As you probably know by now, CMS is changing its policy on therapy services. This should come as no surprise since they also made extensive changes to their chiropractic policy in April of 2012. As a brief summary, under the new guidelines, after the $1880 cap is met, the KX modifier will allow additional payment up to $3700 at which time the provider will need to precertify any additional treatment. This will begin in phases. We have outlined some information below and on page 4 of this newsletter. In addition, you can go to our website at CBCbilling.com for a copy of the provider bulletin from Novitas, as well as copies of the pre-certification forms. We also encourage you to visit your Medicare carrier’s website for more info.
Which “Phase” your personal NPI # is listed under will decide when you are required to start with pre-cert.
Phase 1 – October 1st – December 31st
Phase 2 – November 1st – December 31st
Phase 3 – December 1st – December 31st
You can find this information out by going to https://data.cms.gov/dataset/Therapy-Provider-Phase…/ucun-6i4t and entering the personal NPI. If the personal NPI is not listed, Novitas has indicated you are automatically assigned to Phase 3. All offices should have received a letter by now advising as to which phase the provider is in.
Note the following important points:
1. For services up through $1880 (this means the “allowed amount”. Not just what is paid. It includes the deductible amounts, coins & payments), submit them with CPT codes & applicable modifiers (eg. 97140 – 59)
2. For services from $1881 up through $3700 (this means the “allowed amount”. Not just what is paid. It includes the deductible amounts, coins & payments), submit CPT codes, applicable modifiers (eg. 97140 – 59) AND the KX modifier.
3. For services over $3700 (this means the “allowed amount”. Not just what is paid. It includes the deductible amounts, coins & payments), you need precertification. Once Medicare receives the pre-cert request, they have 10 business days to get a response to the office by either phone, fax, or letter (depends on what you list on the form for NY or the letter you send in for NJ, etc.). They will authorize up to 20 consecutive DOS per authorization…this doesn’t mean that you will get 20, it just means that they will allow no more than 20 per request. Per the phone conference 9/27/12, the authorization is NOT a guarantee of payment.
4. NJ providers must utilize the designated forms and include the information listed on the “Part B Therapy Cap Cover/Transmittal Sheet”, and fax to 717-526-6560. NY providers also have a specific form that must be used, and faxed to 717- 565-3783. Please visit your Medicare carrier’s website for more information.
5. To find out how much of the $3700 has been processed for your patient, you can call 877-235-8073 for NJ providers & for NY providers you can call 877-869-6504. According to Medicare, this information will be available after October 5, 2012. Please visit your Medicare carrier’s website for more information.
