Manual Medical Review Process Update from CMS [02-22-13]

Filed under: Industry Updates — Editor @ 12:26 pm

cmslog4colCMS has posted an update regarding the Manual Medical Review (MMR) process to the Medical Review and Education page on the Therapy Cap (click here to be redirected to the page). Here is a portion of the update:  CMS is developing a long term strategy to deal with manual medical review. However, in the interim, Medicare Administrative Contractors (MACs) will conduct prepayment review on the claims reaching the $3700 threshold. CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process. Additional information will be provided on the MAC websites. Section 603 (b) of the American Tax Relief Act counts outpatient therapy services furnished in a Critical Access Hospital (CAH) toward a beneficiary’s annual cap and threshold amount using the Medicare Physician Fee Schedule rate. CAHs are not subject to the therapy cap, the manual medical review process, or the use of the KX modifier.

What this means to providers:

* There is no pre-approval process, providers will provide treatment and then documentation will be reviewed;
* Provider will have to treat patient, submit documentation, and wait for payment determination;
* Manual medical review of claims is expected to be completed within 10 days;
* Therapy provided at CAHs counts towards the cap and threshold, although CAHs are not subject to these;
* Your regional MAC should be providing additional direction on this process.

You can contact CMS with questions about the therapy cap and new threshold via a designated e-mail box at

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