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CMS

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The Centers for Medicare and Medicaid Services (CMS) conducted a national provider call on January 12, 2017, that focused on therapy information data collection for the inpatient rehabilitation facility patient assessment instrument (IRF-PAI). The therapy information section on the IRF-PAI was finalized in the fiscal year (FY) 2015 IRF prospective payment system (PPS) final rule. The call included a review of examples of each type of therapy and how to accurately code and complete the therapy information section on the IRF-PAI. To assist with the call, CMS utilized a PowerPoint presentation for providers to refer to. The written transcript and audio recording of the national provider call will be posted in approximately two weeks.

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The Centers for Medicare and Medicaid Services (CMS) recently approved five new employment-related services in the Office of Long-Term Living’s (OLTLs) CommCare and Independence waivers. The services offer providers an opportunity to expand their profiles, particularly those who have been providing prevocational services and supported employment. Listed below are the new services, their credentialing and certification requirements, and rates that will be paid for the services.

  • Benefits Counselors must hold a Certified Work Incentives Counselor (CWIC) certification that is accepted by the Social Security Administration for its Work Incentives Planning and Assistance program. To learn more about CWIC, visit this web page.
  • Employment Skills Development (replaces Prevocational Services), Job Coaching (replaces Supported Employment), Job Finding, and Career Assessment workers must hold one of the following:
  1. A Certified Employment Support Professional (CESP) credential from the Association of People Supporting Employment First (APSE); and
  2. A Basic Employment Services Certificate of Achievement or Professional Certificate of Achievement in Employment Services from an Association of Community Rehabilitation Educators (ACRE) organizational member that has ACRE-approved training. Individuals without one of these certifications must be supervised by an individual holding the above certification until certification is achieved. Certification must be achieved within 18 months of employment.

Information on APSE credentialing can be found here.
Information on how to receive a certificate of achievement from ACRE can be found here.

(NOTE: Employment Skills Development services that are provided in vocational rehabilitation facilities that fall under 55 PA Code Chapter 2390 are not required to have the above credential or certification. Employment Skills Development services provided in the community do require the above credential or certification.)

A complete description of these services and provider qualifications can be found in the CommCare and Independence waivers here.

NOTE: OLTL has scheduled a webinar on Friday, November 18, 2016 at 1:00 pm to review and discuss these new services. Registration is required to participate.

Listed below are the rates for the new employment services:

 
Service PT/Spec CC IW Procedure Code Modifier Region 1 Region 2 Region 3 Region 4 Unit
Benefits Counseling 59/502 X X W1740 $9.78 $10.21 $10.54 10.87 15 mins
Career Assessment 59/503 X X W1732 $11.12 $12.12 $12.39 12.67 15 mins
Employment Skills Development (1:1) 59/505 X X W1728 $9.44 $11.22 $10.07 10.12 15 mins
Employment Skills Development (1:2 to 1:3) 59/505 X X W1729 $3.77 $4.49 $4.03 4.05 15 mins
Employment Skills Development (1:15) 59/505 X X W1741 $6.29 $6.50 $6.96 6.54 15 mins
Job Coaching 1:1 (Follow-Along) 59/504 X X W1733 U5 $9.78 $10.21 $10.54 10.87 15 mins
Job Coaching 1:2 to 1:4 (Follow-Along) 59/504 X X W1734 U5 $3.26 $3.40 $3.51 3.62 15 mins
Job Coaching 1:1 (Intensive) 59/504 X X W1733 U4 $9.78 $10.21 $10.54 10.87 15 mins
Job Coaching 1:2 to 1:4 (Intensive) 59/504 X X W1734 U4 $3.26 $3.40 $3.51 3.62 15 mins
Job Finding 59/530 X X W1735 $11.15 $12.11 $11.98 12.34 15 mins

 

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In July 2016, the Centers for Medicare and Medicaid Services (CMS) proposed new bundled payment models to shift Medicare payments from rewarding quantity to rewarding quality by creating strong incentives for hospitals and clinicians to deliver better care to patients at a lower cost. These proposed new bundled payment models focus on heart attacks, heart bypass surgery, and hip fracture surgery, and would reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery. This proposal follows the implementation of the Comprehensive Care for Joint Replacement (CCJR) Model that began earlier this year which introduced bundled payments for certain hip and knee replacements.

CMS just released the second annual evaluation report for Models 2–4 of the Bundled Payments for Care Improvement (BPCI) Initiative, which include both retrospective and prospective bundled payments that may or may not include the acute inpatient hospital stay for a given episode of care. This report describes the characteristics of the participants and includes quantitative results from the first year of the initiative. Key highlights include:

  • 11 out of the 15 clinical episode groups analyzed showed potential savings to Medicare. Future evaluation reports will have more data to analyze individual clinical episodes within these and additional groups;
  • Orthopedic surgery under Model 2 hospitals showed statistically significant savings of $864 per episode while showing improved quality as indicated by beneficiary surveys. Beneficiaries who received their care at participating hospitals indicated that they had greater improvement after 90 days post-discharge in two mobility measures than beneficiaries treated at comparison hospitals; and
  • Cardiovascular surgery episodes under Model 2 hospitals did not show any savings yet but quality of care was preserved. Over the next year, we will have significantly more data available, enabling CMS to better estimate effects on costs and quality.

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The Centers for Medicare and Medicaid Services (CMS) has announced that the inpatient rehabilitation facility (IRF) quality reporting program (QRP) provider preview reports are currently available until September 30, 2016. Members are encouraged to preview the performance date on each quality measure prior to public display on the IRF Compare website. While corrections to the underlying data will not be permitted during this timeframe, members can request a CMS review during the 30-day preview period if you feel the data is inaccurate. Additional information, including instructions on how to access preview reports, is available from the IRF Quality Public Reporting web page.

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RCPA members are reminded to consider soliciting nominations for a Technical Expert Panel (TEP) that will provide input on two new quality measures in development for post-acute care providers (including inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies).

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International and Abt Associates to develop and refine a cross-setting, post-acute care transfer of health information and care preferences quality measure as required by the Improving Medicare Post-Acute Care Transformation Act of 2014. The two new quality measures include:

  • Transfer of Information at Post-acute Care Admission, Start, or Resumption of Care from Other Providers/Settings; and
  • Transfer of Information at Post-acute Care Discharge or End of Care to Other Providers/Settings.

In alignment with the CMS and National Quality Strategy objectives and goals, the purpose of this project is to develop, maintain, re-evaluate, and implement measures that will drive high quality in post-acute care through CMS’ quality reporting programs. This includes the inpatient rehabilitation facility, skilled nursing facility, long-term care hospital, and home health quality reporting programs.

CMS is seeking technical experts with expertise in care transitions and information transfer during transitions, admission and discharge planning, and care coordination, among other areas of knowledge. The call for technical expert panel members is open through August 21, 2016.

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The Centers for Medicare and Medicaid Services (CMS) will be conducting a two-day inpatient rehabilitation facility (IRF) quality reporting program (QRP) training event on Tuesday, August 9 & Wednesday, August 10 in Chicago, IL. For members that can’t attend the training in person, a live webcast will be available (Note: the title of the event on this page hosting the webcast will not be updated until August 9).

  • On August 9, the training will be conducted from 9:00 am to 6:00 pm EDT.
  • On August 10, the training will be conducted from 9:00 am to 3:30 pm EDT.

The focus of this training event will be to provide IRFs with assessment-based data collection instructions and updates associated with the changes in the October 1, 2016 release of the IRF-Patient Assessment Instrument (PAI) version 1.4 and other reporting requirements of the IRF QRP.

The training materials are now available under the Downloads section of CMS’ IRF Quality Reporting Training web page. If members have questions or need additional information about the logistics of the training session, please email CMS’ PAC Training mailbox.

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The Centers for Medicare and Medicaid Services (CMS) issued the calendar year (CY) 2017 Medicare Physician Fee Schedule Proposed Rule, which was published in the July 15, 2016 Federal Register. Some of the key provisions proposed include:

New Physical Therapy and Occupational Therapy Codes

CMS is proposing new CPT codes for physical therapy and occupational therapy evaluative procedures. The new codes are listed on Page 350 of the proposed rule in table 19 and include: 97X61, 97X62, 97X63, 97X64, 97X65, 97X66, 97X67, and 97X68. These codes are deemed “always therapy” regardless of the type of provider who bills for the service, and thus are subject to the statutory therapy caps.

Misvalued Therapy Codes

As part of the continued misvalued code initiative, CMS identifies ten potential therapy codes that fall under the “codes that account for the majority of spending under the physician fee schedule” statutory category. The ten codes that CMS requests comment on include the following: 97032 electrical stimulation; 97035 ultrasound therapy; 97110 therapeutic exercises; 97112 neuromuscular reeducation; 97113 aquatic therapy/exercises; 97116 gait training therapy; 97140 manual therapy 1/regions; 97530 therapeutic activities; 97535 self-care management training; and G0283 electrical stimulation other than wound.

Physician Value-based Modifier

The Value-based Payment Modifier (VM) provides for differential payments under the PFS to self-employed physicians, groups of physicians, and other eligible professionals (EPs) based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare Fee-for-Service (FFS) program. Under the VM Program, performance on quality and cost measures can translate into payment incentives for EPs who provide high quality, efficient care, while EPs who underperform may be subject to a downward adjustment. This program is set to expire on January 1, 2019, as a new comprehensive program required by the Medicare Access and CHIP Reauthorization Act, called the Merit-based Incentive Program, begins in CY 2019. For CY 2017, CMS requests feedback on four scenarios that aim to help physician groups and solo practitioners better predict the outcome of their final VM adjustment and to minimize claims reprocessing.

Medicare Shared Savings Program

Within the Medicare Shared Savings Program, CMS proposes to introduce beneficiary protections related to the use of the skilled nursing facility (SNF) 3-Day Waiver, currently limited to beneficiaries in a Track 3 Accountable Care Organization (ACO). CMS estimates the first SNF 3-day rule waiver applications from Track 3 ACOs to be accepted later this summer. The following additional beneficiary protections are proposed in order to ensure proper use of the SNF 3-day rule waiver:

  • Establishment of a 90-day grace period that would permit payment for SNF services provided to beneficiaries who were initially on an ACO’s prospective assignment list for a performance year, but subsequently excluded during the performance year;
  • Requirement that a beneficiary who was never prospectively assigned to a waiver-approved ACO is not subject to non-covered SNF services; and
  • Misuse of a waiver may result in CMS taking remedial action against an ACO. CMS has indicated they will develop a process for ACOs to confirm that they have met all the SNF 3-day rule waiver requirements and requests comments on the proposed beneficiary protection policies.

Medicare Advantage Provider Enrollment

CMS proposes to require Medicare Advantage (MA) organization providers and suppliers to also be enrolled in Medicare in an approved status. The statutory definition of a “provider of services” includes a hospital, critical access hospital, SNF, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice. According to CMS, this requirement is needed to ensure that MA enrollees receive appropriate or medically necessary items or services from health care providers and suppliers that fully comply with Medicare enrollment requirements and have not had their privileges revoked. The Medicare enrollment requirement would be part of CMS contracts with MA plans, and those failing to meet this requirement could be subject to contract actions ranging from sanctions to termination. This proposal would create consistency with the provider and supplier enrollment requirements for all other Parts of Medicare (i.e., Medicare Part A, Part B, and Part D), and would also parallel requirements for providers participating in Medicaid managed care organizations.

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The Centers for Medicare and Medicaid Services (CMS) will conduct a call on the key quality measures related to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 and how they will affect providers. The IMPACT Act requires the reporting of standardized patient assessment data on quality measures, resource use, and other measures by Post-Acute Care (PAC) providers, including inpatient rehabilitation facilities, skilled nursing facilities, home health agencies, and long-term care hospitals. The call is scheduled for Thursday, July 7, 2016 from 1:30 to 3:00 pm ET. Those interested in participating are encouraged to register early as space is limited.

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On May 3, 2016, the Centers for Medicare and Medicaid Services (CMS) issued an update to the additional documentation request (ADR) limits for Medicare institutional providers under the Medicare fee-for-service (FFS) recovery audit program, which will allow recovery audit contractors (RACs) to request more documents from providers who have high claims denial rates.

For example, a provider with a 0 to 3 percent denial rate will receive no additional RAC document requests for three 45-day review cycles, while providers with denial rates between 91 percent and 100 percent could potentially receive RAC document requests of up to 5 percent of their paid claims. A baseline annual ADR limit is established for each provider based on the number of Medicare claims paid in a previous 12-month period. Using the baseline annual ADR limit, which is one-half of one percent (0.5%) of the provider’s total number of paid Medicare claims from a previous 12-month period, an ADR cycle limit is also established. After three 45-day ADR cycles, CMS will calculate (or recalculate) a provider’s denial rate, which will then be used to identify a provider’s corresponding “Adjusted” ADR limit. Recovery auditors may choose to either conduct reviews of a provider based on their adjusted ADR limit (with a shorter look-back period of six months) or their baseline annual ADR limit (with a longer look-back period of three years).

Questions concerning this update can be submitted via email.

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The Centers for Medicare and Medicaid Services recently identified a system’s error when calculating payments for inpatient rehabilitation facility (IRF) providers. To correct this error, a special wage index under the fiscal year 2016 IRF prospective payment system (PPS) will need to be implemented. This system fix will be implemented sometime around October 26, 2015. Providers’ Medicare administrative contractor will mass adjust affected IRF PPS claims with dates of service on or after October 1, 2015. No provider action is required.

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