Social Security Act §1833

(A)[88]Subject to paragraphs (4) and (5), in thecase of occupational therapy services (of the type that are describedin section 1861(p) (but (except as provided in paragraph (6)) not described in section 1833(a)(8)(B))through the operation of section 1861(g) and of such type which are furnishedby a physician or as incident to physicians services), withrespect to expenses incurred in any calendar year, no more than theamount specified in paragraph (2) for the year shall be consideredas incurred expenses for purposes of subsections (a) and (b). Thepreceding sentence shall not apply to expenses incurred with respectto services furnished after December 31, 2017.(B)With respectto services furnished during 2018 or a subsequent year, in the caseof occupational therapy services (of the type that are described insection 1861(p) through the operation of section 1861(g) and of suchtype which are furnished by a physician or as incident to physicians'services), with respect to expenses incurred in any calendar year,any amount that is more than the amount specified in paragraph (2)for the year shall not be considered as incurred expenses for purposesof subsections (a) and (b) unless the applicable requirements of paragraph(7) are met.(4)This subsectionshall not apply to expenses incurred with respect to services furnishedduring 2000, 2001, 2002, 2004, and 2005.(5)(A)[89]With respect to expenses incurred duringthe period beginning on January 1, 2006, and ending on December 31,2017, for services, the Secretary shall implement a process underwhich an individual enrolled under this part may, upon request ofthe individual or a person on behalf of the individual, obtain anexception from the uniform dollar limitation specified in paragraph(2), for services described in paragraphs (1) and (3) if the provisionof such services is determined to be medically necessary and if therequirement of subparagraph (B) is met. Under such process, if theSecretary does not make a decision on such a request for an exceptionwithin 10 business days of the date of the Secretarys receiptof the request made in accordance with such requirement, the Secretaryshall be deemed to have found the services to be medically necessary.(B)[90]In the case of outpatient therapy servicesfor which an exception is requested under the first sentence of subparagraph(A), the claim for such services shall contain an appropriate modifier(such as the KX modifier used as of the date of the enactment of thissubparagraph) indicating that such services are medically necessaryas justified by appropriate documentation in the medical record involved.(C)[91](i)In applying thisparagraph with respect to a request for an exception with respectto expenses that would be incurred for outpatient therapy services(including services described in subsection (a)(8)(B)) that wouldexceed the threshold described in clause (ii) for a year, the requestfor such an exception, for services furnished on or after October1, 2012, shall be subject to a manual medical review process that,subject to subparagraph (E), is similar to the manual medical reviewprocess used for certain exceptions under this paragraph in 2006.[92](ii)The thresholdunder this clause for a year is $3,700. Such threshold shall be appliedseparately(I)for physicaltherapy services and speech-language pathology services; and(II)for occupationaltherapy services.(E)(i)In place of themanual medical review process under subparagraph (C)(i), the Secretaryshall implement a process for medical review under this subparagraphunder which the Secretary shall identify and conduct medical reviewfor services described in subparagraph (C)(i) furnished by a providerof services or supplier (in this subparagraph referred to as a therapy provider) using such factors as the Secretary determinesto be appropriate.(ii)Such factorsmay include the following:(I)The therapyprovider has had a high claims denial percentage for therapy servicesunder this part or is less compliant with applicable requirementsunder this title.(II)The therapyprovider has a pattern of billing for therapy services under thispart that is aberrant compared to peers or otherwise has questionablebilling practices for such services, such as billing medically unlikelyunits of services in a day.(III)Thetherapy provider is newly enrolled under this title or has not previouslyfurnished therapy services under this part.(IV)The servicesare furnished to treat a type of medical condition.(V)The therapyprovider is part of group that includes another therapy provider identifiedusing the factors determined under this subparagraph.(iii)For purposesof carrying out this subparagraph, the Secretary shall provide forthe transfer, from the Federal Supplementary Medical Insurance TrustFund under section 1841, of $5,000,000 to the Centers for Medicare& Medicaid Services Program Management Account for fiscal years2015 and 2016, to remain available until expended. Such funds maynot be used by a contractor under section 1893(h) for medical reviewsunder this subparagraph.(iv)[94]The targeted review process under this subparagraphshall not apply to services for which expenses are incurred beyondthe period for which the exceptions process under subparagraph (A)is implemented, except as such process is applied under paragraph(7)(B).(6)(A)[95]In applying paragraphs (1) and (3) to servicesfurnished during the period beginning not later than October 1, 2012,and ending on December 31, 2017, the exclusion of services describedin subsection (a)(8)(B) from the uniform dollar limitation specifiedin paragraph (2) shall not apply to such services furnished during2012 through 2017.(B)(i)[96]With respect to outpatient therapy services furnishedbeginning on or after January 1, 2013, and before January 1, 2014,for which payment is made under section 1834(g), the Secretary shall count toward the uniform dollarlimitations described in paragraphs (1) and (3) and the thresholddescribed in paragraph (5)(C) the amount that would be payable underthis part if such services were paid under section 1834(k)(1)(B) instead of being paidunder section 1834(g).(ii)Nothing in clause(i) shall be construed as changing the method of payment for outpatienttherapy services under section 1834(g).(7)[97]For purposes of paragraphs (1)(B) and (3)(B),with respect to services described in such paragraphs, the requirementsdescribed in this paragraph are as follows:(A)Inclusion of appropriate modifier.Theclaim for such services contains an appropriate modifier (such asthe KX modifier described in paragraph (5)(B)) indicating that suchservices are medically necessary as justified by appropriate documentationin the medical record involved.(B)Targeted medical review for certain services above threshold.(i)In general.In the case where expenses that would be incurred for such serviceswould exceed the threshold described in clause (ii) for the year,such services shall be subject to the process for medical review implementedunder paragraph (5)(E).(ii)Threshold.The threshold under this clause for(I)a year before2028, is $3,000;(II)2028,is the amount specified in subclause (I) increased by the percentageincrease in the MEI (as defined in section 1842(i)(3)) for 2028; and(III)a subsequentyear, is the amount specified in this clause for the preceding yearincreased by the percentage increase in the MEI (as defined in section1842(i)(3)) for such subsequent year; except that if an increase undersubclause (II) or (III) for a year is not a multiple of $10, it shallbe rounded to the nearest multiple of $10.(iii)Application.The threshold under clause(ii) shall be applied separately(I)for physicaltherapy services and speech-language pathology services; and(II)for occupationaltherapy services.(iv)Funding.For purposes of carrying out this subparagraph, the Secretaryshall provide for the transfer, from the Federal Supplementary MedicalInsurance Trust Fund under section 1841 to the Centers for Medicare& Medicaid Services Program Management Account, of $5,000,000for each fiscal year beginning with fiscal year 2018, to remain availableuntil expended. Such funds may not be used by a contractor under section1893(h) for medical reviews under this subparagraph.(8)With respect toservices furnished on or after January 1, 2013, where payment maynot be made as a result of application of paragraphs (1) and (3), section 1879 shall apply in the same manner as such sectionapplies to a denial that is made by reason of section 1862(a)(1).[98](h)(1)(A)Subject tosection 1834(d)(1), the Secretary shall establish fee schedules for clinical diagnosticlaboratory tests (including prostate cancer screening tests undersection 1861(oo) consisting of prostate-specific antigen blood tests) for which paymentis made under this part, other than such tests performed by a providerof services for an inpatient of such provider.(B)In the caseof clinical diagnostic laboratory tests performed by a physician orby a laboratory (other than tests performed by a qualified hospitallaboratory (as defined in subparagraph (D)) for outpatients of suchhospital), the fee schedules established under subparagraph (A) shallbe established on a regional, statewide, or carrier service area basis(as the Secretary may determine to be appropriate) for tests furnishedon or after July 1, 1984.(C)In the caseof clinical diagnostic laboratory tests performed by a qualified hospitallaboratory (as defined in subparagraph (D)) for outpatients of suchhospital, the fee schedules established under subparagraph (A) shallbe established on a regional, statewide, or carrier service area basis(as the Secretary may determine to be appropriate) for tests furnishedon or after July 1, 1984.(D)In this subsection,the term qualified hospital laboratory means a hospitallaboratory, in a sole community hospital (as defined in section 1886(d)(5)(D)(iii)), which provides some clinical diagnostic laboratory tests 24 hoursa day in order to serve a hospital emergency room which is availableto provide services 24 hours a day and 7 days a week.(2)(A)(i)Except as providedin clause (v), subparagraph (B), and paragraph (4)[99], the Secretaryshall set the fee schedules at 60 percent (or, in the case of a testperformed by a qualified hospital laboratory (as defined in paragraph(1)(D)) for outpatients of such hospital, 62 percent) of the prevailingcharge level determined pursuant to the third and fourth sentencesof section 1842(b)(3) for similar clinical diagnostic laboratory tests for the applicableregion, State, or area for the 12-month period beginning July 1, 1984,adjusted annually (to become effective on January 1 of each year)by, subject to clause (iv), subject to a percentage increase or decreaseequal to the percentage increase or decrease in the Consumer PriceIndex for All Urban Consumers (United States city average minus, foreach of the years 2009 and 2010, 0.5 percentage points), and, fortests furnished before the date of enactment of section 1834A, subjectto[100]such other adjustments as theSecretary determines are justified by technological changes.(ii)Notwithstandingclause (i)(I)any changein the fee schedules which would have become effective under thissubsection for tests furnished on or after January 1, 1988, shallnot be effective for tests furnished during the 3-month period beginningon January 1, 1988,(II)the Secretaryshall not adjust the fee schedules under clause (i) to take into accountany increase in the consumer price index for 1988,(III)theannual adjustment in the fee schedules determined under clause (i)for each of the years 1991, 1992, and 1993 shall be 2 percent, and(IV)the annualadjustment in the fee schedules determined under clause (i) for eachof the years 1994 and 1995, 1998 through 2002, and 2004 through 2008shall be 0 percent.(iii)In establishingfee schedules under clause (i) with respect to automated tests andtests (other than cytopathology tests) which before July 1, 1984,the Secretary made subject to a limit based on lowest charge levelsunder the sixth sentence of section 1842(b)(3) performed after March 31,1988, the Secretary shall reduce by 8.3 percent the fee schedulesotherwise established for 1988, and such reduced fee schedules shallserve as the base for 1989 and subsequent years.(iv)After determiningthe adjustment to the fee schedules under clause (i), the Secretaryshall reduce such adjustment(I)for 2011and each subsequent year, by the productivity adjustment describedin section 1886(b)(3)(B)(xi)(II); and.(II)for eachof 2011 through 2015, by 1.75 percentage points.