimous consent agreement to pass the Temporary Extension Act of 2010, but did not get it, due to an objection by Sen. Bunning (R-KY), because he wanted the one month extensions paid for. The Senate reconvened at 9:30am this morning to continue debate.

H.R. 4691 still must be passed by the Senate and signed by President Obama before becoming law.

For updates on these issues join our PTeam (www.apta.org/pteam) or check the Medicare Therapy Cap Resource Center (www.apta.org/therapycap).

Anthem Blue Cross
The Department of Health and Human Services (DHHS) is calling for Anthem BC to justify its decision to increase premiums by as much as 39% for California customers. Meanwhile, California’s Department of Insurance is conducting an independent review of the premium rate increase for individual health insurance policies offered by Anthem BC. Anthem BC is required by California law to allocate 70% of premium revenue for policyholders’ health benefits.

APTA Federal Government Affairs staff attended the Congressional hearings on Wednesday, February 24, 2010.

OptumHealth
Due to fiduciary responsibility to their clients and enrollees, OptumHealth will begin auditing out-of-network providers. This program is in the early stages and information is very limited.

APTA will be in communications with OptumHealth regarding their findings.

X12 5010 Standards
Physicians, providers, and suppliers who submit claims to Medicare need to be fully compliant with the X12 5010 standards by January 1, 2012. Detailed information is available in Change Request 6721, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Version 5010 276/277 Claim Status Second Phase located at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6721.pdf

Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Version 5010 Only in Jurisdiction 9 Parts A and B (A/B) Medicare Administrator Contractor (MAC)

CMS Revises ABN Instructions
CMS issued Transmittal 1894 on January 15, 2010 announcing that beginning April 1, 2010 providers should use a new modifier, the -GX modifier when voluntarily issuing an advanced beneficiary notice for a non-covered statutory service. This means that if the therapy cap is exceeded and there is no exceptions process, the provider could voluntarily provide the patient with an ABN and submit the claim with a GX modifier in order to receive a denial from Medicare. CMS also clarifies in this Transmittal that Medicare systems will automatically deny claims submitted with a modifier -GA as a beneficiary liability (rather than subjecting them to possible medical review). The beneficiary would have the right to appeal this determination.

Currently the -GA modifier is used for services exceeding the cap when an ABN is on file. After April 1, the GA modifier should be used for benefits not allowed by statute. For example, custodial care is not a covered benefit. The most likely use by PTs of the GA modifier after April 1 will be for care that is not medically necessary.

The Medlearn Matters article is available at http://www.cms.hhs.gov/ContractorLearningResources/downloads/JA6563.pdf

Provider Enrollment
The Centers for Medicare and Medicaid Services (CMS) has delayed until January 3, 2011 a requirement that all ordering/referring physicians be enrolled in the Medicare program under the Provider Enrollment Chain and Ownership System (PECOS). PECOS is an online system that allows providers to enroll as a Medicare provider for the first time or update enrollment information such as name or address. CMS delayed the implementation of this requirement based on concerns that many physicians were not aware of the new requirement to enroll in the PECOS system. If a physician enrolled in Medicare prior to 2003, his or her information is not contained in the PECOS system. CMS has also developed a database that contains the names and NPIs of physicians who are enrolled in the PECOS system. More information on this requirement can be found on the CMS website.

APTA has developed several resources to help physical therapists and their patients understand their options if the therapy cap is exceeded now that the exceptions process has expired. It is important to note that these resources will be updated if and when Congress passes legislation to extend the exceptions process. An FAQ document and a podcast can now be found on the APTA website.

Coding Changes for 2010
The 2010 version of CPT includes a new wound care code pertaining to treatment of chronic venous insufficiency with multi-layer compression. The following includes a description of the new code and guidance in its use. This code is available for physical therapists to report.

Lower Extremity
Strapping - Any Age
29581 Application of multi-layer venous wound compression system, below knee

This code should not be reported with the following CPT codes:
• 29540 Strapping; ankle and/or foot
• 29580 Strapping; Unna boot
Check payer policy to determine coverage of this code.

Medicare Appeals Process
The revised Medicare Appeals Process brochure (January 2010) provides an overview of the Medicare Part A and Part B administrative appeals process available to Medicare providers, physicians and other suppliers. In addition, the brochure provides details on where to obtain more information about this appeals process. The current version is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/MedicareAppealsProcess.pdf .

APTA Activities

Coding Seminars
There are two (2) Coding Seminars remaining in 2010. These seminars will provide you the latest coding and reimbursement updates. Our expert speakers will answer all your questions about coding, Medicare updates and compliance, documentation and audits and appeals. New for 2010 will be an interactive panel discussion on the future of coding and payment in physical therapy. Expert speakers are Helene Fearon, PT, Steve Levine, PT, DPT, MSHA and Gayle Lee, JD. Coding seminar registration is complimentary for Reimbursement Chairs.

For additional information, click here.

New Resources
Three new FAQs have been published on the APTA website – Iontophoresis, Evaluation and Reevaluation and Vestibular Rehabilitation. Urinary Dysfunction and Casting/Strapping/Taping and Prosthetics/Orthotics are expected to be completed before the next edition of E-Notes.

A new Workers’ Compensation page has been added to the Reimbursement page at www.apta.org/reimbursement. This section includes the newly-developed Workers’ Compensation State Resource Guide and a link to the updated workers’ compensation FAQ.

Additional resources will be added as they are developed. If you have suggestions, please feel free to send them to karenjost@apta.org.

Upcoming Audio Conferences
Please mark your calendars for APTA's Payment Policy and Advocacy Department 2010 audio conferences.

More information on topics will be released closer to the date of each conference. Registration is required and the fee includes a CD-ROM mailed after the conference. For more information, contact evanthorne@apta.org.

• March 11 - Inpatient rehabilitation
• April 8 - SNF PPS and MDS 3.0
• May 13 – Understanding and Evaluating Managed Care Contracts and Fees: the Do’s and Don’ts