Issue: February 7, 2019

Published on February 7, 2019

Articles in this issue:

2019 Medicare Part B Fee Schedule

Author: Carl J. Pucci* Published in Finance & Reimbursement

Attached is the 2019 Medicare Part B Fee Schedule, effective 1/1/19 through 12/31/19. To identify the amount for your facility, please locate the appropriate CPT/HCPCS code and match it to the respective facility location column.

As a reminder, the Medicare Part B outpatient therapy cap (KX Modifier) amounts are updated and are $2,040 for occupational therapy, and $2,040 for physical therapy and speech therapy services combined for CY 2019. The targeted medical review process, now-termed Medical Review threshold, amount is $3,000 for PT and SLP services combined and $3,000 for OT services. The Final Rule also reminds providers that the application of therapy caps and therapy caps exception process was repealed effective 1/1/18.

Please refer to the AHCA bulletin below, which provides details of the methodology, as well as related CMS links.

Thanks again to the efforts of Tony Marshall, President and CEO of the Georgia Health Care Association; AHCA is able to offer members the 2019 therapy fees for each CPT/HCPCS Code in each geographic area on our website under the “Medicare Part B Fee Schedules” heading. Please note that the fees effective January 1, 2019 are calculated based upon the Revisions to Payment Policies Under the Physician Fee Schedule (MPFS) and Other Revisions to Part B for Calendar Year (CY) 2019 Final Rule (CMS-1693-F) published in the Federal Register on November 23, 2018.  

Details about the Excel format 2019 therapy fees file workbook on our website are listed below under the heading “AHCA 2019 Medicare Part B Therapy Fees File Details”. 

On November 23, 2018, the Centers for Medicare and Medicaid Services (CMS) published the CY 2018 Medicare Physician Fee Schedule (PFS) Final Rule (CMS-1676-F) in the Federal Register.  This final rule reflects the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which repealed the Sustainable Growth Rate formula and provisions related to Medicare payment contained in the Bipartisan Budget Act of 2018 (BBA of 2018) signed into law on February 9, 2018. 

The CY 2019 conversion factor is $36.0391 which reflects the update adjustment factor of 0.25 percent and the budget neutrality adjustment of -0.14 percent. Further, the BBA of 2018, Section 50201 - Extension of Work Geographic Practice Cost Index (GPCI) Floor, extended a provision raising the Work GPCI to 1.000 for all localities that currently have a Work GPCI of less than 1.000 through December 31, 2019. Additionally, as required by the ACA, the 1.5 work GPCI floor for Alaska and the 1.0 practice expense GPCI floor for frontier states are permanent, and therefore, applicable in CY 2019.

You may note that after all required adjustments, the conversion factor has increased from $35.9996 for CY 2018 to $36.0391 for CY 2019. However, Table 94 in the Final Rule titled CY 2019 PFS Estimated Impact on Total Allowed Charges by Specialty indicates that, due to relative changes in the weights of various PFS procedure codes, the value of Part B physical and occupational therapy code payments in aggregate will decrease ~1% in 2018.

The final rule continues the multiple procedure payment reduction (MPPR) policy for “always therapy” services.  The MPPR policy required, effective April 1, 2013, a 50 percent reduction to be applied to the practice expense component of payment for the second and subsequent “always therapy” service(s) that are furnished to a single patient by a single provider on one date of service (including services furnished in different sessions or in different therapy disciplines). The MPPR worksheet lists those “always therapy” services subject to the MPPR policy and the reduced fee payment amounts.

Further, the final rule updates the Medicare Part B therapy CPT code list for CY 2019 by deleting two codes (64550 and 96111).

While not impacting fee schedule pricing, the final rule also reminded providers that, effective for January 1, 2018, Section 50202 of the BBA of 2018 repealed the application of the therapy caps and the therapy caps exceptions process while also retaining and adding limitations to ensure appropriate therapy. 

A separate provision of Section 50202 of the BBA of 2018 preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. Claims for therapy services above these amounts without the KX modifier are denied. These amounts are now known as the KX modifier thresholds. Just as with the incurred expenses for the therapy cap amounts, there is one KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined and a separate amount for occupational therapy (OT) services. For CY 2019, the KX modifier threshold amounts are: (a) $2,040 for PT and SLP services combined, and (b) $2,040 for OT services. The targeted medical review process, now-termed Medical Review threshold, amount is $3,000 for PT and SLP services combined and $3,000 for OT services. Please see Transmittal 4178/Change Request 11055 and Centers for Medicare and Medicaid Services (CMS) MLN Matters article MM11055 for complete information on the KX modifier thresholds.

Finally, supporting documentation and downloads for Regulation #CMS-1693-F may be found here. An overview of the Physician Fee Schedule Payment Policies may be found here and an overview of skilled nursing facility consolidated billing and annual updates may be found here

AHCA 2019 Medicare Part B Therapy Fees File Details

The 2019 therapy fees for each CPT/HCPCS Code in each geographic area are provided in the attached Excel file. The file contains the following information:

  1. The 2019 Medicare Part B Fee Schedule for Outpatient Rehabilitation for each Carrier and Locality (Part B Fees)
  2. The 2019 Medicare Part B MPPR Fee Schedule for "Always Therapy Services (50% MPPR Factor) for each Carrier and Locality (MPPR Fees)
  3. The 2019 Relative Value Units for each Outpatient Rehabilitation Therapy Code (RVUs)
  4. The 2019 Geographic Practice Cost Indices by Medicare Carrier and Locality (GPCI)
  5. The 2019 Counties Included in 2018 Localities (GPCI Counties) (Same as 2017)

The Part B Fee Schedule amounts are calculated as follows:
 ((A1 x B1) + (A2 x B2) + (A3 x B3)) x Conversion Factor (Part B Fees), and
 ((A1 x B1) + ((A2 x B2) x (1-MPPR Factor) + (A3 x B3)) x Conversion Factor (MPPR Part B Fees), where:
        A1 = Physician Work RVU
        A2 = Non-Facility Practice Expense RVU
        A3 = Malpractice RVU
        B1 = Work GPCI
        B2 = Practice Expense GPCI
        B3 = Malpractice GPCI

        Conversion Factor = $36.0391

        MPPR Factor = 50%

Medicare Expired Legislative Provisions Extended and Other Bipartisan Budget Act of 2018 Provisions

Physician Fee Schedule (MPFS) and Other Revisions to Part B for Calendar Year (CY) 2019 Final Rule (CMS-1693-F) – November 23, 2018 Federal Register 

Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2019 – Regulation # CMS-1693-F 

Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule – Transmittal 4176/Change Request 11063 

Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule MLN Matters Article – MM11063 

Annual Update to the Per-Beneficiary Therapy Amounts (KX Modifier Thresholds) for CY 2019 – Transmittal 4178/Change Request 11055 

Annual Update to the Per-Beneficiary Therapy Amounts (KX Modifier Thresholds) for CY 2019 MLN Matter Article – MM11055

Physician Fee Schedule Payment Policies 


Carl J. Pucci
Chief Financial Officer
518-462-4800 x36

National Nursing Home Special Campaign Report

Author: Lisa Volk and Nancy Leveille* Published in Clinical & Quality

The National Nursing Home Campaign recently released their January 2019 Report. In this report they highlight a number of their current resources, free webinars on topics of All Cause Harm Prevention, Dementia Care and Psychotropic Medication Tracking tools, etc. They are continually updating their resources for all SNF with the goal of improving quality services. NYSHFA recommends that you review their resources. See attached report and links. 


Nancy Leveille, RN, MS
Executive Director
518-462-4800 x20

Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15

DEA National Drug Take Back Day 4-28-19


National Drug Take Back Day is scheduled for April 28, 2019. Attached are the Frequently Asked Questions for Class 3A (Institutional Dispenser, Limited) Facilities Only. Click on the links below for the BNE forms you will need to participate in the Drug Take Back Day.

DOH-2340 – Request to Destroy Drugs Form

DOH-2340 Instructions to Request to Destroy

DOH-166 -Drug Inventory List


Improving Oral Health: Practice, Policy and Potential - Statewide Conference February 28 - March 1, 2019

Author: * Published in Clinical & Quality

The Foundation for Quality Care (FQC) and The New York State Oral Health Coalition (NYSOHC) have worked hard to put together a conference that will create an opportunity for you to expand your oral health knowledge, develop policies and network with a variety of health professionals from New York State and Nationally. The FQC was awarded a grant from the New York State Health Foundation to provide the Mouth Care Without a Battle Program in 22 Nursing Homes in New York State. The Mouth Care Without a Battle Program brought together various organizations including University of North Carolina founders of the Mouth Care Without a Battle Program and the New York Dental Hygienist Association (NYDHA) to assure the successful implementation of the program. As a result, the NYSOHC and the FQC are collaborating to bring you a two-day statewide conference that you will not want to miss! We are confident that you will find this conference to be beneficial. Who Should Attend? Administrators, DONs, Nursing Staff, Dentists, Dental Hygienists, Elder Care Providers and Advocates, Oral Health Professionals, CE & NAB Credits Available to DDS, RDH and Licensed Nursing Home Administrators. Please see attached brochure and registration information.


Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15

Early Bird Rates Extended! NYC-ACHCA 50th Annual Convention


Early Bird Rates have been extended to February 14th!
Don’t miss Tuesday Night’s Installation Banquet. Cornelius Murray and Jerome Levy to be Honored for their dedication and years of service to our industry.

Join us as we honor Cornelius Murray and Jerome Levy for their contributions in area of health law.

Cornelius Murray is a senior partner with O'Connell & Aronowitz Health Law practice and supervising partner of their Appeals, Constitutional Law and Casino & Gaming practices. He has represented numerous and varied clients in the health care industry and is currently General Counsel for the New York State Health Facilities Association where he focuses on issues involving complex Medicare and Medicaid reimbursement issues, regulatory compliance and Certificates of Need.

Jerome Levy practices in the area of health law. He has conducted a range of administrative negotiations and civil litigation on behalf of health care providers with State and Federal regulatory authorities. He negotiates and prepares agreements related to mergers and acquisitions and other transfers of ownership and also handles licensure applications for new operators, professional discipline matters and new construction.

Click here
for registration details. 

Registration Now Open!! 70th Annual Conference & Expo

Author: * Published in Education

Registration is now open! Join NYSHFA/ NYSCAL for the 70th Annual Conference & Expo, May 6-9th at Turning Stone Resort & Casino. This year we are pleased to announce Jim Boeheim, Head Basketball Coach at Syracuse University as our opening Keynote Speaker. Other hot topics include: Workforce Challenges; The Opioid Crisis; Staff Retention; DOH Updates; Lab Service; Dining Challenges and many more. 

Click here for more details and registration options. 



PDPM Academy Workshop – March 5, 2019

Author: * Published in Education

Join NYSHFA in partnership with AHCA for this NYSHFA Member only in-depth PDPM Academy Workshop. The program will be held March 5th at the Albany Marriott located at 189 Wolf Road, Albany, NY.  The program will present by two top industry experts: Dr. David Gifford, Senior Vice President, Quality & Regulatory Affairs at AHCA and Ms. Maureen McCarthy, President of Celtic Consulting LLC. Registrants will have access to: PDPM 101 workshop webinar (Pre-Requisite for March 5th day program); the March 5th in-person training workshop; Monthly workshop webinars on key topics and emerging PDPM issues; “How To” webinars on implementing additional tools developed by AHCA.  At the in-person workshop, participants will go in-depth with hands on experiential learning by: Aligning buildings and companies to transition to PDPM using AHCA’s PDPM Readiness Tools© and the related core competencies; Classifying residents in case mix groups; Assessing market position in a PDPM environment; and Using organizational, business, and management tools to reconfigure business planning.  Things to know: The new patient driven patient model (PDPM) begins October 1, 2019; Patient clinical characteristics in totality will determine payment; Quick and highly accurate assessment and diagnosis will be critical; Payment will no longer be focused on therapy minutes and ADLs but will rely on over 180 MDS item fields; Failing to accurately code patient needs will have a significant impact on adequate and accurate payment for high quality care; Staff roles must change to operate effectively under PDPM.

For more information and registration details click here

Staff Contact:
Lisa Volk
(518) 462-4800 ext. 15

Registration Now Open! PDPM-Successful Implementation and Understanding the Changes to SNF Post-Acute Care Medicare Reimbursement

Author: * Published in Education

Join NYSHFA in association with Zimmet Healthcare Services Group for our One-Day Seminar entitled PDPM-A Program Designed for Successful Implementation and Understanding the Changes to SNF Post-Acute Care Medicare Reimbursement.
A generational change to SNF work flow including facility admission decisions, assessments, documentation utilization review and care delivery. The new payment system consists of four distinct reimbursement pillars that are focused on the individual needs and characteristics of residents admitted to facility. This program will teach participants the underlying criteria of PDPM and payment requirements including operational changes for success. Critical thinking by the clinical team coupled with “work smart” gathering of information and documentation will result in facilities being on the winning side of CMS changes.

Click one of the three locations for additional details and registration options:

April 9, 2019 – Turning Stone Resort
April 10, 2019 – del Lago Resort & Casino
April 18, 2019 – LaGuardia Marriott

Registration Now Open! 16th Annual Social Services & Activities Conference

Author: * Published in Education

Registration is Now Open! Join NYSHFA / NYSCAL at the 16th Annual Social Service & Activities Conference being held March 28-29, 2019 at the Holiday Inn in Saratoga Springs. Hot topics this year include: Mindful Workplace; Dementia Population; Mental Fitness; Care Planning; and Department of Health updates.

Click here for more details!

Audio Conference - Behavioral Based Interviewing

Author: * Published in Education

Join NYSHFA / NYSCAL on February 15th for our Behavioral Based Interviewing Audio Conference. 

This program will review important requirements that will allow the attendee to perfect their interview skills. After the training attendees will be able to prepare for an interview; describe the Do’s and Don’ts of interview questions; Use behavioral-based interview questions; Explain what to document and how to select the best candidate.

Click here for more details. 


Audio Conference - Requirement of ROP Phase III: CSI-Conducting Successful Investigations

Author: * Published in Education

Join NYSHFA/NYSCAL on February 20th for our Audio Conference entitled "A Requirement of ROP Phase III - CSI: Conducting Successful Investigations". 

CMS mandates that a resident be free from abuse, neglect, misappropriation and exploitation. In response to allegations of this type, skilled nursing facilities are required to report, investigate, protect the alleged victim, take corrective actions if needed and have evidence that the alleged violation was thoroughly investigated.  This program will review pertinent regulatory requirements and discuss non-compliance survey related issues. Participants will receive detailed practical approaches to use when conducting a thorough investigation, gain access to investigative tools for immediate implementation and take back resources their teams can use to incorporate data into routine QAA to become compliant with the upcoming RoP Phase 3 regulations.

Click here for more details.

Audio Conference - Corporate Compliance - Living Under a Microscope in the Year of Compliance

Author: * Published in Education

Join NYSHFA / NYSCAL for an Audio Conference entitled "Corporate Compliance - Living Under a Microscope in the Year of Compliance on Monday, February 25th. During this call, the speakers will address the following: the History of Corporate Compliance, Explain Federal OIG Compliance Guidance, Briefly Describe an overview of the Federal Rules of Participation related to Corporate Compliance, Discuss the NY State Compliance Expectations, Examine the Compliance Environment Today, Explain the Primary Federal Compliance Laws, Illustrate the 7 Federal Elements of Corporate Compliance and strategies to integrate these elements into your corporate compliance program, Discuss the Current Corporate Compliance Planning Process; Compare Your Plan to the Current ROP Requirements and Develop Next Steps to Enhance Your Plan.  The agenda with the call will cover: History; Compliance Today; Federal Elements of Compliance; NY Compliance Expectations; Yates Memo; Communications; Difference Between Rick Management and QAPI; Processes to Employ; Compliance Risk; and Goals for 2019.

For more information click here


Seminar Announcement: Advanced Dementia; Alleviating Distress, Increasing Comfort

Author: * Published in Education

On February 13th and 14th, CaringKind in association with NYSHFA/NYSCAL will host a seminar entitled "Advanced Dementia; Alleviating Distress, Increasing Comfort. The fundamental premise underlying all care for people with dementia is that behavior is communication. This is not a new concept and it is an essential part of all training programs in dementia care. These behavioral expressions are almost always signs of distress, and as the disease progresses, behavior rather than words become the primary mode of communication for most people living with dementia. Comfort—preventing or relieving distress—becomes a cornerstone of care for people with advanced dementia. Special attention will be given to identifying strategies for addressing the role earlier life trauma (such as the Holocaust, or military service) can play in causing distress for people with dementia. Staff trained in dementia care is necessary but insufficient. Organizational systems must be aligned to support a comfort approach and to insure staff efforts are effective. This presentation will address the organizational systems, practices and processes that need to be in place in order to effectively deliver dementia-capable care.

Click here for additional information.