The HHS Office of the National Coordinator for Health Technology released the final rule today that includes provisions for temporary certification of programs for EHR.  (This will eventually be replaced by a permanent certification program).  The entire press release can be found at the HHS website. 

“By purchasing certified EHR technology, hospitals and eligible professionals and hospitals will be able to make EHR purchasing decisions knowing that the technology will allow them to become meaningful users of electronic health records, qualify for the payment incentives, and begin to use EHRs in a way that will improve quality and efficiency in our health care system,” said David Blumenthal, M.D., M.P.P., national coordinator for health information technology.  “We hope that all HIT stakeholders view this rule as the federal government’s commitment to reduce uncertainty in the health IT marketplace and advance the successful implementation of EHR incentive programs.”

According to the press release use of certified EHR technology  is a core requirement for providers who seek to qualify to receive incentive payments under the Medicare and Medicaid Electronic Health Record Incentive Programs  which was authorized by provisions  in the  HITECH Act as part of the American Recovery and Reinvestment Act (ARRA) of 2009.   CMS will issue final regulations to implement the EHR incentive programs also according to the press release.

For therapy and other small providers seeking to move to an electronic health record platform it is time to get in touch with the vendors that you have been considering, your incentive payments will depend on their certification through this program.

In a recent RACMonitor.com article on The Curious Case of the CORF   the CORF was described as an “orphan” program that had conflicting regulatory advice for providers in recent years.  The Conditions of Participation, the State Operations Manual Interpretive Guidelines, and various instructions from the Medicare Contractors (fiscal intermediaries and MACs) put the provider at a disadvantage.  Many long-time rehab providers with Medicare certification as a CORF found that claims were being denied based upon the confusion between the requirement that the physician “wholly” develop the plan of care in a respiratory CORF and the requirement that the physician develop the plan of care in a physical therapy CORF.  Implicit in the physical therapy CORF is that the physical therapist will provide  input from the therapy evaluation to develop (or develop in concert with the physician) the CORF plan of care.  What is different about the CORF is that that therapy cannot begin until the plan of care is certified, whereas in other outpatient rehab settings there is a timeframe of up to 30 days for the physician to certify the plan of care.

For current CORFs providing respitory therapy programs, it is imperative that the plan of care for respiratory therapy be wholly developed by the physician (this can be the referring physician, or the CORF medical director).  For physical therapy programs in a CORF it is equally imperative that providers understand that the plan of care must be certified prior to therapy commencing, and that includes provding any services on the day of the evaluation other than the evaluation.

For all CORFs, as you get prepared for review under the Recovery Audit Contractor (RAC) program, make sure that you have all your regulatory reference material pulled together, particularly as it relates to the particular time period that is under review.  The RAC look-back period is 3 years, but no earlier than October1, 2007.  Scrapbooking your way to success is a good way to get started.

CMS has issued CR6899  indicating that effective 10-1-2010 outpatient rehab providers will no longer have to report value codes for the number of visits (Code 50 for PT, Code 51 for OT, Code 52 for SLP and Code 53 for Cardiac). 

This change affects Part A outpatient therapy providers (billing on CMS 1450/UB04) including CORFs, Rehab Agencies, Hospitals, SNFs, Home Health Agencies.  A corresponding MLNArticle has also been published.

CMS has recently announced a new round of RAC informational sessions for providers.  The video features the slide show used in the original fall RAC informational sessions along with commentary by Commander Marie Casey.  This video production is one of many that have been posted by CMS/HHS on YouTube.  This video is being released as CMS announces a series of RAC 101 informational meetings to be held in the next several weeks.

www.youtube.com/watch?v=IHFXsfP99Bc

CMS has announced the therapy cap for 2010 is $1860, representing a $20 increase over the 2009 therapy cap.  Transmittal R1851 to the Medicare Claims Processing Manual, dated 11/13/2009 and the accompanying MLN Article MM6660 provide information on the implementation.  The Balanced Budget Act of 1997 (BBA) established a $1500 therapy cap for physical therapy (including speech-language pathology) and a separate therapy cap of $1500 for occupational therapy.  The Deficit Reduction Act of 2005  implemented the therapy caps exceptions process based on medical necessity of therapy beyond the caps.

Although the Medicare Improvements for Patients and Providers Act of 2008 (MIIPPA), Section 141, extended exceptions to therapy caps through December 31, 2009, there is indications in the various healthcare reform proposals that the therapy caps exceptions process will be exteneded though 2011, although there is no certainly at this point. 

While Medicare beneficiaries will enjoy the benefit of an additional $20 annually of therapy services under under each therapy cap, therapy providers should brace for the projected 21.2% reduction in the conversion factor in the Medicare Physician Fee Schedule for 2010.

The therapy caps are applicable to outpatient settings including private practice physical, occupational and speech therapy practice, rehab agencies (ORFs) and comprehensive outpatient rehab facilities (CORFs).  Hospital outpatient therapy departments with provider-based status are exempt from the therapy caps and provide a safety net for beneficiaries to receive additional therapy that may not be covered by a diagnosis code, co-morbidity, or complexity identified to meet the medical necessity requirements.

Florida therapy providers are beginning to report the receipt of official “demand letters” from Connolly Healthcare, the Region C Recovery Audit Contractor.   A Florida therapy provider, who asked not to be identified, has reported receiving several demand letters related to the billing of speech therapy untimed codes in units greater than one.  This provider has multiple Florida facilities and the improper billing was found, upon internal investigation to be limited to one facility and individual and likely due to a communication error. 

Connolly (Region C) was the first RAC to post CMS approved issues for automated review.  Among those issues posted was Untimed Codes, as noted in the RACMonitor article predicting likely outpatient rehab targets: http://racmonitor.com/news/43-special-bulletin/198-likely-outpatient-rehab-rac-targets-hiding-in-plain-sight.html .

The same rehab provider has received additional RAC demand letters regarding speech therapy untimed evaluation codes being billed simultaneously with speech therapy untimed treatment codes.  The findings of an internal and external investigation has led the provider to initiate appeals on claims where two  different untimed codes were billed on the same day (on the same claim).

Untimed Codes being billed in increments greater than one were noted in the RAC Demonstration in California, New York and Florida.  The RAC issue with Speech untimed codes has been on the radar screen in rehab cirles for some time due to the $3.2 million in improper speech therapy payments discovered in the RAC demo.  

Health Data Insights (Region D) and CGI (Region B) both posted Untimed Codes as a CMS approved issue for automated review.  It is likely that DCS Healthcare (Region A) has also requested CMS to approve this issue .

Connolly describes the issue as “CPT Codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service.”  Additional information for providers provided as a reference by Connolly:  CMS Pub 100-04, Transmittal 1019, dated 8.3.06, pages 7-11, and CMS Pub 100-04, Ch. 5, § 20.2.  The Connolly reference can be reviewed at: http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx

For a refresher on avoiding problems with the issue of Untimed Codes there are suggestions in the following article:http://www.racmonitor.com/news/43-special-bulletin/215-catch-me-if-you-can-staying-ahead-of-the-rac-reviews-of-untimed-codes.html  (originally published in RACMonitor.com)

Trailblazer , the MAC J4 contractor has released a DRAFT Physical Medicine & Rehabilitation Outpatient LCD (local coverage determination).   The draft LCD is posted as of October 30, 2009 for a 45 day comment period that ends December 14, 2009.  According to Trailblazer:

This LCD establishes frequency limitations of 5 (15-minute) PT or OT services per day and 60 (15-minute) PT or OT services per month. Providers of PT/OT services must be aware however, that any service reported to Medicare, even when reported at a frequency within the following stated covered guidelines, may be denied if done so in association with medical review of the patient’s record. Likewise, providers of PT/OT services must understand that though Medicare will allow the following units of service, each service must be medically reasonable and necessary for the specific patient and his or her condition. Additionally, Medicare expects that the patient’s medical record will clearly demonstrate that medical necessity. Further, Medicare does not expect that maximum allowable services will be routinely necessary, necessary for multiple week periods, or necessary for the entirety of the patient’s course of treatment.

This LCD also include a procedure to diagnosis edit list (78 pages long).

The Comprehensive Outpatient Rehabilitation Facility (CORF) has been around as a Medicare entity for 26 years.  In a CORF,  a plan of care may be certified for 60 days (which has always been the case).  A number of years ago the regulations were changed to state that the physician must develop the plan of care, rather than the physical, occupational or speech therapist who is evaluating the patient.  In all other venues of outpatient rehab the therapist evaluates the patient and develops the plan of care that is sent to the referring physician for Medicare certification.

A number of providers have reported that when their records were reviewed under an ADR request that they were caught by surprise to be denied on the entire claim because the Plan of Care was developed by the therapist, and only certified by the physician.  The regulations state that in a CORF the plan of care must be developed by a physician.  One provider reported that the fiscal intermediary denied the Plan of Care based upon the fact that the hand written plan of care did not match the hand writing of the physician in the signature box!

In a CORF the Plan of Care may be certified for 60 days, which has always been the case.  Don’t be confused with Medicare documenation requirement that allow the Plan of Care to be certified for up to 90 days (except for CORFs and Rehab Agencies).  For Plans of Care not properly certified rehab providers face the risk of having all services provided under the Plan disallowed.