Do you know what will be happening from January 1 through March 31st in 2015?  Since the RAC Manual Medical Reviews have resumed for those claims over the threshold, we will begin seeing RAC Manual Medical Reviews on a post-payment basis emerging in February, for all claims that exceeded the $3,700 threshold for PT/ST and $3,700 threshold for OT.

What Should You Do To Prepare?

  • Review your Part B management reports to see where your patients are with their Part B cap/threshold benefit.  It is that time of the year where those who we care for may be running out of their benefit or may have already run out of their Part B dollars.
  • Documentation should always support that the skills of a therapist are vital to treat the patient’s medical condition/diagnosis and show medical necessity that the therapy interventions are necessary.
  • Justification for continuing therapy is necessary in our documentation and making sure the reviewer has a clear picture of why the patient has exceeded $3,700 is critical.  Make sure you include specifics about the medical episode, things like complications, multiple related complications, and multiple unrelated complications.  Talk about the co-morbidities affecting the treatment progression and participation as well as the potential patient risks of not providing the intervention.
  • Prepare your facility denial team to be on the lookout for ADRs.  Be on your game and submit all necessary therapy supportive documentation and billing at the very beginning of the review to decrease your risk of denials.


Gina Tomcsik

Director of Compliance