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.
G-codes
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.
Background
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.
Resources
For more information, contact a member of the ASHA health care
economics and advocacy team at Reimbursement@asha.org.