Therapists Required to Submit Threshold Exception Request by Year-end

If your office provides physical therapy (PT), speech-language pathology (SLP), or occupational therapy (OT) services, you may receive a letter titled “Notification of Request for Exception Requirements for Therapy” from the Centers for Medicare & Medicaid Services (CMS). All therapy services rendered above the $3,700 threshold set by Congress are subject to manual medical review. Beginning Oct. 1, some therapy providers will also be required to submit requests for exceptions (pre-approval for up to 20 therapy treatment days for beneficiaries at or above the $3,700 threshold).

The requirement to submit an exception request will be phased in over the next three months. Therapy providers will be assigned to one of the following three groups or phases.

  • Phase I October 1 to December 31, 2012
  • Phase II November 1 to December 31, 2012
  • Phase III December 1 to December 31, 2012

You can find your assigned phase here. If you do not find your national provider identifier (NPI) number on the list, then you are in Phase III.

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2 Responses to “Therapists Required to Submit Threshold Exception Request by Year-end”

  1. Rolando Deguzman says:

    Please verify if the interpretation below is correct:
    Our hospital is in Phase II. If by October 1, patient has already reached >$3700 (from January 1 – September 30, 2012), and patient still requires medically necessary therapy, we will request pre-authorization for therapy over $3700 and await authorization prior to continuing with therapy. Medical Review of that patient case will be conducted by Medicare in November. If Medicare finds that services are not covered, pt. is responsible for all of the costs for services (from the beginning of therapy starting 1/1/2012?). Your reply is much appreciated.

  2. Lynn S. Berry, PT, CPC says:

    Part of this is contractor specific. For some contractors, you cannot ask for the pre-authorization more than 15 days prior to the phase. So you would continue to treat the patient using the KX modifier on the claim certifying medical necessity and you should be paid for those services up until November 1. If medically necessary, you can ask for the pre-authorization 15 days prior to November 1 (but not sooner). You send in all your documentation (the contractor will specify what they need and if there is a specific form to do so) and they will decide if and how many days they will authorize (up to a maximum of 20) or they will deny your request. Even If they do pre-approve it, there is no guarantee of payment as Medicare can review your documents at any time. The pre-authorization is usually a special review by the contractor with particular reviewers just doing the pre-authorization (due to budget constraints). However, there is nothing to say that they could not review all of the documents also (perhaps in a separate review) and possibly deny if they believe there is not medical necessity or if there is insufficient documentation to pay. You should definitely self-audit prior to sending your request to make sure all requirements are met. The patient would only be responsible for any denied claims for which you had issued them an ABN saying that Medicare is not likely to cover the specific services or may not cover the services and that they have signed that they will then be responsible and you append the appropriate modifier. Otherwise, they can take the money back from you and the patient is not responsible for payment.

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