Manual Medical Review for Outpatient Therapy: Implementation Phases, Documentation, and the Pre-Approval Process
The Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630) requires that outpatient therapy claims over $3,700 ($3,700 for OT services, and $3,700 for PT and SLP services combined) be subject to manual medical reviews. The Centers for Medicare & Medicaid Services (CMS) has announced that reviews will begin October 1, 2012. Occupational therapy practitioners furnishing services to Medicare beneficiaries will be impacted, including those in the following settings:
- private practices,
- Part B skilled nursing facilities,
- home health agencies (TOB 34X),
- rehabilitation agencies (outpatient rehabilitation facilities-ORFs), and
- comprehensive outpatient rehabilitation facilities.
They will be implemented in three phases: the first beginning October 1, the second beginning November 1, and the third beginning December 1. The reviews are currently slated to sunset December 31, 2012, barring additional Congressional legislation. A list of provider NPIs and their corresponding phases may be found here. Part B outpatient therapy providers that are not listed on this page are in Phase 3.
For additional implementation information, see CMS Therapy Cap Fact Sheet, Requests for Exceptions to the Therapy Threshold: Manual Medical Review Process (FAQs); Transmittal 1124 Manual Medical Review of Therapy Services (eff. October 1, 2012); Transmittal 2537 Expiration of 2012 Therapy Cap Revisions and User-Controlled Mechanism to Identify Legislative Effective Dates (eff. January 1, 2013); MLN MM7881 Expiration of 2012 Therapy Cap Revisions and User-Controlled Mechanism to Identify Legislative Effective Dates (eff. January 1, 2013) and MLN MM7785 Revisions of the Financial Limitation for Outpatient Therapy Services – Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012.
CMS recently held three Open Door Forums (ODFs) for providers related to this issue, on September 5, September 26, and October 22. Information provided on these calls (including therapy documentation guidelines and clarifying supervision requirements can be found on the Physicians, Nurses and Allied Health Professionals ODF webpage. On the most recent call, CMS leadership and contractor representatives from First Coast Service Options, Novatis Solutions, and WPS addressed some of the ongoing problems with the pre-approval process, but not all of the issues that providers and associations – including AOTA - have reported. The contractor representatives cited issues such as incomplete and/or improper NPIs and HICNs on forms, incomplete or duplicate forms, sending the request to the right location (not directly to CMS), including a fax number for return, and ensuring that requested treatment days fall within the provider’s assigned phase (I, II, and III). CMS clarified that evaluations over the threshold amount are covered, but subsequent treatment is subject either to pre-approval or manual medical review. CMS also clarified that if 20 treatment days are approved, there is no time limit for those services.
AOTA staff encourage all therapy providers to participate in relevant CMS ODFs and to sign up for their carrier’s listserv. AOTA is closely following the implementation of the manual medical review process and actively providing feedback about ongoing problems to CMS based on reports from members. Review AOTA’s Medicare Part B Outpatient Therapy Cap and Exceptions Process for 2012: FAQs and email information about your experiences to the Reimbursement and Regulatory Policy Department at firstname.lastname@example.org