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  • Open Door Forum on Manual Medical Review Scheduled for October 22

    The Centers for Medicare and Medicaid Services (CMS) will hold a special open door forum (ODF) on October 22, 2:00 pm-3:30 pm ET, to allow providers to ask questions about the manual medical review of therapy services that exceed $3,700. 

    During this special ODF (conference call only), CMS will discuss therapy documentation requirements and answer any questions providers may have. CMS requests that providers who order or provide therapy services nationally participate in the call. The therapy cap applies to all Part B outpatient therapy settings and providers in:

    • private practices
    •  Part B skilled nursing facilities
    •  home health agencies hospital
    • outpatient departments rehabilitation agencies (outpatient rehabilitation facilities)
    • comprehensive outpatient rehabilitation facilities

    Participants may submit questions prior to the special ODF to therapycapreview@cms.hhs.gov. To participate, call 866/ 501-5502 and enter conference ID 44803009.


    • So this means that the outpatient PT service cap truly includes services provided at the NH, home and outpatient private practice/hospital based outpatient facility all combined? (this is also combined with OT correct?) If a patient has received 3 weeks in a STRNH (5x/week), then 6 visits in homecare, and then comes to see us, how accurate will that CAP on the Medicare PSP really be? If they have already reached the $3700 prior to our evaluation in private practice setting , are we authorized to do the eval prior to submitting the authorization request, to then determine if the treatment is medically necessary? Or, do we have to submit the request, before we see them, so that the eval is paid for?

      Posted by Lori Garabedian, PT on 10/21/2012 9:23 AM

    • Medicare will always pay for an evaluation or re-evaluation to determine medical necessity however if the patient has exceeded the $3700 prior to the new evaluation then any subsequent treatment after the evaluation will not be paid. You must see them and then submit based on medical necessity. If you evaluate and feel that the services are not needed then you will be paid for the evaluation only as no additional services will be required. If you decide that the services are medically appropriate and the patient has exceeded the $3700- then you need to include all the relevant data to that NEW case which would include the evaluation with solid documentation for medical necessity, strong functionally oriented goals to support activity limitations noted requiring the patient to seek your services and the requested documentation as noted by your MAC per the transmittal form (PART B Transmittal) for Out Patient Services.

      Posted by Lisa Kemp on 10/22/2012 3:41 PM

    • Will the transcript of this conference call be made available for people who missed the original call?

      Posted by Bonnie Frank on 10/26/2012 10:15 AM

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