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  • CMS Issues Transmittals on Manual Medical Review Process

    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:

    • Phase I Providers: Subject to manual medical review October 1 - December 31, 2012
    • Phase II Providers: Subject to manual medical review November 1 - December 31, 2012
    • Phase III Providers: Subject to manual medical review December 1 - December 31, 2012

    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. 


    • I heard that they can later deny services even if they approved it prior. Is this true?

      Posted by Tiffany Enns on 9/7/2012 10:12 PM

    • Yes, it is true.

      Posted by Rick Gawenda -> =IY`?L on 9/8/2012 6:24 PM

    • Are critical access hospitals still exempt from caps for therapy services?

      Posted by andrea myszak on 9/10/2012 11:54 AM

    • Is there a form that we have to fill out for the requests for PT sessions beyond the $3700 limit? And how do we find out which MAC to send the request to?

      Posted by Alex Mariano on 9/10/2012 2:50 PM

    • I also would like to know if there is a form. I have not been able to find one on CMS so far.

      Posted by Cyndi Ballenger, CPC on 9/11/2012 10:21 AM

    • for michigan the mac is WPS and the form is on their website www.wpsmedicare.com and if you search for forms it is the request for advance preapproval for therapy services above $3700.00. all the instructions were on the form.

      Posted by Eileen Miller on 9/12/2012 7:24 AM

    • The individual MACs have the forms - not CMS. Palmetto GBA, Novitas Solutions, NGS all have forms and instructios available on their website. You need to find out who your MAC is for your practice/center and check their website. Critical Access hospitals (CAHs) are exempt.

      Posted by Robert Clark on 9/13/2012 3:56 PM

    • When filling in Date Range of Services, is this the date your treatment starts...or the approx date the $3700.00 overage will start?

      Posted by JoAnne Beck on 9/14/2012 7:25 AM

    • What is reviewed to know if services will be approved past the $3700. Is it all done online? Will we need to fax all notes and Rx or just do a Re-eval and compare to Initial? Or will an examiner come to review everthing?

      Posted by Coco on 10/17/2012 8:06 PM

    • Can some one please tell me if "telephonic review" without being recorded and no faxes accepted by an HMO for biweekly/weekly reports, SNF setting, is HIPPA acceptable. While asking simple questions ie: distance ambulated, the reviewer is typing in answers with no regard for quality or environmental function. This is gets their job done but for the PT it is time consuming and takes away from patient care. Without recording or written document who is to say if there was a mistaken entry on reviewer's part. We always have written documentation in front of us when on phone but the review does not.

      Posted by Kathleen Henning -> CKRcC on 12/29/2013 1:29 PM

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