Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part B outpatient therapy services billed on dates of service from January 1, 2022, through December 31, 2022. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Outpatient therapy services including physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services, aim to restore function after an illness or injury, maintain current functional status, or prevent or slow down further deterioration of a patient’s condition.

The Bipartisan Budget Act (BBA) of 2018 amended Section 1833 (g) of the Social Security Act (SSA) repealing the Medicare expense threshold for therapy services. The BBA of 2018 created limitations to ensure appropriate therapy is being provided for PT, OT, and SLP services furnished after January 1, 2018. For CY 2022, this KX modifier threshold (above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record) was $2,150 for PT and SLP services combined, and $2,150 for OT services. Additionally, a medical review expense threshold of $3,000 for PT and SLP services combined and $3,000 for OT services was created.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with place of service 11 (office), CPT/HCPCS codes specific to PT, OT, and SLP services with specific modifiers, GP, GN, GO, indicating services were provided under a PT, OT, or an SLP plan of care, billed with date of service January 1, 2022, through December 31, 2022 to determine if outpatient therapy services were reasonable, necessary, and billed appropriately .

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of the specific documentation requirements that will be included in each ADR letter to obtain the necessary documentation to perform the medical record review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information, if applicable to the claim on review, thereby reducing provider burden. Additionally, the specific requirements will aid in clarity on scope of review to allow the MAC redeterminations teams to process the request accordingly and prevent overturning of correct decisions.

1. Physician/Non-Physician Practitioner (NPP) order or evidence of intent to order
2. History and Physical reports (include medical history and current list of medications)
3. Beneficiary’s medical records which may include: practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary
4. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Local Coverage Article
5. Initial evaluation/re-evaluation signed by ordering physician or practitioner
6. Physical Therapy (PT)/Occupational Therapy (OT)/Speech Language Pathology (SLP) – Initial evaluation/re-evaluation, plans of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
7. Physician/Non-Physician Practitioner (NPP) certification of Plan of Care for Claim Period Including Justification when the Certification is Delayed More than 30 Days
8. Signed and dated overall plan of care including, short and long term goals with any updates to the plan of care
9. Progress reports written by the clinician-services related to progress reports are to be furnished on or before every 10th treatment day
10. Specific Skilled Procedures and Modalities
11. For all therapy services rendered submit attendance/treatment records for the claim period – must include total treatment time and identify each specific skilled modality provided
12. Therapy logs that show services, dates and times for code billed
13. Records of aide visits, times, and dates
14. List of all personnel billing services under your NPI. List credentialing, training, licensure, etc., of all personnel.
15. Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual check-in
16. Providers or suppliers are encouraged to review the documentation prior to submission, to ensure signature information is available when authenticity is not conclusively documented. Please include a signature log or signature attestation for any missing or illegible signature within the medical record.
17. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
18. Any other supporting or pertinent documentation
19. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation.
20. PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.

References

Social Security Act (SSA) Title XI

• §1135. Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• §1815. Payment to Provider of Services
• §1833(e). Payment of Benefit
• §1833(g)(7). (A and B[ii]). Payment of Benefit
• §1833(g)(5)(E). Payment of Benefits
• §1835(2) (C, D, E). Procedure for Payment of Claims of Providers of Service
• §1861(g). Outpatient Occupational Therapy Service
• §1861(p). Outpatient Physical Therapy Services
• §1861(s)(2)(D). Medical and Other Health Services
• §1862(a)(1)(A). Reasonable and Necessary
• §1862(a)(20). Exclusions from Coverage and Medicare as Secondary Payer
• §1879(a)(1). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed

Bipartisan Budget Act (BBA) of 2018, Title II

• BBA, Division E, Title II, §50202. Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy

42 Code of Federal Regulations (CFR)

• §409.17. Physical therapy, occupational therapy, and speech-language pathology services
• §409.32. Criteria for skilled services and the need for skilled services
• §409.44. Skilled Services Requirements
• §410.26. Services and supplies incident to a physician’s professional services: Conditions
• §410.59. Outpatient occupational therapy services: Conditions
• §410.60. Outpatient physical therapy services: Conditions
• §410.61. Plan of treatment requirements for outpatient rehabilitation services
• §410.62. Outpatient speech-language pathology services: Conditions and exclusions
• §424.24. Requirements for medical and other health services furnished by providers under Medicare Part B
• §424.516(f). Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program
• § 424.535. Revocation of enrollment in the Medicare program
• §485.713. Condition of participation: Physical therapy services

Public Law

• Public Law 117–103. Consolidated Appropriations Act, 2022. Subtitle A-Telehealth Flexibility Extensions. March 15, 2022. Retrieved from PUBL103.PS (congress.gov)

Federal Register

• CMS. Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. CMS-1744-IFC. Applicable March 1, 2020. Retrieved from CMS-1744-IFC

• CMS. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. CMS-5531-IFC. Applicable March 1, 2020. Retrieved from CMS-5531-IFC

Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Ch. 15, §60. Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service
• Ch. 15, §220. Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance
• Ch. 15, §230. Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
• Ch. 16, §20. Services Not Reasonable and Necessary
• Ch. 16, §110. Custodial Care

Internet Only Manual (IOM), Medicare National Coverage Determination Manual (NCD), Publication (Pub). 100-03

• NCD Chapter 1, Part 1, §10.2. Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain
• NCD Chapter 1, Part 2, §150.5. Diathermy Treatment
• NCD Chapter 1, Part 2, §150.8. Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders
• NCD Chapter 1, Part 2 §160. Nervous System
• NCD Chapter 1, Part 3, §170.1. Institutional and Home Care Patient Education Programs
• NCD Chapter 1, Part 3, §170.3. Speech-Language Pathology Services for Treatment of Dysphagia
• NCD Chapter 1, Part 4, §240.3. Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions
• NCD Chapter 1, Part 4, §270.1. Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds

Internet Only Manual (IOM), Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 5, §10. Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services-General
• Ch. 5, §20. HCPCS Coding Requirement
• Ch. 5, §30. Special Claims Processing Rules for Outpatient Rehabilitation Claims Form CMS-1500
• Ch. 5, §40. Special Claims Processing Rules for Institutional Outpatient Rehabilitation Claims
• Ch. 30, §50. Advance Beneficiary Notice of Non-coverage (ABN)

Internet Only Manual (IOM), Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3 §3.3.2.4. Signature Requirements
• Ch. 3, §3.3.2.7. Review Guidelines for Therapy Services
• Ch. 13, §13.5.4. Reasonable and Necessary Provisions in an LCD

Local Coverage Determination (LCD)

• L33580. Speech Language Pathology. Effective October 1, 2015
• L33631. Outpatient Physical and Occupational Therapy Services. Effective October 1, 2015
• L34046. Speech Language Pathology. Effective October 1, 2015
• L34049. Outpatient Physical and Occupational Therapy Services. Effective October 1, 2015
• L34427. Outpatient Occupational Therapy. Effective October 1, 2015
• L34428. Outpatient Physical Therapy. Effective October 1, 2015
• L34429. Outpatient Speech Language Pathology. Effective October 1, 201
• L35036. Therapy and Rehabilitation Services (PT, OT). Effective October 1, 2015. Revised March 9, 2022.
• L35070. Speech-Language Pathology (SLP) Services: Communication Disorders. Effective October 1, 2015

Local Coverage Article (LCA)

• A52866. Billing and Coding: Speech Language Pathology. Effective October 1, 2015
• A53064. Billing and Coding: Outpatient Occupational Therapy. Effective October 1, 2015
• A53065. Billing and Coding: Outpatient Physical Therapy. Effective October 1, 2015
• A54111. Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders. Effective October 1, 2015
• A56566. Billing and Coding: Outpatient Physical and Occupational Therapy Services. Effective December 19, 2019
• A56868. Billing and Coding: Outpatient Speech Language Pathology. Effective August 15, 2019
• A57040. Billing and Coding: Speech-Language Pathology. Effective September 19, 2019
• A57067. Billing and Coding: Outpatient Physical and Occupational Therapy Services. Effective September 19, 2019
• A57703. Billing and Coding: Therapy and Rehabilitation Services. Effective November 14, 2019

Last Updated Sep 16, 2024