Therapy Cap/Manual Medical Review (MMR)

Target therapy medical review is required by the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA extended through December 31, 2017, the exceptions process for therapy caps, set at $1,960 for occupational therapy and $1,960 for physical therapy and speech therapy combined in 2016, and directed CMS to target certain therapy claims over $3,700 for manual medical reviews rather than review every claim above that threshold. This policy outlines two criteria, which appear to broaden the scope of claims that could be subject to review, and states that the evaluation of the number of units/hours of therapy provided in a day will be of particular interest in this medical review process. CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis. The SMRC will be selecting claims for review based on:

• Providers with a high percentage of patients receiving therapy beyond the threshold as compared with their peers during the first year of MACRA.
• Therapy provided in skilled nursing facilities, therapists in private practice, and outpatient physical therapy or speech-language pathology providers or other rehabilitation providers.
• Summary of Requirements for Therapy Cap Targeting Criteria
• Medicare Outpatient Therapy Cap Implementation Fact Sheet
• CMS Therapy Services Homepage