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Expedited Review When Therapy Services are Discontinued

July 5, 2013 1 Comment

ComplianceFaced with $1900 therapy caps, and $3700 manual medical review by Recovery Auditors (RACs) therapy providers are cautious about providing therapy services that may not be deemed medically necessary by Medicare contractors.  In light of the change in liability for therapy over the $1900 cap in 2013, therapy providers have a choice of obtaining a mandatory ABN, using the GA modifier to signify that therapy is not medically necessary, or continuing to bill for medically necessary therapy with the KX modifier.  Therapy providers may also playing with fire when they put a patient on “hold” while a claim over $3700 is being reviewed under the RAC manual medical review program.  Unlike last year, therapy providers cannot’ have their cake and eat it too when it comes to transfering liability for claims over $1900 to Medicare beneficiaries.  For a refresher on the 2013 ABN rules for therapy over the cap read our blog post on the 2013 rules.

CORFs, Skilled Facilities and others providing outpatient therapy covered under Part B (even if you are a Part A provider) must advise Medicare beneficiaries of their right to have an expedited review of service determination.  From CMS CR7903:

The expedited determination process is available to beneficiaries in Original Medicare whose Medicare covered services are being terminated in the following settings. All beneficiaries receiving services in these settings must receive a Notice of Medicare Non-Coverage (NOMNC) before their services end: For purposes of this instruction, the term “beneficiary” means either beneficiary or representative, when a representative is acting for a beneficiary.

  1. Home Health Agencies (HHAs)
  2. Comprehensive Outpatient Rehabilitation Services (CORFs)
  3. Hospice
  4. Skilled Nursing Facilities (SNFs)– Includes services covered under a Part A stay, as well as Part B services provided under consolidated billing (i.e. physical therapy, occupational therapy, and speech therapy). A NOMNC must be delivered by the SNF at the end of a Part A stay or when all of Part B therapies are ending. For example, a beneficiary exhausts the SNF Part A 100-day benefit, but remains in the facility under a private pay stay and receives physical and occupational therapy covered under Medicare Part B. A NOMNC must be delivered by the SNF when both Part B therapies are ending.

A explanation of expedited review for discontinued services is provided in an updated CMS MedLearn Matter Article MM 7903.  Additional details are provided in the Medicare Claims Processing Manual.


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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (1)

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  1. Glenda says:

    There is confusion about whether all beneficiaries receiving Part B services are entitled to the expedited review or only those who continue therapy services under their Medicare B benefit as a continuation of their Part A stay after their Part A stay is exhausted. Can you clarify?

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