The Centers for Medicare and Medicaid Services (CMS) has released 2 transmittals regarding the manual medical review process for outpatient therapy services that exceed $3,700. The manual medical review process, which approves or denies requests for therapy services in advance, goes into effect October 1.
Transmittal 1117 provides a list of the documentation and information that physical therapists must submit to their Medicare Administrative Contractors (MACs) to get approval for therapy services when patients exceed $3,700. The transmittal also provides guidance on MACs responsibilities in the review process. Specifically, MACs must make a decision (number of days approved and/or denied) and inform the provider and beneficiary (by telephone, fax, or letter; if by letter the letter must be postmarked by the 10th day) within 10 business days of receipt of all requested documentation. Failure to make a decision within 10 business days will lead to an automatic approval of the request.
If the request is denied, the contractor must provide a letter of denial to the provider and beneficiary. The provider letter must have detailed reasons (eg, not enough evidence of skilled care is not sufficient detail).
CMS recently assigned providers to 1 of 3 phases for manual medical review:
No automatic exceptions apply to claims above $3,700 for claims submitted by providers in their respective phase.
A provider education article related to this instruction will be available on CMS' website shortly.
In addition to providing details on the automatic and manual medical review exception processes, Transmittal 2537 clarifies that therapy evaluations performed after the therapy caps are reached to determine if the patient needs continued services would be exempt from the cap. CPT Codes 97001 97002 are included in this exception for evaluation services.