Managing the Medicare Therapy Cap and Exceptions Process
CMS Manual Medical Review Process and the new $3700 Threshold
Beginning October 1, 2012, CMS begins “phasing-in” a Manual Medical Review of all claims for patients who have received more than $3700 worth of benefits in the calendar year 2012. At the same time, any benefits a patient received in 2012 from a hospital outpatient department will retroactively apply to both the $1880 cap and the $3700 manual review process.
Managing the new caps has brought on confusion and anxiety for most practices. And if that hasn’t intimidated most, requesting an exception to continue treating patients who have reached their cap most likely will. To make matters worse, miscalculating of the therapy cap and failing to correctly request an exception can bring on an automatic pre-payment audit – the very thing most practices dread.
5 Things To Do For Success
To be successful, be sure to do the following:
- Identify the phase of each therapist in your practice
- Re-verify the therapy cap for every Medicare patient beginning Oct. 1st
- Track the therapy cap with extreme care throughout the remainder of the year
- Understand and abide by the exception process per your Medicare intermediary
- Track authorized visits carefully upon approval of an exception
- Most importantly, abide by CMS guidelines on the documentation of therapy services.
Take the Worry Out of Managing the Manual Medical Review with Clinicient
With the support of Clinicient, you’ll experience the freedom from worrying about manually managing therapists phasing, therapy caps, authorizations and approvals. Best of all, Clinicient’s documentation software was designed to help therapist track goals and document defensibly. To learn more, schedule a demonstration and learn how to get started today.
Resources to Help Survive the Manual Medical Review Process
Documentation for Manual Medical Review – Recorded webinar with compliance expert Nancy Beckley (Nov. 7th)
Surving Manual Medical Review – Recorded webinar with compliance expert Nancy Beckley (Oct. 2nd)
Clinicient Can Help Reduce Your Risks
Although therapy is a very small percentage of where Medicare dollars go, therapy CPT codes have become some of the fastest growing codes used today. The manual medical review process is one of the first steps CMS has taken to monitor therapy spending. RAC audits have increased, and experts now warn it is not a matter of IF you are audited, it is a matter of WHEN.
Failure to understand and adhere to the new CMS rules and regulations both in managing the exception process and in documenting defensibly can increase your audit risk and have a serious impact on Medicare reimbursements.
Clinicient has been helping practices manage therapy caps and adhere to Medicare requirements since Medicare implemented therapy caps years ago. We are the leading EMR and Practice Management provider to help manage compliance because our system is loaded with embedded processes that automatically track and alert staff to keep on top of:
- Medicare Therapy Caps, including the new Manual Medical Review Exception
- Authorized Visits
- Plans of Care (POC)
- Physician Certifications
- Progress Reports
Therapists love Clinicient because it allows them to easily establish and track long term functional goals and short term clinical goals. It is one of the only systems that truly allows therapists to focus on patient treatment and makes it easy to create defensible documentation that demonstrates medical necessity. Additionally, each and every visit is pre-audited at sign-off so therapists are automatically prompted with:
- CCI edits that have been applied
- CMS rounding rules that have automatically calculated visit units for them
- Modifiers needed
- Over and under billing
And because your billing is managed in the same system with Clinicient, you can rest assured that what gets billed will always match what gets documented, reducing your audit risk.
Watch our short video on how Clinicient will help manage the manual medical process, minimize your audit risks and give therapists the right tool to help stay compliant.
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