Medicare Basics

How are critical access hospitals (CAHs) reimbursed?

CAHs are reimbursed via cost-based reimbursement. They are reimbursed 101% of reasonable costs. The CAH needs to report everything that was provided to the patient.

What does CMS stand for? What is the difference between Medicare and Medicaid?

CMS = Centers for Medicare and Medicaid. Medicare is the federal program run by the Department of Health and Human Services and Medicaid is managed more at the state level.

What does Medicare Program Integrity refer to?

CMS defined program integrity as "pay it right." Fraud & Abuse: Prevent, Detect, Report - fee-for-service providers. Medicare Part C & D FWA (Fraud, waste, and abuse)

What is national coverage determination?

CMS develops National Coverage Determinations (NCDs) to describe circumstances for Medicare coverage nationwide for a medical service, procedure, or device. NCDs are developed when the following scenarios exist: inconsistent local coverage policies, service in question represents a significant medical advance, or the service is subject of substantial controversy. Example: there was a NCD on biofeedback for treatment of urinary incontinence

When was "allowed practitioner" added to the Medicare HH services eligibility?

"Allowed practitioner" was just added this year. This was likely in response to the public health emergency. It was becoming increasingly difficult to meet the criteria of being under the care of a physician. We are seeing more and more PAs, NPs, and CNSs managing the care of Medicare patients.

What was one of the objectives of CMS?

"CMS, in collaboration with public and private partners, is transforming how we conduct business and operations, connect providers, and empower consumers and beneficiaries. We are working to build a health care delivery system that is better, smarter, and healthier - a system that delivers improved care, spends health care dollars more wisely, and one that makes our communities healthier."

What is the yearly deductible for Medicare Part A?

$1,484 for 2021. This deductible covers share of costs for the first 60 days of the Medicare-covered inpatient hospital stay. The beneficiary requires a supplemental health insurance policy to assist with payments starting at day 61.

What is the dollar threshold for Medicare Part B therapy services (PT/SLP combined)?

$2,110

Decision Tree for Section GG

06 Independent: The resident completes the activity - with or without assistive devices - by him/herself and with no assistance (physical, verbal/nonverbal cueing, setup/cleanup) 05 Setup/Clean-Up Assistance: The resident needs only setup/clean-up assistance from one helper 04 Supervision/Touching Assistance: the resident needs only verbal/non-verbal cueing or steadying/touching/contact guard assistance from one helper 03 Partial/Moderate Assistance: the resident needs physical assistance - for example lifting or trunk support - from one helper with the helper providing less than half of the effort 02 Substantial/Maximal Assistance: the resident needs physical assistance - for example lifting or trunk support - from one helper with the helper providing more than half of the effort 01 Dependent: the helper provides all the effort to complete the activity OR the assistance of 2 ore more helpers is required to complete the activity Within Section GG, you score this on a variety of items.

What are the three aims of the CMS Quality Strategy?

1. Better Care: Improve the overall quality of care by making healthcare more person-centered, reliable, accessible, and safe. 2. Healthier People, Healthier Communities: Improve the health of Americans by supporting proven interventions to address behavioral, social, and environmental determinants of health, and deliver higher-quality care. 3. Smarter Spending: Reduce the cost of quality healthcare for individuals, families, employers, government, and communities.

What are the six priorities of the CMS Quality Strategy?

1. Make Care Safer by Reducing Harm Caused in the Delivery of Care 2. Strengthen Person and Family Engagement as Partners in Their Care 3. Promote Effective Communication and Coordination of Care 4. Promote Effective Prevention and Treatment of Chronic Disease 5. Work with Communities to Promote Best Practices of Healthy Living 6. Make Care Affordable

Discuss the timeline of the 2021 Merit-Based Incentive Payment System

2021 performance year: the performance year opens January 1, 2021 and closes December 31, 2021. During this time, clinicians care for patients and record data during the year. 2022 data submission year: data submission opens January 4, 2022. The deadline for submitting data is March 31, 2022. Clinicians are encouraged to submit data early. 2022 feedback: CMS provides performance feedback after the data s submitted. Clinicians will receive feedback before the start of the payment year. 2023 payment adjustment year: MIPS payment adjustments are prospectively applied to each claim beginning January 1, 2023. Note: even though this is information that Medicare is requesting, you are sending them information on ALL of your patients - not just data on Medicare patients. The (potentially) positive payment adjustment does not take effect until two years after beginning the MIPS process (i.e. if you started MIPS in 2021, you would not see a payment adjustment until 2023. It is not always a positive payment adjustment - it might be neutral or negative.

Who was the CMS Administrator under the Trump Administration and when did she resign?

Seema Verma - she resigned on January 15, 2021.

What are the three SNF prospective payment system (PPS) assessments?

A 5-day assessment, interim payment assessment (optional, completed when clinical change occurs), and discharge

What does comorbidity adjustment refer to when considering the home health resource group?

A comorbidity is a medical condition coexisting in addition to the principal/primary diagnosis. An individual may be classified as none, low, or high. None: no adjustment/no other diagnosis Low: 1 additional diagnosis in one of 13 comorbidity subgroups High: 2 or more diagnoses from one of 31 comorbidity subgroups

What is a critical access hospital (CAH)?

A critical access hospital (CAH) is a short-term care hospital located in a rural area with limited inpatient and outpatient services. These hospitals do not exceed 25 beds and those beds are also used for a swing-bed program.

What is a home health agency (HHA)?

A home health agency refers to skilled nursing and/or therapy services provided to patients who are homebound.

What is the grouper tool?

A lot of home health software systems complete this automatically. Using the grouper tool, we can select what the timing was: early or late? If first 30 days, this is classified as early. We can select the admission source (institutional/community). The primary diagnosis in this case is Parkinson's disease which has a diagnosis code of G20. This automatically says you are in a neuro clinical group. You can add in all sorts of secondary diagnoses (i.e. cerebral atherosclerosis, kidney disease, HTN, etc.) but may only get credit for a few of them (the ones that meet one of the comorbidity subgroups).

How do patients pay for Medicare Part B? How much does Medicare Part B cover?

A majority of patients have Medicare Part B benefits, but it is possible to run into patients who only have Medicare Part A. Generally, the monthly premium for Medicare Part B is taken out of the patient's SS check. If the monthly premium is not taken out of the SS check, the patient is billed quarterly for the premium. Medicare only pays a certain percentage in the outpatient setting. They pay 80% and the patient either pays out-of-pocket or has a secondary/supplemental insurance that picks up the remaining 20%. It is important to let the patient know that they will be responsible for paying the remaining 20% if they do not have secondary insurance in addition to Medicare Part B.

What are some important considerations when using Section GG to define score of function?

Accurate assessment and coding is vitally important in the new reimbursement model. Section GG is scored based on the resident's usual performance on days 1 through 3 of the SNF stay. This assessment should be completed prior to treatment interventions to get a true indication of the patient's baseline performance. If the patient is scored better than they actually were, this decreases reimbursement.

Describe Acute Care Hospitals (ACHs) under Medicare Part A coverage

Acute care hospitals (ACHs) refer to short-term inpatient care. Requires 2-midnight stay to qualify for Part A payment.

How is an acute care hospital reimbursed?

Acute care hospitals are reimbursed based on the inpatient prospective payment system (IPPS). This is a per-discharge or per-case basis. At discharge, the individual is assigned to a Medicare Severity Diagnosis Related Group (MS-DRG). This is a lump sum of money to treat an individual because he/she came in with a particular condition. For example, diabetes has its own MS-DRG

What is an Advance Beneficiary Notice (ABN)?

Advanced Beneficiary Notices (ABNs) are used for beneficiaries in Original Medicare. The ABN conveys that Medicare is not likely to provide coverage for an item/service.

When is an ABN issued?

An ABN is issued when one of the following occurs: Medicare is expected to deny payment for an item/service because it is not reasonable/necessary under Medicare program standards; Medicare considers care to be custodial care; HH services requirements are not met (i.e. patient not confined to home or does not need intermittent skilled nursing care); item/service is experimental and investigational or research only; item/service is not indicated for the current diagnosis and/or treatment

When is an ABN never required?

An ABN is never required in emergency or urgent care situations

Provide a specific example when an ABN may need to be issued in physical therapy

An ABN may need to be issued if you want to provide dry needling services to a Medicare beneficiary. There are dry needling CPT codes (20560/20561), but Medicare does not recognize dry needling as a reimbursable service. Before you provide dry needling to the patient, you need to issue the ABN to the patient and follow the advanced beneficiary notice guidelines.

What are the two quality payment programs implemented by CMS for eligible clinicians in outpatient settings?

CMS is required by law to implement a quality payment incentive program. There are two ways to participate n the Quality Payment Program: MIPS (Merit-based Incentive Payment System) - if you are a MIPS eligible clinician, you will be subjected to a performance-based payment adjustment through MIPS OR Advanced APMs (Advanced Alternative Payment Models) - if you decide to take part in an Advanced APM, you earn a Medicare incentive payment for sufficiently participating in an innovative payment model.

How can you stay tuned regarding the legislative changes in Medicare?

CMS reimbursement methodology and therapy coverage are ever evolving. What we know today might be completely revamped in 2022. CMS.gov is an excellent resource for staying up to date. There are many larger organizations that are hiring PTs to assist specifically with compliance because it continues to become more complicated/complex. It is important to stay linked into APTA throughout career/make it a priority. The APTA provides updates on legislative changes/how programs are changing. There are also software systems who have compliance people who provide webinars regarding recent changes/compliance issues.

What are the three choices a HHA has to choose from in a Review Choice Demonstration for Home Health Services?

Choice 1 = Pre-Claim Review: HHA must request pre-claim review (PCR) for all episodes. HHA can request more than one episode on a PCR request. Claims submitted without PCR will a) undergo payment review and b) receive a 25% payment reduction on all payable claims. The affirmation rate is calculated calculated every 6 months. If higher than 90%, the facility undergoes a less strict review process of spot check (i.e. MAC selects 5% of HHA claims every 6 months and MAC sends additional documentation requests/follows CMS prepayment review procedures) or selective post payment review (MAC reviews a statistically valid random sample every 6 months. The provider remains active in this choice for the duration of the demo) or the HHHA can select choice 1 again. Choice 2 = Postpayment Review: HHHA submits claims for each episode. Each claim is processed and paid per CMS procedures. MAC sends additional documentation requests and follows CMS post payment review procedures. The Approval rate is calculated every 6 months. If higher than 90%, the facility undergoes a less strict review process of spot check (i.e. MAC selects 5% of HHA claims every 6 months and MAC sends additional documentation requests/follows CMS prepayment review procedures) or selective post payment review (MAC reviews a statistically valid random sample every 6 months. The provider remains active in this choice for the duration of the demo) or the HHA can select choice 1 again. Choice 3 = Minimal Review with 25% Payment Reduction: The HHA received a 25% payment reduction on all payable claims. The claims are excluded from MAC targeted Probe and Educate reviews. Claims are not excluded from potential Recovery Audit Contractor review. The provider remains active in this choice for the duration of the demo.

What are classification groups under the Patient Driven Payment Model (PDPM)?

Classification groups refer to the clinical reason for the SNF stay - the primary diagnosis - used to assign the resident to 1 of 10 clinical categories. The 10 categories are collapsed into 5 PT/OT clinical category groups.

What does clinical grouping refer to when considering the home health resource group?

Clinical grouping is intended to reflect the primary reason for home health services. It is defined by the principal medical diagnosis.

How are mis-valued codes related to the proposed 9% cut?

It was proposed that E and M codes needed to be reimbursed better (mis-valued codes). Because of budget neutrality, elevating other codes required Medicare to decrease other codes to offset paying more for the E and M codes.

How can you check your quality payment program participation status?

Clinicians can visit the CMS.gov website and enter their 10 digit NPI number. The QPP participation tool will determine whether the clinician exceeds the low volume threshold. The QPP participation tool breaks down the low volume threshold criteria into the number of Medicare patients seen (needs to exceed 200), the amount of money that was billed (needs to exceed $90,000), and covered services for the clinician (needs to exceed 200). The tool also determines whether the clinician is eligible based on clinician type criteria, and determines whether they were enrolled in Medicare before January 1, 2021. PTs almost always qualify based on the criterion of billing over 200 professional services (each unit of a CPT code counts toward the professional service total). The PT in this example is not required to report because she did not meet all low-volume threshold criteria, but she can opt in because she exceeded 200 services provided.

What are the different classifications for admission source and timing?

Community early, community late, institutional early, institutional late

What are the different types of outpatient settings?

Comprehensive Outpatient Rehabilitation Facilities (CORFs), Outpatient Rehabilitation Facilities (ORFs), Private Practice Clinics, and Rural Health Clinics

What is a comprehensive outpatient rehabilitation facility (CORF)?

Coordinated outpatient diagnostic, therapeutic, and restorative services at a single fixed location. OT, PT, and SLP may be provided at an off-site location. At minimum, there are physician services, PT, and social or psychological services.

To be considered a critical access hospital (CAH), what does the average acute care inpatient length of stay need to be?

The CAH must report an annual average acute care inpatient length of stay of 96 hours or less.

What is the Anti-Kickback Statute (AKS)?

Crime to knowingly and willfully offer, pay, solicit, or receive remuneration directly or indirectly to include or reward patient referrals or generation of business involving any item/service. Example: provider receives cash or below-fair-market value rent for medical office space in exchange for referrals.

What are the advanced beneficiary notice guidelines?

Deliver the ABN before providing the item/service, verbally review the ABN with the patient and/or representative, answer any questions before the patient and/or representative signs, provide a copy of the ABN to the patient and/or representative, maintain an original copy of the ABN notice on file in the patient's medical records

How does Telemedicine coverage continue to change?

During the length of the public health emergency, PTs/OTs/SLPs were able to provide Telehealth to Medicare patients, but normally PTs/OTs/SLPs are not considered "eligible clinicians." Approved providers include: physicians, nurse practitioners, physician assistances, nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists/social workers, and registered dietitians and nutrition professionals. It will require legislative action for OTs/PTs/SLPs to be included as eligible practitioners to provide Telehealth to Medicare patients once the exception due to the PHE is lifted. It will require congressional action since Medicare is a federal program. There are some private insurances (i.e., BCBS and UH) that have adjusted their medical policies to include therapist in permanent Telehealth provisions. We do not currently have this for Medicare beneficiaries.

How is clinical group related to the primary reason for home health encounter?

Each clinical group is associated with a primary reason for the home health encounter. Musculoskeletal rehabilitation and neuro/stroke rehabilitation are the two clinical groups that have therapy (PT/OT/SLP) listed as the primary reason for the home health encounter. Other clinical groupings may have other primary reasons, but therapy is still frequently needed for these clinical groupings. Example: Behavioral healthcare is mostly related to psychiatric care/substances abuse, but there still could be a need for physical therapy.

What are Medicare Final Rules?

Each year, Medicare submits final rules. Within the rules, they publish any changes for acute care hospitals (i.e. SNFs final rule). For outpatient facilities, they have a physician fee schedule final rule. In 2020, Medicare put out final rules that completely changed the reimbursement models for skilled nursing facilities and home health agencies.

What does timing refer to when considering the home health resource group?

Early and late are defined as the first and second/subsequent 30 day billing periods. Any start of HH within 60 days of previous admit will be a late period (ex. a patient who improved, was discharged, and 45 days later had an accident occur and now needs HH for more rehabilitation. The patient is considered late admission because it has not been 60 days beyond the last time they were seen). Every late 30-day period will also be community admit source. Second 30 days in home is scored as community late. Home Health agencies discretion regarding whether to discharge patient when hospitalized for short term during episode of care. Things can get complicated if a patient who had a total knee replacement contracts pneumonia and has to go to the hospital - the HH agency can decide whether it is appropriate to discharge and readmit or to keep care open and have the patient come back under the same episode.

What does earning 40 credits through payroll taxes guarantee?

Earning 40 credits through payroll taxes guarantees that the individual will not have to pay premiums for Part A benefits.

Who will be the CMS administrator under the Biden administration?

Elizabeth Richter is the interim administrator. Chiquita Brooks-LaSure and Mandy Cohen are currently the leading candidates for CMS administrator.

What is the grouper tool cont.?

Eventually, you are given a function score (five character score/code). There are 432 options for this home health resource group (HHRG). You will also receive a case-mix weight, which in this case was 1.68. This is similar to what was seen in SNF reimbursement - there was a per diem base rate in the SNF. In HH, there is a base 30-day reimbursement. We take this base 30-day reimbursement and multiply it by 1.68 to determine how much more you will be reimbursed based on the complexity of the patient. Does this limit complexity? Debatable. But at least there is a clearer picture of how the patients present.

True or false: by the time you reach retirement age, you get free insurance.

FALSE. The general population thinks insurance is free by the time they reach retirement age. In reality, people pay into the system for years of their working life and have to pay premiums for additional benefits. The premiums are based off of how taxes are filed (individual or married). The higher the taxable income, the higher the monthly premium. Some people of retirement age do not even realize that the premium is pulled out of the SS check even though they opted into this. They often do not realize what is occurring to allow them to receive these benefits.

What are the fraud and abuse laws?

False Claims Act (FC), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark Law), the Social Security Act, and the Criminal Code

Provide a specific example of MS-DRGs

For major joint replacement or reattachment of LE, the MS-DRG code is 469/470. For hip replacement with principal diagnosis of hip fracture, the MS-DRG code is 521/522. This code used to be lumped together with joint replacements but was added as a distinct code this year.

What is PT and OT functional score based on under Section GG?

Functional Score for both PT and OT is based upon 10 indicators under section GG. All six areas are scored with total sum representing Functional Score. The Functional Score is one component that goes into the per diem rate.

What does functional impairment level refer to when considering the home health resource group?

Functional impairment is classified as low, medium, or high. It is based on responses to the 8 OASIS items. Impairment level scores vary depending on the primary reason (primary clinical grouping). The OASIS is score is classified in a variety of ways based on the clinical grouping.

Describe the thresholds for functional levels by clinical group

Functional level group can be classified as low, medium, or high. How an individual's score on the OASIS correlates to his/her functional level is not consistent across the different clinical groups. For example, if an individual scores a 40 in behavioral group, this is considered medium functional level. In other clinical groups, such as neuro, a 40 is considered low functional level. Based on the OASIS score, the functional level is classified differently depending on the patient's primary clinical group. This adds another level of complexity to how all of this information is scored.

What was the goal of the IMPACT Act?

Goal of establishing payment rates according to individual characteristics of the patient, not care setting.

What is HCAPS?

HCAPS (H-caps) stands for Hospital Consumer Assessment of Healthcare Providers and Systems. It is a value-based incentive payment system that evaluates how well ACHs perform on quality measures and how much the ACH improves during a baseline period. HCAPS is a national, standardized patient feedback survey that is given to a random sample of recently discharged patients. The data set includes 10 measures of patients' perspectives of care. Medicare incentivizes better HCAPS scores by increasing reimbursement.

What is HH Review Choice Demonstration?

HH Review Choice Demonstration refers to 3-choice (pre-claim review, post payment review, or minimal review with 25% payment reduction) selection for review of home health claims. This began with Illinois in April 2019, then Ohio started a program in August 2019, and the remaining states of Texas, North Carolina, and Florida started a program in 2020. They chose these states because there is a high percentage of Medicare beneficiaries in these states (i.e., a lot of people retire here).

Historically, how did Medicare pay for SNF services?

Historically, Medicare paid for SNF services through prospective payment system with per diem payments. Now, physical therapists can make sure the facility is capturing an accurate picture of the patient which turns into more accurate reimbursement for caring for that patient.

Historically, how did Medicare pay for home health services?

Historically, Medicare paid for home health services through prospective payment system with 60 day episodic payments. (this has now been broken down into two 30 day time periods)

How long are hospice services available to eligible patients?

Hospice services are available for two 90-day periods and an unlimited number of subsequent 60-day periods. This covers therapy for palliative care. Providers are reimbursed by a per diem payment rate.

What is the IMPACT Act?

IMPACT stands for Improving Medicare Post-Acute Care Transformation Act. This bipartisan bill was passed on September 18, 2014 and signed into law by President Obama on October 6, 2014.

Provide an example of how the value of certain CPT codes might differ from state to state

In NC, the rate for 97110 is $24.23 for one unit. In Iowa, it is a few cents less. Medicare looks at cost of living, wage index, and other factors in each state. This is why there are slight adjustments for particular CPT codes and how they are reimbursed.

How would a SNF utilize CPT codes differently if they were billing for Part A or Part B?

If a SNF was providing post-acute care services, the SNF would be reimbursed via the PDPM. Therapists only use CPT codes to describe what they did with the patient (but they are not paid based on the CPT codes). If delivering outpatient services in a SNF, the therapist would describe everything that was done and for how long using CPT codes, and that is also how they would be reimbursed. Anytime you are billing outpatient therapy to Medicare Part B, you are reimbursed using CPT codes (no matter the setting - might even be home health). If in hospital providing acute care, then reimbursed via MS-DRG (primary diagnosis). If in SNF and Part A, then PDPM for reimbursement. If in HHA using Part A, then reimbursed off of PDPGM (complex five-digit code).

What is the rule regarding a Medicare beneficiary who requires HH occupational therapy?

If a patient is receiving HH services and they need OT, OT cannot stand alone when the patient is first admitted into HH. The patient either needs PT and OT, PT/OT/SLP, or SLP and OT. When a patient is first admitted, there has to also be a PT/SLP need for OT to come in. A PT can evaluate the patient and determine that it is okay to discharge PT, and OT can continue to see the patient. However, OT cannot initiate.

What issues might an outpatient physical therapist run into when treating patients who are receiving HH services?

If a patient is receiving HH services under Medicare Part A, an outpatient PT cannot treat that patient and expect reimbursement for his/her outpatient services under Medicare Part B. Even if the patient is only receiving nursing in the HH setting - if the patient is under a HH episode, Medicare will not pay for outpatient therapy/other outpatient services. If a patient is considered homebound, they should not be coming to outpatient therapy. The patient needs to be discharged from the home health care episode. The outpatient PT should asked for signed discharged paperwork before continuing care in the outpatient setting.

PDPM Resources - Items that Contribute to Determination of Each Component

If a patient's primary reason for going to a SNF is for therapy, then look at OT and PT. There is a daily reimbursement rate that is determined in these categories. For the first 20 days, the reimbursement is the same each day. The reimbursement is based on the individual patient characteristics. When day 21 comes, the established payment rate goes down 2% per week.

If an individual/group/entity is not required to report to MIPS, can they still opt in to report?

If an individual/group/entity meets all three of the low-volume threshold criteria, they are required to report to MIPS. Medicare allows clinicians, groups, and APM entities who exceed 1 or 2 of these thresholds to opt-in to MIPS eligibility and participation.

What is does Targeted Probe & Educate refer to?

If chosen for this program, you will receive a letter from your Medicare Administrative Contractor (MAC). The MAC will review 20-40 of your claims and supporting medical records. If you are found to be compliant, you will not be reviewed again for at least 1 year on the selected topic. If some of your claims are denied, you will be invited to a one-on-one education session. You will be given at least a 45-day period to make changes and improve, and then the MAC will review 20-40 of your claims and supporting medical records to determine if you are now compliant, or if some of your claims are still denied.

Example of a Medicare ABN

If you were going to perform dry needling, you would state that you are going to provide dry needling to certain muscle groups. Medicare does not pay for dry needling because it is a non-covered service. The ABN will include the estimated cost (i.e., based on dry needling these 3 muscle groups, the charge is estimated at $70/visit). The patient signs the ABN once they understand what it is saying. The patient only needs to sign the ABN once and then you can provide dry needling as often as you see medically necessary and the patient understands that they will have to pay out of pocket for the service.

Discuss Medicare Outpatient Therapy Spending

In 2017, Medicare spent 8 billion dollars on outpatient therapy - this is an increase of 6% from 2016. Physical therapy services accounted for 72% of Medicare outpatient spending while OT and SLP services accounted for 20% and 8%, respectively. Note: it is possible for a SNF to provide outpatient therapy services (not always associated with Medicare Part A).

What are the PT and OT Case-Mix Classification Groups?

In general, higher Function Score equates to higher CMI (case-mix index) classification for PT and OT. The reimbursement is higher for residents who are more independent because they will likely be discharged sooner. The residents who are more dependent require a longer length of stay, so Medicare reduces payment per day since they have to reimburse for more days.

What are the 2021 Per Diem Unadjusted Rates?

In urban and rural SNFs, the per diem rate starts at $62 and $70.72, respectively. The case-mix index boosts the value of the original rate. If an individual needs PT, OT, and SLP, we add all of those daily rates.

What happens if an individual or group exceeds the low volume threshold (i.e billing > $90,000, Medicare patients > 200, and services > 200) but fails to report to MIPS?

Individuals/groups who are required to report to MIPS but fail to do so are subject to a full downward penalty of -9% in Medicare reimbursement in two years (i.e., failed to report in 2021, then subject to payment cut in 2023). This 9% cut is completely separate from the 9% cut that was proposed by CMS due to budget neutrality issues. There is a very small portion of therapists who are required to report (less than 10-20%).

What is an inpatient rehabilitation facility (IRF)?

Inpatient rehabilitation facilities (IRFs) are comprehensive coordinated medically based programs in specialized hospital settings. Patients in inpatient rehabilitation facilities require 24-hour nursing care. There is intensive rehabilitation therapy including, PT, OT, and ST - the therapy needs to be appropriate for the patient and the patient needs to be able to tolerate 3 ours of therapy per day.

What are inpatient rehabilitation facilities (IRFs) required to report?

Inpatient rehabilitation facilities (IRFs) are required to report quality indicators (no longer FIMs). The quality indicators are captured during the first 3 days of admission and the last 3 days before discharge. There may be interim scores during PT treatment sessions. In IRFs, physical therapists contribute more to quality indicators that can help the facility with its reimbursement structure.

What is included under hospital coverage for Medicare Part A?

Inpatient/acute hospital care, surgery, skilled nursing services (i.e. SNFs), laboratory tests, home health visits, and hospice services

What does admission source refer to when considering the home health resource group?

Institutional: acute or post-acute in 14 days prior to HH admission Community: no stay within the prior 14 days.

What are the various Medicare Part A/B jurisdictions?

Iowa works with WPS (Wisconsin physician services) - this is the Medicare Administrative Contractor (MAC) that we work with; the MAC helps manage all of the Medicare claims on Medicare's behalf. If you go to Washington, North Dakota, or Idaho, Noridian is the MAC. In the East Coast, Palmetto or Novitas serve as the MACs. Each of these have different local coverage determinations (LCDs).

What is fraud?

Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain Federal health care payment for which no entitlement otherwise exists. Knowingly soliciting, receiving, offering or paying remuneration to induce or reward referrals for items/services reimbursed by Federal health care programs.

What are the different levels for appealing Medicare decisions?

Level 1: Redetermination by a Medicare Administrative Contractor (MAC). For example, say WPS reviewed 30 claims and said that 5 of them were incorrect and were denied reimbursement. You can go through a level 1 appeal to say that you think you did bill correctly or that the service was medically necessary and why. Level 2: Reconsideration by a Qualified Independent Contractor (QIC). If WPS still stands by their decision after your level 1 appeal, you can go through a level 2 appeal so the claims are reviewed by an independent contractor within the Medicare system that is not affiliated with the MAC. The QIC may say that you billed correctly/your services were medically necessary and you will receive the appropriate reimbursement. Alternatively, the QIC will agree with the MAC that the claims should not be reimbursed. If you are still denied, there are three more levels you can go through for appeals. However, there a certain dollar amounts required to for level 4/5 appeals (a denied claims hat is only worth $100 will not meet the dollar amount criteria to get all the way to the U.S. District Court. As PTs, we generally only reach level 2 appeals. Level 3: Decision by Office of Medicare Hearings and Appeals (OMHA) Level 4: Reviewed by the Medicare Appeals Council (Council) Level 5: Judicial review in U.S. District Court

What were the goals of the Patient-Driven Payment Model?

Limit complexity of the new payment system, address concerns related to therapy utilization, and maintain simplicity by decreasing reassessments

What is local coverage determination (LCD)?

Local coverage determination refers to the decision by the Medicare Administrative Contractor (MAC) on whether an item/service is reasonable, necessary, and covered by Medicare. MACs develop LCDs when there is no NCD or when there is a need to further define the NCD for a specific region. LCDs provide guidance regarding: which services are covered and reimbursable, how to properly code for reimbursement, documentation requirements, utilization guidelines, and diagnosis codes that support or do not support medical necessity

What is a long-term care hospital (LTCH)?

Long-term care hospitals provided extended medical and rehabilitative care to patients with clinically complex problems (i.e. TBI, spinal cord injury, severe stroke, post-MVA, etc.). These patients have a need for hospital-level care for relatively extended periods of time. There are only 436 long-term care hospitals that were recognized by Medicare in 2011.

Who is required to submit information for the IMPACT Act?

Long-term care hospitals: Long-Term Care Hospital CARE Data Set (LCDS) Inpatient rehabilitation facilities: IP Rehab Facility Patient Assessment Instrument (IRF-PAI) Skilled nursing facilities: Minimum Data Set (MDS) Home health agencies: OASIS Hospice: Hospice Quality Reporting System (HQRS) Although these all have different names, they provide very similar information.

Discuss the rules associated with use of therapy students under Medicare Part C

Medicare Advantage plans must follow Medicare rules. Thus, if the patient is in an outpatient setting, the rules for Medicare Part B should be followed. If the patient is in an acute care setting, the rules for Medicare Part A should be followed.

Discuss the MIPS eligibility factors (MIPS eligible clinician types, low volume threshold, and other exclusions)

MIPS eligible clinician types: physician, osteopathic practitioner, chiropractor, physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, physical therapist, occupational therapist, clinical psychologist, qualified speech language pathologist, qualified audiologist, registered dietician or nutrition professional (PT/OT/SLP were not included until 2019). Low volume threshold: you exceed the low-volume threshold and are a MIPS eligible clinician if you: bill more than $90,000 in Part B covered professional services, AND see more than 200 Part B patients, AND provide more than 200 covered professional services to Part B patients (Medicare evaluates individuals, groups, and APM entities on the low-volume threshold) Other exclusions: you are excluded from MIPS if you: enrolled in Medicare on or after January 1, 2020, or if you are a Qualifying APM participant

What is the impact of quality payment programs on private practice PTs?

Measures attributed at provider/practice level (facility based PTs contributed to quality score in addition to other staff/healthcare professionals) Measures focused on impact of PT services (not considering services provided by other healthcare professionals) Process measures Outcome measures (how much the patient improved based on PT services provided)

What is the impact of quality payment programs on facility-based PTs?

Measures attributed to facility (i.e. ACH, SNF, LTCH, HHA) - looking at the quality programs attributed to the facility (overall as a hospital, are the services provided high quality? anything you do well or not well is equated to the facility). Measures often measure the combined efforts of staff (i.e. HCAPS) - HCAPS encompasses a variety of healthcare professionals and even cleaning crews when considering the overall quality of the hospital (how well did nurses/doctors communicate, was the bathroom clean, etc.) PTs should understand how they impact these measures. Readmissions, falls, functional change (these are the things that facilities are trying to prevent - this is how PTs contribute to the quality score of the facility)

What constitutes group therapy for Medicare Part A, Part B, and all other payers?

Medicare Part A (acute): treatment of 2-6 residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals. Recall that group therapy for a SNF patient cannot exceed 25% of total time spent with the patient. Medicare Part B (outpatient): the treatment of two or more patients, regardless of payer source, at the same time. This might occur if the PT had to overlap two patients (i.e., seeing Mrs. Smith and Mr. Jones at the same time - Mr. Jones has Medicare, so you need to bill each patient one unit of group therapy (even if Mrs. Smith does not have Medicare). All other payers: follow Medicare Part A descriptor unless otherwise directed per payer policy. Some do not recognize group therapy as being allowed. So if Mrs. Smith has BCBS and it does not allow group therapy, you can not overlap her appointment with Mr. Jones who has Medicare because this would require you to bill group therapy to each patient.

What is Medicare Part C?

Medicare Part C refers to Advantage Plans. Advantage plans take the place of Original Medicare and allows for enrollment in a private health plan (e.g. PPO or HMO). Advantage plans include all parts of Medicare A and B plus extra benefits such as dental and vision. The beneficiary is responsible for paying a monthly premium affiliated with the private insurance company. The insurance company has to comply with all the original Medicare rules and regulations and provide everything that Medicare would have. The therapist bills directly to the BCBS Medicare Advantage Plan (it is under the larger umbrella of BCBS). You may see a United Healthcare Medicare Advantage plan, BCBS Medicare Advantage Plan, etc. Medical Advantage Plans have all the same coverage of Medicare plus some supplemental services such as vision and dental (may also have better prescription drug coverage). Note: starting to see trend toward Medicare Advantage Plans requiring prior authorization before seeing patients which does not occur with Original Medicare. You would need to submit a prior authorization submitting why the patient requires therapy/what the diagnosis is and the advantage plan may authorize 12 visits, for example.

What is Medicare Part D?

Medicare Part D provides prescription drug coverage (outpatient prescription drugs). Medicare Part D is available in standalone plans or as part of a Medicare Advantage Plan.

What was the issue regarding Medicare's reimbursement for maintenance therapy?

Medicare claimed that they did not have an improvement standard (e.g. only reimbursing therapy that improved the condition). However, Medicare was denying claims for a patient who had Parkinson's disease. PD is a degenerative disease, so the patient was receiving therapy to assist with preventing functional decline rather than working on improving the condition. Medicare said that they never had an improvement standard, but they now recognize maintenance therapy as skilled therapy that should be reimbursed. Although Medicare covers maintenance therapy, it is not commonly a covered benefit in Medicaid or other commercial insurances.

When was Medicare coverage expanded? Who was it expanded to?

Medicare coverage was expanded in 1972 to cover individuals under age 65 with long-term disabilities and people with ESRD.

When does Medicare Cover HH services?

Medicare covers HH services when the following criteria are met: eligible medicare beneficiary, HH agency has a valid agreement to participate in the Medicare program, and the Medicare beneficiary must meet homebound status: confined to home, under care of physician or allowed practitioner (PA, NP, CNS), receiving services under established POC and periodically reviewed by physician or allowed practitioner, requires skilled nursing care on intermittent basis or PT/SLP, have continuing need for OT.

When does Medicare cover hospice services?

Medicare covers hospice services when the following criteria are met: the patient is entitled to Medicare Part A benefits and the patient is certified as being terminally ill (life expectancy of 6 months or less)

Discuss the future of Medicare Program Integrity

Medicare is developing a five-pillar program integrity strategy: stopping bad actors, fraud prevention, tracking "new and emerging" risks, ease provider burdens, and take advantage of new technology

What might result from a targeted medical review?

Medicare might say the therapist's documentation looks great and then no money is owed. Or, Medicare may determine that after the 25th visit, it was not medically necessary to continue seeing the patient and they will not pay the additional 5 visits (assuming the therapist billed for 30 visits) and you owe them a certain dollar amount (i.e. $2,000). Then, Medicare will withhold this dollar amount from any future claims submitted to Medicare.

How has the reimbursement of home health (HH) services changed?

Medicare now utilizes the Patient-Driven Groupings Model (PDGM) to reimburse home health services. Patient characteristics are the driving factor of reimbursement.

What are the different types of improper payments?

Mistakes: result in errors - such as incorrect coding. Inefficiencies: result in waste - such as ordering excessive diagnostic tests Bending the rules: results in abuse - such as improper billing practices (like up-coding) - using manual therapy CPT code because you know it bills more when you actually provided neuromuscular reeducation Intentional deceptions: results in fraud - such as billing for services or supplies that were not provided (billing services to Medicare when you never actually saw any patients)

What are the various HH and Hospice MAC jurisdictions?

NGS, CGs, and Palmetto

What are the 10 measurements of patients' perspectives of care that are used in the HCAPS survey?

Nurses communicate well Doctors communicate well Received help as soon as they wanted (responsive) Pain well controlled Staff explain medicines before giving to patients Room and bathroom are clean Area around room is quiet at night Given information about what to do during recovery at home Overall hospital rating Recommend hospital to friends and family

Describe the history of Medicare

On July 30, 1965, President Lyndon Johnson signed law that lead to both Medicare and Medicaid programs. This was a federal health care plan for the poor - seniors were the population most likely to be living in poverty. The federal agency became The Centers for Medicare and Medicaid Services (CMS).

How is it possible for HH services to be covered under Medicare Part B?

On rare occasions, it is possible to exhaust HH benefits under Medicare Part A. This might occur if there is a significant medical incident that requires extensive healthcare. If a patient has exhausted their HH benefits under Medicare Part A but still requires HH visits, they can be transferred to Medicare Part B. If HH services are reimbursed under Medicare Part B, the reimbursement is based off of CPT codes rather than the Patient-Driven Groupings Model.

What is an outpatient rehabilitation facility (ORF)?

Outpatient rehabilitation facilities provide coverage of therapy services only. There are no physician or psychosocial services provided.

Discuss the difference in threshold values between OT/PT/SLP

PT/SLP are lumped together for the therapy threshold value. So if a patient is receiving speech therapy, the reimbursement for those services contribute to the threshold for physical therapy as well. OT has its own therapy threshold of $2,110, so occupational therapists do not need to consider the other disciplines when determining how close a patient is to the therapy threshold.

Discuss transitioning a patient from rehab therapy to maintenance therapy

PTs need to discharge patients when it is medically appropriate to do so. Some patients will require transition from rehabilitative therapy to maintenance therapy program because the PT needs to follow up with the patient in one month to make sure the patient has not lost the progress that was made in rehabilitative therapy. Medicare states that the PT needs to use his/her professional judgment and they understand that there are times when maintenance therapy is necessary. Maintenance therapy is not meant to be provided at the same frequency as rehabilitative therapy, however, Under the maintenance therapy program, the PT will see the patient once every other week or once a month to reassess/reevaluate and make sure the patient is maintaining and not digressing. It is possible for a patient to require a switch back to rehabilitative therapy after being transitioned to maintenance therapy if the PT notices significant declines in the patient's function. The PT just needs to state why the patient is being transitioned back onto the rehabilitative therapy program (state which declines you noted in documentation/how they are affecting patient function). The patient can be switched back to the maintenance therapy program again once they reach their baseline level they had previously attained.

What are the four parts to Medicare? What is included in each part?

Part A: inpatient hospital care, skilled nursing services, hospice care (acute care) Part B: doctor's visits, outpatient hospital services, durable medical equipment, physician administered drugs Part C: Medicare advantage plans, which combine parts A & B; may cover vision, dental and hearing (many people are starting to opt into this - even big commercial insurance companies are opting into Medicare advantage plans) Part D: prescription drug coverage

How are inpatient rehabilitation facilities (IRFs) different from long-term care hospitals?

Patients in long-term care hospitals might receive some therapy, but it is not the primary focus. The patients still have enough medical complexities going on that they need a variety of clinicians. In an inpatient rehabilitation facility, the focus is on rehabilitation.

What is included in medical coverage under Medicare Part B? How are providers reimbursed under Medicare Part B?

Physician visits, outpatient services (including OT, PT, and SLP), preventative services, and some home health services. Providers are reimbursed using the Medicare Physician Fee Schedule (PFS) and HCPCS/CPT codes.

What is abuse?

Practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care. Example: continuing to see the patient when it is not medically necessary - you knew 10 visits ago that the patient was independent with the HEP, but you continue to see them and bill Medicare for your services.

When does Medicare auditing occur?

Providers to Medicare beneficiaries should be prepared for audits at any time. However, audits are generally only conducted for those whose data sticks out from their peers' data. For example, if a therapist consistently bills more than $3,000 for each patient, they will likely be targeted for a targeted medical review.

What is the difference between rehabilitative therapy and maintenance therapy?

Rehabilitative therapy is skilled therapy to improve the patient's current condition. Maintenance therapy is skilled therapy to maintain the patient's current condition or prevent/slow further deterioration of the patient's condition.

How might per diem adjustments affect SNF behavior?

Reimbursement may dictate behavior - we may see SNFs trending toward discharging a majority of patients before day 20 to avoid decreased reimbursement. The hope is that SNFs will consider what is best for the individual patient rather than basing decisions on reimbursement. Medicare will look at this data to determine if this trend has developed.

What does the future of the Quality Payment Program look like?

Right now, the QPP refers to MIPS. Medicare is looking into a "MIPS Value Pathway." There might be a PT specific value pathway that PTs report on that would make more sense to PTs. There might also be pathways that are directed more toward OT/SLP. They will still incorporate the four components of quality, promoting interoperability, improvement activities, and cost, but they will be presented in an manner that promotes more overlap of each component.

What are the issues associated with speech therapy and SNF reimbursement?

SLP reimbursement is very low, so the addition of SLP can be difficult for SNFs because this does not allow them to break even with what they are paying the speech therapist. For this reason, the SNF may utilize OT for cognition instead of a SLP. For conditions such as swallowing dysphagia, SLP is required. Although SLPs are paid a good hourly rate, the reimbursement for their services is poor in SNFs.

What is functional scoring in Section GG?

Section GG items are translated to functional score. Higher points are assigned to higher levels of independence.

Describe the transition from acute care to post-acute care

Short term/acute care in a hospital (ACH or CAH) and the patient may be transitioned to post-acute care (long-term acute care hospital, inpatient rehabilitation facility, or skilled nursing facility).

What were the fiscal year 2021 hospice payment rates?

Similar to the other settings, hospice providers can receive increased reimbursement based off of quality data. Continuous home care reimbursement is so high because that patient requires around the clock care.

What are skilled nursing facilities (SNFs)?

Skilled nursing facilities focus on patients requiring nursing and therapy services following a 3-day or longer stay in a general acute-care hospital. The patient health problems are too severe or complicated for home care or assisted living. Note: there have been some exceptions to the 3-day rule during the public health emergency (but this exception will not likely remain).

What Quality Measure Domains are assessed by Medicare for the post-acute care settings? What is the goal of these quality measure domains?

Skin integrity and changes in skin integrity Functional status, cognitive function and changes in function and cognitive function Medication reconciliation Incidence of major falls Transfer of health information and care preferences when an individual transitions Resource use measures Medicare spending per beneficiary Discharge to community All-condition risk-adjusted potentially preventable hospital readmission rates If patients are cared for more holistically in PAC settings, this saves Medicare money by reducing the likelihood that the patient is readmitted to the hospital.

What is Section GG of the MDS (Minimum Data Set)?

The CMS Manual for Resident Assessment Instrument (RAI) provides instruction for scoring the Minimum Data Set (MDS). Under RUG-IV, Section G used to define score of function. Under PDPM, Section GG is used to define score of function.

Who is the CMS Administrator appointed by?

The CMS administrator is appointed by the President of the United States.

What are the responsibilities of the CMS administrator?

The CMS administrator oversees $1 trillion budget, which is 26% of the total federal budget. Responsibilities include directing planning, coordination, and implementation of programs; overseeing establishment of program goals and objectives; overseeing development of policies, standards, and guidelines; evaluating progress in administration of CMS programs; and ensuring required actions are taken to achieve program objectives

What is the CMS Quality strategy?

The CMS quality strategy includes aims to provide better, more affordable care, and priorities to guide efforts to improve health and health care quality.

What is the False Claims Act (FC)?

The False Claims Act imposes civil liability on any person who knowingly submits, or causes submission of, false or fraudulent claim(s). Example: a doctor knowing submits claims to Medicare for services not provided

How do quality payment programs differ between health care settings?

The IMPACT Act affected Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs) by standardizing the data and quality measures across the PAC setting. In the outpatient setting, the MIPS quality payment program serves as a value-based payment model.

What was the purpose of the IMPACT Act of 2014?

The IMPACT Act requires standardized patient assessment data that enables: data element uniformity, quality care and improved outcomes, comparison of quality and data across post-acute care (PAC) settings, improved discharge planning, and coordinated care. Prior to 2014, each post-acute care facility was reporting different information. This Act created more uniformity regarding the information that is provided to Medicare.

What is the MIPS potential bonus incentive?

The MIPS potential bonus incentive refers to payment adjustments for accurate reporting on Medicare Part B claims. While Medicare says you could be eligible for a 9% positive adjustment, this never happens. You could be the best reporter and do everything correctly, but you will not see the 9% elevation in payment due to budget neutrality. All of the bad reporters/those who do not do well are paying for the good reporters. If there are a ton of good reporters inputing data into the system, this will decrease the positive payment adjustment because there is less money to disperse from the bad reporters to the good reporters.

What is the 2021 Merit-Based Incentive Payment System (MIPS)?

The Merit-Based Incentive Payment System (MIPS) looks at quality of services, cost, improvement activities, and promoting interoperability. This infographic shows how the points are broken down for each category. As a PT, there are only two factors you can report on: quality and improvement activities. Thus, instead of the quality being worth 40%, it is worth 85% for PTs and the improvement activity is worth (15%) to get to the 100% MIPS final score.

What is the National Quality Strategy (NQS)?

The National Quality Strategy (NQS) was first published in March 2011 as a National Strategy for Quality Improvement in Health Care. It was led by the Agency for Healthcare Research and Quality on behalf of the U.S. Department of Human Health Services (HHS). It is updated annually in a report to congress. The report articulates the broad aims and priorities that guide development of CMS programs, regulations, and strategic plans for new initiatives. (Within the Medicare system, we started looking at what we need to do from a national strategy standpoint on improving quality within healthcare. Medicare created NQS, and NQS defines what they feel like they need to do to improve U.S. healthcare quality. This report is submitted to congress for review).

When was the Patient-Driven Groupings Model effective? What are some key factors of this model?

The PDGM was effective January 1, 2020. Some key factors include: Therapy is not the determining factor in reimbursement (PTs contribute to scoring function, but reimbursement is based more on clinical characteristics of the patient upon admission) Payment driven by patient's clinical characteristics Episode of care is 60 days with two 30-day billable units (first 30 days are usually reimbursed at a higher rate unless there is a new medical complexity that occurs during the second 30 days). Identifies 432 case-mix groups Therapy POC still requires reassessment every 30 days (PTA cannot treat that day - supervising PT has to reassess)

What is the Patient-Driven Payment Model?

The Patient-Driven Payment Model (PDPM) is the first all-new SNF Medicare reimbursement system in 20 years. SNFs used to be reimbursed based on volume of care vs. quality of care. Reimbursement structure can create incentive to change the way you practice (for good or for bad).

When was the Patient-Driven Payment Model (PDPM) initiated? What were some changes that occurred due to the new PDPM?

The Patient-Driven Payment Model was effective October 1, 2019. The PDPM replaces RUG-IV. There is patient-focus to improve appropriate, accurate payment (based on patient presentation). There is a new group therapy definition. There is section GG - methodology to determine a patient's function score.

What is the Physical Therapy Outcomes Registry?

The Physical Therapy Outcomes Registry shows what factors are being reported on for the Quality Payment Program (i.e BMI screening). The PTs have to notate that they are documenting information about the selected factors for the MIPS program (i.e. medications, pain, prevention of depression, dementia, fall risk assessment, outcome assessments, BMI, etc.). There are percentages that show the percentage of time these factors were included in documentation. Each year, Medicare sets what these percentages have to be to receive the positive payment adjustment - the PT is compared to other PTs entering data into the program.

What is the Physician Fee Schedule (PFS) final rule?

The Physician Fee Schedule (PFS) final rule updates payment policies, payment rates, and other provisions for services furnished under Medicare Physician Fee Schedule (PFS). This information is updated every year, and the new rules for the next year are submitted in October/November. The PFS final rule also adds services to the Telehealth list, updates policies affecting calculation of payment rates, and assess mis-valued codes.

What is the Physician Self-Referral Law (Stark Law)?

The Physician Self-Referral Law (Stark Law) prohibits a physician from referring patients to receive "designed health services" payable by Medicare/Medicaid to any entity with which the physician or member of the physician's immediate family has financial relationship (i.e. funneling orthopedic patients to diagnostic group for MRIs/X-rays/CT scans because there was financial incentive to do so).

What is the Social Security Act and the U.S. Criminal Code?

The Social Security Act includes Exclusion Statute and Civil Monetary Penalties Law (CMPL). The U.S. Criminal Code can come into play depending on how big of a felony has been committed.

Discuss the rules associated with use of therapy students under Medicare Part A

The amount of supervision must be appropriate to the student's level of knowledge, experience, and competence. Students who have been approved by supervising therapist/assistant to practice independently in selected patient situations can perform those selected patient services. The supervising therapist/assistant must: be physically present in the facility and immediately available to provide observation, guidance, and feedback; review, verify, and co-sign all student documentation for all levels of clinical experience; and retain full responsibility for the care of the patient.

Discuss the comprehensive assessment in a home health admission start of care

The comprehensive assessment needs to be completed within 5 days. This is a full comprehensive assessment including OASIS. This develops the plan of care.

When do long-term care hospitals qualify for Medicare payment?

The facility needs to meet Medicare's conditions of participation for acute care hospitals and there needs to be an average inpatient length of stay greater than 25 days.

How are there 432 case-mix groups?

The following factors are considered and result in one of the 432 home health resource group scores: admission source and timing (from claims), clinical grouping (from principal diagnosis reported on claim), functional impairment level (from OASIS items), and comorbidity adjustment (from secondary diagnosis reported on claims). The reimbursement is based off of the home health resource group score (HHRG)

Discuss the initial assessment in a home health admission start of care

The initial assessment must be completed within 48 hours. The assessment is focused on reducing hospitalizations (home assessment, family dynamics, etc.). The individual conducting the assessment confirms eligibility (including homebound status) is met and consent forms are signed. The admission packets are signed. A medication reconciliation/drug regimen review is completed. The initial assessment may be completed by a therapist with therapy only orders (only need therapy, no skilled nursing).

Considering the MS-DRG code, does length of patient stay impact reimbursement? How does this impact length of patient stay in ACHs?

The length of stay does not matter. ACHs are reimbursed based off of the MS-DRG. Because hospitals only receive a set amount of money for each condition, patients are spending less time in acute care hospitals. Hospitals try to move people through the system as quickly as possible. The way you are reimbursed can dictate your behavior for good or bad.

Why is maintenance therapy important for chronic/degenerative diseases?

The natural progression of diseases such as MS and PD may require periodic follow ups in therapy to maintain a baseline level of of function or to slow the deterioration associated with these naturally progressive diseases. Therapy will not likely improve their current functioning, but the patient requires skilled therapy to manage the disease progression.

Discuss the home health prospective payment system

The previous home health (HH) reimbursement model was largely determined by the episode count and number of therapy visits. The episode of care was 60 days. There were 153 HH resource groups. PTs were previously reimbursed based on the number of therapy visits: 0-13 visits, 14-19 visits, and 20+ visits. The greater volume, the higher the reimbursement. Medicare has attempted to adjust their reimbursement method to base reimbursement on patient presentation rather than number of visits.

When are SNF services covered?

The resident requires skilled nursing or skilled rehabilitation services on a daily basis. The services rendered are for the condition that required inpatient hospital services (patient had to have a 3-day or longer stay in an ACH and then has to go to SNF for the same reason - has to be primary diagnosis from one setting to the next). Skilled services defined: management and evaluation of patient care plan, observation and assessment of the patient's condition, teaching and training activities, direct skilled nursing services (provided 7 days/week), and direct skilled rehabilitation services (provided 5 days/week).

What is a swing-bed program in a CAH?

The swing-bed program is used if someone needs to have a longer-term stay (i.e. no SNF in area/not stable enough to go home or go to outpatient setting - need long term stay). The CAH can use some beds for the long-term stay. If individual cannot be discharged in less than 96 hours, the hospital will discharge the patient from the acute care stay and readmit them under the swing bed stay. Sometimes these patients do not leave the room - it is just an accounting procedure (go from acute care stay to swing bed stay). The patient will likely need more intensive rehab than they did on the acute care side.

What does the therapist need to do if they believe it is medically necessary to continue seeing the patient after the $2,110 threshold has been reached for therapy services?

The therapist must apply the KX modifier. By applying this modifier, the therapist is attesting that continued therapy service is medically necessary. Supportive justification for continued therapy is documented. By applying this modifier, Medicare will continue to reimburse the therapist for services beyond the $2,110 threshold.

What is the Value-Based Approach?

The value-based approach refers to service delivery based on contribution towards desirable and sustainable outcomes (value to the payer). The goal of the value-based approach is to reduce hospital readmissions, which saves the payer money. The value-based approach is effective (achieving desired outcomes by safely managing specific health condition(s)), efficient (prudent use of resources), and sustainable (making it likely that the results will stick)

What is a variable per diem adjustment factor?

The variable per diem (VPD) adjustment adjusts the per diem rate over the course of the stay. The longer the patient stays, the more the daily rate goes down.

What to the x's on this chart refer to?

The x's refer to how the information is reported to Medicare. The APTA outcomes registry can link into the software system in a PT clinic and pull the data directly from the documentation so there is no extra step required for PTs beyond gathering the necessary information at the time of evaluation. At the time of evaluation, the PT documents the required information and the MIPS information is transferred directly to the outcomes registry to directly provide the score.

What are the quality measures for PTs reporting to MIPS?

There are several options to choose from when deciding what to report to Medicare for the MIPS program. The reporter has to choose a minimum of 6 to report on and there has to be a minimum of 20 patients for each clinical measure to meet the criteria required by Medicare. These quality measures contribute to 85% of the final MIPS score. The 15% refers to improvement activities - over a 90-day-period, have to do something within the clinic to improve quality of care. Medicare chose these outcome measurements to choose from because they want PTs to address the patient as a whole (PTs will be considered more as a primary care provider in the future).

What are medicare reimbursement adjustments?

There is a base payment rate that Medicare sets for CPT codes. The CPT code reimbursement values can be altered via Physician Fee Schedule (PFS) adjustments including a rural add-on percentage and wage index adjustments. So, there are base payment rates for CPT codes but the values can change depending on the setting: rural (boosts the value) and different states have different values depending on a variety of factors. Medicare was going to initiate a 9% cut on reimbursement for physical therapy CPT codes due to budget neutrality requirements, but this was lowered to 2%.

What is the new rule for group therapy under the PDPM?

There is a combined limit of 25% group and concurrent therapy per discipline. For example, you have to demonstrate that across the entire stay that the patient was in the SNF, no more than 25% of that time was designated to group or concurrent therapy (concurrent therapy means working with two patients at the same time). Therapists have to account for all of their time

What is a targeted medical review?

There is a targeted medical review process for Medicare Part B therapy services that exceed a $3,000 threshold. These reviews are conducted on a post-payment basis. Claims selected for review are based on: high claims denial percentage and/or aberrant billing patterns compared to peers.

How does payment work under the Patient Directed Payment Model (PDPM)?

There is classification methodology utilizing a combination of 6 components. 5 components are case-mix adjusted based on patient characteristics. Group totals: 16 PT, 16 OT, 12 SLP, 25 nursing, 6 NTA (non-ancillary therapy services). The other component is the variable per diem (VPD) adjustment factor.

What were the driving forces of the IMPACT Act? Why was it enforced on the post-acute care settings?

There were escalating costs associated with post-acute care (PAC) and lack of data/standards/interoperability across PAC setting. Previously, there were no uniform standards, there was no sharing of information, or consistency between PAC settings.

Discuss the Outcome and Assessment Information Set (OASIS)

These are the things that the PT or OT asses for the OASIS: grooming, current ability to dress upper body safely, current ability to dress lower body safely, bathing, toilet transferring, transferring, ambulation and locomotion, and risk for hospitalization. Nursing is generally the first provider to go into the home for HH care. If nursing has looked at transfers and ambulation, PT needs to review nursing's score to make sure it is most reflective of how the patient functions. If PTs are second into the home and bathing/grooming/dressing have not been addressed, the PT will not take the individual through a bath, but will ask questions or talk with the family/caregivers to come up with a score.

Describe the WPS Local Coverage Determination (LCD) for wound care

This LCD was effective February 9, 2020. Changes include: physician order(s) for therapy/wound care services and signed plan of treatment detailing treatment modalities for therapy/wound care services must be established as soon as possible or within 30 days. Every 10 days, progress notes are required to include current wound status, measurements (including size and depth), and treatment provided. Depending on the state you practice in, you need to know who the MAC is for Medicare beneficiaries and if they have rules/guidelines specific to therapy.

What are the MIPS payment adjustments?

This chart shows the points breakdown for 2020 vs. 2021. In 2020, the reporter had to get more than 45 points total just to break even (neutral payment adjustment). This year, reporters need to get more than 60 points for a neutral payment adjustment. Anything below these point values is a negative payment adjustment and anything above is a positive payment adjustment.

Medicare at a Glance: 2021

This infographic shows the cost to Medicare patients for each Part of Medicare. If an individual hits the 40 quarter mark, there is no premium to pay for Medicare Part A. If an individual has 30 or more credits, there is a discount on what is owed for the Medicare Part A premium. If an individual has built up less than 30 quarters, he/she owes $471 for the Medicare Part A premium. Individuals who became U.S. citizens later in life or who were stay-at-home parents may have to pay the full price for Medicare Part A because they were not able to build up 30 or more quarters. Each Part of Medicare has a standard premium and deductible. Takeaway: Medicare beneficiaries are paying for this insurance.

What criteria does an individual need to meet to be eligible for Medicare at age 65 or older?

To receive full Medicare benefits at age 65 or older, and individual needs to meet the following requirements: U.S. citizen or permanent legal resident who lived in the U.S. for at least five years; and an individual or spouse has worked long enough to be eligible for SS or railroad retirement benefits (usually having earned 40 credits over 10 years of work; or individual or spouse is a government employee or retiree who has not paid SS but paid Medicare payroll taxes while working.

What criteria does an individual need to meet to be eligible for Medicare under age 65?

To receive full Medicare benefits under age 65, an individual needs to meet the following requirements: entitled to SS disability benefits for at least 24 months that need not be consecutive; or receive disability pension from Railroad Retirement board and meet certain conditions; or have Lou Gehrig's disease (ALS); or have permanent kidney failure requiring regular dialysis or kidney transplant, and individual or spouse had paid SS taxes for specified length of time depending on the person's age.

Discuss the rules associated with use of therapy students under Medicare Part B

Under the Medicare Part B benefit, only services of the licensed physical therapist can be billed and paid. The therapy student may participate in deliver of services if the licensed therapist/assistant is: directing service, making skilled judgment, responsible for assessment and treatment, and present in the room guiding the student in service delivery. The supervising therapist/assistant will NOT be engaged in treating another patient or doing other tasks at the same time. The supervising therapist/assistant is responsible for all skilled services, including review, verification, and co-signature of student documentation within the patient's medical record.

What was the recent provision of Medicare regarding PTAs and maintenance therapy?

Until this year, PTAs were not allowed to provide maintenance therapy, but assistants are now allowed to provide maintenance therapy in all settings.

What is value in health care?

Value = quality/cost = (outcomes + patient experience)/(direct costs + indirect costs) This is what we are looking at when we move toward the value-based healthcare model for reimbursement

Who is value demonstrated to?

Value is not just value to the payer. We also have to demonstrate value to our patients - i.e. making sure they feel like they are meeting their goals. In addition, a PT who is employed by an agency needs to demonstrate value to the employment agency. There is a lot of complexity when it comes to demonstrating value. We are providing value to patients, the payer, and our employment agency.

When is the targeted medical review threshold reached? What is a targeted medical review?

When the reimbursement for services provided to a patient reaches the $3,000 mark, Medicare may contact the facility to review all of the documentation for that patient. This is a post-payment review. Medicare has already paid for all the services the facility has been reimbursed for. Medicare wants to look at all of the documentation to make sure it is supporting medical necessity for the services your provided over the patient's episode of care.

Discuss the misconceptions surrounding the Patient-Driven Groupings Model

When this reimbursement model first came out, there were misconceptions that home health agencies would think they should withhold therapy. Similar to SNFs, at 21 days, reimbursement is reduced by 2% each week. There is concern that certain HH agencies may be discouraging therapy because the less services the agency provides, the less individuals they have to pay, so the HH agency pockets more money. It is not the intention of the Patient Driven Groupings Model to discharge patients after 20 days. The PDGM does not restrict utilization of skilled therapy (therapy thresholds were eliminated). CMS stated, "We disagree that PDGM diminishes or devalues the clinical importance of therapy."

Describe the evolving payment system (i.e. where we have been, where we are, and where we are going)

Where we have been: fee-for-service, some quality reporting, functional limitation reporting, and manual medical review. Where we are: now we are looking at alternative payment models (i.e. PDPM, PDGM) - looking more at the actual patient to base reimbursement off of patient complexity/outcomes (new complexity of evaluation codes). We are better about describing each individual patient's clinical presentation. Where we are going: looking more at episode payment based on meaningful outcomes. In the future, we may be reimbursed based off of a lump sum of money to rehabilitate the patient rather than basing reimbursement on each CPT code. This is what we are seeing in acute/PAC settings.

What is the grouper tool cont.?

You can input the OASIS and how it was scored for risk of hospitalization, grooming, upper/lower dressing, toiling, transferring, etc.