Friday, February 22, 2013 CMS Issues Interim Instructions for Manual Medical Review Process for 2013 Yesterday, 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. From 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 additional visits. For 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. CMS currently is working on a long-term strategy for the manual medical review process. Physical therapists should consult their MACs' websites for specific information about submitting documentation in response to an ADR.