Client receiving therapy
Pass MMR audits with flying colors.

Manual Medical Review

Medicare only pays for therapy services that are demonstrated reasonable and medically necessary. However, Medicare not only caps payments, but when a beneficiary’s treatment reaches a $3700 annual threshold, therapy claims may go through an audit process known as Manual Medical Review (MMR).

Sounds complex and confusing?  It can be— unless you have a system like Clinicient. Clinicient helps guide you through Medicare guidelines for physical therapy, occupational therapy and speech enabling you to:

  • Minimize audit risk and Medicare reimbursement problems
  • Document defensibly and supply appropriate documentation
  • Automate therapy cap and MMR tracking and management

The results? With Clinicient, you’re notified—and prepared—to keep on top of Medicare therapy caps, manual medical review and other requirements.

Minimize your audit risk with our single system

Minimize your compliance risk and financial exposure with automated compliance management tools that take the guesswork out of following Medicare guidelines for physical therapy, occupational and speech therapy.

Single System
  • One source of truth for clinical documentation and billing information
  • Ensures documentation always matches the claim
Automated Tracking and Alerting
  • Helps manage therapy caps and MMR based on Medicare Fee Schedules
  • Simplifies medicare requirements for plans of care, physician certifications, progress reports, modifiers, PQRS, functional limitations, co-signing requirements and Advanced Beneficiary Notices
Goal tracking and chart templates
  • Guides you through requirements to support medical necessity
  • Easily establish and track long term functional goals and associate with short term clinical goals 
  • Provides pre-audit at every visit at sign-off
  • Automatic therapist prompts for CCI edits when appropriate, automatic aggregation of timed procedures and units, and time reconciliation
Reporting tools
  • Reporting tools make it easy to produce all required documentation on review
  • Paperless charge ticket created at signoff and pushed to billing
Ongoing Medicare updates and education
  • Webinars, cheat sheets, blogs and other resources
  • Ongoing training and updates

Manual Medical Review Requirements

CMS Manual Medical Review process and $3700 threshold

In 2016 the Medicare Part B outpatient therapy cap for Occupational Therapy is $1,960 and the combined cap for Physical Therapy and Speech-Language Pathology services is $1,960.

Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. However, services above $3,700 for PT and SLP services combined and/or $3,700 for OT services may be subject to manual medical review.

Manual medical reviews are performed by Recovery Audit Contractors, commonly known as RAC auditors. RAC auditors identify and recover improper Medicare payments paid to healthcare providers under fee-for-service Medicare plans.

Failure to understand and adhere to the CMS rules and regulations and establish medical necessity in your clinical documentation increases your audit risk and will have a serious impact on Medicare reimbursements.

Jerry Henderson PT

Learn how Clinicient can help you simplify manual medical review with PT Jerry Henderson.