Latest news regarding Medicare Part B Outpatient Therapy Cap and Exceptions Process: 

CMS held a conference on Tuesday August 7th to announce the “manual review process” for Part B therapy claims above the $3700 threshold.  The $3700 threshold for PT and ST combined and $3700 threshold for OT will begin October 1, 2012 and will end on December 31, 2012.

Beginning October 1st, CMS will require  providers to obtain pre-approval  of additional therapy services when a resident exceeds the $3700 threshold.

Providers can make requests in up to 20-day increments and will need to submit the therapy plan of treatment/updated plan of treatment, therapy orders, daily therapy notes, and weekly therapy notes to the MAC for review.

The MACs will have 10 days to provide pre-approval and if the MAC fails to provide a decision to the provider, the request for additional therapy visits is automatically approved.  If the claim is denied, the MAC must explain in detail why.

Rollout will occur in three phases to avoid the MACs from being overwhelmed.  CMS will mail a letter by the end of August to every provider that billed therapy in 2011 stating which phase the provider will be in.  CMS determined which phase the provider falls into based on specific provider characteristics such as claims volume and payment. CMS will also have a table posted on the CMS website were providers can look up their phase as well.  The phases are below.

Phase 1:           October 1, 2012 through December 31, 2012

Phase 2:           November 1, 2012 through December 31, 2012

Phase 3:           December 1, 2012 through December 31, 2012

The manual review process applies to all Medicare Part B outpatient therapy settings and providers.  These include: private practices, skilled nursing facilities, home health agencies, outpatient rehab facilities, comprehensive outpatient rehab facilities (CORFs), and hospital outpatient departments.  Critical Access Hospitals are excluded.

For more detailed information, please review CMS’ therapy cap fact sheet Therapy Cap Fact Sheet as well as CMS’ question and answer document Q & A MMRP document.

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