Therapy Cap

On December 21, 2005, the Senate approved the FY 2006 Budget Reconciliation Conference Report. The bill contains a legislative victory for the therapy community, as provisions implement a program that fixes the outpatient therapy cap for 2006. ASHT applauds the membership that answered “action alerts” and contacted their legislators on this issue. Their action helped shape this positive outcome as Congress listened to constituents and members of the therapy community. The provision:

• Creates a process (by the Secretary of Health and Human Services) in which beneficiaries enrolled in Medicare may request an exemption from the $1,760 (approximate) dollar limitation for outpatient therapy services.
• Services deemed medically necessary will be reimbursed.
• The approval is passive. If the Secretary does not respond that the service is not medically necessary within 10 business days of receiving the request, the care can be provided.
• Implements clinically appropriate code edits to identify and eliminate improper payments for therapy services.

Next, the bill will return to the House for a procedural vote and then President Bush will sign the legislation into law.

Originally, the Budget Reconciliation bills in the House and Senate differed a great deal. The House version did not include any language that dealt with the cap, while the Senate’s bill called for a one-year moratorium of the outpatient therapy cap. While this outcome is a victory for the therapy community, a permanent fix will still be needed in 2007.

Two members of Congress, one member of the House and one from the Senate, have taken up the call to permanently fix the therapy cap. Last year, both H.R. 1125, introduced by Representative English (R-PA) and S.1024, introduced by Senator Ensign (R-NV), sought to repeal the Medicare caps on outpatient rehabilitation therapy. This year Representative English and Senator Ensign have reintroduced this legislation as H.R. 916 and S.438 with the same goal in mind. Although the Budget Reconciliation has postponed the $1,760 cap, a permanent fix remains a priority for ASHT.

ASHT's Position:   Support the legislation and repeal the cap.

For more information about H.R. 916 and S.438 please CLICK HERE.

Direct Access

Last year, H.R. 792 and S. 493, the "Medicare Patient Access to Physical Therapists Act of 2003," were aimed at amending Medicare in order to authorize qualified physical therapists to provide services for Medicare beneficiaries without the requirement of a "primary care" physician referral. Both pieces of legislation, however, preserve the existing law that requires Medicare beneficiaries to obtain a physician referral before seeking the care of an occupational therapist. This legislation has been reintroduced in the House of Representatives by Representative Hart (R-PA) as H.R. 1333 and in the Senate by Senator Lincoln (D-AR) as S. 647.

ASHT's Position:   No formal position, although currently ASHT is carefully considering its stance on this issue.

For more information about H.R. 1333 and S. 647 please CLICK HERE.

Competitive Bidding on Durable Medical Equipment (DME)

Section 302 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, authorizes the Secretary to utilize a competitive acquisition authority, and requires Medicare to replace the current DME payment methodology for certain items with a competitive acquisition process. This new bidding process will establish payment amounts for certain DME, enteral nutrition, and off the shelf orthotics. In addition, last year both Representative Hobson (R-OH) and Representative McCarthy (D-NY) introduced legislation that would repeal the reduction in Medicare payment for certain items of DME.  

There has been no new legislation introduced in the 109th Congress.

ASHT's Position:   Oppose the CMS regulation which allows less qualified individuals to provide DME to patients, and which may cause delay in treatments due to the necessity of a bidding process. Support legislation to repeal the reduction in Medicare reimbursement for DME.

HCPCS: Code Revision/Reimbursement

HCPCS is divided into two subsystems:   Level I and Level II

Level I:   CPT-4, a numeric coding system maintained by the AMA to identify medical services and procedures furnished by physicians and other healthcare professionals.

Level II:   Standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 Codes.

There have been no new HCPCS legislation/regulations introduced this year.

ASHT's Position:   Level II "L" codes should be revised.

30 Day Rule

The 30 day rule requires that patients visit their physician every thirty days to continue treatment and therapy.

There has been no new legislation/regulations regarding the 30 day rule introduced this year.

ASHT's Position:   The 30 day rule is a barrier to effective and consistent treatment and it should be eliminated.