Sec. 3005. PAYMENT FOR OUTPATIENT THERAPY SERVICES
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## SEC. 3005 PAYMENT FOR OUTPATIENT THERAPY SERVICES ###
(a)Application of Additional Requirements Section 1833(g)(5) of the Social Security Act (42 U.S.C. 1395l(g)(5)), as amended by section 304 of the Temporary Payroll Tax Cut Continuation Act of 2011 (Public Law 112-78), is amended— ####
(1)by inserting “(A)” after “(5)”; ####
(2)in the first sentence, by striking “February 29, 2012” and inserting “December 31, 2012”; ####
(3)in the first sentence, by inserting “and if the requirement of subparagraph
(B)is met” after “medically necessary”; ####
(4)in the second sentence, by inserting “made in accordance with such requirement” after “receipt of the request”; and ####
(5)by adding at the end the following new subparagraphs: > > ##### “(B) > > In the case of outpatient therapy services for which an exception is requested under the first sentence of subparagraph (A), the claim for such services shall contain an appropriate modifier (such as the KX modifier used as of the date of the enactment of this subparagraph) indicating that such services are medically necessary as justified by appropriate documentation in the medical record involved. > > > ##### “(C) > > > ######
(i)> > In applying this paragraph with respect to a request for an exception with respect to expenses that would be incurred for outpatient therapy services (including services described in subsection (a)(8)(B)) that would exceed the threshold described in clause
(ii)for a year, the request for such an exception, for services furnished on or after October 1, 2012, shall be subject to a manual medical review process that is similar to the manual medical review process used for certain exceptions under this paragraph in 2006. > > > ###### “(ii) > > The threshold under this clause for a year is $3,700. Such threshold shall be applied separately— > > > ###### “(I) > > for physical therapy services and speech-language pathology services; and > > > ###### “(II) > > for occupational therapy services.” > . ###
(b)Temporary Application of Therapy Cap to Therapy Furnished as Part of Hospital Outpatient Services Section 1833(g) of such Act (42 U.S.C. 1395l(g)) is amended— ####
(1)in each of paragraphs
(1)and (3), by striking “but not described in section 1833(a)(8)(B)” and inserting “but (except as provided in paragraph (6)) not described in subsection (a)(8)(B)”; and ####
(2)by adding at the end the following new paragraph: > > #### “(6) > > In applying paragraphs
(1)and
(3)to services furnished during the period beginning not later than October 1, 2012, and ending on December 31, 2012, the exclusion of services described in subsection (a)(8)(B) from the uniform dollar limitation specified in paragraph
(2)shall not apply to such services furnished during 2012.” > . ###
(c)Requirement for Inclusion on Claims of NPI of Physician Who Reviews Therapy Plan Section 1842(t) of such Act (42 U.S.C. 1395u(t)) is amended— ####
(1)by inserting “(1)” after “(t)”; and ####
(2)by adding at the end the following new paragraph: > > #### “(2) > > Each request for payment, or bill submitted, for therapy services described in paragraph
(1)or
(3)of section 1833(g), including services described in section 1833(a)(8)(B), furnished on or after October 1, 2012, for which payment may be made under this part shall include the national provider identifier of the physician who periodically reviews the plan for such services under section 1861(p)(2).” > . ###
(d)Implementation **[**[42 U.S.C. 1395l note](/us/usc/t42/s1395l)**]** The Secretary of Health and Human Services shall implement such claims processing edits and issue such guidance as may be necessary to implement the amendments made by this section in a timely manner. Notwithstanding any other provision of law, the Secretary may implement the amendments made by this section by program instruction. Of the amount of funds made available to the Secretary for fiscal year 2012 for program management for the Centers for Medicare & Medicaid Services, not to exceed $9,375,000 shall be available for such fiscal year and the first 3 months of fiscal year 2013 to carry out section 1833(g)(5)(C) of the Social Security Act (relating to manual medical review), as added by subsection (a). ###
(e)Effective Date **[**[42 U.S.C. 1395l note](/us/usc/t42/s1395l)**]** The requirement of subparagraph
(B)of section 1833(g)(5) of the Social Security Act (42 U.S.C. 1395l(g)(5)), as added by subsection (a), shall apply to services furnished on or after March 1, 2012. ###
(f)MedPAC Report on Improved Medicare Therapy Benefits Not later than June 15, 2013, the Medicare Payment Advisory Commission shall submit to the Committees on Energy and Commerce and Ways and Means of the House of Representatives and to the Committee on Finance of the Senate a report making recommendations on how to improve the outpatient therapy benefit under part B of title XVIII of the Social Security Act. The report shall include recommendations on how to reform the payment system for such outpatient therapy services under such part so that the benefit is better designed to reflect individual acuity, condition, and therapy needs of the patient. Such report shall include an examination of private sector initiatives relating to outpatient therapy benefits. ###
(g)Collection of Additional Data **[**[42 U.S.C. 1395l note](/us/usc/t42/s1395l)**]** ####
(1)Strategy The Secretary of Health and Human Services shall implement, beginning on January 1, 2013, a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)). Such strategy shall be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes. ####
(2)Consultation In proposing and implementing such strategy, the Secretary shall consult with relevant stakeholders. ###
(h)GAO Report on Manual Medical Review Process Implementation Not later than May 1, 2013, the Comptroller General of the United States shall submit to the Committees on Energy and Commerce and Ways and Means of the House of Representatives and to the Committee on Finance of the Senate a report on the implementation of the manual medical review process referred to in section 1833(g)(5)(C) of the Social Security Act, as added by subsection (a). Such report shall include aggregate data on the number of individuals and claims subject to such process, the number of reviews conducted under such process, and the outcome of such reviews.
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- Pub. L. 112-78
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