CMS Releases Schedule for Manual Medical Review Phase-In

The Middle Class Tax Relief and Job Creation (MCTRJC) Act of 2012 extended the Medicare Part B outpatient therapy cap exceptions process through December 31, 2012.  Through the exceptions process, providers may receive payment for therapy services above the $1,880 cap on outpatient therapy (OT), and the $1,880 cap on physical therapy (PT) and speech language pathology (SLP) services combined, when they are reasonable and medically necessary, require the specialized skills of medical professionals, and are justified by supporting documentation in the patient’s medical record. The MCTRJC Act also required that providers submit a request for an exception for therapy services above the threshold of $3,700 for OT, and $3,700 for PT and SLP services combined. These requests for exceptions will be manually medically reviewed. Providers will be required to submit requests for exceptions to the threshold in advance of furnishing therapy services above the threshold.

The Centers for Medicare and Medicaid Services (CMS) is phasing in its new manual medical review policy of requiring pre-approval for therapy provided to a patient that will exceed the $3,700 cap.  CMS has assigned providers to one of three phases.  Phase 1 starts October 1st, Phase 2 begins November 1st, and Phase 3 begins December 1st.  CMS has posted information on which phase each provider has been assigned.  If a provider is not listed in Phase 1 or 2, then they are in Phase 3. Providers are listed by their National Provider Identifier (NPI).

Additional information about the Manual Medical Review process is below.

CMS Therapy Cap Fact Sheet

CMS Manual Medical Review FAQ

Phase-In Schedule Information

SODF Transcript

CR 6698: Signature Guidelines