Adjustment of Therapy Claims Subject to 2010 Medicare Physician Fee Schedule Changes
Health care reform legislation passed by the Obama Administration made some retroactive changes to the 2010 Medicare Physician Fee Schedule, including changes to the way the Centers for Medicare & Medicaid Services (CMS) paid for certain fee-for-services therapy claims subject to the therapy cap during the period of January 1 - May 31, 2010. CMS had been automatically reprocessing claims for that period, but on June 28, 2011, the agency announced that contractors will no longer automatically reprocess claims involving services subject to the therapy cap. Providers must now specifically request that contractors reprocess old therapy claims. AOTA will continue to monitor developments relating to the therapy cap, and we invite you to email us at email@example.com with any billing/payment problems you encounter.
The CMS notice is below in its entirety:
On Tue Mar 23, 2010, President Obama signed into law the Affordable Care Act. Various provisions of the new law were effective Thu Apr 1, 2010, or earlier and, therefore, were implemented some time after their effective date. In addition, corrections to the 2010 Medicare Physician Fee Schedule (MPFS) were implemented at the same time as the Affordable Care Act revisions to the MPFS, with an effective date retroactive to Fri Jan 1, 2010.
Due to the retroactive effective dates of these provisions and the MPFS corrections, a large volume of Medicare Fee-For-Service claims are being reprocessed. We expect that this reprocessing effort will take some time and will vary depending upon the claim-type, the volume, and each individual Medicare claims administration contractor.
We have previously advised providers that, in the majority of cases, they will not have to request adjustments because Medicare claims administration contractors will automatically reprocess claims, and that remains the case. However, there have been situations where the original claim for a service subject to the therapy cap as per Internet Only Manual 100-04, Chapter 5, Section 10.2, was processed without a KX modifier, presumably because the beneficiary had not yet reached the therapy cap and, therefore, no KX modifier was necessary. When processing adjustments for such claims, Medicare contractors have found that the therapy cap was often subsequently reached, causing the adjustment claim to reject, and in some cases for the original claim to be subject to overpayment recovery.
In order to prevent this, contractors will not be automatically processing Affordable Care Act adjustments on claims for services subject to the therapy cap. If you performed services subject to the therapy cap between Fri Jan 1 and Mon May 31, 2010, and if you believe you are entitled to an additional payment as a result of the change to the fee schedule in that year, then you will need to request that your Medicare contractor reopen those claims in order to receive the adjustment. When doing so, you should also indicate which of those services would have been subject to the KX modifier if the therapy cap had been reached when the original claim was processed. While there is normally a one-year time limit for physicians and other providers and suppliers to request the reopening of claims, CMS believes that these circumstances fall under the “good cause” criteria described in the Claims Processing Manual, Publication 100-04, Chapter 34, Section 10.11. CMS is, therefore, extending the time period to request adjustment of these claims, as necessary.
In some cases the Medicare contractor may generate an adjustment claim without the provider requesting it and either return it to the provider (RTP) or deny it. If you receive such a notice, believe you are entitled to an adjustment, and want to pursue the matter, you should contact the Medicare contractor and request it be reopened. You should also indicate whether the service would have qualified for the KX modifier.
The Centers for Medicare and Medicaid Services wants to remind physicians, practitioners and other providers impacted by the retroactive increases in payment rates by the Affordable Care Act and the 2010 MPFS changes of the Office of Inspector General policy related to waiving beneficiary cost-sharing amounts attributable to retroactive increases in payment rates resulting from the operation of new Federal statutes or regulations. The policy may be found here.
Please contact your Medicare claims administration contractor with any questions about this information.