Details and Discussion on the $3,700 Threshold Update

Today's post comes from Tom Ambury, PT and compliance officer at PT Compliance Group, based off this month’s “Compliance Chat” blog post.

We are now well into the exception process associated with the $3,700 threshold. The clinics that I’ve been working with have done fairly well in that they have not received any outright denials of services. But let's look at the responses we have received:

The responses from the Medicare Administrative Contractors (MACs) have fallen into three categories: Approval, Partial Approval, and Additional Documentation Requests (ADRs). Let's go through each one to see what Medicare will require of you.

• Approval: Your request for 20 treatment days (or however many you requested) has been accepted. The only thing you need to do is count your visits to make sure you don't exceed the number of visits approved.
• Partial Approval: You requested 20 treatment days, but Medicare granted you a lower amount. Again, the only thing you need to do is count your visits to make sure you don't exceed the number of visits granted.

Note that just because you’ve received approval for 20 visits maximum doesn’t mean you’re limited to those visits. The number of visits you can ultimately receive depends upon your ability to justify the medical necessity of the care you’re providing. So, as you treat, if your patient still needs care and you can justify the additional visits, you can reapply for another exception and request up to 20 additional visits.

I am seeing requests to justify ESUN (Electrical Stimulation Unattended, G0283). ESUN is traditionally for pain reduction so Medicare would expect you to document pain, so be sure to include the pain rating scale and how the patient responded to the treatment. Again, in your addendum to your note you want to relate back to those objective measures. I would also include a statement regarding the patient's ability to function.

Is it true that I only need to send to the MAC what the ADR has requested? No.

Remember, this is Medicare. You must justify the date of service requested within the ADR, so in addition to the addendum to your note, send the following:

• Prescription
• Initial evaluation/reevaluation
• Signed POC (Plan of Care) covering the visit(s) requested
• Visit note(s) for the requested date of service(s)
• Addendum explaining your clinical rationale and your justification of your treatment
• Flow sheet covering the date of service
• Signature attestation sheet
• Anything else you think might be helpful in justifying the care you provided

The letters from MACs that I have seen give you 30 or 45 days to respond. The letter includes a fax number, so reference that, and when you fax the information to the MAC, include the initial letter you received.

Once you fax the required information to the MAC, the MAC then has ten business days to make a decision, right? Wrong.

The ten business days were for the initial preapproval exception only. Now that you have received an ADR, the MAC will handle it in traditional manner, i.e., as much time as they need to make a decision (generally 45 to 60 days, or even longer in some instances). With an ADR, the MAC is now trying to determine if the services you provided and are requesting to provide are reasonable and medically necessary. Consider having your documentation reviewed before submitting it to your MAC for their review.

Denials: I have not seen one, but I know they are out there. You have a choice of responses to the denial:

• Acceptance: You accept the denial of the services you requested and thus you are not required to take any further action.
• Appeal: If you receive a denial, but you feel the services you provided are reasonable and necessary, you can appeal. (Note that you cannot initiate the appeal until you first submit a claim and the MAC denies that claim.) If you appeal, though, be aware that the argument will center on what you have documented in that record. If you want to appeal, check the record and make sure it supports the services provided. The more objective, measurable, and therefore, defensible your documentation is, the better chance you have at appealing the denial.

This is a weighty topic, I know, so if you have any questions or comments, please post them in the comments section below. You can also contact the PT Compliance group at questions@prcompliancegroup.com or 888-680-7688.