What is restorative nursing?
Restorative nursing refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible and attain maximum functional potential. The restorative nursing program actively focuses on achieving and maintaining optimal physical, mental and psychosocial function.
Why is it important to implement a well-planned restorative nursing program?
The concept of restorative nursing actively focuses on optimal improvement of the resident's physical, mental and psychosocial functioning. Communication and documentation of resident progress is vital for the success of restorative programs.
Learn More: docs/Developing_a_Restorative_Nursing_Program-1 (2).pdf
E2XPONENTIAL™ Health Care Consulting Group, A HealthPRO Company, is offering a comprehensive mock RAC Audit to assess the following areas:
- Medicare Eligibility
- MDS 3.0 Technical Audit
- Rehabilitation Therapy
- Clinical Audit
This 1-2 day Mock RAC audit will help your facility be proactive in Securing Medicare Part A Revenue.
Learn more docs/RAC_Audit_Flyer_CMS-1 (2).pdf.
On March 21, 2013, CMS updated its Therapy Cap Services webpage with the final guidance on Manual Medical Review (MMR) for therapy claims above $3,700. Below is the policy posted by CMS.
The American Taxpayer Relief Act of 2012 (ATRA) was signed into law by President Obama on January 2, 2013. This law extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013. Section 603 of this Act contains a number of Medicare provisions affecting the outpatient therapy caps and manual medical review (MR) threshold.
The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,900 for 2013, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,900 for 2013. This is an annual per beneficiary therapy cap amount determined for each calendar year. Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. Per beneficiary, services above $3,700 for PT and SLP services combined and/or $3,700 for OT services are subject to manual medical review. CMS is not precluded from reviewing therapy services below these thresholds.
Beginning April 1, 2013, Recovery Audit Contractors (RACs) will conduct prepayment review for all claims processed on or after April 1, 2013.
Medicare Administrative Contractors (MACs) will conduct prepayment review on claims reaching the $3,700 threshold with dates of service January 1, 2013 to March 31, 2013. CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process. Effective April 1, 2013, the Recovery Auditors will conduct prepayment review for all claims processed on or after April 1, 2013.
Recovery Auditors will complete two types of review.
Claims submitted in the Recovery Audit Prepayment Review Demonstration states will be reviewed on a prepayment basis. These states are Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri.
In these states, the MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor (unless another process is used by the MAC and the Recovery Auditor).
The Recovery Auditor will conduct prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision.
In the remaining states, the Recovery Auditors will conduct immediate post-payment review.
In these states, the MAC will flag the claims that meet the criteria, request additional documentation and pay the claim. The MAC will send ADR to the provider requesting the additional documentation be sent to the Recovery Auditor. The Recovery Auditor will conduct post--payment review and will notify the MAC of the payment decision.
Section 603 (b) of the American Tax Relief Act counts outpatient therapy services furnished in a Critical Access Hospital (CAH) toward a beneficiary’s annual cap and threshold amount using the Medicare Physician Fee Schedule rate. CAHs are not subject to the therapy cap, the manual medical review process, or the use of the KX modifier.
Please contact CMS with questions about the therapy cap review process at [click here].
Senior care communities are looking for ways to drive revenue through ancillary services, and many are turning to on-site rehabilitation and therapy as strategy to counteract shrinking Medicare reimbursement margins for skilled nursing care.
Continuing care retirement communities (CCRCs) in particular have the ability to harness potential revenue from Medicare Part B, which provides coverage and payment for outpatient therapy services, including physical therapy, occupational therapy, and speech-language pathology services, says Richard Boyson, Jr., Chief Financial Officer at Therapy Partners, a division of Baltimore, Maryland headquartered HealthPro Rehab, based in Middleburg, Ohio.
- Settlement in the Medicare Improvement Standard case, Jimmo v. Sebelius, was approved on January 24, 2013 by a federal judge during a scheduled fairness hearing.
- Case involved woman denied Medicare coverage for treatment of her chronic diabetes related conditions.
- As a result of the settlement with the Department of Health and Human Services, individuals who need maintenance care for conditions that are not improving CAN NO LONGER BE DENIED MEDICARE COVERAGE UNDER AN IMPROVEMENT STANDARD.
- CMS will need to update policy manual and undertake an educational campaign to increase awareness of the policy.
- Determining issue for Medicare coverage is whether the SKILLED SERVICES of a health care professional are needed NOT whether the beneficiary will improve.
- Skilled services covered when they are required to maintain a patient’s condition, or prevent further deterioration.
- Standards apply NOW.
- Applies to both Medicare Part A and Medicare Part B services.
- Applies to Medicare Advantage as well as traditional Medicare programs.
- Settlement not limited to particular conditions or diseases. Applies to anyone who requires skilled service to maintain or slow deterioration regardless of underlying illness, disability or injury.
- Applies in Medicare home health, outpatient therapy and skilled nursing facility settings.
- Settlement does not increase the coverage benefit period of 100 days in a SNF.
- Settlement is retroactive to January 18, 2011.
- A re-review process will be established by CMS for beneficiaries who received a denial for skilled services. Support will be provided by our therapy teams for clients and patients who will need to participate in the process to be established by CMS and the MACs.
- Indicate in the Plan of Treatment that the services being provided are skilled maintenance services.
- Indicate the diagnosis for which the skilled maintenance services are being provided and reason for current intervention.
- Be sure to justify skilled intervention in daily and weekly notes to support services.
- Be sure to tie the treatment provided in the maintenance program to functional activities that will maintain the patient’s quality of life.
On New Year’s Day Congress passed the American Taxpayer Relief Act of 2012. The main purpose of this legislation was to stop the automatic tax increases and federal budget cuts that took effect on January 1, 2013. This legislation also included provisions related to the Medicare program.
- PART B REIMBURSEMENT: There is now a delay to the planned cut in Medicare reimbursement for all services paid by the Physician Fee Schedule which include outpatient therapy services. The announced spending cut for payments was to be 26.5% for 2013. Under the legislation, the conversion factor is set at 0, which means payments will remain relatively unchanged for 2013. Specifics related to the impact on therapy CPT codes to follow.
- MULTIPLE PROCEDURE PAYMENT REDUCTION (MPPR): For therapy services furnished on or after April 1, 2013 the 25% multiple procedure payment reduction is increased to 50% for all providers.
- THERAPY CAP
- Previous legislation set the therapy cap for 2013 at $1900 for PT/ST combined and $1900 for OT.
- The therapy cap extension process has been extended to 12/31/13.
- The therapy cap is extended to hospital outpatient settings through 12/31/13.
- The therapy cap is extended to therapy furnished as part of outpatient critical access hospital services.
- The Manual Medical Review process is extended through 12/31/13 for claims at or above $3700 for PT/ST combined and a separate $3700 for OT.
- SEQUESTRATION CUTS: Postponed until March 1, 2013. Under these cuts Medicare providers would see a 2% reduction in payment.
Additional information will be provided as clarification is received from our national associations.
If you have questions related to these changes, please contact your Regional Vice President for clarification.
On November 1, 2012 CMS released the CY 2013 Physician Fee Schedule Final Rule.
Key provisions are as follows:
- Final rule contains a 26.5% across the board reduction to Medicare payment rates effective 1/1/13. Congress has overridden the required reduction every year since 2003.
- Therapy cap amount for 2013 is $1900 for PT/ ST combined and $1900 for OT.
- An exceptions process to the caps has been in effect since 1/1/2006. If Congress does not act to extend the exceptions process, the exceptions process for the $1900 cap and the manual medical review for claims over $3700 expires 12/31/2012.
NEW THERAPY PROVISIONS
- CMS will collect information on functional status of beneficiaries requiring PT, OT, and ST on 1/1/2012 to assist with developing potential alternatives to the therapy caps.
- Information for functional outcomes will be reported on claims and in therapy documentation through the use of Non-payable G-codes and modifiers.
- Reporting requirements apply to all providers and suppliers of outpatient therapy services. This includes services provided in a Skilled Nursing Facility for residents who receive Part B therapy.
- These non-payable G-codes will be used to define functional limitations. Reporting is required on 1 functional limitation. If the primary functional limitation goal is achieved, reporting will begin on a subsequent functional limitation using another set of G-codes.
- G-codes will be used to describe the functional limitation that is primary to the plan of care:
- Mobility: Walking and Moving Around
- Changing and Maintaining Body Position
- Carrying, Moving and Handling Objects
- Self- Care
- Other PT/OT Primary Functional Limitations
- Other PT/OT Subsequent Functional Limitations
- Motor Speech
- Spoken Language Comprehension
- Spoken Language Expression
- Other SLP Functional Limitation
- Modifiers will be required for each functional limitation to report the severity and/or complexity utilizing a 7 point scale.
- 0% impaired, limited or restricted
- At least 1% but less than 20% impaired, limited or restricted
- At least 20% but less than 40% impaired, limited or restricted
- At least 40% but less than 60% impaired, limited or restricted
- At least 60% but less than 80% impaired, limited or restricted
- At least 80% but less than 100% impaired, limited or restricted
- 100% impaired, limited or restricted
- CMS continues to require the use of objective measures to document functional status. A specific assessment tool or test is not required. Therapists may elect to use the most appropriate measure.
- A projected goal for the beneficiary’s functional status at the end of the therapy episode will be translated to the G-code/modifier scale and reported on the first claim.
- Reporting Frequency
- Outset of therapy: current status and projected goal status
- At least once every 10 treatment days. PROGRESS REPORTS WILL BE DUE EVERY 10 TREATMENT DAYS NOT EVERY 10 TREATMENT DAYS OR 30 CALENDAR DAYS WHICH EVER IS FIRST. CMS Manuals will be changed.
- If there is a significant change in beneficiary condition resulting in formal re-evaluation
- Implementation date is 1/1/2013 with enforcement beginning on 7/1/2013.
On October, 31, 2012, Kathleen Sebelius, Secretary for the Department of Health & Human Services, informed Senator Harry Reid, Majority Leader, United States Senate, and Speaker of the House John Boehner, that as a consequence of Hurricane Sandy in New York, she has determined that a public health emergency exists and has existed since October 27, 2012 in the State of New York, and that on November 2, 2012, she intends to waive or modify certain HIPPAA and Medicare, Medicaid, and Children’s Health Insurance Program requirements as indicated in the Waiver or Modification of Requirements Under Section 1135 of the Social Security Act. These waivers or modifications will become effective at 12:00 PM EST on November 2, 2012, and will be retroactive to October 27, 2012. We expect that CMS may issue additional details following execution of this waiver by Secretary Sebelius.
Click here to view the letters and the waiver:
In the wake of Hurricane Sandy, providers up and down the east coast are dealing with the dangerous storm’s aftermath and experiencing many challenges. The physical damage, power outages, flooding, and closures of mass transportation systems are creating staffing shortages as people struggle to get to work. Many dedicated staff have been spending consecutive days/nights at their facility to make up for those who cannot get to work so that patient care is not interrupted. These staffing challenges are sometimes exacerbated by facilities who have accepted patient overflow from hospitals forced to evacuate. As a result, many providers, most especially those in NY, NJ, and CT, are going the extra mile to maintain patient care under very challenging conditions.
To address this issue, HealthPRO® has been working collaboratively with providers to coordinate staff sharing and facilitate coverage. In addition, we have reached out to association leaders at the state and federal levels to ask for relief from CMS related to the MDS COT/EOT and Manual Medical Review Process for Cap Extension rules during this difficult time. There is precedent for this type of relief – during Katrina CMS issued a waiver temporarily lifting ARD regulations to ease the burden of care. Some states have also temporarily lifted staffing restrictions in terms of supervision of registered therapists and assistants during times like this.
We share the plight of our partners in this challenging time and are both in the trenches working to solve the immediate issues and strategically promoting a moratorium on stringent requirements that could punish providers financially during an already difficult time. We encourage everyone to make their issues known through the associations so that a clear message reaches CMS.
As you know, October was the first month in a three-month rollout of CMS’ Manual Medical Review process, intended to help control spending for Medicare Part B services by instituting a pre-payment review for claims above $3,700.
So far in the first month, we have seen a fair amount of variability in the way the individual MACs are interpreting this initiative and processing claims. Some are denying claims outright, others are quick to respond and seem focused on appropriately limiting expenses incurred above the caps, some are slow to respond, and still more seem to be struggling with the quality and quantity of response communications. Several providers have reported receiving multiple letters related to the same patient claim and/or authorizations that don’t address which discipline has been approved. Providers themselves seem to be responding differently with some electing to be more conservative with programming and others operating business as usual.
As with all regulatory changes, the key is having an organized approach: understanding the success drivers, continuing to create treatment plans that meet the clinical needs of those in our care, ensuring good documentation, and implementing a strong tracking mechanism. Medicare Part B has the most stringent documentation requirements of any payer – now more than ever it is critical to justify services and clearly document goals, related treatment, and progress.
HealthPRO®, has created an extensive approach to mitigate risk and manage the process, while maintaining excellent clinical care. Our strategy entails self-imposing a cap at $2,700 to allow for processing and uninterrupted treatment time. In addition, we are recommending a pre-submission review for each claim so that our compliance team can make recommendations to ensure the best possible outcome. The pre-existing charges are now updated in the common working files for Medicare. These must be entered into the therapy technology system for all Medicare B patients being treated in the month of October. This will also help identify any high risk preauthorization cases that may currently be on caseload. The pre-existing charges MUST be identified for each patient that is identified for therapy, which requires good communication between Therapy and Finance. In addition, a specific report has been created to help identify and manage associated risk.
So far, our approach has proven successful and we believe that with good clinically-driven programs, strong documentation, and proactive management, this regulatory requirement can be managed effectively. It is possible that some providers who were routinely delivering services beyond the cap will experience a downward shift in caseload volume and billable Part B services. While this can be a concern from a revenue standpoint, there is likely to be a concomitant cost-savings related to the overall volume of therapy.
The MedPAC Commissioners have described this process as offering “administrative tools to manage the therapy benefit.” MedPAC Chairman, Glenn Hackbarth, put these draft recommendations into context by saying,” he doesn’t want to recommend hard caps or go back to a hard cap. He wants to put these payment controls in place to control spending.” There was almost unanimous agreement among Commissioners for the following draft recommendations.
The final mandated report on “Improving Medicare’s Payment System for Outpatient Therapy Services” is due on June 15, 2013. However, Congress asked MedPAC to forward their recommendations in early- November so they are relevant to the discussion that will take place during the Lame-Duck session, when Congress is expected to consider Medicare extenders, which includes extending the therapy cap exceptions process that expires on December 31, 2012. These recommendations could be appealing to Congress to help “fund” a give back of the 27% physician fee schedule reduction. The Commissioners are expected to vote on the final Outpatient Therapy Services recommendations during the November 1-2, 2012, meeting.
A summary of the rollout process and claims processing guidelines can be found at
[click here] and search by your provider number.