The Centers for Medicare & Medicaid Services (CMS) has released clarification and a new e-mail address for speech-language pathologists requiring assistance with G-codes and the manual medical review process.
Transmittal #SE1307, Outpatient Therapy Functional Reporting Requirements, offers definitions, claims instructions, and answers to several of the questions posed by therapy providers. This transmittal is in addition to the Functional Reporting: PT, OT, and SLP Services Frequently Asked Questions (FAQs) that was released earlier this summer.
Manual Medical Review
CMS has updated the Therapy Cap page and offers assistance via e-mail at RAC@cms.hhs.gov.
ASHA and other therapy organizations participate in a monthly meeting with CMS staff involved with the manual medical review process managed by Recovery Audit Contractors (RACs). CMS has requested copies of communication from Medicare Administrative Contractors (MACs) or RACs that are unclear or inconsistent with Medicare policy or other documentation of issues providers may be experiencing with reviews. Documentation should have all patient identifying information redacted. In addition to the CMS e-mail, ASHA has created a dedicated manual medical review e-mail address (MMR@asha.org) where members are encouraged to send de-identified documents and cases, including denial letters, for presentation to CMS.
Before e-mailing, please make sure to remove all patient identification data and include communication from the MAC or RAC.
The Middle Class Tax Relief and Job Creation Act (MCTRJCA) of 2012 (Pub. L. 112-96) mandated a claims-based data collection strategy for reporting patient functional status across the course of treatment for Part B therapy services; the approach is implemented by CMS through the addition of G-codes and severity modifiers to claims for certain conditions. From January 1 through July 1, submissions with codes/modifiers were accepted, but not mandatory; for dates of service beginning July 1, 2013, claims submitted without the appropriate G-codes/modifiers are returned to providers unpaid.
MCTRJCA also mandated a manual medical review process for Medicare Part B therapy services that exceed $3,700. The process was initially implemented in October 2012, as a pre-approval process. However, the methodology used was burdensome to MACs and providers and-because it was manually based-requests were lost, not received, or never reviewed. In March 2013, CMS released its long-term solution to meeting the requirements for the manual medical review process, which shifts the responsibility of review to RACs and places providers in a pre- or post-payment review system based on geographic location.
For more information, contact a member of the ASHA health care economics and advocacy team at Reimbursement@asha.org.