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Examining Billing and Payment Changes for Therapy Services

Analysis  |  By Kimberly A. Hoy JD CPC  
   June 25, 2019

The new updates relate to statutory and regulatory changes.

This article appears in the May/June 2019 edition of HealthLeaders magazine.

Editor's note: This excerpt from a February 2019 "Note from the instructor" from Revenue Cycle Advisor has been edited for brevity.

CMS recently published several Benefit Policy Manual and Claims Processing Manual transmittals updating various therapy-related issues. The updates primarily relate to statutory and regulatory changes to billing and payment for therapy, including the expansion of coverage for intensive cardiac rehabilitation programs (ICR).

Instructions related to supervised exercise therapy for symptomatic peripheral artery disease were also published.

Functional reporting

In the CY 2019 Medicare Physician Fee Schedule (MPFS) final rule, CMS eliminated reporting of functional status codes, effective January 1, 2019, due to stakeholder concerns about the burden of reporting the codes. The functional status codes consisted of sets of HCPCS Level II G-codes that were reported indicating the beneficiary's functional limitation addressed by the therapy.

The codes were reported in pairs indicating the current status, goal, or discharge status, depending on the reporting situation. Each code was reported with a severity modifier to indicate the beneficiary's level of functioning in order to collect data on the types and duration of therapy for various conditions.

CMS issued Benefit Policy Manual Transmittal 255 and Claims Processing Manual Transmittal 4214 to revise manual language to note that the functional status codes were eliminated in 2019. They did not remove the codes from the manual, but rather clarified that these codes were only required for therapy provided from January 1, 2013, through December 31, 2018. They also published associated MLN Matters 11120.

ICR programs

The Bipartisan Budget Act of 2018 expanded coverage of ICR, effective February 9, 2018, to the following two conditions:

  • Stable, chronic heart failure, defined as a patient with left ventricular ejection fraction of 35% or less and New York Heart Association class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks; and
  • Any additional condition for which the Secretary has determined that a cardiac rehabilitation program shall be covered, unless the Secretary determines, using the same process used to determine that the condition is covered for a cardiac rehabilitation program, that such coverage is not supported by the clinical evidence.

CMS published Benefit Policy Manual Transmittal 256 and Claims Processing Manual Transmittal 4222 to implement the expanded coverage, which was effective nearly a year ago. CMS indicated they will further address the expansion of coverage and its implementation in the CY2020 MPFS proposed rule.

Although the effective date of the expanded coverage is February 9, 2018, the transmittal indicates the implementation date will not be until March 19, 2019. This means that while patients with these conditions are covered for the service of ICR from dates of service February 9, 2018 and forward, the claims will not process correctly for payment until March 19, 2019.

CMS has directed contractors to adjust claims brought to their attention by providers with dates of service after February 9, 2018 but received before the implementation date of March 19, 2019, because they will presumably be denied incorrectly for lack of coverage if submitted before this date.

Rehabilitation claims are generally submitted on monthly claims. Claims for dates of services from February 9, 2018, through March or April of 2018 should be submitted for the incorrect denial, then the provider should request reprocessing due to the one-year timely filing deadline.

For claims with later dates of service, the provider can either submit the claims and ask for reprocessing or hold the claims and submit them after the March 19, 2019 implementation date.

Kimberly A. Hoy, JD, CPC, is the director of Medicare and compliance for HCPro, a division of Simplify Compliance. 

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