Through your feedback and requests (thank you by the way) today’s blog is a clarification of the Therapy Caps.
In 2018, the Bipartisan Budget Act of 2018 (HR 1892), canceled the existence of Medicare Part B Therapy Caps. The historically named Medicare Part B Therapy Caps (now known as the KX Modifier Thresholds) went into effect January 1, 2019.
The Act maintained the requirement that a modifier be included on claimsover the exception threshold. The modifier represents confirmation that the services are medically necessary.
A higher level of scrutiny regarding the content of therapy documentation has been noted in the published findings of government funded auditing agencies. Harmony (HHI) has assisted numerous facilities in the audit process and has identified trends in risk areas as well as frequent denial reasons through analysis of government agency audit findings. An area requiring serious attention by SNF Administrators and Rehabilitation managers is documentation in the medical record supporting the patient’s medical necessity for Part B Rehabilitation services.
On March 26, 2015, the House of Representatives passed legislation to fix the Medicare physician payment problem and to extend the Medicare therapy cap exceptions. The Medicare Access and CHIP Reauthorization Act (H.R. 2) repeals the Sustainable Growth Rate (SGR) formula and significantly changes payment under Medicare Part B to pay for value over volume. Within this bill the House included a two-year extension of the therapy cap exceptions process.
With the spiraling cost of health care in the United States, it is critical to demonstrate the effectiveness and efficiency of therapy treatment. As payers, health care systems and the public question the efficacy and cost effectiveness of rehabilitation, objective documentation is becoming more important. Therapists must have a more scientific basis for their practice. Evidence based treatment is indeed best practice. Referrals are increasingly based on objective, value-based criteria including metric-driven rehabilitation performance, rates of successful home discharges, re-hospitalization rates and patient experience ratings.
Every good treatment starts with the evaluation process. A thorough evaluation is key, but the documentation is cumbersome and time consuming. Frequently, therapists give away services to the Part B population of the skilled nursing facility simply because they feel the services are too insignificant to warrant the laborious task of documenting what we do.
Successful case management for Case Mix involves the coding of the accurate minutes of care provided by therapy on the MDS for those patients seen under Medicare Part B. There is significant opportunity to increase the case mix index with the intervention of rehabilitation during the appropriate assessment windows. Increased communication between the Rehabilitation staff and the MDS Coordinator regarding patients receiving Medicare Part B services has the potential to increase the case mix index in two ways.
Today we will be discussing the Medicare meeting, otherwise known as the beneficiary review meeting. This meeting is set up so that the interdisciplinary team can discuss the clinical status of a patient and whether that patient continues to meet the criteria for skilling under their Medicare Part A benefit. This meeting provides an opportune time to review the Medicare Part B beneficiaries or your managed care patients during this meeting. The goal of the meeting is not to focus on when the patient is going to be discharged. This is not a discharge planning meeting, the meeting is designed to review what the skilling criteria or the needs on a daily basis of the patient from nursing and from therapy. HHI recommends that the entire interdisciplinary team attend this meeting and that each member of the team be aware of what they are going to be reporting on during the meeting. For example, the business office would be discussing how many days the patient has used in their benefit period or how many days the patient has left. MDS may be discussing what the potential selected ARD date is. As well, MDS may discuss ADL assistance provided to the patient to make sure that team members are in agreement with the level of assistance provided to assure levels are accurately reflected on the MDS. Nursing should be talking about why the patient requires daily skilled care and therapy should talk about the patient’s status in relationship to their ability to continue to provide daily skilled care to the patient. Again, this meeting is so that the team can assure that the facility is accurately utilizing the patient’s Medicare Part A benefit.