Close up image of a caretaker helping older woman walk
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Another proposed rehab rule threatens to cut significant revenues from long-term care providers.

The rule applies to the Medicare Physician Fee Schedule. It would reduce Medicare Part B reimbursement for secondary procedures when residents receive more than one therapy service on the same day.

Specifically, it would reduce the practice expense (a cost component in the Physician Fee Schedule) by 50% for a second procedure. Third and four procedures also would receive the 50% cut.

If this takes effect, it would reduce therapy reimbursement among all Medicare Part B settings where Part B is reimbursed by 12%, said Peter Clendendin, executive vice president for the National Association for the Support of Long Term Care. That translates to $500 million across the board, he said. Skilled nursing facilities, which are one of the larger providers of this type of therapy, would see a bigger loss than the other providers.

Not pretty, Clendenin notes, especially because it comes on top of the concurrent therapy rule, which is set to start in October, and, of course, the longstanding Part B therapy caps.

“You add this to concurrent therapy in Part A and the therapy cap in Part B, it’s starting to get to be a number of therapy issues and can create some real instability,” he said.

A bit surprising

The proposed rule, which the Centers for Medicare & Medicaid Services introduced in June, was a bit of a surprise, Clendenin said. CMS introduced such a rule for surgeons four years ago and for X-ray imaging three years ago. He said he sensed it would be coming.

But the troubling part is that skilled nursing providers operate in a different way than other therapy providers, the industry veteran explained. Residents don’t usually receive therapy services one after another. They make take two in the morning, come back and then do one in the afternoon. That means that some of the rituals that CMS believes are redundant still have to occur.

“To have the reduction for that third code is really inappropriate because you have to start all over again,” he said. 

Finding efficiencies

The purpose of the rule is to find efficiencies, Clendenin explained. CMS claims there is a duplication between the therapy codes.

Clendenin offers an example that could occur in the skilled nursing setting:

Mrs. Jones has therapy in the morning—wheelchair positioning and gait training. CMS allots three minutes for greeting and gowning of the patient. Both those codes—wheelchair positioning and gait training—have a three-minute allowance for greeting and gowning.

CMS believes that if Mrs. Jones goes directly from wheelchair positioning to gait training, there is no need to greet and gown again. So the agency has decided that for wheelchair positioning it will pay 100%, but for gait training, it will reduce the practice expense by 50%. 

Some of that efficiency makes sense, Clendenin said, but CMS already took such duplications into account back in the 1990s.

“I think this clearly is way over the top,” Clendenin said, adding his group intends to fight this proposed rule “pretty hard.” 

Proposed rules are subject to a 60-day comment period. You can bet nursing home providers will take full advantage of that.