CMS posted updated information about the agency’s Manual Medical Review process.

The annual Medicare Part B therapy benefit for each Medicare beneficiary is $1,900 for Occupational Therapy and $1,900 for Physical Therapy/Speech Therapy combined.  There are exceptions to the these therapy caps for reasonable and necessary therapy services.

Once the beneficiary reaches $3,700 for Occupational Therapy and $3,700 for Physical Therapy/Speech Therapy combined, these services are subject to manual medical review.

The therapy caps apply to all Part B outpatient therapy settings and providers:

  • Private practices
  • Physician offices and certain nonphysician practioners
  • Part B skilled nursing facilities
  • Home Health Agencies
  • Rehabilitation agencies
  • Comprehensive Outpatient Rehabilitation Facilities
  • Hospital outpatient departments

CMS is working on a long term strategy to deal with manual medical review.  However, in the meantime, Medicare Administrative Contractors (MACs) will conduct prepayment review on the claims reaching $3,700 threshold.

CMS has requested that the MACs conduct these manual medical reviews within 10 days.

Currently, there is no advance request for an exception to the $3,700 threshold.

MACs will be providing additonal information on their websites and when information is posted, we will be sure to communication that information.

To view CMS’ communication, please click here.