September 28, 2012

Medical Manual Review Change

Medicare Administrative Contractors (MACs) will not, as previously indicated, have data available on Oct. 1 for congressionally mandated medical review of Medicare therapy claims that exceed $3,700 per beneficiary.

The Centers for Medicare and Medicaid Services (CMS) announced it will not be able to download the necessary data into patient eligibility files by that date. Instead, CMS officials stated, it will take approximately a week to update patient histories with the amount of speech-language treatment and occupational and physical therapy reimbursed through September 30.

CMS also reminded providers that each patient's reimbursement history depends on whether claims have been submitted, and acknowledges that the total therapy dollar amount changes constantly based on claims submission and reimbursement.

After the system changes are completed, providers can access the total amount of dollars reimbursed on therapy, per beneficiary, to all Part B outpatient facilities, including hospital outpatient departments. The total includes the amount reimbursed by Medicare and deductibles or co-insurance paid by the beneficiary.

Providers are encouraged to seek additional information from their MACs. ASHA has compiled a number of resources, including MAC links to their provider eligibility systems and information on the therapy cap pre-approval process, found on ASHA's website.

For more information, please contact ASHA's health care economics and advocacy team at


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