Medicare has started Phase one of their implementation of the new Physical Therapy Policy below.  Please go to

http://www.mbssi.net/mbss-blog.html to download your forms and see what phase your NPI is listed in.

If you are a billing client, our staff will contact you to advise what phase your practice is in.  MBSS will continue to append the KX modifier at the provider's instruction.  In addition, you should receive a letter from Medicare.  Please forward that to us as soon as possible.

Manual Medical Review of Therapy Services

Issued: September 07, 2012

Therapy Cap:
Certain providers are required to submit a request for an exception in advance of furnishing therapy services above the threshold of $3,700. The request will be manually medically reviewed.

What is the Therapy Cap?
 The Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630) was signed into law on February 22, 2012. This law extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2012.

The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,880 for 2012, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,880 for 2012. This is an annual per beneficiary therapy cap amount determined for each calendar year. Similar to the therapy cap, there is a threshold of $3,700 for PT and SLP services combined and another threshold of $3,700 for OT services.

Services above the $3,700 are subject to manual medical review and certain providers will be required to submit a request for an exception.

What does the $3,700 threshold represent?
The threshold represents the total allowed charges under Part B for services furnished by independent practitioners, and institutional services under Part B (hospital outpatient departments, skilled nursing facilities).

How is the $3,700 calculated?
The $3,700 is calculated using all outpatient therapy services provided (except those provided in Critical Access Hospitals) within the category of physical therapy/speech language therapy and then a separate category for occupational therapy services.

How can I determine how close to the $3,700 is a patient?
Providers can use the HIPAA Eligibility Transaction System (HETS) which effective October 1, 2012 will provide this information.

How can I determine how close to the $3,700 is a patient and eligibility?
Providers can use the HIPAA Eligibility Transaction System (HETS) which effective October 1, 2012 will provide this information. In addition, they can access this information using the Health Insurance Quality Access (HIQA).

Therapy Cap and eligibility information is also available through Novitas Solutions, Inc.'s interactive voice response.

• Jurisdiction H: 1-855-252-8782
• Jurisdiction 12: 1-877-235-8073

Who Does the Therapy Cap apply to?

The Therapy Cap applies to all Part B outpatient therapy settings and providers including:

• Private practices
• Part B skilled nursing facilities
• Home health agencies (TOB 34X)
• Outpatient rehabilitation facilities (ORFs)
• Rehabilitation agencies (Comprehensive Outpatient Rehabilitation Facilities-CORFs)
• Hospital outpatient departments (HOPDs)-beginning Oct. 1, 2012 until Dec. 31, 2012

The law requires an exception process to the therapy cap that allows providers to receive payment from Medicare for services above the therapy cap amount. No automatic exceptions will be granted in 2012.

Providers may submit a request for preapproval of a specific number of days, not to exceed 20 per discipline.

Please note that the Therapy Cap Pre-Authorization process applies to therapy services with the following dates of service:

October 1, 2012 through December 31, 2012
Any claims that are submitted with a date of service prior to October 1, 2012, will be treated by Novitas Solutions, Inc. under the manual medical review threshold of $3,700.

Providers will be required to submit requests for exceptions to the threshold in advance of furnishing therapy services above the threshold. Providers will be divided into three Phases. Providers may go to the following link to determine which Phase they have been assigned (you are in Phase III if not listed in Phase I or II):

What are the Phases?

• Phase I: October 1, 2012 to December 31, 2012
• Phase II: November 1, 2012 to December 31, 2012
• Phase III: December 1, 2012 to December 31, 2012

How do I know what Phase I am in?
Providers can determine which phase they are subject to by accessing the Therapy Provider Phase Information* website.

Does therapy provided in a critical access hospital (CAH) count?
No. Services provided in a CAH are not counted and CAHs are not subject to the manual medical review provision.

How do Providers submit Pre-Claim Review Requests?
Providers may submit pre-claim review requests via fax or mail. In all cases, providers must include Therapy Cap Cover/Transmittal Sheet:

1. Print the Therapy Cap Cover/Transmittal Sheet*
2. Place Therapy Cap Cover/Transmittal Sheet on top of the pre-authorization request
3. Pre-authorization request must include clinical documentation to support the request for an exception to therapy services above the threshold
4. Submit request by fax or mail:
   
   
   1. By Fax: 412-802-1833
       
   2. By Mail:
       Novitas Solutions, Inc.
       Therapy Cap Part A
       Post Office Box 890365
      Camp Hill, PA 17089-0365

1. Print the Therapy Cap Cover/Transmittal Sheet*
2. Place Therapy Cap Cover/Transmittal Sheet on top of the pre-authorization request
3. Pre-authorization request must include clinical documentation to support the request for an exception to therapy services above the threshold
4. Submit request by fax or mail:
   
   
   1. By Fax: 717-526-6560
       
   2. By Mail:
      Novitas Solutions, Inc.
       Therapy Cap Part B
       Post Office Box 890065
      Camp Hill, PA 17089-0065

What should I expect?
Upon receipt of the all requested records, Novitas Solutions, Inc. will review the records and make a decision (number of days approved and/or denied). This determination will be made using the coverage and payment policy requirements contained within Pub. 100-02, Section 220 of the Medicare Benefit Policy manual and any applicable local coverage decisions when making decisions as to whether a service shall be preapproved.

When will My Request for Pre-Authorization be Reviewed?
Pre-approval requests cannot be reviewed any sooner than 15 calendar days before the start of each Phase. The pre-approval requests reviews shall start no sooner than September 16, 2012.

How long will Novitas Solutions have to make a decision on a pre-approval request?
Novitas Solutions, Inc. will make a decision and inform the provider and the beneficiary of that decision within 10 business days by letter, telephone, or fax.

Approvals
If Novitas Solutions, Inc. approves your request, you will be notified of this decision within 10 business days via letter, telephone, or fax. The beneficiary will also be notified of this approval via telephone, fax, or letter.

If Novitas Solutions, Inc. fails to make a decision within 10 business days, this will lead to an automatic approval of the request. The provider and beneficiary will be notified of this automatic approval via telephone, fax, or letter.

Denials
If the request for an exception is denied, Novitas Solutions will provide notification via telephone, fax, or letter of denial to the provider and beneficiary. This notification will include detailed reason(s) for the determination.

If the provider furnishes the denied services and submits a claim, this claim would not be payable under Medicare. The claim will be denied and the beneficiary would be held liable.

A provider may render the services that are unapproved and submit the claim, which shall be denied by Novitas Solutions, Inc. At that time, the provider may request an appeal.

If the provider chooses to not render the unapproved services, they may send in a new preapproval request only if they have additional information to supply and the original request was denied.

Providers may submit a request for preapproval of a specific number of additional therapy treatment days, not to exceed 20 per discipline, each time the beneficiary is expected to require more therapy treatment days than previously approved.

Pre-approval requests shall not be reviewed any sooner than 15 calendar days before the start of each Phase. The pre-approval requests reviews shall start no sooner than September 16, 2012.

Novitas Solutions, Inc. will track all preapproval requests in a database. The provider must submit the following information with each preapproval request:

• Beneficiary Last Name
• Beneficiary First Name
• Beneficiary Middle Initial
• Beneficiary Medicare Claim Number (HICN)
• Beneficiary Date of Birth
• Beneficiary Address and Telephone Number
• Name of Provider Certifying Plan of Care
• Address of Provider Certifying Plan of Care
• Telephone and Fax Number of Provider Certifying Plan of Care
• National Provider Identifier (NPI) of Physician/Non-Physician Practitioner Certifying Plan of Care
• Name of Performing Provider
• Address of Performing Provider
• Performing Provider Number
• Telephone and Fax Number of Performing Provider
• Number of Treatment Days Requested
• Expected Date Range of Services
• Date of Submission

Novitas Solutions, Inc. will notify providers when Therapy Cap reviews have been discontinued by posting on this website.

For additional information please refer to the CMS Therapy Cap website*.