(Medicare Program Integrity Manual)

If the medi cal documentation includes any of the information included in the definition of psychotherapy notes in 164.501, as stated above, the provider is responsible for extracting information required to support that the claim is for reasonable and necessary services. MACs, Recovery Auditors, CERT or UPICs shall review the claim using the supporting documentation submitted by the provider. If the provider does not submit information sufficient to demonstrate that services were medically necessary, the claim shall be denied. Beneficiaries cannot be held liable for these denials unless they received proper liability notification before services were rendered, as detailed in CMS Pub. IOM, 100-04 chapter 30, 30.1.  3.3.2.7 - Review Guidelines for Therapy Services  (Rev . 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11)  This section applies to MACs.  Financial limitations on therapy services (therapy caps) were originally initiated by the Balanced Budget Act of 1997 and have been implemented at times without an exceptions process.  During a time when no exceptions process exists, contractors shall deny claims for Part B occupational, physical, and speech-language pathology therapy services, except for hospital outpatient therapy services, which exceed the therapy cap.  There is no therapy cap for hospital outpatient therapy services.  Automatic Process for Exception from the Therapy Cap  Section 1833(g)(5) of the Social Security Act provides that contractors shall, at the request of the individual enrolled under the Part B benefit or a person acting on behalf of that individual, grant an exception to the therapy cap in certain circumstances.  For therapy services provided during a time when a therapy cap exceptions process is in effect, the contractor shall presume the beneficiary to be excepted from the therapy cap without submission of request for exception or supporting documentation if:   The beneficiary meets specific conditions listed in CMS Pub.100-04, chapter 5, 10.2 for exception from the therapy cap, or   The beneficiary does not meet the specific criteria in CMS Pub.100-04, chapter 5, 10.2, but has a need for medically necessary therapy services above the therapy cap.  In both of these situations, the contractor shall require that the the rapist maintain on file, necessary documentation to support the medical necessity of therapy services. Documentation requirements are found in CMS Pub.100-02, chapter 15, section 230.3.  Request for Exception from Therapy Caps  Contractors shall not require providers to submit written requests for exception from the therapy cap.  Instead, the placement of the KX modifier on the claim shall be interpreted as a request for exception from the cap.  For beneficiaries who the clinician believes will require therapy treatment days in excess of those payable under the therapy cap, and who meet the above bulleted criteria for automatic exception, the Medicare contractor shall require the provider to maintain sufficient documentation on file to support the medical necessity for this service.   Use of the KX modifier shall be interpreted as the therapists attestation that services provided above the cap are medically necessary.   The contractor shall require the provider to maintain on file documentation in accordance with CMS Pub.100-02, chapter 15, section 220.3 and CMS Pub.100-04, chapter 5, sections 10.2 and 20 with the request for treatment days in excess of those payable under the therapy cap.  If the clinician attests that the requested services are medically nec essary by using a KX modifier on the claim line, the contractor may make the determination that the claim is medically necessary.  That determination is binding on the contractor in the absence of:   potential fraud; or   evidence of misrepresentation of facts presented to the contractor, or   A pattern of aberrant billing by a provider.  Should such evidence of potential fraud, misrepresentation, or aberrant billing patterns by a provider be found, claims are subject to medical review regardless of whether th e KX modifier was used on the claim.  Progressive corrective action (PCA) and medical review have a role in the therapy exception process. Although the services may meet the criteria for exception from the cap due to condition or complexity, they are still subject to review to determine that the services are otherwise covered and appropriately provided.  The exception is granted on the clinicians assertion that there is documentation in the record justifying that the services meet the criteria for reasonable and necessary services.  For example, the documentation must accurately represent the facts, and there shall be no evidence of patterns of aberrant billing of the services by the provider/supplier.  Services deemed medically necessary are still subject to review related to fraud or abuse. An example of inappropriate use of the process is the routine use of the KX modifier on every claim for a patient that has an excepted condition or complexity, regardless of the impact of the condition on the need for s ervices above the cap.   3.3.2.8 - MAC Articles  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs.  A. General   The MACs have the discretion to publish articles communicating certain information to providers, such as any newly developed educational materials, coding instructions or clarification of existing medical review related billing or claims policy. The MACs are required to enter articles that address LCDs, coding or medical revi ew-related billing and claims considerations into the Medicare Coverage Database (MCD).   For the purposes of this manual, the term "publish" will be used to describe any form of dissemination including posting on a Web site, distributing at a seminar, e -mailing, or printing in a hardcopy bulletin. The MAC Medical Review Departments are responsible for the development of articles associated with new or revised LCDs and for entering those articles into the Medicare Coverage Database. Other widespread educatio nal articles shall not be charged to MR.   The MAC medical review departments shall send articles to the appropriate department within the MAC for publishing. All newly created articles shall be posted on the MAC's Web site where duplicate copies can be obt ained by providers/suppliers.   When NCDs or other coverage instructions issued by the CMS include specific conditions or parameters for covered services, the MACs have the discretion to develop and publish a list of covered codes associated with the covera ge provision. MACs have the discretion to automate denials for codes not included on the list without the development of a LCD if the NCD indicates or states that no other condition or parameters will be covered.   MACs also have the discretion to:    Publish definitions of procedure codes, lists of items that may be billed under a particular code, or minimum requirements that providers must meet in order to bill using a certain code.    Publish a product classification list that instructs providers about  which  specific products meet the definitional requirements of a particular HCPCS code. Developing or revising an LCD for this article is  unnecessary.   Explain which off-labeled uses of the Food and Drug Administration (FDA) approved drugs are considered r easonable and necessary within the diagnosis codes that reflect such uses.    Explain the benefit category decisions and publish a list of drugs/biologicals that are considered usually self -administered. MACs should enter their self- administered medication exclusion list into the Medicare Coverage Database. This database can be accessed at  www.cms.gov/mcd.   MACs have the discretion to explain which HCPCS code or group of codes proper ly describes a particular  service.    MACs have the discretion to publish State non-physician licensure information that governs services billed by the physician under the "incident to" provision.  The MACs shall ensure that articles do not conflict with NCDs, LCDs, policy, or coverage provisions in interpretive manuals. Although a comment and notice process is not required, MACs are encouraged to consult with stakeholders in the provider community when developing articles. MACs shall monitor comments about a rticles from clinician providers and respond to their concerns, as needed, by issuing revised or clarifying articles.   NOTE: Nothing in this section precludes the MACs or UPICs from making individual claim determinations, even in the absence of an article or LCD.   3.3.3 - Reviewing Claims in the Absence of Policies and Guidelines  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  The MACs, CERT, Recovery Auditors, and UPICs have the discretion to review claims, in the absence of polices, whether a NCD, coverage provision in an interpretive Medicare manual, or LCD exists for that service. When making individual claim determinations, they shall determine that the service in question is covered based on whether the service meets all of the conditions listed in section 3.6.2.1.  3.4 - Prepayment Review of Claims (Rev. 902, Issued: 09-27-19, Effective: 10 -28-19, Implementation: 10-28-19)  This section applies to MACs and UPICs.  A. General   Non-random (targeted) review is defined as review conducted with a specific reason or logic to substantiate the cause for review. MACs are encouraged to initiate non- random service- specific prepayment r eview to prevent improper payments for services identified by CERT or Recovery Auditors or other sources.   The MACs shall initiate targeted provider -specific prepayment review only when there is the likelihood of a sustained or high level of improper paym ents.  B. 100% Prepayment Review and Random Review Instructions   Section 1302 of the Health Care and Education Reconciliation Act (HCERA) repealed section 1874A (h) of the Social Security Act which had placed restrictions on prepayment medical review. CMS review contractors shall comply with Section 1 random review and Section 2 100% prepayment review.   1. Random Review   Random review is defined as review conducted without a specific reason or logic to substantiate the cause for review. MACs have the discretion to conduct random reviews of services; however, CMS does not recommend random reviews. MACs shall notify the CMS Contracting Officers Representative (COR), Regional Office Technical Monitor (TM), and Business Function Lead (BFL) of its intent t o conduct random review. The MAC shall describe what the intended result of the random review will be, an estimate of the number of claims to be reviewed randomly and the rationale as to why random review would be more effective than targeted review.   2. 100% Prepayment Review   100% prepayment review is defined as review of every claim submitted by a targeted provider for a specific code (i.e., DRG, CPT, HCPCs). 100% prepayment review also includes review of every claim submitted by the targeted provider.   MACs have the discretion to conduct 100 % prepayment review of providers. CMS considers 100 % prepayment review to be appropriate when a provider has a prolonged time period of non- compliance with CMS policies. Any MAC that plans to conduct 100 % prepaymen t review shall inform the CMS COR, Regional Office TM, and BFL in advance about any provider being placed on 100 % prepayment review. In addition, the MAC shall provide    The background information on attempts to educate the provider.    The historical improp er payment rate of the provider before beginning 100% prepayment review.    The length of time the provider is expected to be on 100 % prepayment reviews.   The estimated number of claims and the dollar value of claims expected to be reviewed per month.   The criteria for removing the provider from 100 % prepayment review.  3.  UPIC Initiated Prepayment Reviews   No UPIC shall initiate a 100% prepayment review without CMS approval, except 100% prepayment reviews associated with a Payment Suspension. Therefore, t he UPIC shall provide its COR and IAG BFL a summary of the investigation, any prior history (if applicable) with the provider/supplier in question, and any other relevant information in a format agreed upon by the COR and IAG BFL.   If the COR and IAG BFL agree that 100% prepayment review is appropriate, the UPIC shall include the case on the next case coordination meeting agenda for discussion and final approval. During the case coordination meeting, the UPIC may receive additional guidance from CMS related to subsequent actions related to these investigations.  If the UPIC has subsequent questions following the case coordination meeting, the UPIC shall coordinate with its COR and IAG BFL.  3.4.1 - Electronic and Paper Claims  (Rev. 721; Issued: 06-09- 17; Effective: 07 -11-17; Implementation: 07 -11-17)