CMS has issued guidance for reviews at the redetermination and reconsideration levels resulting in new rules applicable for therapy appeals. Given that providers are now receiving the results of manual medical review of therapy over the $3700 threshold therapy providers have an interest in appealing unfavorable decisions, particularly for institutional providers billing on the UB04 claim form. Redetermination is the fist level in the CMS appeals process and reconsideration is the second level of appeals. Perhaps you have experienced insult after injury when a “new” issue surfaces as the reason for denial, even if the original reason for the denial is cured.
New Rules Applicable for Therapy Appeals
On Aug. 13, the Centers for Medicare & Medicaid Services (CMS) released MLN Matters SE 1521, “Limiting the Scope of Review on Redeterminations and Reconsiderations of Certain Claims.” In short this means that if you submit an appeal, then the Medicare Administrative Contractor (MAC) cannot deny the claim for a new reason during the redetermination process. Likewise the Qualified Independent Contractor (QIC) cannot deny the claim for a reason other than the basis for the original denial.
CMS notes that MACs and QICs have discretion while conducting appeals to develop “new issues and review all aspects of coverage and payment related to a claim or line item”. But they note that as a result, in some cases where the original denial reason is cured, that additional review of the documentation submitted results in an unfavorable appeal decision for a different reason. CMS guidance instructs as follows:
For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. Post-payment review or audit refers to claims that were initially paid by Medicare and subsequently reopened and reviewed by, for example, a Zone Program Integrity Contractor (ZPIC), Recovery Auditor, MAC, or Comprehensive Error Rate Testing (CERT) contractor, and revised to deny coverage, change coding, or reduce payment.
Prepayment Review Therapy Appeals
Note that if an appeal involves a claim or line item that was denied on a pre-payment basis, MACs and QICs may continue to develop new issues and evidence at their discretion and “may issue unfavorable decisions for reasons other than those specified in the initial determination.” For example if your MAC is doing a service specific probe of 97022 for whirlpool, which includes fluidotherapy (as the J6 NGS is currently doing), and you appeal the denial of 97022, the MAC and the QIC can review for other issues than the denial of 97022 for medical necessity.
A bit of bad news: if you submitted your appeal prior to August 1, 2015 the new guidance is not applicable. In it’s Technical Direction Letter-150407 to the MACs and the QICs CMS pointed out that the updated instruction applies to redetermination requests received by a MAC or QIC on or after August 1, 2015, and will not be applied retroactively.
Do you have current denials? Are you planning appeals? Do you have a process to ensure that the results of your appeals after August 1, 2015 are not for a new reason?