Special Open Door Forum: Manual Medical Review of Therapy Claims

August 7, 2012

2p.m. EST - 3:30p.m. EST

The purpose of this Special Open Door Forum (ODF) conference call is to offer an opportunity for providers to ask questions about the mandated manual medical review of therapy services from October 1-December 31, 2012 that was enacted by the Middle Class Tax Relief and Job Creation Act of 2012.

During this Special Open Door Forum, CMS will discuss the implementation of a process to request exceptions from manual medical review, and what the process entails. CMS requests provider’s participation who orders or provides therapy services nationally.

The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,880 for 2012, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,880 for 2012. This is an annual per beneficiary therapy cap amount determined for each calendar year. 

Medicare allowable charges, which includes both Medicare payments to providers and beneficiary coinsurance, are counted toward the therapy cap. In outpatient settings, Medicare will pay for 80% of allowable charges and the beneficiary is responsible for the remaining 20% of the amount.

The therapy cap applies to all Part B outpatient therapy settings and providers including:

  • Private practices.
  • Skilled nursing facilities.
  • Home health agencies.
  • Outpatient rehabilitation facilities.
  • Comprehensive outpatient rehabilitation facilities. 

Beginning this year, the therapy cap will also apply to therapy services furnished in hospital outpatient departments (HOPDs) until December 31, 2012. Before 2012, therapy provided in hospital outpatient departments did not count towards the therapy cap.


Event Contacts
Participants may submit questions prior to the Special ODF to therapycapreview@cms.hhs.gov

Dial: (800) 603-1774 & Conference ID: 16032541 
Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 800-855-2880. A Relay Communications Assistant will help.