the Centers for Medicare and Medicaid Services (CMS) issued interim guidance on how the manual
medical review process will be implemented in 2013 for outpatient therapy
claims that exceed $3,700.
October 1, 2012, through December 31, 2012, CMS used a prior approval process
at $3,700 under which providers would submit a request to their Medicare
Administrative Contractors (MAC) for approval of up to 20 visits. With the
request, providers would include information from the patients' medical record
(eg, progress reports, daily notes, plan of care) to support the need for the
2013, CMS has replaced the prior approval process with prepayment review, at
least for the interim. Under prepayment review, when the patient reaches $3,700
in outpatient therapy services, the MAC will send the provider an additional
development request (ADR) asking him or her to submit documentation so that the
MAC can determine whether the services are medically necessary. Typically under
Medicare, MACs have 60 days to make a determination. However, CMS has requested that with regard to the therapy cap manual medical review process, MACs decide within 10 days of receipt of the documentation whether the services exceeding
$3,700 will be paid.
currently is working on a long-term strategy for the manual medical review
therapists should consult their MACs' websites for specific information about
submitting documentation in response to an ADR.