LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2013-03 Manual Medical Review of Outpatient Therapy Claims Will Begin April 1

Jurisdiction 11 Part B
Manual Medical Review of Outpatient Therapy Claims Will Begin April 1

On January 2, 2013, President Barack Obama signed the American Taxpayer Relief Act of 2012. Section 603 of this Act, contains a number of Medicare provisions which directly impacts claims submitted for outpatient therapy services. Revisions of the Financial Limitation for Outpatient Therapy Services – Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012 requires Original Medicare to temporarily apply therapy caps (and related provisions) to therapy services furnished in outpatient hospital settings between the dates of January 1 through December 31, 2013.

What you need to know
Effective April 1, 2013, Recovery Auditors will begin the process of reviewing all therapy claims, which have exceeded the $3,700 threshold cap for the year. Importantly, there are two separate thresholds triggering manual medical reviews (MMRs) and build upon the separate therapy caps as follows: one for occupational therapy (OT) services, and; one for physical therapy (PT) and speech language pathology (SLP) services combined. Although PT and SLP services are combined for triggering the threshold, the medical review will be conducted separately by discipline. Additional conditions include the requirement that all suppliers and providers who report on the beneficiary’s claims for therapy services provide the National Provider Identifier (NPI) of the physician (or non-physician practitioner where applicable) who is responsible for reviewing the therapy plan of care.

Recovery Auditors will complete two types of review:
Prepayment Review:
Eleven states will be participating in the Recovery Audit Prepayment Review Demonstration. All therapy claims that have exceeded the $3,700 therapy cap threshold for the year will be reviewed and compared to the medical record before the claim is processed for payment. The demonstration will occur in the following 11 states (FL, CA, MI, TX, NY, LA, IL, PA, OH, NC and MO).
If the Recovery Auditors determine an improper claim has been submitted, a review results letter will be sent to the provider, which clearly documents the rationale for the determination. The letter provides vital information to the provider regarding the Recovery Auditors findings and detailed description of the Medicare policy or rule that was violated.
Typical Additional Documentation Requests (ADR) limits will not apply. All therapy claims at or above the $3,700 threshold cap will trigger the MMR process and will need to be reviewed by the Recovery Auditors.
The Recovery Auditors will conduct prepayment review within 10 business days of receiving the medical record.
The ADR will be sent to the provider by the Medicare Administrative Contractor (MAC) with instructions to send the records to the Recovery Auditor
Post Payment Review:
In the remaining states, the Recovery Auditors shall conduct immediate post-pay reviews
All therapy claims that have exceeded the $3,700 therapy cap threshold for the year will be reviewed and compared to the medical record after the claim has been processed for payment.
If the Recovery Auditors determine an improper payment has resulted, a demand letter will be sent to the provider, which clearly documents the rationale for the determination. The letter provides vital information to the provider regarding the Recovery Auditors findings and detailed description of the Medicare policy or rule that was violated.
Typical ADR limits will not apply. All therapy claims at or above the $3,700 threshold cap will trigger the manual medical review process and will need to be reviewed by the Recovery Auditors.
The ADR will be sent to the provider immediately after the claim is paid. The ADR will be sent by the MAC to the provider with instructions to send the records to the Recovery Auditor.

The threshold cap will accrue for claims with dates of service from January 1 through December 31, 2013. The therapy cap applies to all Part B outpatient therapy settings and providers including:
Private Practices
Part B Skilled Nursing Facilities
Home Health Agencies (TOB 34X)
Outpatient Rehabilitation Facilities (ORFs)
Rehabilitation Agencies (Comprehensive Outpatient Rehabilitation Facilities)
Outpatient Hospitals

Questions
Additional guidance on the MMR process for Therapy claims above the $3,700 threshold, as well as helpful medical review guidelines can be found on the Therapy Cap web page. For all additional questions, please contact the appropriate Recovery Audit Contractor (RAC) and/or A/B MAC in your region at their toll-free number, which may be found on the Provider Compliance Group Interactive Map.

TDL 13263

last updated on 03/28/2013