In 2012, CMS made some major changes to the Medicare Part B benefit. One of these changes included removing the exempt status to hospital-based outpatient departments, or HOPDs. At this news, most of us shrugged our shoulders, and continued to worry about our own long-term care residents. Well, every time we send our patients to the hospital for rehab-related tests, exams, or services, these services are billed to Medicare Part B, and therefore, reduce our cap allowances.

So, the most common of these events would be sending a patient to the hospital to receive a modified swallow study through speech therapy. This could be a small oversight, but it could have major impacts on our ability to successfully track the therapy cap.

Cap tracking is very important because it alerts our business office when to apply –KX modifiers as proof of medically necessary and “automatic exception” approved services, as well as when to submit “pre-approval” requests due to the manual medical review process.

Unfortunately, there is no easy solution to this problem. But I have a few ideas. The current process of updating a resident’s cap amount is through checking the “Common Working File” (CWF). This file is a master list of all Medicare Part B therapy services billed for the year to date. It’s a good system, but it’s not always accurate. If another provider, such as another SNF, outpatient clinic, hospital, etc. is delayed in its billing of services, the Common Working File has no current record of these services. In terms of reimbursement, Medicare Part B pays whichever provider submits the claims first.

The problem becomes when we ignore the CWF because the resident has been a long-term care resident at our facility since Jan. 1 of the current year. Another scenario may be where we are quickly approaching our $3,700 limit, but we fail to include the hospital-based outpatient therapy services in our calculations. (Some good news: The cost of the modified-barium video fluoroscopy does not count against our cap limits. However, the billing charges that the hospital-based speech therapist charges are counted towards our cap limits.)

So here are my recommendations:

·       Request a copy of the billing sheet in addition to a copy of the report when patients receive hospital-based outpatient department services

·       Notify your business office to regularly check the Common Working File

·       Consider portable options — some communities are able to offer portable swallow studies that can come to your SNF. If your speech therapist administers the swallow study, her services are billed through the SNF and they’re easier to track.

I’m sure there are many more loopholes. We’re still just beginning to realize some of them, so I hope to bring attention to as many of them as possible. If you have noticed any other concerns or issues with these new Med B regulations, please feel free to comment below or contact me directly at

Shelly Mesure (“Measure”), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a much sought after speaker and writer on therapy and reimbursement issues.