Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 13, 2012 PDF

Plus: Hospices must keep promises, one MAC says.

CMS has finally revealed details about the manual medical review process for outpatient therapy dollar amounts exceeding $3,700 with the release of MLN Matters article MM8036, effective Oct. 1

Background: Last February, the Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630) saved the therapy cap exceptions process by a hair -- but not without a catch. Effective Oct. 1, 2012, after a patient hits $3,700 in exceptions, further therapy payments will be subject to manual medical review.

How it works: The first level to therapy cap exceptions stays the same. When you hit the $1,880 therapy cap, bill with the KX modifier -- as long as you're under $3,700 for OT or for PT/SLP combined. If you hit or exceed $3,700 in your claims, your reimbursement will stop, and CMS will request medical records for a prepayment review -- which could take up to 60 days.

Better option: CMS has offered providers to get advanced approval for payments above $3,700, which allows patients to receive up to 20 more days of therapy -- and this approval will take only 10 business days. But you have to apply before your claims hit $3,700. You can submit a request for advanced authorization up to 15 days before manual medical review takes effect. So if you know you're going to reach $3,700, get the ball rolling sooner rather than later.

Resource: To read the MLN Matters article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8036.pdf.