$3700 therapy threshold RAC reviews have resumed even though the larger RAC program has been “paused”. Therapy over the $3700 per beneficiary thresholds ($3700 for PT & SLP combined, another $3700 for OT) is mandatorily reviewed for medical necessity. CMS has assigned the review task to the RACs. According to information provided by CMS to the therapy cap coalition the resumption will begin with those received first and proceed to current – so requests should come to providers beginning with February claims that exceeded $3700 and proceeding forward. All claims over $3700 have been paid, so the reviews by the RACs will be on a post-payment basis, even in you are in one of the pre-payment review states.
$3700 Therapy Threshold RAC Reviews – The Chess Game
We are also at the time of the year where there is a higher probability for a beneficiary to exceed one of the therapy caps as well as the $3700 threshold. You will be playing a chess game to determine all the moves related to patient care, and supportive documentation in determining medical necessity for therapy over $3700. For therapy documentation key tips to demonstrate medical necessity:
- A single complicated episode of care
- Multiple related episodes of care
- Multiple unrelated episodes of care
Follow with any complexities and comorbidities – keeping in mind that seniors in therapy are likely to have complexities and comorbidities – but it is not enough to list them, but to indicate how they will affect therapy participation and progress – and then continue to update and report on that status. Don’t hesitate to change and update the plan of care as a result of patient response to therapy, and so indicate in required progress reports. This all sets the tone for the underlying medical necessity documentation being supported in the $3700 therapy threshold RAC reviews. A final word: Don’t be lulled into relying on the non-payable g codes and functional limitation reporting to support continued therapy – it is the progress toward the mandatory functional outcome goals based upon objective tests and measures and patient functional performance, but rather progress toward functional goals that lowers the gap between prior level of function and current level of function.
Do you have patients over the $3700 threshold? Is their documentation to support the medical necessity of exceeding the threshold?