I am working through the last few seasons of Breaking Bad and Dexter, when I get notice of the agreement between House and Senate leaders in preventing the 27.4% pending cut to Medicare payments.  After reading it (starts on page 82), I no longer ask myself why I am drawn to TV shows about a high school chemistry teacher who makes methamphetamine or one about a moral serial killer.

While full vote on this legislation might be as early as today, it is always difficult to filer the consequences of such legislation but here is my stab to decipher:

1. If one cap is good, two is better but let’s call it a Manual Medical Review.

While this blog has taken great pleasure to poke holes at the exception process (see here and here), the message hasn’t quite gotten through to CMS.  Beginning March 1st, there is a mandate to continue the KX modifier to the cap ($1880 for 2012) and then beginning Oct 1, 2012 there is a 1980’s style medical review of patients that exceed $3700.   I can almost hear the fax machines gearing up for what will likely be delayed payments pending a thorough medical review by some CMS staffer.  While they site 2006 process for medical review, in my experience this appears to be something very new and I will refer to it as “the cap beyond the exceptions cap”.  Oh, and by the way, let’s keep PT/speech cap combined since it makes so much sense and OT will have their own $3700 double cap.  Oh, and less you think this is just some wanton policy, there is a provision that by May 1, 2013 (for those still seeing medicare patients) that a GAO report will be sent that will include date on the process, number of reviews, and the outcomes of the reviews (how many denied).

2. We love the plan of care.

While there have been numerous task forces of PT and OT’s who have recommended getting rid of the plan of care, it appears that it will not only stay but that the NPI of the physician who periodically reviews (is it 30 or 60 days?) will now have to be included.  By the way, why not have the PT provider number indexed to their real setting so that data analysis and relationship between referral sources can be documented?

3.  We don’t read data, we just dictate policy.

In some ways, the most asinine change is removing the hospitals from exemption of the therapy cap until end of 2012.  Is this part of some type of Fairness Doctrine?  CMS’ own data clearly shows that their exemption has not given them any competitive advantage in the market and in fact hospitals continue to have less percentage of the outpatient PT market every year.  As a private practice dude, I have never begrudged hospitals having that exemption and believed it should be extended to all settings not taken away from them.

Also under this category there will be by Jan 1, 2013  implementation of a claims based data collection system designed to provide collection of data on patient function during the course of therapy services in order to better understand the patient condition and outcomes.  This will undoubtedly force some new type of modifiers or changes to claims submission.

4. We really care and we never act but it always sounds good.

As with almost every one of these settlements involving outpatient rehab, there is always the windfall to CMS contractors via the mandate that by a certain date (this time June 15, 2013) that MedPAC will submit to various House Committees recommendations on how to reform the payment system so that the benefit is better designed to reflect individual acuity, condition and therapy, and needs of the patient.  This reminds me of a few years ago when there were at least 2 industry task groups gathered under a similar mandate who made all kinds of recommendations (I was privileged to be on one of them) and all were rebuffed.  What did we get instead?  The famous multiple procedure payment reduction (MPPR) which other payers are now putting in place.

By the way, if you think the exceptions process will go on indefinitely, think again. It has only been extended to the end of 2012.

Clarity of much of this will be forthcoming over the next several weeks assuming it passes.  While there will be some celebration that a 27.4% cut has been averted, the implementation of these changes will increase the cost of doing business which really is the same as a cut.  The only piece of good news came in an unrelated release which stated that the ICD-10 implementation has been delayed indefinitely.

Ok, now it is time to go back to my stories.

@physicaltherapy