Welcome to The Billers' Association For Long-Term Care

The Billers’ Association for Long-Term Care is a membership community created specifically for long-term care billing professionals. This national association provides members with a resource of continuously updated tools, billing-specific education, and reimbursement and regulatory guidance. Become a member today and join your long-term care billing colleagues as you navigate the evolving world of post-acute care billing.

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CMS update changes requirements for functional reporting

Feb 01, 2019
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The Bottom Line

CMS announced an update on therapy caps and functional reporting in an MLN Matters article dated January 25, 2019. Effective for dates of service on or after January 1, 2018, providers of therapy services shall continue to report the KX modifier on claims as applicable. The modifier no longer represents an exception request but serves as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record after the beneficiary has exceeded the threshold of incurred expenses

New CMP amounts adjusted for inflation and quarterly updates to NCCI PTP edits available

Jan 25, 2019
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The Bottom Line

New CMP amounts that have been adjusted for inflation and are effective October 11, 2018 were announced in a final rule published by CMS on January 22, 2019. The adjusted amounts apply to CMPs assessed on or after October 11, 2018. For SNFs, NFs and SNF/NFs, the CMP Analytic Tool instructions and calculations will be updated to reflect these changes. Appendix A of the final rule announcement contains the new rates, which have seen an increase.

CMS alert: CY2019 DMEPOS fee schedule update and KX modifier amounts

Jan 18, 2019
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The Bottom Line

CR 11064 (MLN Matters) provides the Calendar Year 2019 annual update for the Medicare DMEPOS fee schedule. The update includes information on the data files, new and deleted HCPCS codes, adjusted fee schedule amounts, and other information related to the update of the fee schedule. Click here to read the full article.

KX modifier amounts announced for CY19

Dec 07, 2018
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The Bottom Line

The annual per-beneficiary incurred expense amounts are now known as the KX modifier thresholds. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 (BBA of 2018) was signed into law. CMS recently posted a MLN Matters article with these amounts for CY2019, which were lowered by the BBA of 2018 which are as follows.

Two jurisdictions announce new Targeted Probe and Educate topic

Oct 19, 2018
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The Bottom Line

The MACs for the J5 (Iowa, Kansas, Missouri, and Nebraska) and J8 (Indiana and Michigan) jurisdictions (WPS Government Health Administrators) announced that CMS has authorized them to conduct a Targeted Probe and Educate (TPE) review of outpatient therapy (CPT code 97110). The announcement was made on October 15 on the WPS website. The webpage states thatThis is a required process for providers identified by Medical Review. The TPE review process incudes three rounds of prepayment or post-payment probe review with education. If high denial rates continue after three rounds or review, WPS GHA will refer the provider and results to CMS. CMS will determine any additional action, which may include but is not limited to extrapolation, referral to the Unified Program Integrity Contractor (UPIC), and/or referral to the Recovery Audit Contractor (RAC).”

New proposed payment system, part I: Case-mix components drill-down

Jun 08, 2018
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Billing Alert for Long-Term Care

With the release of the proposed rule on April 27, 2018, the Centers for Medicare & Medicaid Services (CMS) introduced the Patient-Driven Payment Model (PDPM) with a proposed implementation date of October 1, 2019. This model is intended to replace the current prospective payment system reimbursement structure, Resource Utilization Groups, Version IV (RUG-IV), and significantly revises the Resident Classification System, Version I (RCS-I), which was introduced to the industry as a proposed RUG-IV replacement in an Advanced Notice of Proposed Rule Making (ANPRM) in 2017. RCS-I and PDPM were developed in conjunction with Acumen, a consulting group hired by CMS, and an interdisciplinary technical expert panel.

Proposed payment rule PDPM: What SNFs need to know

Jun 01, 2018
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The Bottom Line

The Patient-Driven Payment Model (PDPM), as proposed, is designed to replace the current SNF payment methodology known as RUG-IV. Unless date changes, etc. are made by CMS post commentary review, the effective date of the change (from resource utilization groups to PDPM) is October 1, 2019. PDPM as an outgrowth of the initially proposed resident classification system (RCS) and received commentary is a simplified payment model designed to be more holistic in patient assessment, capture more clinical complexity, eliminate or greatly reduce the therapy focus by eliminating the minute levels for categorization, and simplifying the assessment process and schedule (reducing to three possible assessments/MDS tasks). Below is a summary of PDPM core attributes/features as proposed. Click here to access the PDPM Calculation Worksheet for SNFs that provides additional details beyond the reference points below.

Patient-driven payment model, survey, and quality: Understanding MDS accuracy and what you need for success

May 11, 2018
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Billing Alert for Long-Term Care

On Friday, April 27, 2018, the Centers for Medicare & Medicaid Services (CMS) published a highly anticipated proposed rule containing a recommendation to replace the existing case-mix classification methodology, the Resource Utilization Groups, Version IV (RUG-IV). The proposed model, Patient-Driven Payment Model (PDPM), significantly revises the Resident Classification System, Version I (RCS-I), which was introduced as a potential RUG-IV replacement last April in an Advanced Notice of Proposed Rulemaking.

Tips to avoid improper payments for lower limb orthoses

May 04, 2018
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The Bottom Line

CMS recently reported that the Medicare Fee-For-Service (FFS) improper payment rate for lower limb orthoses was 66.7 percent, representing a projected improper payment amount of $319.6 million. The agency’s 2017 reporting period indicates the following reasons for improper payments for lower limb orthoses: Insufficient documentation errors (92.2 percent); No documentation (2.1 percent); Medical necessity (1.5 percent).

CMS makes major revisions to RCS model, introduces new proposed Patient-Driven Payment Model

Apr 30, 2018
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The Bottom Line

Many concerns and questions from stakeholders followed the introduction of the Resident Classification System (RCS),  a proposed replacement for the Prospective Payment System’s RUG-IV model published in an Advanced Notice of Proposed Rule-Making (ANPRM) last April. Highly anticipated ever since, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule late Friday, announcing significant revisions to the RCS model. The result? The Patient-Driven Payment Model (PDPM).

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