July 3, 2012 News

Manual Medical Review: Are You Ready?

Speech-language pathologists treating Medicare patients: If 2012 outpatient therapy claims for a Medicare beneficiary on your caseload total $3,700 or more, those claims may be subject to a special medical review.

The Middle Class Tax Relief and Job Creation Act of 2012 calls for this review. It established 2012 Medicare reimbursement rates and extended the therapy cap exceptions process through Dec. 31, 2012. The 2012 therapy cap is $1,880 for combined physical therapy and speech-language pathology services. To request an exception on claims greater than this amount, providers can use the KX modifier, which indicates that services are reasonable and necessary and are documented as such in the patient's medical record.

But the Act tightens the therapy cap by requiring the Centers for Medicare and Medicaid Services (CMS) to conduct a "manual medical review" of claims that exceed $3,700 on or after Oct. 1. That total includes claims from outpatient hospital settings.

CMS has released limited direction regarding the manual medical review process, but recently published an article in the Medicare Learning Network's MLN Matters [PDF] that offers some guidance:

  • Claims for services that exceed the $3,700 threshold are subject to a manual medical review process.
  • Claims for which an exception is not granted will be denied as a benefit category denial, and the beneficiary will be liable.
  • Providers are encouraged—as a courtesy—to give the voluntary advance beneficiary notice (ABN) to patients who require services greater than the $1,880 cap. The ABN alerts them of their possible financial liability.
  • As of Oct. 1, the national provider identifier of the physician or non-
    physician practitioner certifying the therapy plan of care is required on institutional claims for outpatient therapy services.
  • Although physical therapy and speech-language treatment are combined for triggering the threshold, medical review is conducted separately by discipline.

The current medical review mandate includes language similar to that used in 2006, when therapy claims that exceeded $1,740 outside an approved exceptions list were reviewed. The 2006 exceptions included many diagnoses from the International Classification of Diseases, Ninth Revision (ICD-9), including aphasia, dysphagia, and nervous system disease, and added exceptions for complexities such as concurrent speech-language and physical therapy, and mental or cognitive disorders affecting the recovery rate. The 2006 manual medical review process was replaced by the introduction of the KX modifier in 2007.

ASHA, the American Physical Therapy Association, and the American Occupational Therapy Association have suggested to CMS the ICD-9 codes and exceptions that would require services that exceed $3,700. Although officials have been open to suggestions, CMS has released no official documentation regarding review.

Clinicians are urged to comply with documentation guidelines published in the Medicare Benefit Policy Manual Publication, 100-02, Chapter 15, Section 220.3, including evaluation/plan of care, certification of the plan of care, progress reports, treatment notes, and, if necessary, justification of further care. Claims submitted with the KX modifier for services over the 2012 therapy cap of $1,880 should have this documentation if requested.

For an overview of documentation for Medicare outpatient therapy services, visit ASHA's reimbursment webpage. The site includes a link to the Medicare Benefits Policy Manual, and will be updated as more information on manual medical review becomes available.

Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at lsatterfield@asha.org.

cite as: Satterfield, L. (2012, July 03). Manual Medical Review: Are You Ready?. The ASHA Leader.


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