• Currently, no news to report for this area

---

Downloadable Documents:

• Cap Clarifications 11-6 Trans 1106
• Cap Clarifications 11-6
• Clarification of the Cap Trans 171
• APTA Cap FAQs
• Medicare ABN
• Medicare Claims Processing Manual
• Medicare Exceptions Flowsheet (7-06)
• Medicare NEMB
• WPTA Medicare Cap Memorandum from CMS
• WPTA Medicare Exception to the Cap 1-06
• WPTA Medicare Memorandum of Codes Changes 2006

• A Call to Action from CMS Administrator Mark B. McClellan, MD, Ph.D MEDICARE PRESCRIPTION DRUG COVERAGE - Starting January 1, 2006, Medicare will offer prescription drug plans to help you pay for the prescriptions you need. If you don’t join a Medicare prescription drug plan by May 15, 2006, you will pay a higher premium unless you have drug coverage that, on average, is at least as good as standard Medicare prescription drug coverage (such as from a former employer or union). Your insurer will notify you before fall to let you know if your coverage, on average, is at least as good as standard Medicare prescription drug coverage. Download Full Brochure with Reproducible Forms and Artwork
• MODIFIER -59 Information and Examples - Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. More Details
• DAVE Project (Data Assessment and Verification)- The objective of the Data Assessment and VErification (DAVE) project is to assess the accuracy and reliability of assessment data submitted by nursing homes and home health agencies; the project is also intended to support improvements in the quality of care, support CMS’ program integrity initiatives to improve payment accuracy, and support payment policy development. More Information
• National Coverage Determination (NCD) on the Use of Electrical Stimulation for Wound Care - Electrical stimulation is defined as the application of electrical current through electrodes applied directly to the skin in close proximity to the ulcer. Based on all of the evidence that we have reviewed in this matter, it is our intention to issue a positive coverage decision only on the use of electrical stimulation for chronic Stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers. Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence. Program Memorandum
• National coverage decision for biofeedback - biofeedback for the treatment of urinary incontinence is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. Program Memorandum
• CMS’ program memorandums and transmittals --Program instructions are day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives. They are used by CMS program components, contractors, and State survey agencies to administer CMS programs. For many others, they are a good source of technical and professional information about the Medicare and Medicaid programs. More Information
• CMS’ open door initiative -- The Centers for Medicare & Medicaid Services (CMS) is above all else, a service agency. Previously known as the Health Care Financing Administration (HCFA), the CMS is responsible for administering Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), Health Insurance Portability and Accountability Act (HIPAA), and Clinical Laboratory Improvement Amendments (CLIA). More Information
• Beneficiary Notices Initiative (BNI) - The below link goes directly to CMS’ Beneficiary Notice Initiative web link. The link contains information about ABNs (Advanced Beneficiary Notices) and NEMBs (Notice of Exclusions from Medicare Benefits). A pdf version of these forms can be downloaded free of charge. More Information
• Online CMS Manual System - Beginning October 1, 2003, CMS will transition from a paper-based manual to a Web-based system. The process includes streamlining, updating, and consolidating of CMS' various program instructions (i.e., day-to-day operation instructions, policies and procedures) into an electronic Web-based manual system for all users. The new system is called the Online CMS Manual System (also called the Medicare and Medicaid Program Instructions Web Site) and is located by clicking here..

• August 8, 2005 Recent changes from CMS involving ‘Incident to’ provisions and other PTA services
  • Subject: Update from APTA about Medicare and "incident to" therapy services

    As of Monday, July 25, Medicare will only pay for physical therapy services provided in physician offices “incident to” the physician’s services if the physical therapy services are provided by “qualified personnel” as defined in a June 24 transmittal (http://www.cms.hhs.gov/manuals/pm_trans/R36BP.pdf) to Medicare contractors. The immediate implementation of the standards follows the dismissal last week of a lawsuit filed by the National Athletic Trainers Association (NATA) challenging the personnel standards, as explained in a new MedLearn article (http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3648.pdf) released by the Centers for Medicare and Medicaid Services.

    In addition to the implementation of the personnel requirements for physical therapy services provided incident to a physician/NPP, Section 230.5 of the Medicare Benefit Policy Manual also clarifies the requirement that services provided by PTAs cannot be billed incident to the physician/NPP’s services. PTAs must be supervised by a physical therapist in all treatment settings, including in a physician/NPP office. The services of PTAs are covered under the benefit for physical therapy services and not under the benefit for services provided incident to a physician/NPP. In order to bill for the PTA’s services in a setting where the PT and PTA are employed by a physician/NPP, the PT would need his or her own Medicare provider number. Payment for physical therapy services billed using the PT provider number would then be reassigned to the physician/NPP. (refer to the highlighted text below)

    230.5 - Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and (Rev. 36, Issued: 06-24-05, Effective: 06-06-05, Implementation: 06-06-05)

    References: §1861(s)(2)(A) of the Act
    42 CFR 410.10(b)
    42 CFR 410.26
    Pub. 100-02, ch. 15, § 60.

    The Benefit. Therapy services have their own benefit under §1861 of the Social Security Act and shall be covered when provided according to the standards and conditions of the benefit described in Medicare manuals. The statute 1862(a)(20) requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions--other than licensing--that would apply to a therapist. (For example, see coverage requirements in Pub. 100-08, chapter 13, §13.5.1(C), Pub. 100-04, chapter 5, and also the requirements of this manual, §220 and §230.

    Incident to a Therapist. There is no coverage for services provided incident to the services of a therapist. Although PTAs and OTAs work under the supervision of a therapist and their services may be billed by the therapist, their services are covered under the benefit for therapy services and not by the benefit for services incident to a physician/NPP. The services furnished by PTAs and OTAs are not incident to the therapist’s service.

    Qualifications of Auxiliary Personnel. Therapy services appropriately billed incident to a physician’s/NPP’s service shall be subject to the same requirements as therapy services that would be furnished by a physical therapist, occupational therapist or speech-language pathologist in any other outpatient setting with one exception. When therapy services are performed incident to a physician’s/NPP’s service, the qualified personnel who perform the service do not need to have a license to practice therapy, unless it is required by state law. The qualified personnel must meet all the other requirements except licensure. Qualifications for therapists are found in 42CFR484.4 and in section 230.1, 230.2, and 230.3 of this manual. In effect, these rules require that the person who furnishes the service to the patient must, at least, be a graduate of a program of training for one of the therapy services as described above. Regardless of any state licensing that allows other health professionals to provide therapy services, Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology. That means that the services of athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as therapy services.

    The services of PTAs and OTAs also may not be billed incident to a physician’s/NPP’s service. However, if a PT and PTA (or an OT and OTA) are both employed in a physician’s office, the services of the PTA, when directly supervised by the PT or the services of the OTA, when directly supervised by the OT may be billed by the physician group as PT or OT services using the PIN/NPI of the enrolled PT (or OT). (See Section 230.4 for private practice rules on billing services performed in a physician’s office.) If the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA billed incident to the physician’s service, because they do not meet the qualification standards in 42CFR484.4.

    Therapy services provided and billed incident to the services of a physician/NPP also must meet all incident-to requirements in this manual in chapter 15, §60. Where the policies have different requirements, the more stringent requirement shall be met.

    For example, when therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings.

    The mandatory assignment provision does not apply to therapy services furnished by a physician/NPP or "incident to" a physician's/NPP’s service. However, when these services are not furnished on an assignment-related basis; the limiting charge applies.

    For emphasis, following are some of the standards that apply to therapy services billed incident-to the services of a physician/NPP in the physician’s/NPP’s office or the beneficiary’s residence.

    A. Therapy services provided to the beneficiary must be covered and payable outpatient rehabilitation services as described, for example, in this section as well as Pub. 100-08, chapter 13, §13.5.1.

    B. Therapy services must be provided by, or under the direct supervision of a physician (a doctor of medicine or osteopathy) or NPP who is legally authorized to practice therapy services by the state in which he or she performs such function or action. Direct supervision requirements are the same as in 42CFR410.32(b)(3). The supervisor must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician/NPP must be present in the same room in the office where the service is performed.

    C. The services must be of a level of complexity that require that they be performed by a therapist or under the direct supervision of the therapist, physician/NPP who is licensed to perform them. Services that do not require the performance or supervision of the therapist, physician/NPP, are not considered reasonable or necessary therapy services even if they are performed or supervised by a physician/NPP or other qualified professional.

    D. Services must be furnished under a plan of treatment as in §220.1.2 of this chapter. The services provided must relate directly to the physician/NPP service to which it is incident.