The Centers for Medicare and Medicaid Services (CMS) has released an article in which CMS creates edits in original Medicare claims processing systems to ensure that certain ‘always therapy’ evaluation and reevaluation codes are reported with the correct modifier. It also makes several clarifications of details in the “Medicare Claims Processing Manual,” Chapter 5 – Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services. In the past, occupational therapy evaluation and re-evaluation CPT codes have been reimbursed even though they contained the GP discipline modifier instead of the GO discipline modifier. The same has also occurred when the

The Medical Directors for all 4 DME Medicare Administrative Contractors (MACs) have developed “Dear Physician” letters to help define medical necessity requirements of specific items such as diabetic supplies, oxygen equipment, power wheelchairs and power operated devices, hospital beds, therapeutic shoes for diabetics, nebulizers, etc., for ordering physicians. If the treatment plan includes durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), Medicare requires that suppliers have access to information from the patient’s medical record that addresses the coverage criteria for the items prescribed. Utilization of these “Dear Physician” letters will ensure the required information and documentation are available. Suppliers are

On January 31, 2014, The Centers for Medicare & Medicaid Services extended for six months the partial enforcement delay of its two-midnight policy for inpatient admission and medical review criteria. Under the extension, recovery auditors and other Medicare review contractors will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after Oct. 1, 2013 through Sept. 30, 2014. However, Medicare Administrative Contractors will continue to conduct pre-payment “probe and educate” audits on select claims for patients admitted between Oct. 1, 2013 and Sept. 30, 2014. For more on the claims review policy, see

The Settlement Agreement in Jimmo v. Sebelius provides that Medicare beneficiaries who were previously denied Medicare coverage may have claims re-reviewed under the revised manual provisions.  The process is not automatic: people who wish to take advantage of the re-review process must fill out and submit a form, known as a Request for Re-Review. Per the Medicare Advocacy Organization, a Medicare beneficiary is eligible for a review if he/she 1. Has received skilled nursing or therapy services in a skilled nursing facility, home health setting, or outpatient therapy setting, and 2. Has received a partial or full denial of Medicare

The Office of the Inspector General (OIG) has released their 2014 work plan and to no one’s surprise, therapy is in the work plan.The OIG will focus on critical access hospitals (CAH’s) and the Medicare beneficiaries cost for outpatient therapy services as well as the cost the Medicare program reimburses for swing beds in a CAH compared to the same service provided in a skilled nursing facility. The OIG will look at inpatient rehabilitation facilities (IRF) and adverse events that occur to Medicare beneficiaries in the IRF setting and determine the extra cost to the Medicare program due to the

The Centers for Medicare and Medicaid Services has revised the Inpatient Rehabilitation Facility Prospective Payment Fact Sheet. To access the revised fact sheet, click HERE.

The Centers for Medicare and Medicaid Services has released an article intended for physicians who refer patients to home health, order home health services, and/or certify patients’ eligibility for the Medicare home health benefit, home health agencies, and non-physician practitioners (NPPs). Effective January 1, 2011, the Affordable Care Act mandates that prior to certifying a beneficiary’s eligibility for the HH benefit, the certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the beneficiary. This article provides the narrative requirements of what a physician or NPP must document in the medical

The Centers for Medicare and Medicaid Services have released instructions regarding the implementation of the therapy cap to critical access hospitals. This will also include the exceptions process and the manual medical review of claims in excess of the therapy threshold when required by statute. Click