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Medical Rehab

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On July 31, 2019, the Centers for Medicare and Medicaid Services (CMS) released the fiscal year (FY) 2020 inpatient rehabilitation facility prospective payment system (IRF PPS) final rule. This final rule is scheduled to be published in the Federal Register on August 8, 2019.

Key provisions contained in the final rule include:

  • Motor Score Provisions: Based on feedback received with the proposed rule, CMS is adopting an unweighted motor score to assign patients to case-mix groups (CMGs), rather than the use of a weighted motor score as originally proposed. CMS also finalized as proposed the removal of GG0170A1 (roll left and right) from the motor score (leaving 18 unweighted data items).
  • CMGs, Relative Weights, & Average Length of Stay: The final rule includes three additional CMGs than were included in the proposed rule:
    • Stroke RIC (01) will have 6 CMGs, compared to 7 in the proposed rule
    • Non-traumatic spinal cord injury RIC (05) will have 5 CMGs, compared to 4 in the proposed rule
    • Replacement of lower extremity joint RIC (08) will have 5 CMGs, compared to 4 in the proposed rule
    • Rheumatoid other arthritis CMG RIC (13) will have 5 CMGs, compared to 4 in the proposed rule
    • Major multiple trauma without brain or spinal cord injury RIC (15) will have 5 CMGs, compared to 4 in the proposed rule
  • Rebasing and Revising IRF Market Basket: CMS is rebasing and revising the IRF market basket to reflect a 2016 base year and is forecasted to be 2.9 percent.
  • Clarification of “Rehabilitation Physician”: CMS is amending the regulations to clarify that the determination as to whether a physician qualifies as a rehabilitation physician (that is, a licensed physician with specialized training and experience in inpatient rehabilitation) is to be determined by the IRF, as the provider is in the best position to make that determination.
  • Ensuring Quality: CMS finalized two new quality measures to implement the final requirements of the Improving Medicare Post-Acute Transformation (IMPACT) Act. Those two measures are: 1) Transfer of Health Information (TOH) from IRF to another Provider, and 2) Transfer of Health Information (TOH) from IRF to the Patient.
  • IRF Quality Reporting Program (QRP): CMS is adopting two new quality measures that satisfy the IMPACT Act domain pertaining to the transfer of health information when a patient is transferred or discharged from the IRF to another PAC provider or the home of the individual. Specifically, both of these measures would assess whether the IRF provides a reconciled medication list at the time of transfer or discharge. They also support the CMS Meaningful Measures initiative of promoting effective communication and coordination of care, specifically the meaningful measure area of the transfer of health information and interoperability. In addition, CMS is adopting a number of standardized patient assessment data elements

(SPADEs). These SPADEs assess key domain areas including functional status, cognitive function and mental status, special services, treatments and interventions, medical conditions and comorbidities, impairments, and social determinants of health (SDOH). The addition of these SPADEs to the IRF-Patient Assessment Instrument (IRF-PAI) will improve coordination of care and enable communication between PAC providers and other members of the health care community, aligning with CMS’ strategic initiative to improve interoperability. CMS is also updating the specifications for the Discharge to Community PAC IRF QRP measure to exclude baseline nursing home residents. CMS is also finalizing their policy to no longer publish a list of compliant IRFs on the IRF QRP website. CMS proposed to collect standardized patient assessment data and other data required to calculate quality measures using the IRF PAI on all patients, regardless of the patient’s payer; however, in response to stakeholder feedback, they have decided not to finalize this proposal.

The payment provisions contained in the final rule become effective for discharges on or after October 1, 2019 and the new quality reporting requirements go into effect on October 1, 2020. Contact RCPA Director of Rehabilitation Services Melissa Dehoff with questions.

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The Centers for Medicare and Medicaid Services (CMS) filed the unpublished and proposed Medicare Physician Fee Schedule (MPFS) rule for calendar year 2020 on July 29, 2019. The proposed rule is scheduled to be published in the Federal Register on August 14, 2019. Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service, including nurse practitioners, physician assistants, physical therapists, etc.

Some of the key provisions in this proposed rule include:

  • Medicare Telehealth Services: Proposing to add HCPCS codes GYYY1, GYYY2, and GYYY3 to the list of telehealth services, which describe a bundled episode of care for treatment of opioid use disorders.
  • Payment for Evaluation & Management (E/M) Services: Proposing to align the E/M coding changes with changes presented by the CPT Editorial Panel for office/outpatient E/M visits. The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions. The CPT changes also revise the times and medical decision-making process for all of the codes and requires performance of history and exam only as medically appropriate. The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision making or time.
  • Physician Supervision Requirements for Physician Assistants (PAs): CMS is proposing to modify their regulation on physician supervision of PAs to give them greater flexibility to practice more broadly in the current health care system in accordance with state laws and scope of practice.
  • Therapy Services: In the CY 2019 PFS final rule, in accordance with amendments to the Medicare law, CMS established modifiers to identify therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy (OT) assistants, and set a de minimis 10 percent standard for when these modifiers will apply to specific services. CMS also established that the statutory reduced payment rate for therapy assistant services, effective beginning for services furnished in CY 2022, does not apply to services furnished by critical access hospitals because they are not paid for therapy services at PFS rates. Beginning January 1, 2020, these modifiers are required by statute to be reported on claims. CMS is proposing a policy to implement the modifiers as required by statute, and apply the 10 percent de minimis standard, while imposing the minimum amount of burden for those who bill for therapy services while meeting the requirements of the statute.
  • Review and Verification of Medical Record Documentation: CMS has received feedback from clinicians in response to their Patients Over Paperwork initiative request for information (RFI). Stakeholders have shared how undue burden is created when physicians and other practitioners, including those serving as clinical preceptors for students, must re-document notes entered into the medical record by other members of the medical team. To reduce burden, CMS is proposing broad modifications to the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, nurses, students, or other members of the medical team.
  • Care Management Services: CMS is proposing to increase payment for Transitional Care Management (TCM), a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays. CMS is also proposing a set of Medicare-developed HCPCS G-codes for certain Chronic Care Management (CCM) services.
  • Bundled Payments Under the PFS for Substance Use Disorders: CMS is proposing to create new coding and payment for a bundled episode of care for management and counseling for opioid use disorders (OUD).

Contact RCPA Director of Rehabilitation Services Melissa Dehoff with questions.

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The Centers for Medicare and Medicaid Services (CMS) hospital open door forum, scheduled for today at 2:00 pm, includes the topic of inpatient rehabilitation facilities (IRF) appeals settlement initiative.

To participate in this open door forum, please dial: 800-837-1935 and reference conference ID: 2818049. If you are unable to participate in the call today, an encore audio recording will be available beginning four hours after the original call has ended. To listen to the recording, dial: 855-859-2056 and reference conference ID: 2818049. This recording will expire after two business days.

Contact RCPA Rehabilitation Services Director Melissa Dehoff with questions.

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President Trump recently signed the Executive Order on Advancing American Kidney Health. The purpose of this Executive Order (EO) is to improve kidney health and promoting increased treatment options for Americans suffering from kidney disease. The kidney health initiative seeks to prevent kidney failure through better diagnosis, treatment, and preventative care; increase affordable alternative treatment options, educate patients on treatment alternatives, and encourage the development of artificial kidneys; and increase access to kidney transplants by modernizing the transplant system and updating counterproductive regulations. Under the executive order, Medicare will test adjusting payment incentives to encourage preventative kidney care and the use of home dialysis and kidney transplants.

Following the issuance of this EO, the Centers for Medicare and Medicaid Services (CMS) announced in a press release five new CMS Center for Medicare and Medicaid Innovation (CMMI) payment models that aim to transform kidney care in order for patients with chronic kidney disease to have access to high quality, coordinated care. One of the models, the proposed End-Stage Renal Disease Treatment Choices (ETC) Model, would encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with end-stage renal disease (ESRD) in order to enhance their quality of care while reducing Medicare expenditures. Under the proposed ETC Model, CMS would make certain payment adjustments that would encourage participating ESRD facilities and Managing Clinicians to ensure that ESRD beneficiaries have access to, and receive education about, their kidney disease treatment options. CMS would positively adjust certain Medicare payments to participating ESRD facilities and Managing Clinicians for the first three years of the model for home dialysis and dialysis-related services. The payment adjustments under the proposed ETC model would begin January 1, 2020, and end June 30, 2026.

The other optional models announced by CMS are the Kidney Care First (KCF) Model and the Comprehensive Kidney Care Contracting (CKCC), which includes the Graduated, CKCC Professional, and Global models that are designed to help health care providers reduce the cost and improve the quality of care for patients with late-stage chronic kidney disease and ESRD. These models also aim to delay the need for dialysis and encourage kidney transplantation. The final model announced by CMS is the Radiation Oncology (RO) model aimed at improving the quality of care for cancer patients receiving radiotherapy treatment. This model, which would involve required participation, would test whether prospective site neutral, episode-based payments to physician group practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for radiotherapy (RT) episodes of care would reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries.

Contact RCPA Director of Rehabilitation Services, Melissa Dehoff, with questions.

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The Centers for Medicare and Medicaid Services (CMS) recently announced an upcoming in person inpatient rehabilitation facility quality reporting program (IRF QRP) training. This two-day “train-the-trainer” event for providers is scheduled for August 15–16, 2019 at the Four Seasons Hotel, 200 International Drive, Baltimore, MD 21202.

The primary focus of this training, which is open to all IRF providers, associations, and organizations,  will be to provide those responsible for training staff at IRFs with information about IRF QRP changes and updates to the IRF Patient Assessment Instrument (PAI) v.3.0, which will become effective on October 1, 2019. Topics will include, but are not limited to:

  • An overview of the changes between the IRF-PAI v.2.0 and v.3.0;
  • Updated training materials for Section GG, which will include videos of patient scenarios; and
  • An interactive session on the use of reports to identify opportunities for process improvement and utilize information contained in reports available via the Certification and Survey Provider Enhanced Reports (CASPER) system, which will be used to develop quality improvement plans.

A full agenda is available for both days of the training. Registration is limited to 100 people on a first-come, first-served basis. Questions or additional information requests should be sent to the PAC Training mailbox.

The Department of Human Services (DHS) has released a Request for Information (RFI) to gather input from vendors and other stakeholders on the specific measures it may undertake to improve the quality, consistency and effectiveness of the Office of Long-Term Living’s (OLTL’s) Independent Enrollment Broker’s (IEB’s) services.

This RFI will gather input and information concerning the application and enrollment services and support services for the beneficiaries of two Medical Assistance (MA) managed care programs, one 1915(c) MA home and community-based services (HCBS) waiver program and a state-funded program, all administered by the DHS OLTL. Through these programs, eligible beneficiaries receive long-term services and supports (LTSS) and other benefits, depending on the particular program.

Specifically, DHS issued this RFI to solicit input on its potential strategies and solutions to improve the LTSS application and enrollment services and beneficiary support services provided by the OLTL’s IEB to individuals who apply for and enroll in the Community HealthChoices (CHC) Program, the Pennsylvania Living Independence for the Elderly Program (LIFE), the OBRA Waiver and the state-funded Act 150 Attendant Care Program.

DHS is requesting that all responses to the RFI be submitted by 12:00 p.m. on July 29, 2019. Responses must be submitted electronically to the following email account with “OLTL Application and Enrollment Services RFI” in the email subject line: RA-PWRFICOMMENTS@PA.GOV.

DHS does not intend to respond to questions or clarifications during the RFI response period; however, respondents may submit questions related to the RFI electronically to: RA-PWRFICOMMENTS@PA.GOV using “OLTL Application and Enrollment Services RFI question” in the email subject line. DHS may or may not respond based on the nature of the question.

If you have any questions regarding this email please contact Michael Hale, Bureau Director, Fee for Service Programs at mhale@pa.gov.

RCPA will be scheduling teleconference calls in the coming weeks to review this RFI and obtain feedback from members.

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Today, the following important notice was issued by the American Medical Rehabilitation Providers Association (AMRPA) regarding a historic appeal settlement that they, along with the FAIR Fund and the Federation of American Hospitals, reached with the Centers for Medicare and Medicaid Services (CMS) that will allow inpatient rehabilitation facilities (IRFs) to settle their pending Medicare appeals.

Today CMS, AMRPA, the FAIR Fund, and the Federation of American Hospitals announced that an agreement has been reached with CMS which will allow IRFs to settle their pending Medicare appeals. For most pending claims, providers will be able to settle their pending appeals for 69% of the net payable amount of the claim. This is the highest percentage global settlement CMS has ever agreed to. In addition, some claims, such as those denied for failing to justify the use of group therapy, can be settled at 100% of the net payable amount. Here are some of the key things AMRPA members should know:

  • The settlement is voluntary. Providers can choose whether to settle their claims or continue to exercise their appeal rights.
  • Providers choosing to settle claims will receive 69% of the net payable amount (Medicare approved amount, less any applicable deductible or co-insurance).
  • Claims denied solely on the basis of threshold of therapy time not being met (3-hour or 15-hour rule), where the claim did not undergo further review for medical necessity, will be paid at 100% of the net payable amount. Claims denied solely because justification for group therapy was not documented will also be paid at 100% of the net payable amount.
  • If participating in the settlement, providers must settle all currently pending appeals. Providers cannot choose only select claims to settle.
  • To be eligible for settlement, the claim must have been denied in full, and the denial must have been appealed on or before August 31, 2018. The appeal must also still currently be pending at any level of appeal, and appeal rights must not have been exhausted at time of settlement.

Providers should read the entire template agreement for additional important details. CMS has provided instructions for how providers can participate in the settlement on its website.

This settlement was reached due to the diligent efforts of AMRPA’s sister organization, the FAIR Fund, in collaboration with AMRPA and the Federation of American Hospitals. AMRPA would especially like to thank longtime counsel to AMRPA and the FAIR Fund, Peter Thomas and Ron Connelly of Powers Law Firm, whose dedication to the rehabilitation field led to this historic settlement.

Contact Melissa Dehoff, RCPA Rehabilitation Services Director, with questions.

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The Centers for Medicare and Medicaid Services (CMS) has issued a press release with a Request for Information (RFI) seeking new ideas from the public on how to continue progress of the Patients Over Paperwork Initiative to be published in the June 11, 2019 Federal Register. The initiative was originally launched in the fall of 2017. Since that time, CMS estimates that through regulatory reform alone, the health care system will save an estimated 40 million hours and $5.7 billion through 2021. These estimated savings come from both final and proposed rules.

This RFI invites patients and their families, the medical community, and other health care stakeholders to recommend further changes to rules, policies, and procedures that would shift more of clinicians’ time — and our health care system’s resources — from needless paperwork to high quality care that improves patient health. CMS is especially seeking innovative ideas that broaden perspectives on potential solutions to relieve burden and ways to improve:

  • Reporting and documentation requirements;
  • Coding and documentation requirements for Medicare or Medicaid payment;
  • Prior authorization procedures;
  • Policies and requirements for rural providers, clinicians, and beneficiaries;
  • Policies and requirements for dually enrolled (i.e., Medicare and Medicaid) beneficiaries;
  • Beneficiary enrollment and eligibility determination; and
  • CMS processes for issuing regulations and policies.

Comments on this initiative must be submitted by August 12, 2019. For additional information, visit the Patients over Paperwork page on the CMS website.

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The Centers for Medicare and Medicaid Services (CMS) has published a new “Outpatient Rehabilitation Therapy Services: Complying with Medicare Billing Requirements” booklet. Outpatient rehabilitation therapy services include physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services.

The booklet describes common outpatient rehabilitation therapy services Comprehensive Error Rate Testing (CERT) program errors, how CMS calculates improper payment rates, the necessary documentation to support billed Medicare Part B claims; and managing potential overpayments. Contact Melissa Dehoff, RCPA Rehabilitation Services Director, with questions.