Is There a 2-Tiered Therapy Threshold for Medicare?
Ever since the Centers for Medicare and Medicaid Services (CMS) implemented the Targeted Medical Review process, providers of outpatient therapy services have referred to this as the “second cap”, the “second tier”, or the “second threshold” with the “first cap” or “first tier” being the annual therapy threshold (formerly called the therapy cap). In this article, I will answer common questions I receive on the annual therapy threshold and the targeted medical review and provide criteria on how claims may be selected for a targeted medical review.
Question
What is annual therapy threshold dollar amount for calendar year 2021?
Answer
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Question
In calendar year 2021, what is the targeted medical review threshold dollar amount?
Answer
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Question
What additional and/or special documentation does CMS require to support outpatient therapy provided above the annual therapy threshold dollar amount in calendar year 2021?
Answer
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Question
What additional and/or special documentation does CMS require to support outpatient therapy provided above the targeted medical review threshold dollar amount in calendar year 2021?
Answer
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Question
Since the targeted medical review threshold dollar amount was lowered from $3700 prior to 2018 to $3000 beginning in 2018, does that mean more claims will be reviewed?
Answer
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Question
Who is responsible for conducting medical reviews of claims that have exceeded $3000 in a calendar year?
Answer
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Question
What criteria will Noridian utilize to select claims for medical review for claims exceeding $3000 in a calendar year?
Answer
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Question
Once a Medicare beneficiary exceeds the annual therapy threshold in calendar year 2021 and I still feel therapy is medically necessary and requires the unique skills of a therapist to provide, can I also have them sign an advance beneficiary notice of noncoverage (ABN) just incase my Medicare Administrative Contractor denies my claim?
Answer
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Question
Once a Medicare beneficiary exceeds the targeted medical review threshold in calendar year 2021 and I still feel therapy is medically necessary and requires the unique skills of a therapist to provide, can I also have them sign an advance beneficiary notice of noncoverage (ABN) just incase my claim is denied upon a targeted medical review?
Answer
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Once a Medicare beneficiary exceeds the targeted medical review threshold in calendar year 2021 and I still feel therapy is medically necessary and requires the unique skills of a therapist to provide, but my claim is denied upon a targeted medical review, is the patient responsible to pay for the visits, and is there any Medicare documentation to provide the patient with in advance?
Patient is not responsible and you would have the ability to appeal the denial.
Hi Rick. In your summary of how Noridian is selecting claims for review, one of the items you mention is:
” 4. The services are furnished to treat a type of medical condition”
Is there any guidance on what types of medical conditions Noridian is likely to prioritize?
Thanks!
No
Has anyone experienced any denials if the kx modifier is appended before the therapy threshold is exceeded?
No, but I recommend against appending the KX modifier when it is not required.