Manage and Track Medicare's Manual Medical Review

Although there is no longer a yearly cap on therapy services, when allowed charges to Medicare exceed an arbitrary, annual amount CMS requires the application of a KX modifier to show that the therapist stipulates further treatment is medically necessary.

All Medicare cases that have $3,000 in allowed charges exceeding the annual PT and Speech cap and the separate OT cap are subject to a Manual Medical Review. INSIGHT includes a system of alerts and features to support Medicare's review. Use this document to see how you can manage and track Medicare's Manual Medical Review process in INSIGHT.

Set Up Clinicient to Track the Medicare Therapy Threshold

To track the Medicare Therapy Threshold, the payer must have the setting Claim Type set to either Medicare-A (UB-04) or Medicare-B (CMS-1500). This setting makes it possible to enter a Medicare Therapy Threshold dollar total when setting up a patient’s payer mix.

Make sure your Clinical issues are set to track against the cap. Go to Run>Clinical Issues and click on the Settings button at the bottom of the form. The Medicare Therapy Threshold Limitation Warning is the amount prior to the $2,150 cap is reached that alerts will prompt the user for action. The Manual Medical Review setting is the amount prior to $3,000 that alerts will prompt the user for action.

Note: If the patient has an insurance authorization entered in their payer mix, that authorization overrides the MMR warning in the Clinical Issue Listing.

The Medicare Therapy Threshold tracker relies on estimating each charge’s allowed amount at time of sign-off. To get the most accurate estimate, make sure you have an allowed reimbursement fee schedule set for your Medicare payers. Go to Billing>Allowed Reimbursement to check your settings.

Tracking a Patient through the Manual Medical Review Process

  1. Reconfirm the patient’s eligibility.
    Let’s follow Fredric Goethe, a 64-year-old Medicare patient, through the Manual Medical Review Process. On September 25th, the front desk checks the eligibility and learns that $2604.23 of benefits has been used toward the Medicare Therapy Threshold. Open Billing>Medicare Eligibility Entry and enter $2604.23 in $ Used and 9/25/2012 in Used As Of. This one form can used to update all your Medicare Eligibility amounts in one place. NOTE: we have changed the cap tracker from recording the remaining amount to recording the used amount as of a specific date. This makes it easier for providers to enter information and for Insight to alert on two thresholds.
  2. Check your Clinical Issues.
    Clinicient automatically tracks Clinical Issues for both the Medicare Therapy Threshold and the new Manual Medical Review Process threshold. This new alert is called Medicare MMR. Go to Run>Clinical Issue Listing and select the Medicare MMR alert. Fredric Goethe is at $3,343.23 used on the Medicare Therapy Threshold. This is a combination of the amount Medicare reports as used and the amount of pending allowed reimbursement on services captured in Insight.
  3. Review the MMR Upcoming Appointments report .
    The most critical part of the process is the “Phasing In” of therapists. It is critical that clinics know whether a patient nearing the $3,000 threshold is going to be treated by a Phased In therapist in order to decide when the exemption should be applied for. Clinicient has provided a report that includes all patients approaching the MMR Process, their upcoming appointments and the phase of the therapist. Go to Reports> Management>Manual Medical Review Upcoming Appointments and Run Report For Mr. Goethe he will be seeing Chris Berman, a phase 1 therapist, on 10/2/2012. For that reason it is time to apply for an extension.
  4. File for an exception when appropriate.
    The extension process has been defined by your Medicare Administrative Contractor (MAC). For that reason processes vary from customer to customer.
  5. Enter a task to track approval.
    Each MAC has 10 days to reject an application for extension. It is up to the provider to track this process and ensure services are not provided that exceed the cap during this time. Clinicient’s Task Management system is an excellent tool to flag the date approval or denial must be sent. In our example, a new task has been made for Mr. Goethe’s approval request. A follow-up date has been set 10 days out from the date of submission and the task has been assigned to the Front Desk.
  6. Enter an Authorization when approved.
    When a threshold exception is approved, it is assumed to be for an additional 20 treatment days. Clinicient’s Payer Authorization tracker is the ideal place to track this process. Go to Client Editor> Case Information> Payer Information and add a new Insurance authorization to the existing payer mix.
    For patients who have multiple cases (ie. SLP and PT running simultaneously). The team will need to split the 20 treatment days between the cases for tracking purposes.

Other Useful Tools

It is good to make sure that Clinicient has the correct Phase information Clinicient has integrated the therapist, Clinic or Company NPI phase information into the application to help with identifying when to submit patients for exception. But, this is based on what we know from payer settings and therapist credentialing.

How we calculate the Medicare Therapy Threshold Predicting the Medicare Therapy Threshold is a difficult and imprecise science, but Clinicient has worked hard to give you the best possible estimate based on our complete view of the patient’s account. We have provided a report that exposes how we have arrived at our cap total. There are three components:

  • Medicare Used Amount: The amount Medicare reported as used by all parties as of a specific date. Because Medicare has counted this money in their total, Insight will ignore all payments for services with a payment date prior to the Medicare Used by date.
  • Medicare Paid: The actual allowed amount from the EOB of paid services that have a payment date after the Medicare Used by date.
  • Medicare Pending: The allowed amount from the Allowed reimbursement schedule for all services that have not yet been paid.
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