Wednesday, May 29, 2013

Drill Down – Why LCDs are Your Starting Point

May 28, 2013

Approved RAC issues posted this week by both RAC Region A Performant and RAC Region D HDI, highlight the importance of knowing your Local Coverage Determination (LCDs) policies. Performant posted two approved issues based on LCDs: both Magnetic Resonance Angiography and Filgrastim audit issues for incorrect billing using ICD-9-CM codes that are not listed in the policies. HDI will be targeting DME providers billing more than one spring powered device (A4258) per 6 months. HCPCS code A4258 is listed directly in the DME LCD, Glucose Monitors and Testing Supplies, as being allowed 1 per every 6 months.

As a provider, knowing your LCDs should be the starting point to Medicare patient encounters - from what is covered and what is not, to documentation required, code combinations and utilization. Providing products and services that are not covered by Medicare and not securing a signed Advance Beneficiary Notice (ABN) before patient encounters will leave you unable to bill for your charges. Billing incorrect code combinations and overutilization will leave you open to audits.

Most automated RAC issues reference LCD polices where code combinations for medical necessity and utilization are spelled out. However, deciphering an LCD policy is not easy and may be a time consuming task. Building system edits for billing and practice management software could also get complicated. Most providers turn to software vendors to do this for them. Vendors will keep up with the numerous monthly changes in LCDs that may occur. Vendors can build edits such as alerts for providers to obtain signed ABNs for non-covered items, avoid overutilization and bill with allowed CPT/HCPCS/ICD combinations. Complex edits can also check for patient billing history to avoid providing services or dispensing items that are only covered on certain time frames. For example the spring powered device that can only be billed every 6 months and is listed as an approved DME RAC issue for this week.

Web-based look-up tools from vendors allow for medical necessity checks to be done quickly and before a patient encounter or item is dispensed. Entering a code combination and finding out if those are listed in an LCD can be done in seconds rather than spending time trying to locate the correct policy on CMS’ website.

Other RAC issues for the week of May 27^th - May 31^st, 2013:

RAC Region A Performant

Physician /Non-Physician Practitioner Claim Types

§ Evaluation and Management (E/M) Facility vs. Non-facility - Incorrect Place of Service (POS) - J13 - Medicare Part B reimburses physicians at higher rate for certain services performed in their offices to account for the increased expenses (e.g., overhead) that they incur by performing services in their offices. However, when physicians perform these services in facility settings such as an inpatient facility, Medicare reimburses the overhead expenses to the facilities and the physicians receive a lower reimbursement rate than if the services were performed in the physicians' offices. An improver payment exists when physicians bill these services with the physician-office place of service (POS 11) rather than the facility POS in which the services were rendered.

§ Magnetic Resonance Angiography (MRA) - J13 - Incorrect billing occurred for claims billed with ICD-9-CM codes that are not listed by National Government Services (NGS) Local Coverage Determination (LCD) L25367 as medically necessary.

§ Filgrastim Billed without a Medically Necessary Diagnosis - J13 - Potential incorrect billing occurred for claims with ICD-9-CM codes that are not listed in the National Government Services (NGS) Article A48208 (related to the NGS Local Coverage Determination [LCD] L25820) as diagnoses codes that support medical necessity.

Outpatient Hospital Claim Types

§ Panretinal (Scatter) Laser Photocoagulation Excess Frequency - J13 - Potential incorrect billing occurred for Panretinal Laser Photocoagulation services (CPT code 67228) paid more than once, per eye, within a 90 day global period.

RAC Region C Connolly

SNF Claim Types

§ Units in Excess of PPS Assessment Maximum - Medicare assigns standard scheduled payment periods for SNF assessments. Overpayment occurs when additional units in excess of assessment maximums are billed.

RAC Region D HDI

DME Non-Physician Claim Types

§ Excessive Units of Spring Powered Device - More than one spring powered device (A4258) per 6 months is not reasonable and necessary.

Professional Services (Physician/Non-Physician Practitioner) Claim Types

§ External Breast Prosthesis Garment Dispensed after Mastectomy Bra and Prosthesis - An external breast prosthesis garment with mastectomy form (camisole) is covered for use in the postoperative period prior to permanent breast prosthesis or as an alternative to mastectomy bra and breast prosthesis. The camisole is covered prior to a permanent breast prosthesis being dispensed or as an alternative to a breast prosthesis and mastectomy bra. Once the breast prosthesis and bras are dispensed, Medicare no longer covers the camisole.

Drill Down – Global Period Violations

May 13, 2013

RAC Region A Performant posted a semi-automated review issue on April 25, 2013 targeting all of Region A states with regard to procedures performed in the postoperative or global period. These would be procedures or surgeries that are performed during the 90 day or 10 day global post-op period of the initial procedure, which Performant considers an overpayment when it is billed without the following:

· Modifier 58 - this modifier allows for billing a staged or related surgical procedure done during the postoperative period of the first procedure) or

· Modifier 78 - describes the services involving a return trip to the operating room to deal with complications or

· Modifier 79 - reports an unrelated procedure by the same physician during the postoperative period or

· A clinically appropriate NCCI-associated anatomical modifier that justifies separate payment (i.e., indicating different body areas).

Medicare contractors apply the national definition of a global package to all procedures using the Medicare Fee Schedule Data Base (MFSDB), Column (O) titled Global Days, where the payment rules for surgical procedures apply to codes with entries of 000, 010, and 090. Codes with 090 are major surgeries, and codes with 000 and 010 are minor surgical procedures or endoscopies. In the sample below, Column (O) titled GLOB DAYS displays the global days for each procedure.

Physician and Non-Physician Practitioners should be aware that performing additional procedures, major or minor, during the global postoperative of the initial procedure will be considered an over-payment if billed without using the appropriate modifiers 58, 78, 79 or a clinically appropriate NCCI-associated anatomical modifier that justifies separate payment.

Other RAC issues for the week of May 13^th - May 17^th, 2013:

RAC Region A Performant

Outpatient Hospital Claim Types

§ Nerve Conduction Studies (NCS) - Maximum Units - J12 - Potential incorrect billing occurred for claims reporting CPT codes 95900, 95903 and 95904 for units in excess of what is medically necessary, based on information found in Novitas Local Coverage Determination (LCD) L29547. Payment will be recouped when no additional, supporting documentation is received from the provider for complex review within the 45-day response period.

§ Zoledronic Acid (Zometa®) Excessive Daily Units - J13 - Potential incorrect billing occurred when Zoledronic Acid (Zometa®), HCPCS code J3487, is reported in excess of the standard intravenous infusion dosage of four units (4 mg), per day, per patient.

Outpatient Rehabilitation Facility Claim Types

Physician/Non-Physician Practitioner Claim Types

RAC Region C Connolly

Carrier Claim Types

§ Mohs Surgery with Pathology billed by different provider - Mohs micrographic surgery used for removal of complex or ill-defined skin cancer requires physicians to act in two integrated but separate capacities: surgeon & pathologist. If either surgery or pathology is delegated to another physician who reports services separately, Mohs codes should not be reported since they include both the excision and the pathology services.

§ Post-payment Part B Review - Manual Medical Review of Therapy Claims Above the Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

Comprehensive Outpatient Rehabilitation Facility Claim Types

§ Post-payment Review - Manual Medical Review of 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, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

Home Health Claim Types

Outpatient Hospital Claim Types

§ Non-Covered use of Arpetitant (J8501) - Coverage for aprepitant (J8501) is predicated by its use as the three drug combination of aprepitant, a 5-HT3 antagonist and dexamethasone, and must be used in conjunction with one or more specified chemotherapuetic agents.

Outpatient Rehab Facility Claim Types

SNF Claim Types

§ SNF Coding Validation - C000412013 - We will review claims submitted by SNFs to determine the extent to which the Minimum Data Set (MDS) is accurate and supported by the resident's medical records. Upon receipt of the requested documentation, the entire benefit period will be reviewed to determine the appropriate level of care. (Medical Necessity will not be included in this review)

§ SNF Coding Validation - C000422013 - We will review claims submitted by SNFs to determine the extent to which the Minimum Data Set (MDS) is accurate and supported by the resident's medical records. Upon receipt of the requested documentation, the entire benefit period will be reviewed to determine the appropriate level of care. (Medical Necessity will not be included in this review)

§ SNF Level of Care Review - C000972013 - While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term “non-covered care” refers to any level of care, which is less intensive than the SNF level of care, which is covered under the program.

§ SNF Level of Care Review - C000982013 - While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term “non-covered care” refers to any level of care, which is less intensive than the SNF level of care, which is covered under the program.

Drill Down – Hospice Face-to-Face Re-certification Issue

May 7, 2013

HDI, the Recovery Audit Contractors (RAC) for Region D, recently posted an approved issue for Hospice providers. The complex audit will focus on whether a face-to-face encounter occurred when a patient was re-certified for hospice. Documentation in the patient’s records will be reviewed and must reflect that a face-to-face encounter took place for Hospice claims on or after January 1, 2011.

Hospice re-certifications on or after January 1, 2011, requires that the physician or nurse practitioner must have a face-to-face encounter with a patient prior to the beginning of the patient’s third benefit period and prior to each subsequent benefit period. Failure to meet the face-to-face encounter requirement results in a failure by the hospice to meet the patient’s re-certification of terminal illness eligibility requirement.

Per the Medicare Benefit Policy Manual, Chapter 9, Section 20.1, the face-to-face encounter requirement is satisfied when the following criteria are met:

a. Timeframe of the encounter: The encounter must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to every subsequent benefit period thereafter.

b. Attestation requirements: A hospice physician or nurse practitioner who performs the encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of the encounter. The attestation, its accompanying signature, and the date signed, must be a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled. Where a nurse practitioner performed the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course.

c. Practitioners who can perform the encounter: A hospice physician or a hospice nurse practitioner can perform the encounter. A hospice physician is a physician who is employed by the hospice or working under contract with the hospice. A hospice nurse practitioner must be employed by the hospice. A hospice employee is one who receives a W-2 from the hospice or who volunteers for the hospice.

d. Timeframe exceptional circumstances for new hospice admissions in the third or later benefit period: In cases where a hospice newly admits a patient who is in the third or later benefit period, exceptional circumstances may prevent a face-to-face encounter prior to the start of the benefit period. For example, if the patient is an emergency weekend admission, it may be impossible for a hospice physician or NP o see the patient until the following Monday. Or, if CMS data systems are unavailable, the hospice may be unaware that the patient is in the third benefit period. In such documented cases, a face-to-face encounter which occurs within 2 days after admission will be considered to be timely. Additionally, for such documented exceptional cases, if the patient dies within 2 days of admission without a face-to-face encounter, a face-to-face encounter can be deemed as complete.

Other RAC issues for the week of May 6^th - May 10^th, 2013:

RAC Region A Performant

Physician/Non-Physician Practitioner Claim Types

§ Procedures in the Post-Op Period of Other Procedures - All of Region A - Additional major and minor surgical procedures performed during the 90-day or 10-day global postoperative period of the initial procedure are considered an overpayment when billed without modifier 58, 78, or 79, or a clinically appropriate NCCI-associated anatomical modifier that justifies separate payment (i.e., indicating different body areas).

RAC Region C Connolly

Inpatient Claim Types

§ Medical Necessity: IP Psych - Medical records will undergo clinical review by a psychiatric nurse, with direct supervision from the contract medical director. The documentation will be reviewed to validate if true psychiatric conditions exist or currently being evaluated for an acute psychiatric condition. The medical record will then be evaluated to ensure that the patient is not in an inpatient psychiatric facility, to further continue treatment for urinary tract infection and pneumonia. There are clear CMS regulations, that state, inpatient psychiatric facilities, cannot be used for respite care.

§ Medical Necessity: MAJOR MALE PELVIC PROCEDURES, MS-DRG'S 707 AND 708 W CC/MCC, W/O CC/MCC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRG’S 707 and 708. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRG’S 707 and 708, requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

§ Medical Necessity: Diseases And Disorders of the Musculoskeletal System And Connective Tissue, MS-DRG'S, 534, 535 AND 536, W/MCC, W/O MCC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRG’S 534, 535 and 536. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRG’S 534, 535 and 536. requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

Skilled Nursing Facility Claim Types

§ SNF Coding Validation - C000392013 -We will review claims submitted by SNFs to determine the extent to which the Minimum Data Set (MDS) is accurate and supported by the resident's medical records. Upon receipt of the requested documentation, the entire benefit period will be reviewed to determine the appropriate level of care. (Medical Necessity will not be included in this review).

§ SNF Coding Validation - C000402013 -We will review claims submitted by SNFs to determine the extent to which the Minimum Data Set (MDS) is accurate and supported by the resident's medical records. Upon receipt of the requested documentation, the entire benefit period will be reviewed to determine the appropriate level of care. (Medical Necessity will not be included in this review).

§ SNF Level of Care Review -C000952013 - While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term “non-covered care” refers to any level of care, which is less intensive than the SNF level of care, which is covered under the program.

§ SNF Level of Care Review - C000962013 - While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF, the term “non-covered care” refers to any level of care, which is less intensive than the SNF level of care, which is covered under the program.

RAC Region D HDI

Hospice Claim Types

§ Face to Face Evaluation for Re-Certification of Hospice Care - To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. Recertification on or after January 1, 2011, require the hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient prior to the beginning of the patient’s third benefit period. Failure to meet the face-to-face encounter requirement results in a failure by the hospice to meet the patient’s recertification of terminal illness eligibility requirement. Medical documentation will be reviewed to determine timeliness of the face to face re-certification.

Drill Down – Documentation is Key for Therapy Claim Reviews

April 30, 2013

As of April 1st, the Recovery Audit Contractors (RACs) will start to review therapy claims above the $3,700 threshold cap. Several contractors have already posted both pre- and post-payment issues to their websites. All claim reviews will be done manually and requests for supporting documentation will be sent to the provider. Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. Documentation will be the key to these reviews and the provider should be prepared to send all records as soon as the ADR is received.

Previously, the Medicare Administrative Contractors (MACs) conducted pre-payment reviews on claims reaching the threshold with dates of service January 1, 2013 to March 31, 2013, but as of April 1, the RACs will take over these audits.

The RACs will complete two types of review – pre- and post-payment.

Pre-payment Reviews types for:

· Claims submitted in the RAC Review Demonstration states will be reviewed on a pre-payment basis: Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri.

· In these states, the MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor (unless another process is used by the MAC and the Recovery Auditor).

· The RAC will conduct manual medical review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision.

Post-payment Review types for:

· In the remaining states, CMS will grant an exception for all claims with a KX modifier and pay the claim upon receipt; the RAC will then conduct post-payment manual medical review on the claim.

· In these states, the Recovery Auditor will request additional documentation and conduct post-payment review and will notify the MAC of the payment decision.

Providers submitting claims over the cap will need to use the KX modifier on their claims to not receive a denial. However, using the KX modifier does not exempt the provider from an audit.

Critical Access Hospitals (CAHs) are not included in the therapy cap, the manual medical review process, or the use of the KX modifier.

The American Taxpayer Relief Act of 2012 (ATRA) was signed into law by President Obama on January 2, 2013 and extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013.

The Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,900 for 2013, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,900 for 2013. The therapy cap is an annual per beneficiary amount determined for each calendar year. 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.

Per CMS, the therapy cap applies to all Part B outpatient therapy settings/providers including:

· Therapists’ private practices

· Offices of physicians and certain non-physician practitioners

· Part B skilled nursing facilities

· Home health agencies (Type of Bill 34X)

· Rehabilitation agencies (also known as Outpatient Rehabilitation Facilities - ORFs)

· Comprehensive Outpatient Rehabilitation Facilities (CORFs)

· Hospital outpatient departments (HOPDs)

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

· TOB 12X (excluding CAHs) or 13X;

· Revenue code 042X, 043X, or 044X;

· Modifier GN, GO, or GP; and

· Date of service on or after January 1, 2013

Other RAC issues for the week of April 29^th- May 3^rd, 2013:

RAC Region A Performant

Home Health Agency (TOB 34x) Claim Types

§ Post-payment Review - Manual Medical Review of Outpatient Therapy Claims Above the $3,700 Threshold - The Balanced Budget Act of 1997 enacted financial limitations on outpatient physical therapy, occupational therapy, and speech-language pathology services in certain settings. Exceptions to the limits were enacted by the Deficit Reduction Act, and have been extended by legislation several times. Claims for services at or above $3700 will require a complex medical review process where the beneficiary therapy services have exceeded the threshold for the year. Claims for services furnished January 1, 2013, through December 31, 2013, are subject to this audit.

Outpatient Hospital Claim Types

§ CPT and HCPCS Code, Duplicate Billing -J13 - Potential incorrect billing occurred for claims billed with the same CPT/HCPCS code more than once per day with the same or different revenue code.

Outpatient Rehabilitation Facility Claim Types

Physician/Non-Physician Practitioner Claim Types

§ Cardiac Monitoring, Outpatient, Real-time - J12, DOS on or after 6/29/2011 - The use of real-time, outpatient cardiac monitoring is only allowable under a very select set of conditions. Reviews will determine whether the use of real time monitoring meets the coverage criteria as outlined in the Novitas Local Coverage Determination (LCD) L27520.

§ Cardiac Monitoring, Outpatient, Real-time - J12 for DOS through 6/28/2011 - The use of real-time, outpatient cardiac monitoring is only allowable under a very select set of conditions. Reviews will determine whether the use of real time monitoring meets the coverage criteria as outlined in the Novitas (Formerly Highmark) Local Coverage Determination (LCD) L27520.

§ Darbepoetin Alfa - Maximum Units - J12 - Potential incorrect billing occurred for claims billed with dosing amounts not supported in the Darbepoetin Alfa FDA-approved prescribing information, when no additional supporting documentation is received from the provider for complex review within the 45-day response period.

Private Practice Claim Types

Rehabilitation Agency (Comprehensive Outpatient Rehabilitation Facility) Claim Types

Skilled Nursing Facility (Part B Only) Claim Types

RAC Region D HDI

HHA Claim Types

§ Post-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 Home Health settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

§ Home Health Services for 5 to 9 Visits - The unit of payment under home health PPS is a national 60-day episode rate with applicable adjustments. An episode with four or fewer visits is paid the national per visit amount by discipline adjusted by the appropriate wage index based on the site of service of the beneficiary. Such episodes of four or fewer visits are paid the wage-adjusted per visit amount for each of the visits rendered instead of the full episode amount. These payment adjustments, and the episodes themselves, are called Low Utilization Payment Adjustments (LUPAs). Medical documentation will be reviewed to determine that services for only 5 to 9 services within a 60-day episode were medically reasonable and necessary and not subject to the LUPA adjustment.

Outpatient Hospital Claim Types

§ Post-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 Outpatient Rehabilitation Facility settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

§ Medical Necessity of Vagus Nerve Stimulation - Vagus Nerve Stimulation (VNS) is reasonable and necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for all other types of seizure disorders which are medically refractory and for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for resistant depression. Medical documentation will be reviewed to determine that services were medically reasonable and necessary.

Other FI Biller Claim Types

§ Pre-payment Review – 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 outpatient settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

Physician Claim Types

§ Post-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 Comprehensive Outpatient Rehabilitation Facility settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.

SNF Claim Types

§ Post-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 SNF settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.