Re: Medicare Hospital Outpatient Cap?

[Guest guest]

The cap only applies to outpatient PT, OT, and ST when provided in a clinic.

If they are receiving outpatient services billed through a hospital, the cap

does not apply.

Amy Stelly

Clinic Coordinator (Office Manager)

LeBlanc, Chamberlain and Physical Therapy Services

4027 I-49 South Service Road

Opelousas, Louisiana 70570

Telephone: Facsimile:

________________________________

From: PTManager [PTManager ] On Behalf Of Marita

[mcdaniel@...]

Sent: Tuesday, October 30, 2007 2:05 PM

To: PTManager

Subject: Medicare Hospital Outpatient Cap?

I have a question that I'm hoping someone has the answer to.

If a patient receives treatment at a hospital on an outpatient basis,

are the charges supposed go toward the PT cap? I'm asking because we

have a patient whose previous treatment at the hospital has not gone

toward the cap, but he has showed me the EOB where it was paid.

When I called Noridian and questioned this, the girl couldn't tell me

why it didn't show up.

This patient has stopped treatment because he is afraid that he will go

over the cap and he is not willing to sign an ABN.

Can anybody point me to a regulation that addresses this question?

Thank you!

Marita Mc

Secretary

Dana Austin Physical Therapy

________________________________

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[Guest guest]

I was told by Medicare inpatient charges do not go

towards the cap.

--- Marita wrote:

> I have a question that I'm hoping someone has the

> answer to.

> If a patient receives treatment at a hospital on an

> outpatient basis,

> are the charges supposed go toward the PT cap? I'm

> asking because we

> have a patient whose previous treatment at the

> hospital has not gone

> toward the cap, but he has showed me the EOB where

> it was paid.

> When I called Noridian and questioned this, the girl

> couldn't tell me

> why it didn't show up.

> This patient has stopped treatment because he is

> afraid that he will go

> over the cap and he is not willing to sign an ABN.

> Can anybody point me to a regulation that addresses

> this question?

> Thank you!

>

> Marita Mc

> Secretary

> Dana Austin Physical Therapy

>

>

Diane Mckeon

Medical Billing/ Office Procedures Consultant

cell

__________________________________________________

[Guest guest]

Outpatient therapy services provided at a hospital are

cap exempt and the Medicare allowed amount does not

count towards the therapy cap dollar amount for each

calendar year.

Rick Gawenda, PT

President, Section on Health Policy & Administration

APTA

--- Marita wrote:

> I have a question that I'm hoping someone has the

> answer to.

> If a patient receives treatment at a hospital on an

> outpatient basis,

> are the charges supposed go toward the PT cap? I'm

> asking because we

> have a patient whose previous treatment at the

> hospital has not gone

> toward the cap, but he has showed me the EOB where

> it was paid.

> When I called Noridian and questioned this, the girl

> couldn't tell me

> why it didn't show up.

> This patient has stopped treatment because he is

> afraid that he will go

> over the cap and he is not willing to sign an ABN.

> Can anybody point me to a regulation that addresses

> this question?

> Thank you!

>

> Marita Mc

> Secretary

> Dana Austin Physical Therapy

>

>

__________________________________________________

[Guest guest]

Hospital Based outpatient services are exempt from the Therapy Cap.( Part of the

inconsistencies in Medicare). If he continues his treatment at the hospital

based OP program, as long as it is medically necessary, it should be covered.

Also depending on his diagnosis, there is an exceptions process whereby services

exceeding the cap may be covered. However, that exceptions cap will go away

December 31st, 2007 if Congress does not do something, preferably repeal the

cap. ( Sorry for the political message)

Marcy Stalvey, PT, NCS

Kent, OH

>>> mcdaniel@... 10/30/07 03:05PM >>>

I have a question that I'm hoping someone has the answer to.

If a patient receives treatment at a hospital on an outpatient basis,

are the charges supposed go toward the PT cap? I'm asking because we

have a patient whose previous treatment at the hospital has not gone

toward the cap, but he has showed me the EOB where it was paid.

When I called Noridian and questioned this, the girl couldn't tell me

why it didn't show up.

This patient has stopped treatment because he is afraid that he will go

over the cap and he is not willing to sign an ABN.

Can anybody point me to a regulation that addresses this question?

Thank you!

Marita Mc

Secretary

Dana Austin Physical Therapy

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[Guest guest]

>> Hospital Based outpatient services are exempt from the Therapy Cap.( Part

of the inconsistencies in Medicare). If he continues his treatment at the

hospital based OP program, as long as it is medically necessary, it should

be covered. <<

Thank you, it sure would be nice to get the correct answers from Noridian. I

had called and asked about it when this patient first came in, and they told

me that as long as it was on an outpatient basis, that it would be applied

to the cap.

>> Also depending on his diagnosis, there is an exceptions process whereby

services exceeding the cap may be covered. However, that exceptions cap

will go away December 31st, 2007 if Congress does not do something,

preferably repeal the cap. ( Sorry for the political message) <<

I do know about the exceptions process, and this particular patient's

diagnosis does apply, but he will not sign an ABN because he just does not

want to chance having to pay anything. Well, I guess now we don't have to

worry about the cap for a while.

Thanks again everyone who answered, I really do appreciate it.

Marita Mc

Secretary

Dana Austin Physical Therapy

[Guest guest]

Okay, if the patient goes to the hospital based OP facility they have no cap, we

are all agreed on that.? However, I think Martia is asking a different

question.? If the patient goes to a hospital based OP clinic and incurs $1,200

toward the cap, and then decides they really don't like the hospital clinic and

decides to go to a private practice clinic.? Does the $1,200 they incurred at

the hospital based clinic count toward the cap or do they start at $0.00??

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: Medicare Hospital Outpatient Cap?

I was told by Medicare inpatient charges do not go

towards the cap.

--- Marita wrote:

> I have a question that I'm hoping someone has the

> answer to.

> If a patient receives treatment at a hospital on an

> outpatient basis,

> are the charges supposed go toward the PT cap? I'm

> asking because we

> have a patient whose previous treatment at the

> hospital has not gone

> toward the cap, but he has showed me the EOB where

> it was paid.

> When I called Noridian and questioned this, the girl

> couldn't tell me

> why it didn't show up.

> This patient has stopped treatment because he is

> afraid that he will go

> over the cap and he is not willing to sign an ABN.

> Can anybody point me to a regulation that addresses

> this question?

> Thank you!

>

> Marita Mc

> Secretary

> Dana Austin Physical Therapy

>

>

Diane Mckeon

Medical Billing/ Office Procedures Consultant

cell

__________________________________________________

[Guest guest]

>> If the patient goes to a hospital based OP clinic and

> incurs $1,200 toward the cap, and then decides they really don't like the

> hospital clinic and decides to go to a private practice clinic.? Does the

> $1,200 they incurred at the hospital based clinic count toward the cap or

> do they start at $0.00?? <<

-------------------

That was the exact scenario, thank you for pointing that out, Matt.

Marita Mc

Secretary

Dana Austin Physical Therapy

[Guest guest]

They start at zero. Only therapy provided in a non- hospital based OP setting

counts toward the Cap. The first $1200 does not count toward the CAP.

Doesn't do much for continuity of care does it?

Marcy Stalvey, PT, NCS

Akron General Edwin Shaw Rehab

Akron OH, 441312

>>> acceleratedptbsl@... 11/01/07 01:25PM >>>

Okay, if the patient goes to the hospital based OP facility they have no cap, we

are all agreed on that.? However, I think Martia is asking a different

question.? If the patient goes to a hospital based OP clinic and incurs $1,200

toward the cap, and then decides they really don't like the hospital clinic and

decides to go to a private practice clinic.? Does the $1,200 they incurred at

the hospital based clinic count toward the cap or do they start at $0.00??

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: Medicare Hospital Outpatient Cap?

I was told by Medicare inpatient charges do not go

towards the cap.

--- Marita wrote:

> I have a question that I'm hoping someone has the

> answer to.

> If a patient receives treatment at a hospital on an

> outpatient basis,

> are the charges supposed go toward the PT cap? I'm

> asking because we

> have a patient whose previous treatment at the

> hospital has not gone

> toward the cap, but he has showed me the EOB where

> it was paid.

> When I called Noridian and questioned this, the girl

> couldn't tell me

> why it didn't show up.

> This patient has stopped treatment because he is

> afraid that he will go

> over the cap and he is not willing to sign an ABN.

> Can anybody point me to a regulation that addresses

> this question?

> Thank you!

>

> Marita Mc

> Secretary

> Dana Austin Physical Therapy

>

>

Diane Mckeon

Medical Billing/ Office Procedures Consultant

cell

__________________________________________________

[Guest guest]

Are you saying that the first $1200 in a hospital based setting does not count

toward the cap but that anything over $1200.00 does count toward the cap?

Noreen Giovannone

Shore Rehabilitation Institute

Brick, NJ

Marcy Stalvey wrote:

They start at zero. Only therapy provided in a non- hospital based OP

setting counts toward the Cap. The first $1200 does not count toward the CAP.

Doesn't do much for continuity of care does it?

Marcy Stalvey, PT, NCS

Akron General Edwin Shaw Rehab

Akron OH, 441312

>>> acceleratedptbsl@... 11/01/07 01:25PM >>>

Okay, if the patient goes to the hospital based OP facility they have no cap, we

are all agreed on that.? However, I think Martia is asking a different

question.? If the patient goes to a hospital based OP clinic and incurs $1,200

toward the cap, and then decides they really don't like the hospital clinic and

decides to go to a private practice clinic.? Does the $1,200 they incurred at

the hospital based clinic count toward the cap or do they start at $0.00??

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: Medicare Hospital Outpatient Cap?

I was told by Medicare inpatient charges do not go

towards the cap.

--- Marita wrote:

> I have a question that I'm hoping someone has the

> answer to.

> If a patient receives treatment at a hospital on an

> outpatient basis,

> are the charges supposed go toward the PT cap? I'm

> asking because we

> have a patient whose previous treatment at the

> hospital has not gone

> toward the cap, but he has showed me the EOB where

> it was paid.

> When I called Noridian and questioned this, the girl

> couldn't tell me

> why it didn't show up.

> This patient has stopped treatment because he is

> afraid that he will go

> over the cap and he is not willing to sign an ABN.

> Can anybody point me to a regulation that addresses

> this question?

> Thank you!

>

> Marita Mc

> Secretary

> Dana Austin Physical Therapy

>

>

Diane Mckeon

Medical Billing/ Office Procedures Consultant

cell

__________________________________________________

[Guest guest]

ALL therapy services provided in a hospital based Outpatient setting are exempt

form the Medicare Therapy cap- could be $1200 or $5000- it won't count toward

the cap.

Marcy Stalvey, PT, NCS

Edwin Shaw Rehab

Akron, OH

>>> rdbk07701@... 11/06/07 09:15PM >>>

Are you saying that the first $1200 in a hospital based setting does not count

toward the cap but that anything over $1200.00 does count toward the cap?

Noreen Giovannone

Shore Rehabilitation Institute

Brick, NJ

Marcy Stalvey wrote:

They start at zero. Only therapy provided in a non- hospital based OP

setting counts toward the Cap. The first $1200 does not count toward the CAP.

Doesn't do much for continuity of care does it?

Marcy Stalvey, PT, NCS

Akron General Edwin Shaw Rehab

Akron OH, 441312

>>> acceleratedptbsl@... 11/01/07 01:25PM >>>

Okay, if the patient goes to the hospital based OP facility they have no cap, we

are all agreed on that.? However, I think Martia is asking a different

question.? If the patient goes to a hospital based OP clinic and incurs $1,200

toward the cap, and then decides they really don't like the hospital clinic and

decides to go to a private practice clinic.? Does the $1,200 they incurred at

the hospital based clinic count toward the cap or do they start at $0.00??

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: Medicare Hospital Outpatient Cap?

I was told by Medicare inpatient charges do not go

towards the cap.

--- Marita wrote:

> I have a question that I'm hoping someone has the

> answer to.

> If a patient receives treatment at a hospital on an

> outpatient basis,

> are the charges supposed go toward the PT cap? I'm

> asking because we

> have a patient whose previous treatment at the

> hospital has not gone

> toward the cap, but he has showed me the EOB where

> it was paid.

> When I called Noridian and questioned this, the girl

> couldn't tell me

> why it didn't show up.

> This patient has stopped treatment because he is

> afraid that he will go

> over the cap and he is not willing to sign an ABN.

> Can anybody point me to a regulation that addresses

> this question?

> Thank you!

>

> Marita Mc

> Secretary

> Dana Austin Physical Therapy

>

>

Diane Mckeon

Medical Billing/ Office Procedures Consultant

cell

__________________________________________________

[Guest guest]

Hospital outpatient treatment does not count towards

the cap at all. If someone has been in a hospital

outpatient 3 months, or 6 months, then comes to a

freestanding outpatient facility, the cap initiates at

the freestanding facility.

--- dominick giovannone wrote:

> Are you saying that the first $1200 in a hospital

> based setting does not count toward the cap but that

> anything over $1200.00 does count toward the cap?

>

> Noreen Giovannone

> Shore Rehabilitation Institute

> Brick, NJ

>

> Marcy Stalvey wrote:

> They start at zero. Only therapy provided

> in a non- hospital based OP setting counts toward

> the Cap. The first $1200 does not count toward the

> CAP.

> Doesn't do much for continuity of care does it?

>

> Marcy Stalvey, PT, NCS

> Akron General Edwin Shaw Rehab

> Akron OH, 441312

>

> >>> acceleratedptbsl@... 11/01/07 01:25PM >>>

> Okay, if the patient goes to the hospital based OP

> facility they have no cap, we are all agreed on

> that.? However, I think Martia is asking a different

> question.? If the patient goes to a hospital based

> OP clinic and incurs $1,200 toward the cap, and then

> decides they really don't like the hospital clinic

> and decides to go to a private practice clinic.?

> Does the $1,200 they incurred at the hospital based

> clinic count toward the cap or do they start at

> $0.00??

> Matt Capo, PT

> Accelerated Physical Therapy and Occupational

> Health, Inc.

> Bay St. Louis and Diamondhead, Mississippi

>

> Re: Medicare Hospital

> Outpatient Cap?

>

> I was told by Medicare inpatient charges do not go

> towards the cap.

>

> --- Marita wrote:

>

> > I have a question that I'm hoping someone has the

> > answer to.

> > If a patient receives treatment at a hospital on

> an

> > outpatient basis,

> > are the charges supposed go toward the PT cap? I'm

> > asking because we

> > have a patient whose previous treatment at the

> > hospital has not gone

> > toward the cap, but he has showed me the EOB where

> > it was paid.

> > When I called Noridian and questioned this, the

> girl

> > couldn't tell me

> > why it didn't show up.

> > This patient has stopped treatment because he is

> > afraid that he will go

> > over the cap and he is not willing to sign an ABN.

> > Can anybody point me to a regulation that

> addresses

> > this question?

> > Thank you!

> >

> > Marita Mc

> > Secretary

> > Dana Austin Physical Therapy

> >

> >

>

> Diane Mckeon

> Medical Billing/ Office Procedures Consultant

> cell

>

> __________________________________________________

>