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Region

Region B

Issue Title

Skilled Nursing Facility Post-Payment Review – Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold

Number

B001012013

Description

There has been a steady increase in therapy spending over the past few years, Based on this increase, there are multiple reasons why post payment review is necessary at this time: Clinically inappropriate modalities, patient’s clinical therapy needs do not match what was reported, excessive or inappropriate therapy was furnished, lack of physician/NPP certified therapy plan of care.

States

MN, WI, MI, IL, IN, OH, KY

Provider Type

Skilled Nursing Facility

Date of Service

1/1/2013 - 12/31/2013

References

http://beta.congress.gov/bill/112th-congress/house-bill/8/text
American Physical Therapy Association, FAQ: 2013 Medicare Therapy Cap, March 26, 2013

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/TherapyCap.html
Centers for Medicare & Medicaid Services, Therapy Cap, March 22, 2013

http://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/TherapyServices
Congress.gov, H.R.8: American Taxpayer Relief Act of 2012

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c05.pdf
Centers for Medicare & Medicaid Services, Therapy Services, April 4, 2013

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/TherapyCapSlidesv10_09052012.pdf
Centers for Medicare & Medicaid Services, Office of Financial Management, Physical, Occupational, and Speech Therapy Services, September 5, 2012

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
CMS Internet Only Manual 100-2 Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance, Section 220.1.2 - Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services, Section 220.3 - Documentation Requirements for Therapy Services.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf
CMS Internet Only Manual 100-04 Medicare Claims Processing Manual, Chapter 5 – Part B Outpatient Rehabilitation and CORF/ORF Services, Section 10.6 – Functional Reporting

Date Posted

4/29/2103

Date Revised

 

More Information

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Attachments

Created at 6/5/2013 8:36 AM by Aaron Gough
Last modified at 6/5/2013 10:36 AM by Aaron Gough