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 Therapy Cap

Annual per-beneficiary Part B payment limitations (caps) were extended to Medicare’s coverage of therapies (physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services) in facilities, including skilled nursing facilities in 1999. The therapy caps limit payments for services irrespective of clinical need or outcomes. The cap limits apply to services received in all health care settings furnishing Part B therapy services (SNF, hospital, a therapist's or physician’s office, a home health agency, or a rehabilitation agency). That means, services received before the patient was seen in the SNF during the current year count towards the cap. Today’s therapy cap is $1,940 for PT/SLP combined. OT has a separate $1,940 cap limit. The cap threshold limits are adjusted annually. 

However, Congress established an exceptions process in 2006 to permit medically necessary services beyond the cap limit as long as the therapist attests to the medical necessity and certain coding requirements are met. The exceptions process was recently extended by Congress through December 31, 2017. 


 Manual Medical Review (MMR)

Congress now requires that a Manual Medical Review (MMR) process be conducted for Medicare Part B therapies exceeding $3,700 as a way to control utilization. The current policy will be in effect through December 31, 2017. 

 MMR Clearinghouse

Medicare Part B therapy manual medical review (MMR) is required by Congress through December 31, 2015. The Centers for Medicare and Medicaid Services (CMS) has said that it wants to know about any problems in the review process. This prompted AHCA to set up the MMR Clearinghouse as a way for members to submit their issues regarding claims payment and AHCA would assist in getting answers from CMS. In some cases AHCA may have the answer you seek based on previous interactions with CMS. If a provider is facing a glitch or a problem that it cannot get resolved, describe the problem to the clearinghouse and we’ll get back to you. ​

 Improvement Standard

In January, 2013, a Federal court approved a settlement in a case called Jimmo v. Sebelius. In this case, the defendants asserted that Medicare contractors were inappropriately applying a nonexistent “improvement standard” in making Medicare claims determinations in skilled care settings (e.g., SNFs, home health and outpatient therapy), while dismissing the concept of “maintenance.” The final settlement ensures that Medicare patients receive the services to which they are entitled and not be limited by a non-clinical restoration standard. CMS has issued updated program manual guidance and related educational materials and has educated Medicare contractors on the proper application of the coverage requirements, including that ”No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims that require skilled care.” ​


 Ultra-High RUGs

In 2012, the Zone Program Integrity Contractors (ZPICs) began focusing on ultra-high RUGs in Florida SNFs and the US Department of Justice (DOJ) and the Office of Inspector General (OIG) have begun joint investigations focusing on the alleged over-utilization of ultra-high RUGs in SNFs.