AOTA-APTA-ASHA Proposal for Limiting Manual Medical Reviews of Outpatient Therapy Claims
The Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630), signed February 22, 2012, extended the Medicare Part B Outpatient Therapy Cap Exceptions Process through the end of the calendar year, and, among other things, set a new threshold for outpatient therapy claims beginning October 1, 2012. Amounts toward the cap (which is currently $1,880 for occupational therapy) are tallied beginning January 1, 2012, and certain therapy claims that exceed the threshold amount of $3,700 over the course of the year will be subject to what the new law states is a “manual medical review process.” The law provides for a $3,700 threshold for OT and a separate $3,700 threshold for PT and SLP combined. Congress’ intent was to put in place another point to determine necessity of therapy. AOTA knows that occupational therapists continually determine medical necessity and appropriateness as part of good clinical care and that only about 5% of Medicare beneficiaries receiving therapy exceed $3,700 in therapy costs per calendar year. AOTA is working with CMS leadership now to help shape the manual medical review process. We are advocating for the adoption of a process that is limited in scope, not overly punitive or burdensome to providers, and that includes peer reviews of claims by occupational therapy practitioners wherever possible. As a part of our cooperative work, today AOTA, along with the American Physical Therapy Association (APTA) and the American Speech-Language-Hearing Association (ASHA) submitted a proposal to CMS advocating that certain ICD-9 code pairs and patient conditions be automatically excepted from manual medical review. Please contact AOTA’s Reimbursement and Regulatory Policy Department with questions or comments: rrpd@aota.org.
Resources:
AOTA-APTA-ASHA Joint Letter to CMS (Members Only)
Proposed ICD-9 Code List (Members Only)
AOTA Medicare Part B Outpatient Therapy Cap and Exceptions Process for 2012: FAQs
