Effective October 1, 2013, hospitals, critical access hospitals, inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCH) will be able to submit claims for Part B payment when Part A therapy services are denied, provided that the claims include the necessary procedure codes and functional outcomes reporting G-codes required for typical Part B services.
In the final rules for the 2014 inpatient prospective payment system (IPPS), Medicare reversed its proposed position of excluding therapy services from the list of services that could be rebilled after a denied inpatient stay because therapy was legislatively defined as outpatient services only. ASHA submitted comments illustrating the inpatient services provided by speech-language pathologists (SLPs) and also requested exemption of those services from Part B therapy cap provisions. CMS agreed that speech-language services are not defined as outpatient-only services and determined it was appropriate to pay for the therapy services furnished to inpatients under Part B when the Part A admission was denied as not reasonable and necessary. However, CMS maintains that all therapy services billed to Part B fall under the therapy cap rules and provisions, including manual medical review and functional outcomes reporting.
SLPs providing services in inpatient settings will need to consider how to manage the Medicare beneficiaries admitted as inpatients and if it is reasonable or feasible to include the G-code in the medical record in case it is needed for reporting a Part B claim at a later date. SLPs using the National Outcomes Measurement System for all of their patients will have the ability to search their submitted cases for the Part A patients and retrieve the Functional Communication Measures scored at admission to therapy.
The Centers for Medicare & Medicaid Services (CMS) was compelled to re-evaluate its policy on inpatient hospital billing regarding denied Part A inpatient claims reversed in high-level appeals. Appeal decisions ordered payment of the services as if they were rendered at an outpatient or "observation" level of care, allowing hospitals to bill Part B for the services and requiring Medicare to issue payment as if the beneficiary had originally been treated as an outpatient rather than an inpatient. In the proposed rules issued in March, CMS expanded the list of services that could be rebilled under these conditions, but determined that therapy services were legislatively defined as outpatient-only services and would not be performed on inpatients. Under this assumption, hospitals would have lost the ability to bill Medicare Part B for therapy services provided in the inpatient setting, and rehabilitation departments would have lost revenue.
The final IPPS rule includes updates to all policies and payment adjustments for services provided in inpatient acute care hospitals and long-term care hospitals.
Centers for Medicare & Medicaid Services (CMS) FY2014 IPPS Final Rule Home Page
ASHA's Medicare Part B Therapy Cap Exceptions Process
ASHA's Claims-Based Outcomes Reporting for Medicare Part B Therapy Services
For more information, please contact Lisa Satterfield, ASHA's director of health care regulatory advocacy, at firstname.lastname@example.org.