Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare outpatient therapy billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Background

A series of Medicare laws defined payment rules for physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP). Beginning in 2015, the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act, (MACRA) allowed providers to apply for exceptions to the PT, OT and SLP legal limits on behalf of beneficiaries. MACRA additionally repealed mandatory manual review requirement and instead required that claims submitted after a beneficiary’s claims have already reached a specified total more than the caps be subject to targeted medical review described in the SSA §1833 (g)(5)(E).
In January 2018, The Bipartisan Budget Act (BBA) of 2018 amended Section 1833(g) of the Social Security Act (SSA) by repealing the Medicare expense threshold for therapy services and creating limitations to ensure appropriate therapy services are furnished. The BBA of 2018 is applicable for PT, OT, and SLP services furnished after January 1, 2018. The law creates a Medical Review (MR) expense threshold of $3,000 for PT and SLP services combined and $3,000 for OT services.
The SMRC was directed to perform data analysis on outpatient therapy claims below the 2019 therapy threshold and recommend codes to be selected for review, recommend a sampling strategy, and identify an MR strategy for this project.

Reason for Review

The SMRC was tasked with performing claim review on a sample of outpatient therapy claims from January 1, 2019, through December 31, 2019. The SMRC conducted medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• No Response to the Documentation Request
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A), requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Missing Certifications
  • Certifications were not present for the Plan of Care (POC). Documentation did not support the initial plan of care was certified by the physician /NPP. There was no evidence of delayed certification or attempts to obtain certification from the physician / NPP. Refer to Social Security Act (SSA) 1862; 42 CFR §424.24 2c, Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3 B-D.
• Incorrect Billing
  • CMS Internet Only Manual (IOM), Publication 100-4, Medicare Claims Processing Manual (MCPM), Chapter 5, Section 20.2.C indicates that documentation must support the units billed.

Resources

Social Security Act (SSA) Title XVIII

• § 1815(a). Payment to Providers of Services.
• § 1833(e). Payment of Benefits.
• § 1833(g)(5)(E). Payment of Benefits.
• §§ 1833(g)(7) (A and B[ii]). Payment of Benefits.
• §§ 1835(2) (C, D, E). Procedure for Payment of Claims of Providers of Services.
• § 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.

Public Law

• Bipartisan Budget Act (BBA) of 2018, Division E, Title II, § 50202. Repeal of Medicare payment cap for therapy services; limitation to ensure appropriate therapy. January 3, 2018. Retrieved from https://www.govinfo.gov/content/pkg/BILLS-115hr1892enr/html/BILLS-115hr1892enr.htm  

Code of Federal Regulations (CFR) Title 42

• 409.17. Physical therapy, occupational therapy, and speech-language pathology services.
• 409.32. Criteria for skilled services and the need for skilled services.
• 410.100(b)(1)(ii). Included Services.
• 410.102. Excluded Services.
• 410.105(b)(1) and (c). Requirements for coverage of CORF services.
• 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.
• 424.27(a) (1 and 2). Requirements for comprehensive outpatient rehabilitation facility (CORF) services.
• 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.

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

• Chapter (Ch.) 1, § 170.3. Speech-Language Pathology Services for the Treatment of Dysphagia

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 Claims Processing Manual (MCPM), Pub. 100-04

• 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.

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

• 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 Determinations (LCDs)

• L33580. Speech Language Pathology. Effective October 1, 2015
• L33631. Outpatient Physical and Occupational Therapy Services. Effective October 1, 2015
• L34043. Dysphagia/Swallowing Diagnosis and Therapy. Effective October 1, 2015. Retired July 1, 2020
• 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
• L35036. Therapy and Rehabilitation Services (PT, OT). Effective October 1, 2015
• L35070. Speech – Language Pathology (SLP) Services: Communication Disorders. Effective October 1, 2015

Local Coverage Articles (LCAs)

• A52773. Billing and Coding: Billing and Coding: Therapy Evaluation, Re-Evaluation, and Formal Testing. Effective October 1, 2015
• A52775. Billing and Coding: Medical Necessity of Therapy Services. Effective October 1, 2015
• A52776. Billing and Coding: Therapy Students and Aides. 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
• A53304. Billing and Coding: Medical Necessity of Therapy Services. Effective October 1, 2015
• A53339. Billing and Coding: Therapy Students and Aides. Effective October 1, 2015
• A54111. Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders. Effective October 1, 2015
• A57675. Billing and Coding: Dysphagia/Swallowing Diagnosis and Therapy. Effective October 3, 2018. Retired July 1, 2020

Last Updated Oct 10, 2022