This message relates to speech-language pathology services provided in Medicare Part B outpatient therapy settings, including hospital outpatient departments. If you provide services in an inpatient hospital setting, please forward this to the appropriate individuals in your facility's outpatient department.
On October 1, 2012, outpatient hospital-based speech-language pathology therapy services will be subject to the Medicare therapy cap. SLPs in hospital outpatient departments should understand that, while this process may be new in their facilities, for years SLPs in other Part B settings have successfully rendered medically necessary treatment, through the "exceptions process," to those patients who require services over the $1,880 therapy cap.
CMS will host a Special Open Door Forum (ODF) [PDF] for providers to ask questions on Wednesday, September 26, 2012, 3:00 p.m.–4:00 p.m., Eastern Time. The conference number is 866-501-5502; Conference ID is 34261274.
ASHA has compiled the necessary information for all Medicare Part B providers to understand the application of the therapy cap, the exceptions process, and the pre-approval process for the manual medical review:
Here are some quick facts and tips that every provider should be aware of:
- Therapy caps are applied to fee-for-service, Medicare Part B (outpatient) services, and do not include Critical Access Hospitals, Part A (inpatient) therapy, or privately contracted Medicare plans (i.e., Medicare Advantage).
- Therapy services performed in private practice, Part B skilled nursing facilities, home health agencies (only as Part B clinics), outpatient rehabilitation facilities (ORFs), rehabilitation agencies, comprehensive outpatient rehabilitation facilities (CORFs), and hospital outpatient departments are included in the total amount.
- Services performed in hospital outpatient departments will not be available in the patient eligibility file until October 1, 2012, but will include all services performed beginning January 1, 2012.
- Only those services provided in hospital outpatient settings on or after October 1 are subject to the requirements for (a) the exceptions process for services exceeding $1,880 and (b) beginning October 1, the new manual medical review pre-approval process for services above $3,700.
- Therapy caps include dollars paid by Medicare Part B, co-payments, and co-insurance; and can be accessed through the Medicare Administrative Contractors (MAC) patient eligibility files. ASHA has created a MAC Resource for therapy provider, which includes links to key sites.
- Hospital providers should not check the beneficiary's therapy dollar amount until October 1. The total dollar amount will not be updated to include hospital outpatient therapy claims until that date. Providers can, however, begin preparation for the manual medical review pre-approval process 15 days prior to their application date (Phase 1, Phase 2, or Phase 3).
Hospital outpatient departments should also consider contacting referral sources to provide education regarding the exceptions process, which will allow the continuation of medically necessary services exceeding the $1,880 therapy cap.
For more information, please contact ASHA's health care economics and advocacy team at email@example.com.