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NARA's Response to CMS' Proposed MPPR Policy:
Recently, The Centers for Medicare & Medicaid Services, (CMS) proposed a policy in the physician fee schedule rule, referred to as the multiple procedure payment reduction policy (MPPR) that would result in significant reductions in payment for outpatient therapy services in addition to the projected reductions due to the Sustainable Growth Rate (SGR). The proposed multiple procedure payment reduction policy would apply to both the services paid under the physician fee schedule (PFS) that are furnished in the office setting and those services paid at the PFS rates that are furnished by outpatient hospitals, home health agencies (Part B), skilled nursing facilities (Part B), comprehensive rehabilitation facilities, and other entities that are paid by Medicare for outpatient therapy services.
This proposed policy will have a profound impact on the ability of businesses and providers to make vital skilled rehabilitation therapy services accessible to Medicare beneficiaries. Further, as opposed to other critical legislation that NARA has advocated for its’ membership during the past several years, (i.e. Therapy Cap), this proposed policy is particularly of concern in that it will impact a much broader scope of care delivered in multiple settings, as noted above.
NARA has already begun serving its’ membership and the industry by participating in and becoming a stakeholder in a variety of key collaborative efforts with other associations such as the APTA & AOTA. More specifically, thus far, NARA has responded in the following ways:
1. George Olsen (NARA's Legislative Advocate), Gregg Altobella, NARA's President, and Mark Anderson, NARA's Legislative & Reimbursement Chair, and other NARA Board Members have participated at various levels in the APTA coordinated coalition efforts;
2. Ongoing communication efforts have updated Membership regarding the genesis and status of the MPPR proposed policy via NARA's e-Alerts and a recent Membership Audio Conference with George Olsen;
3. Creation of a NARA MPPR Work Group to further mobilize NARA membership to network and provide key data and intelligence at a "grass roots" / local level in support and recognition of the business aspects that are necessary for quality care / service to be delivered.
NARA's President recently made a "Call for Action" to Membership to participate in communicating with their local legislative representatives as well as providing data via a NARA membership survey and an APTA created data format. NARA continues its' commitment to support and advocate for key issues impacting the businesses that provide rehabilitation therapy services.
AOTA Mobilize's Advocacy Efforts in Response to Draft CMS Manual Student Supervision in Skilled Nursing Facilities
CMS is in the process of updating the Resident Assessment Instrument (RAI) Manual for Minimum Data Set Version 3.0 (MDS 3.0), which goes into effect October 1, 2010. All certified Medicare or Medicaid nursing facilities must complete, record, encode and transmit the MDS for all residents in the facility, regardless of age, diagnosis, length of stay or payment category. The RAI Manual provides guidance for using the MDS. CMS’ draft changes include revisions to Chapter 3, Section O of the RAI 3.0 Manual (pages 19-21) regarding therapy students. The revisions describe how students would be involved in individual therapy, concurrent therapy and group therapy in SNFs.
The draft RAI Manual for MDS 3.0 is available on the CMS Web site. Note that the 3.0 manual is IN PROGRESS and is not yet final.
The current assessment instrument is MDS 2.0, and current guidance regarding therapy students for MDS 2.0 is in the RAI Manual 2.0, Chapter 3 (page 189).
CURRENT Policy Regarding Students – SNF Part A – MDS 2.0 RAI Manual
Supervision (Medicare A only):
- Aides cannot independently provide a skilled service. The services of aides performing therapy treatments may only be coded when the services are performed under line of sight supervision by a licensed therapist when allowed by state law. This type of coordination between the licensed therapist and therapy aide under the direct, personal (e.g., line of sight) supervision of the therapist is considered individual therapy for counting minutes. When the therapist starts the session and delegates the performance of the therapy treatment to a therapy aide, while maintaining direct line of sight supervision, the total number of minutes of the therapy session may be coded as therapy minutes.
- Therapy students are recognized as skilled providers under Medicare A only. They must be “in line of sight” supervision (Federal Register November 4, 1999).
Proposed Policy Regarding Students – SNF Part A & B – MDS 3.0 RAI Manual (Effective October 1, 2010)
O0400: Therapies (cont.)
Therapy Students
- Medicare Part A—Therapy students must be in line-of-sight supervision of the professional therapist (Federal Register, July 30, 1999). Time may be coded on the MDS when the therapist provides skilled services and direction to a student who is participating in the service under line-of-sight supervision.
- Medicare Part B—The following criteria must be met in order for services provided by a student to be billed by the long-term care facility:
- The qualified professional is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
- The practitioner is not engaged in treating another patient or doing other tasks at the same time.
- The qualified professional is the person responsible for the services and, as such, signs all documentation. (A student may, of course, also sign but it is not necessary because the Part B payment is for the clinician’s service, not for the student’s services.)
- Physical therapy assistants and occupational therapy assistants are not precluded from serving as clinical instructors for therapy assistant students while providing services within their scope of work and performed under the direction and supervision of a qualified physical or occupational therapist.
Modes of Therapy
A resident may receive therapy via different modes during the same day or even treatment session. The therapist and assistant must determine which mode(s) of therapy and the amount of time the resident receives for each mode and code the MDS appropriately.
Individual Therapy
The treatment of one resident at a time. The resident is receiving the therapist’s or the assistant’s full attention. Treatment of a resident individually at intermittent times during the day is individual treatment, and the minutes of individual treatment are added for the daily count. For example, the speech-language pathologist treats the resident individually during breakfast for 8 minutes and again at lunch for 13 minutes. The total of individual time for this day would be 21 minutes.
When a therapy student is involved with the treatment of a resident the minutes may be coded as individual therapy when only one resident is being treated by the therapy student and supervising therapist/assistant (Medicare A and Medicare B). The supervising therapist/assistant shall not be engaged in any other activity or treatment.
Concurrent Therapy
Medicare Part A
The treatment of 2 residents, who are not performing the same or similar activities, at the same time, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant. When a therapy student is involved with the treatment, and one of the following occurs, the minutes may be coded as concurrent therapy:
- The therapy student is treating one resident and the supervising therapist/assistant is treating another resident and the therapy student is in line-of-sight; or
- The therapy student is treating 2 residents, both of whom are in line-of-sight of the therapy student and the supervising therapist/assistant; or
- The therapy student is not treating any residents and the supervising therapist/assistant is treating 2 residents at the same time, regardless of payer source, both of whom are in line-of-sight.
Medicare Part B
The treatment of two or more residents, regardless of payer source, at the same time is documented as group treatment.
Group Therapy
Medicare Part A
The treatment of 2 to 4 residents, regardless of payer source, who are performing similar activities, and are supervised by a therapist or assistant who is not supervising any other individuals. When a therapy student is involved with group therapy treatment, and one of the following
occurs, the minutes may be coded as group therapy:
- The therapy student is providing the group treatment and all the residents participating in the group (see definition above) and the therapy student are in line-of-sight of the supervising therapist/assistant who is not supervising other individuals (students or residents); or
- The supervising therapist/assistant is providing the group treatment and the therapy student is not providing treatment to any resident.
Medicare Part B
The treatment of 2 or more individuals simultaneously who may or may not be performing the same activity. When a therapy student is involved with group therapy treatment, and one of the following occurs, the minutes may be coded as group therapy:
- The therapy student is providing group treatment and the supervising therapist/assistant is present and in the room and is not engaged in any other activity or treatment; or
- The supervising therapist/assistant is providing group treatment and the therapy student is not providing treatment to any resident.
NARA President Announces Formation of MPPR Work Group
Recently, The Centers for Medicare & Medicaid Services, (CMS) proposed a policy in the physician fee schedule rule, referred to as the multiple procedure payment reduction policy (MPPR) that would result in significant reductions in payment for outpatient therapy services in addition to the projected reductions due to the Sustainable Growth Rate (SGR). The proposed multiple procedure payment reduction policy would apply to both the services paid under the physician fee schedule (PFS) that are furnished in the office setting and those services paid at the PFS rates that are furnished by outpatient hospitals, home health agencies (Part B), skilled nursing facilities (Part B), comprehensive rehabilitation facilities, and other entities that are paid by Medicare for outpatient therapy services.
This proposed policy will have a profound impact on the ability of businesses and providers to make vital skilled rehabilitation therapy services accessible to Medicare beneficiaries. Further, as opposed to other critical legislation that NARA has advocated for its’ membership during the past several years, (i.e. Therapy Cap), this proposed policy is particularly of concern in that it will impact a much broader scope of care delivered in multiple settings, as noted above.
NARA has already begun serving its’ membership and the industry by participating in and becoming a stakeholder in a variety of key collaborative efforts with other associations such as the APTA & AOTA. Personally being a participant in some of these efforts on behalf of NARA, I am proud and appreciative of the levels of both proactive and reactive measures that are being discussed and/or acted upon to communicate, educate, and hopefully prevent this policy from being implemented.
Consistent with NARA’s 31 year history of uniting organizations and providers in advocating for the preservation, advancement, and success of ethical business practices that enable service delivery, I ask for you to participate in our efforts to aggregate the efforts and voice of our vital industry. NARA’s unique ability to facilitate networking and communication amongst industry leaders, providers & organizations, as well as the various professions/disciplines in our industry will be of particular benefit to our membership and the efforts mentioned above.
Therefore, NARA is establishing a MPPR Work Group that will be facilitated by me and our Legislative & Reimbursement Committee Chair, Mark Anderson. The key objectives will be to inform and update membership on the status of this proposed policy, as well as stimulate critical local “grass roots” communication efforts with consumers and legislators. Further, our ability to aggregate data and Intel relative to the impact of this legislation on businesses and providers delivery of quality care will be essential in providing commentary to CMS before they make a final ruling.
We have established a conference call for July 28th at 4pm CST. If you would like to participate please contact Christie Sheets at christie.sheets@naranet.org or 866-839-7710 to participate in this important Work Group.
CMS will hold Nationwide RAC 101 Calls starting April 28, 2010
CMS Announces Series of Nationwide RAC 101 Calls. The subject matter of the RAC conference calls will be RAC 101. They will be presented by CMS staff. The content on each call will not change drastically. The RAC operational process will be discussed and there will be a question and answer session held at the end. The information presented will not be drastically different from other RAC 101 sessions that were held in the past in conjunction with the hospital and/or medical associations. These calls offer another opportunity for providers who missed the earlier presentations to hear the RAC 101 session and to ask any questions they may have regarding the RAC process. Registration is not required for the calls.
April 28, 2010 1:00pm - 2:30pm EST: Nationwide RAC 101 Call, 1-877-251-0301, meeting ID: 66532244
May 4, 2010 1:00pm - 2:30pm EST: Nationwide RAC 101 Call for Home Health and Hospice Providers, 1-877-251-0301, meeting ID: 66524952
May 5, 2010 1:00pm - 2:30pm EST: Nationwide RAC 101 Call for DMEPOS, 1-877-251-0301, meeting ID: 66527260
May 12, 2010 1:00pm - 2:30pm EST: Nationwide RAC 101 Call for Physicians, 1-877-251-0301, meeting ID: 66529242
Medicare Enrollment
The first step in participation in the Medicare program for rehab providers is the enrollment process. CMS has a traditional paper and pencil system and a new internet-based enrollment process called PECOS. The CMS Provider and Supplier Enrollment page is the starting point.
Carriers, Fiscal Intermediaries and MACs
Check out our list of Medicare contractors for your state.
Medicare Administrative Contractors
Medicare is in the processing of transitioning to Medicare Administrative Contractors. Keep updated on the process with NARA by checking out the latest updated CMS information on Medicare Administrative Contractors.
Manuals
Find the Medicare Manuals and references to rehabilitation without having to browse the Medicare website to look for the information.
Regulations
Survey and Certification
CMS has established a Tier 4 status for survey and certification of rehab agencies and CORFs. Find out more information about becoming a rehab agency and obtaining your initial survey and subsequent Medicare certification.
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