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CHIP Reauthorization Act of 2015 Revisited with Milestone Discussions

Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, May 28, 2015 Posted in: Outpatient Rehab

The Sustainable Growth Rate formula replaced through the Medicare and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) may not have been thought of much lately since Congress acted in mid-April. However, this, and the therapy caps exceptions process was reinstated April 1 with redefined manual medical review to begin July 1st, therefore, the Act is worth reviewing once more. Exactly what happened with MACRA?  If you’re paid based on the physician fee schedule, it’s time to review!

The March 31st deadline to repair the sustainable growth rate for the Physician Fee Schedule and  sun-setting of the exceptions process for therapy services that reached the cap, came and went without the Senate taking action at the end of the 1st quarter.

Therapy providers everywhere were juggling expectations on what to do without congressional leaders stepping in to guide lawful practice before they went on break.  When Congress went on spring vacation, everyone paid on the physician fee schedule was in a predicament as to payment, and therapy caps guidance without the exceptions process caused major confusion without the ability to designate medically necessary extensions of care.

Upon return from vacation, lawmakers swiftly adopted H.R. 2, known as MACRA, and retroactively calmed many of those unknowns. Although this established some calming; new dates, milestones, facts and figures continue to roll out because of this Act.

Thank goodness the chaos is behind us!  However, rules were made and another milestone date will begin on  July 1, 2015. Let’s refresh our memories on what was achieved in the passing of the CHIP Reauthorization Act of 2015.

Retroactively, MACRA allowed a zero percent update continuing from March 31, 2015 through to June 30, 2015 in the Physician Fee Schedule (PFS) payment. Starting July 1, 2015 to December 31, 2015, that same Act allows for a 0.5 percent increase in the PFS and extends the geographic practice cost index (GPCI) floor of 1.0. Just recently, CMS released MedLearn Matter 9152 outlining the quarter’s three physician fee schedule updates to conform to the Act.

Along with many other extensions in the Act, (25 in all),  the therapy caps exceptions were held through December 2017 with different manual medical review guidelines defined by the Secretary and enacted after July 1, 2015.

On July 1, 2015, a new manual medical review process will be initiated by CMS. Rather than 100 percent review of all charts triggered by the KX modifier, that signal continued medical necessity over the capped amount for physical therapy/ speech pathology and language together and occupational separately, CMS has instructed the Medicare Administrative Contractors (FI’s) to instead review only some claims AND all providers with:

  • patterns of aberrant billing practices compared to their peers
  • high claims denial percentage who are less compliant with applicable Medicare program requirements
  • those who are newly enrolled Medicare providers
  • those that treat certain types of medical conditions
  • those who are part of a group that includes another therapy provider identified by any of the above factors

This change in guidance should surely reduce the administrative burden for additional development requests (ADRs). Medicare contractors can requisition any chart for review, but this process should help to reduce backlog, improve cash flow and improve patient access to appropriate plans of care. In hindsight, if your charts are continuously triggered, you should assume that any of the conditions mentioned in the list above are suspect in your facility and you should work with your administrative contractor to educate and correct issues, perceived or real. Choosing not to do so could lead to something more serious like a pre-payment review process and/or CERTactions.

Take the time to review MACRA changes with your staff so they are aware of payment policy and the effect on their practices along with the continued need for ‘KX ‘modifiers when reaching the Medicare therapy cap.  Manual medical review will continue with a slightly different process beginning July 1, 2015, and extending through December 2017.