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Compliance

Regulations are ever-increasing. You can't afford mistakes.

therapy_complianceHIPAA, PQRS, ICD-10, Functional Limitation Reporting, Therapy Cap, 8-minute rule…

This list is sure to grow. A single slip-up can sink your practice. Best case scenario, you’re looking at significant fines and penalties. You don’t need to worry. With Practice Pro’s secure, cloud-based EMR, you can rest easy knowing your data is protected because you’ll have peace of mind knowing Practice Pro has your back, because it knows the rules. All of them.

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HIPAA Compliance. Single mistake can sink your practice. Best case scenario, significant fines and penalties. You don’t need to worry with Practice Pro, with our secure, cloud-based EMR, you can rest easy knowing your data is protected.

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Accurate Physical Therapy billing requires integrated intelligence to be compliant with Medicare’s 8 Minute Rule for time-based codes. Billing codes are either timed or untimed codes. Practice Pro takes care of this automatically, so you can focus on what you do best—treating patients.

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The World Health Organization develops and publishes ICD codes, and national governments adopt the system. Lack of compliance means you won’t get paid. Our integrated ICD-10 tools are developed to keep your cash registers ringing.

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Integrated charges in your documentation coupled with Medicare NCCI Edits Rule base will make your biller’s job a breeze. Dig them out from the rut of data entry so they can focus on billing better, not harder.

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Physican Quality Reporting System. Track your clinic’s participation in our ‘Compliance Dashboard’. Relax knowing that the system will remind your clinical staff when PQRS codes are due.

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Another Medicare missile that hits you where it hurts the most – in payments! Practice Pro gives you the tools you need to steer clear of its path—therapy cap tracking, alerts, and automatic KX modifier application.

HIPAA (Health Insurance Portability and Accountability Act)

HIPAA for Professionals

To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, included Administrative Simplification provisions that required HHS to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security. At the same time, Congress recognized that advances in electronic technology could erode the privacy of health information. Consequently, Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.
  • HHS published a final Privacy Rule in December 2000, which was later modified in August 2002. This Rule set national standards for the protection of individually identifiable health information by three types of covered entities: health plans, health care clearinghouses, and health care providers who conduct the standard health care transactions electronically. Compliance with the Privacy Rule was required as of April 14, 2003 (April 14, 2004, for small health plans).
  • HHS published a final Security Rule in February 2003. This Rule sets national standards for protecting the confidentiality, integrity, and availability of electronic protected health information. Compliance with the Security Rule was required as of April 20, 2005 (April 20, 2006 for small health plans).
  • The Enforcement Rule provides standards for the enforcement of all the Administrative Simplification Rules.
  • HHS enacted a final Omnibus rule that implements a number of provisions of the HITECH Act to strengthen the privacy and security protections for health information established under HIPAA, finalizing the Breach Notification Rule.
  • View the Combined Regulation Text (as of March 2013). This is an unofficial version that presents all the HIPAA regulatory standards in one document. The official version of all federal regulations is published in the Code of Federal Regulations (CFR). View the official versions at 45 C.F.R. Part 160, Part 162, and Part 164.
Other HIPAA Administrative Simplification Rules are administered and enforced by the Centers for Medicare & Medicaid Services, and include:
PQRS (Physician Quality Reporting System)

Measures Codes

The Measures Codes webpage contains information about Physician Quality Reporting System (PQRS) quality measures, including detailed specifications and related release notes for the individual PQRS quality measures and measures groups. This page also contains other measures-related documentation needed by individual eligible professionals (EPs) for reporting the PQRS measures through claims or qualified registry-based reporting. Selecting Measures for 2016 PQRS At a minimum, the following factors should be considered when selecting measures for reporting:

  • Clinical conditions usually treated
  • Types of care typically provided – e.g., preventive, chronic, acute
  • Settings where care is usually delivered – e.g., office, emergency department (ED), surgical suite
  • Quality improvement goals for 2016
  • Other quality reporting programs in use or being considered

2016 Cross-Cutting Measures Requirement In order for EPs to satisfactorily report PQRS measures, EPs or group practices are required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter.  A cross-cutting measure is defined as a measure that is broadly applicable across multiple providers and specialties. The Centers for Medicare & Medicaid Services (CMS) defines a face-to-face encounter as an instance in which the EP billed for services such as general office visits, outpatient visits, and surgical procedure codes under the Medicare Physician Fee Schedule (MPFS). CMS does not consider telehealth visits as a face-to-face encounter. At least 1 cross-cutting measure must be satisfactorily reported for those individual providers with face-to-face encounters. CMS will analyze claims data to determine if at least 15 cross-cutting measure denominator eligible encounters can be associated with the individual eligible professional. If it is determined that at least 1 cross-cutting measure was not reported, the individual eligible professional with face-to-face encounters will be automatically subject to the 2018 PQRS payment adjustment. For those individual eligible professionals with no face-to-face encounters as found within the 2016 PQRS List of Face-to-Face Encounters, CMS would not require the reporting of a cross-cutting measure. Please reference the 2016 PQRS Measures List  or the2016 Cross-Cutting Measures List  for broadly applicable measures that are defined as cross-cutting and reference the 2016 PQRS List of Face-To-Face Encounter Codes  for the billable codes that identify face-to-face encounters for the purposes of 2015 PQRS reporting.  All stakeholders should use the most up-to-date measures and supporting documentation for reporting purposes. Resources for 2016 PQRS Measures The following resources are available when trying to determine which documents pertaining to the 2016 PQRS quality measures to report:

  • 2016 PQRS Claims Reporting Made Simple – This beginner-level resource describes claims-based reporting and outlines steps EPs should take prior to participating in 2016 PQRS.
  • 2016 PQRS Claims Based-Coding and Reporting Principles – This beginner-level resource provides detailed instructions for EPs participating in 2016 PQRS via claims, including coding tips and reporting guidance.
  • 2016 PQRS Measures List – Identifies and describes the measures used in PQRS, including all available reporting mechanisms, corresponding PQRS number and National Quality Forum (NQF) number, National Quality Strategy (NQS) domains, plus measure developers and their contact information.
  • New for 2016 PQRS: The 2016 PQRS Individual Measure Specifications for Claims and Registry Reporting can be viewed on the web-based tool. This is a measures list tool that eligible professionals (EPs) can use to search for measures to report for the 2016 PQRS Program. The web-based measures list tool allows users to search for measures using a number of criteria and then access detailed information about each measure, including measure specifications materials.

The following documents pertaining to the 2016 PQRS individual measures are included in the zip file titled: 2016 PQRS Individual Claims Registry Measure Specifications.

  • 2016 Physician Quality Reporting System (PQRS) Individual Measure Specifications for Claims and Registry Reporting – Documents that include reporting instructions, coding to identify the measure’s intended patient population, and numerator options for the 2016 PQRS Claims and/or Registry-based reporting measures.
  • New for 2016 PQRS: The 2016 PQRS Measure Flows have been incorporated within the 2016 Individual Measure Specification.  It is currently displayed after the individual measure specification as a visualization of the reporting and performance algorithm for each individual specification.

The following supporting documents pertaining to the 2016 PQRS individual measures are also helpful resources to supplement the 2016 PQRS Individual Measure Specifications:

The following documents pertaining to the 2016 PQRS measures groups are included in the zip file titled 2016 PQRS Measures Groups Specifications Supporting Documents:

  • 2016 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual –Measures group specifications are different from those of the individual measures that form the group. Therefore, the specifications and instructions for measures group reporting are provided in a separate manual. The 2016 measures groups specifications include common denominator coding to identify the measures group intended patient population, reporting instructions for the PQRS measures groups for registry-based reporting, and numerator options for each of the individual measures included in the measures group.
  • 2016 Physician Quality Reporting System (PQRS) Measures Groups Release Notes – This document outlines 2016 measures groups specifications updates to the 2015 PQRS measures groups specifications. The updates outlined may include items such as common denominator coding updates, revisions to numerator options, or general language updates that correlate to the most current clinical guidelines.
  • 2016 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups – This document contains general implementation guidance, measures groups strategies, and information to facilitate satisfactory reporting by eligible professionals who wish to pursue this alternative reporting method.
  • 2016 Physician Quality Reporting System (PQRS) Measures Groups Single Source Code Master – This document includes a numerical listing of all codes included in 2016 PQRS Measures Groups that may be used to find measures for coding billed by individual eligible professionals or group practices, billing software, or vendors that may report on 2016 PQRS Measures Groups.
  • 2016 Measures Group Flow Documents – 2016 PQRS Measure Group Flow documents are available as additional resources to assist in better understanding the reporting and performance algorithms for measures groups. These measures group flows should be utilized with the corresponding measures group specifications as they are supplemental documents. The Measures Group Flows are included in the zip file titled 2016 PQRS Measures Group Flows and Flow Manual. This zip file also includes a measures group flow manual to assist in interpreting the measures group flows.

2016 Specialty Measure Sets CMS has been collaborating with specialty societies to ensure that the measures represented within the Specialty Measure Sets accurately outline quality actions that may occur within a particular clinical area. The Specialty Measure Sets should be used as a guide for eligible professionals to choose measures applicable to their specialty. The Specialty Measure Sets are NOT required measures but are suggested measures for specific specialties. The 2016 Specialty Measure Sets are indicated below.

  1. 2016 Cardiology Preferred Specialty Measure Set
  2. 2016 Dermatology Preferred Specialty Measure Set
  3. 2016 Emergency Medicine Preferred Specialty Measure Set
  4. 2016 Gastroenterology Preferred Specialty Measure Set
  5. 2016 General Practice/Family Practice Preferred Specialty Measure Set
  6. 2016 General Surgery Preferred Specialty Measure Set
  7. 2016 Hospitalist Preferred Specialty Measure Set
  8. 2016 Internal Medicine Preferred Specialty Measure Set
  9. 2016 Mental Health Preferred Specialty Measure Set
  10. 2016 Multiple Chronic Conditions Preferred Specialty Measure Set
  11. 2016 Obstetrics/Gynecology Preferred Specialty Measure Set
  12. 2016 Oncology/Hematology Preferred Specialty Measure Set
  13. 2016 Ophthalmology Preferred Specialty Measure Set
  14. 2016 Pathology Preferred Specialty Measure Set
  15. 2016 Physical Therapy/Occupational Therapy Preferred Specialty Measure Set
  16. 2016 Radiology Preferred Specialty Measure Set
  17. 2016 Urology Preferred Specialty Measure Set

It is important to utilize the measure specifications and program requirements within each reporting method chosen to satisfactorily report within PQRS. Links to the PQRS Measure Specifications for Claims, Registry, and Measures Groups are listed above on this web page. The 2015 Specialty Measure Sets are located here for reference.

2015 PQRS

The PQRS measures documents for the current program year may be different from the PQRS measures documents for a prior year. EPs are responsible for ensuring that they are using the documents for the correct program year. The 2015 PQRS CMS-1500 claim is an example of how an individual National Provider Identifier (NPI) reporting on a single CMS-1500 claim for 2015 PQRS should look. The 2015 Physician Quality Reporting System (PQRS) Implementation Guide contains the 2015 PQRS CMS-1500 claim information. Selecting Measures for 2015 PQRS At a minimum, the following factors should be considered when selecting measures for reporting:

  • Clinical conditions usually treated
  • Types of care typically provided – e.g., preventive, chronic, acute
  • Settings where care is usually delivered – e.g., office, emergency department (ED), surgical suite
  • Quality improvement goals for 2015
  • Other quality reporting programs in use or being considered

2015 Cross-Cutting Measures Requirement In order for EPs to satisfactorily report PQRS measures, a new reporting criterion has been added for the claims and registry reporting of individual measures. EPs or group practices are required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter. The Centers for Medicare & Medicaid Services (CMS) defines a face-to-face encounter as an instance in which the EP billed for services that are associated with face-to-face encounters under the Medicare Physician Fee Schedule (MPFS). This includes general office visits, outpatient visits, and surgical procedure codes; however, CMS does not consider telehealth visits as a face-to-face encounter. Please reference the 2015 PQRS Measures List or the 2015 Cross-Cutting Measures List for broadly applicable measures that are defined as cross-cutting and reference the 2015 PQRS List of Face-To-Face Encounter Codes for the billable codes that identify face-to-face encounters for the purposes of 2015 PQRS reporting.  All stakeholders should be cognizant of the most up-to-date list and reference it for reporting purposes. Resources for 2015 PQRS Measures The following documents pertaining to the 2015 PQRS quality measures are included in the zip file titled 2015 PQRS Measures List:

  • 2015 PQRS Implementation Guide – Provides guidance about how to select measures for reporting, how to read and understand a measure specification, and outlines the various reporting mechanisms available for 2015 PQRS. The Implementation Guide also details how to implement claims-based reporting of measures to facilitate satisfactory reporting of quality-data codes by EPs.
  • 2015 PQRS Measures List – Identifies and describes the measures used in PQRS, including all available reporting mechanisms, corresponding PQRS number and National Quality Forum (NQF) number, National Quality Strategy (NQS) domains, plus measure developers and their contact information.

The following documents pertaining to the 2015 PQRS individual measures are included in the zip file titled 2015 PQRS Individual Claims Registry Measure Specification Supporting Documents.

  • 2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures – Includes codes and reporting instructions for the 2015 PQRS measures for claims and/or registry-based reporting.
  • 2015 Physician Quality Reporting System (PQRS) Measure Specification Release Notes – Outlines 2015 updates made to the 2014 PQRS Measures Specifications Manual in the form of release notes.
  • 2015 Physician Quality Reporting System (PQRS) Quality-Data Code (QDC) Categories – Outlines, for each claims and registry measure, each QDC that should be reported for a corresponding quality action performed by the individual eligible professional as noted in the measures specification. This document identifies how each code will be used when CMS calculates performance rates. The QDC categories table also clarifies those measures that require 2 or more QDCs to report satisfactorily. Insufficiently reporting the QDCs (as specified in the 2015 PQRS measure specifications) will result as invalid reporting.
  • 2015 Physician Quality Reporting System (PQRS) Single Source Code Master – Includes a numerical listing of all codes (denominator and numerator) included in 2015 PQRS Individual Claims and Registry Measures for incorporation into billing software.

The following documents pertaining to the 2015 PQRS measures groups are included in the zip file titled 2015 PQRS Measures Groups Specifications Supporting Documents:

  • 2015 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual –Measures group specifications are different from those of the individual measures that form the group. Therefore, the specifications and instructions for measures group reporting are provided in a separate manual. The 2015 measures groups specifications include codes and reporting instructions for the PQRS measures groups for registry-based reporting.
  • 2015 Physician Quality Reporting System (PQRS) Measures Groups Release Notes – Outlines 2015 updates made to the 2014 PQRS Measures Groups Specifications Manual in the form of release notes.
  • 2015 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups – Provides guidance about how to select measures groups for reporting, and how to read and understand a measure group specification in order to satisfactorily report.
  • 2015 Physician Quality Reporting System (PQRS) Quality-Data Code (QDC) Categories – Outlines every QDC that should be reported for a corresponding quality action performed by the individual EP as noted in the measures specification. This identifies how each code will be used when calculating performance rates. This also clarifies those measures that require two or more QDCs to report satisfactorily. Insufficiently reporting the QDCs (as specified in the 2015 PQRS) will result as invalid reporting.

Note: Measures groups specifications may differ from their individual measures counterpart. This document will define the differences between the QDCs for individual and measure group specifications.

  • 2015 Physician Quality Reporting System (PQRS) Measures Groups Single Source Code Master – Includes a numerical listing of all codes included in 2015 PQRS Measures Groups for incorporation into billing software.

2015 PQRS Individual Measures for Claims/Registry and Measures Groups Flow Documents 2015 PQRS Individual Measure Flow and Measure Group Flow documents are available as additional resources to assist in better understanding the reporting and performance algorithms for measures and measures groups. These measure flows should be utilized with the corresponding measure specification or measure group specification as they are supplemental documents. The Individual Measure Flows are included in the zip file titled 2015 PQRS Individual Measure Flows and Flow Manual. This zip file also includes an individual claims/registry measure flow manual to assist in interpreting the measure flows. The Measures Group Flows are included in the zip file titled 2015 PQRS Measures Groups Flows and Flow Manual. This zip file also includes a measures group flow manual to assist in interpreting the measures group flows.

ICD-10 (International Classification of Diseases)

International Classification of Diseases (ICD)

The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situation of population groups. It is used to monitor the incidence and prevalence of diseases and other health problems, proving a picture of the general health situation of countries and populations. ICD is used by physicians, nurses, other providers, researchers, health information managers and coders, health information technology workers, policy-makers, insurers and patient organizations to classify diseases and other health problems recorded on many types of health and vital records, including death certificates and health records. In addition to enabling the storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States. Finally, ICD is used for reimbursement and resource allocation decision-making by countries. All Member States use the ICD which has been translated into 43 languages. Most countries (117) use the system to report mortality data, a primary indicator of health status. ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States as from 1994. ICD is currently under revision, through an ongoing Revision Process, and the release date for ICD-11 is 2018.

FLR (Functional Limitations Reporting)

Functional Reporting

Functional Reporting: PT, OT, and SLP Services Frequently Asked Questions Document Now Available

On June 19, CMS released a new Frequently Asked Questions (FAQ) document on Functional Reporting for PT, OT, and SLP Services. Please view the new FAQ document here, or find it in the Downloads section below.

Functional Reporting

Functional Reporting gathers data on beneficiaries’ functional limitations during the therapy episode of care as reported by therapy providers and practitioners furnishing physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services. The Functional Reporting system will better our understanding of beneficiary conditions, outcomes, and expenditures. This system was established through the Calendar Year (CY) 2013 Physician Fee Schedule final rule (77 Federal Register 68958). Implementation of the claims-based data collection strategy for outpatient therapy services was required by The Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA). Application of Coding Requirements Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report nonpayable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care. Functional Reporting is required on therapy claims for certain dates of service (DOS) as described below:

  • At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service;
  • At least once every 10 treatment days on the claim for services on the same DOS that the services related to the progress report are furnished;
  • At the DOS that an evaluative or re-evaluative procedure code is submitted on the claim; and
  • At the time of discharge from the therapy episode of care, unless discharge data is unavailable, e.g., this may occur when the beneficiary discontinues therapy unexpectedly.

For a comprehensive understanding of the Functional Reporting requirements during an episode of care, refer to the links within the “Resources for Functional Reporting” section below. Functional Reporting Codes — G-codes G-codes are used to report a beneficiary’s functional limitation being treated and note whether the report is on the beneficiary’s current status, projected goal status, or discharge status. There are 42 functional G-codes that are comprised of 14 functional code sets with three types of codes in each set. Six of the G-code sets are generally for PT and OT functional limitations and eight of G-code sets are for SLP functional limitations. Providers and practitioners report the G-code set for the functional limitation that most closely relates to the primary functional limitation being treated or the one that is the primary reason for treatment. Functional Reporting Codes — Severity/Complexity Modifiers For each non-payable G-code reported, a modifier must be used to report the severity level for that functional limitation. The severity modifiers reflect the beneficiary’s percentage of functional impairment as determined by the providers or practitioners furnishing the therapy services. Therefore, the beneficiary’s current status, projected goal status, and discharge status are reported via the appropriate severity modifiers. For a complete list of the Functional Reporting G-codes and Severity/Complexity Modifiers, refer to the Functional Reporting Quick Reference Chart. For a complete understanding of how to properly select a functional limitation and determine a severity level, refer to the links within the “Resources for Functional Reporting” section below. Documentation Requirements Providers are required to document in the patient’s medical record the functional G-codes and severity modifiers that were used to report the patient’s current, projected goal, and discharge status. For the severity modifiers, providers should include a description of how the modifiers were determined. These requirements are applicable for each date of service for which the reporting is done. Resources for Functional Reporting Federal Regulation: CY 2013 Physician Fee Schedule Final Rule National Provider Call: See the Preparing for Therapy Functional Reporting Implementation in CY 2013 National Provider Call Details page for the slide presentation, audio recording, and written transcript from the call; as well as a list of Therapy Functional Reporting G-code Short Descriptors, and MLN Matters Article MM8005 – “Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services”. MLN Special Edition Article 1307: Outpatient Therapy Functional Reporting Requirements CR 8005: Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services — Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 Frequently Asked Questions (FAQs): Functional Reporting FAQ Document Pub. 100-02: Medicare Benefit Policy Manual, chapter 15, section 220 for more details on the Functional Reporting requirements at specified points during the therapy episode Pub. 100-04: Medicare Claims Processing Manual, chapter 5, section 10.6 for details about the Functional Reporting requirements on claims for therapy services If you have any questions, please contact your Medicare contractor at their toll-free number, which can be found by visiting the Provider Compliance Interactive Map.

8 MINUTE RULE - AMA or Medicare

Medicare 8-Minute Rule

In this chart below, the numbers in the left column represents the total number of minutes spent on treatment, and the sum on the right represents the maximum number of units that can be billed.

Medicare 8-minute-rule

Using the 8-Minute Rule to determine the allowable number of time-based units for a patient visit, you add that total to your number of service-based units. The sum is the total number of units you can bill Medicare for a specific date of service.

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AMA 8-Minute Rule

The AMA defines time as: “Time is the face-to-face time with patients.” The AMA’s difference in their guidelines from the Medicare Billing Guidelines is there is no cumulative factor. With the AMA 8-Minute Rule guidelines, you cannot use the cumulative total of your remaining time to justify billing additional units.

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The Good News

Practice Pro knows the difference, and handles all this automatically, so you don’t have to worry about it.

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CPT Codes - Current Procedural Terminology

Medicare 8-Minute Rule

CPT codes are much like ICD codes in that they communicate uniform information about services and procedures to healthcare payers. The difference is that on claim forms, CPT codes identify procedures or services rendered rather than patient diagnoses.

CPT code set is maintained by the American Medical Association through the CPT Editorial Panel, and is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Health Care Procedure Coding System.

More information.

Therapy Cap - Medicare

Manual Medical Review of Therapy Claims Above the $3,700 Threshold 

Update February 09, 2016

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the thresholds and instead allows a targeted review process. MACRA also prohibits the use of Recovery Auditors to conduct the reviews.

CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis. The SMRC will be selecting claims for review based on:

  • Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA.
  • Therapy provided in skilled nursing facilities (SNFs), therapists in private practice, and outpatient  physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers

Of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day.

For CY 2015, the limit on incurred expenses (therapy cap) is $1,940 for physical therapy (PT) and speech-language pathology services (SLP) combined and $1,940 for occupational therapy (OT) services.

Manual Medical Review of Therapy Claims Above the $3,700 Threshold – Updated April 4, 2014

On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014.  This new law extends the exceptions process for outpatient therapy caps through March 31, 2015.  Section 103 of this Act contains a number of Medicare provisions affecting the outpatient therapy caps and manual medical review (MR) threshold.

The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,920 for 2014, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is $1,920 for 2014. This is an annual per beneficiary therapy cap amount determined for each calendar year. Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. Per beneficiary, services above $3,700 for PT and SLP services combined and/or $3,700 for OT services are subject to manual medical review. CMS is not precluded from reviewing therapy services below these thresholds.

The therapy cap applies to all Part B outpatient therapy settings and providers including:

  • Therapists’ private practices
  • Offices of physicians and certain nonphysician practitioners
  • Part B skilled nursing facilities
  • Home health agencies (Type of Bill (TOB) 34X)
  • Rehabilitation agencies (also known as Outpatient Rehabilitation Facilities-ORFs)
  • Comprehensive Outpatient Rehabilitation Facilities (CORFs)
  • Hospital outpatient departments (HOPDs)
  • Critical Access Hospitals (CAHs) (TOB 85X) – (2014)

In addition, the therapy cap will apply to outpatient hospitals as detected by:

  • Type of Bill 12X, 13X or 085X
  • Revenue code 042X, 043X, or 044X
  • Modifier GN, GO, or GP; and
  • Dates of service on or after January 1, 2014

CMS will continue to update this page as necessary.