Medicare Review of Therapy Claims Above $3700

October 7, 2015
Rick Gawenda

In mid-January 2015, CMS approved the Recovery Auditors to begin reviewing Outpatient Therapy Threshold claims (those over the $3700 threshold) that were paid March 1, 2014 through December 31, 2014. In an effort to minimize provider burden, CMS set restrictions on the number of Additional Documentation Requests (ADRs) that could be sent related to these claims, as shown below.

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  1. We currently have a patient who has reached the $3700 threshold. I called medicare and they said until they deny payment to keep submitting claims with the kx modifier and once it denies then I will have to do a redetermination. Is that accurate, or should I be sending in documentation? This patient definitely needs physical therapy. The patient caught on fire and suffered 2nd and 3rd degree burns all down one side of his body and had to have skin grafts etc. I have never had to deal with a patient reaching the caps, can you give me some guidance on what I need to do?