Part B Insider (Multispecialty) Coding Alert

Published on Fri Apr 12, 2013 PDF

If you furnish outpatient Part B therapy, prepare now for some major headaches billing for patients who exceed the $3,700 therapy threshold. Review for therapy claims when the patient has received $3,700 in therapy services is required for Part B therapy. In some states, that review will take place before you get paid, while in the others it will occur afterward.

“Eleven states will be participating in the Recovery Audit Prepayment Review Demonstration,” MAC Palmetto GBA explains on its website. “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 states are Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri.

When reviewers find the submitted claim improper, providers will receive a review results letter with specifics about the decision. “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,” Palmetto says.

Prepay auditors will conduct the review within 10 days of receiving the medical record, the MAC adds.

In the remaining non-demo states, review will occur immediately after the claim is paid, Palmetto explains.

Don’t forget: The $3,700 threshold is reached across all Part B therapy settings — HHAs, therapy practices, Part B skilled nursing facilities, outpatient rehab facilities, CORFs, and outpatient hospitals.