Recent Updates from CMS


The Protecting Access to Medicare Act extends the authorization for physician reimbursement under Medicare under current law (Sustainable Growth Rate or SGR) through March 31, 2015, postponing the efforts to reform and improve Medicare physician reimbursement methodology or the “Doc Fix” yet again.

Protecting Access to Medicare Act of 2014 states:

      • Physician Fee Schedule cut of 23.7% is delayed till March 31, 2015 (replace it with a 0.5% conversion factor through December 31, 2014 and a 0.0% update from January 1, 2015 through March 31, 2015)
      • Therapy Cap Exceptions Process (KX modifier) would be extended through March 31, 2015 (including manual medical review)
      • Caps and exception process includes hospital outpatient departments through March 31, 2015.
      • ICD-10 delayed till October 1, 2015.


Currently, Congress has a bipartisan agreement on Sustainable Growth Rate (SGR) repeal policy and the Senate has included provisions to repeal and reform the Medicare therapy cap once and for all. Because of this agreement, it’s imperative that Congress acts on a permanent solution before adjourning at the end of the Congressional year.

Completing this legislation before the end of the year provides an opportunity to end the pattern of yearly extensions that puts access to medically necessary therapy for ~1 million Medicare beneficiaries at risk. Delaying action on this legislation until next year would add the burden of reworking the policy and running up against the March 31, 2015 deadline.

The 114th Congress’ new members are being sworn into office on January 3, 2015 and meeting on January 6, 2015.  The current Congress will be in Lame Duck session.  While it is hopeful they will address the Medicare Access to Rehabilitation Services legislation during this time, it is not likely.


Therapy Caps for 2015

CMS has announced effective January 1, 2015 the cap for outpatient therapy services for the calendar year 2015 for PT/ST combined will be $1940.00; for OT services $1940.00.


HCPCs (CPT) Changes

Specifically, CR 8985 updates the code list by adding HCPCS Codes 97607 (Neg press wound tx) and 97608 (Neg press wound tx >50 cm) to the “sometimes therapy” codes and deleting HCPCS Codes G0456 and G0457 from the 2015 therapy code list. Code 97608 replaces current code G0457 effective January 1, 2015 and 97607 replaces current code G0456 effective January 1, 2015.


ADR Timeframes Revised

Change Request (CR) 8583, instructs MACs and Zone Program Integrity Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond within 45 days of a pre-payment review ADR will result in denial of the claim(s) related to the ADR. Make sure your billing staffs are aware of these changes.