Knowledge Base Article

Do you sometimes feel that your life is a circus? Does this especially apply at times to your role in healthcare? The circus often includes people and animals jumping through hoops – lions, small dogs, clowns - through big hoops, small hoops, or flaming hoops. In Medicare’s clarification concerning reporting “therapy-like” services that appeared in the October 2016 OPPS Update, providers have a choice of hoops.

Before we choose a hoop, let’s consider what exactly Medicare means when they refer to “non-therapy outpatient department services that are similar to therapy services.” Rehabilitative therapy services, that is physical therapy, occupational therapy, and speech language pathology services, are provided by therapists under a plan of care in accordance with Section 1835(a)(2)(C) and Section 1835(a)(2)(D) of the Act and are paid for under Section 1834(k) of the Act. These services require functional limitation reporting and are subject to the therapy cap. Sometimes, hospital outpatients will be provided therapy-like services during the perioperative period of a Comprehensive APC (C-APC) procedure without a certified therapy plan of care. When non-therapy outpatient department services are included on the same claim as a C-APC procedure (status indicator (SI) = J1) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), these services are considered adjunctive to the primary procedure and their payment is included as a packaged part of the payment for the C-APC procedure.

Hoop One

In the July 2016 OPPS Update, CMS put forth a requirement to be effective July 1, 2016, for these non-therapy outpatient department services adjunctive to a C-APC to be reported without HCPCS codes and with revenue code 0940. In comments on the June 8, 2016 Hospital Open Door Forum, CMS stated this change in reporting requirements was due to provider concerns about having to report functional limitation G codes and modifiers with these packaged “therapy-like” services. Provider response to CMS’s explanation was that this solution simply created different problems from the one it solved. Shortly after, CMS delayed the implementation of the reporting change for therapy-like services until October 1, 2016. The October OPPS update gives provider two options for claims received on and after October 1, 2016 for dates of services on and after January 1, 2015. One option continues to be reporting these “non-therapy” therapy services with revenue code 0940 and no HCPCS codes. Hopefully CMS has made modifications to claim processing systems to allow the reporting of revenue code 0940 without HCPCS codes, since this revenue code historically has required the presence of HCPCS codes.

Hoop Two

The second option in the October update for reporting “therapy-like” services adjunctive to C-APCs is that providers can continue to report these with the therapy revenue codes (042x, 043x, and 044x) and with therapy HCPCS/CPT codes. However, if a provider chooses this option, they must follow all the requirements of rehabilitative therapy code reporting, including occurrence codes, therapy modifiers, and the reporting of functional limitation G codes and modifiers. The therapy cap will not be affected since payment for these services is packaged into the comprehensive APC payment.

So do you want to jump through the hoop into the lion’s mouth or the flaming hoop? Your choice, but neither one is without its complications.