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Region B

Issue Title

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




In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in certain settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. When one or more lines of a claim have reached a therapy threshold, all lines of therapy services on that claim are subject to review.



Provider Type

Skilled Nursing Facility

Date of Service

1/1/2013 - 12/31/2013


American Physical Therapy Association, FAQ: 2013 Medicare Therapy Cap, March 26, 2013

Centers for Medicare & Medicaid Services, Therapy Cap, March 22, 2013, H.R.8: American Taxpayer Relief Act of 2012

Centers for Medicare & Medicaid Services, Therapy Services, April 4, 2013

Centers for Medicare & Medicaid Services, Office of Financial Management, Physical, Occupational, and Speech Therapy Services, September 5, 2012

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.

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


Date Revised


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Created at 10/3/2013 2:39 PM by Aaron Gough
Last modified at 9/21/2016 2:47 PM by Aaron Gough