Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part B outpatient therapy services billed on dates of service from January 1, 2022, through December 31, 2022. Below are the review results:

Background

Outpatient therapy services including physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services, aim to restore function after an illness or injury, maintain current functional status, or prevent or slow down further deterioration of a patient’s condition.

The Bipartisan Budget Act (BBA) of 2018 amended Section 1833 (g) of the Social Security Act (SSA) repealing the Medicare expense threshold for therapy services. The BBA of 2018 created limitations to ensure appropriate therapy is being provided for PT, OT, and SLP services furnished after January 1, 2018. For CY 2022, this KX modifier threshold (above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record) was $2,150 for PT and SLP services combined, and $2,150 for OT services. Additionally, a medical review expense threshold of $3,000 for PT and SLP services combined and $3,000 for OT services was created.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record reviews on claims billed with place of service 11 (office), CPT/HCPCS codes specific to PT, OT, and SLP services with specific modifiers, GP, GN, GO, indicating services were provided under a PT, OT, or an SLP plan of care, billed with date of service January 1, 2022, through December 31, 2022, determining if outpatient therapy services were reasonable, necessary, and billed appropriately.

The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Non-Response to the Additional Documentation Request (ADR)
  • The requested records were not received. Code of Federal Regulations (CFR) Title 42, §§405.929 and 405.930, Social Security Act (SSA)1815(a), Social Security Act (SSA) 1833(e) and Social Security Act §1862(a)(1)(A). This requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request. The requested documentation was not submitted or not submitted timely to support reasonable and necessary criteria for the therapy services.
• Certification of Plan of Care
  • Documentation does not support the initial plan of care was certified by the physician / NPP. There was no evidence of delayed certification or attempts to obtain certification from the physician / NPP. Refer to Social Security Act (SSA) 1862; 42 CFR §424.24 2c, Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3 B-D.
• Unit(s) Not Supports
  • The documentation submitted did not support the unit(s) billed. Refer to Internet Only Manual (IOM), Pub 100-4, Medicare Claims Processing Manual (MCPM), Chapter 5, Section 20.2.C. The treatment note did not contain specific minutes that therapy was provided.

References

Social Security Act (SSA) Title XI

• §1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• §1815 Payment to Provider of Services
• §1833(e) Payment of Benefit
• §1833(g)(7)(A and B[ii]) Payment of Benefit
• §1833(g)(5)(E) Payment of Benefits
• §1835(2)(C, D, E) Procedure for Payment of Claims of Providers of Service
• §1861(g) Outpatient Occupational Therapy Service
• §1861(p) Outpatient Physical Therapy Services
• §1861(s)(2)(D) Medical and Other Health Services
• §1862(a)(1)(A) Reasonable and Necessary
• §1862(a)(20) Exclusions from Coverage and Medicare as Secondary Payer
• §1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed

Bipartisan Budget Act (BBA) of 2018, Title II

• BBA, Division E, Title II, §50202. Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy

42 Code of Federal Regulations (CFR)

• §409.17 Physical therapy, occupational therapy, and speech-language pathology services
• §409.32 Criteria for skilled services and the need for skilled services
• §409.44 Skilled Services Requirements
• §410.26 Services and supplies incident to a physician’s professional services: Conditions
• §410.59 Outpatient occupational therapy services: Conditions
• §410.60 Outpatient physical therapy services: Conditions
• §410.61 Plan of treatment requirements for outpatient rehabilitation services
• §410.62 Outpatient speech-language pathology services: Conditions and exclusions
• §424.24 Requirements for medical and other health services furnished by providers under Medicare Part B
• §424.516(f) Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program
• §424.535 Revocation of enrollment in the Medicare program
• §485.713 Condition of participation: Physical therapy services

Public Law

• Public Law 117–103. Consolidated Appropriations Act, 2022. Subtitle A-Telehealth Flexibility Extensions. March 15, 2022. Retrieved from PUBL103.PS (congress.gov)

Federal Register

• CMS. Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.CMS-1744-IFC. Applicable March 1, 2020. Retrieved from CMS-1744-IFC

• CMS. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. CMS-5531-IFC. Applicable March 1, 2020. Retrieved from CMS-5531-IFC

Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Ch. 15, §60 Services and Supplies Furnished Incident to a Physician’s / NPP’s Professional Service
• Ch. 15, §220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance
• Ch. 15, §230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
• Ch. 16, §20 Services Not Reasonable and Necessary
• Ch. 16, §110 Custodial Care

Internet Only Manual (IOM), Medicare National Coverage Determination Manual (NCD), Pub. 100-03

• NCD Chapter 1, Part 1, §10.2 Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain
• NCD Chapter 1, Part 2, §150.5 Diathermy Treatment
• NCD Chapter 1, Part 2, §150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders
• NCD Chapter 1, Part 2 §160 Nervous System
• NCD Chapter 1, Part 3, §170.1 Institutional and Home Care Patient Education Programs
• NCD Chapter 1, Part 3, §170.3 Speech-Language Pathology Services for Treatment of Dysphagia
• NCD Chapter 1, Part 4, §240.3 Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions
• NCD Chapter 1, Part 4, §270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds

Internet Only Manual (IOM), Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 5, §10 Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services-General
• Ch. 5, §20 HCPCS Coding Requirement
• Ch. 5, §30 Special Claims Processing Rules for Outpatient Rehabilitation Claims Form CMS-1500
• Ch. 5, §40 Special Claims Processing Rules for Institutional Outpatient Rehabilitation Claims
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

Internet Only Manual (IOM), Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3 §3.3.2.4 Signature Requirements
• Ch. 3, §3.3.2.7 Review Guidelines for Therapy Services
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in an LCD

Local Coverage Determination (LCD)

• L33580 Speech Language Pathology. Effective October 1, 2015
• L33631 Outpatient Physical and Occupational Therapy Services. Effective October 1, 2015
• L34046 Speech Language Pathology. Effective October 1, 2015
• L34049 Outpatient Physical and Occupational Therapy Services. Effective October 1, 2015
• L34427 Outpatient Occupational Therapy. Effective October 1, 2015
• L34428 Outpatient Physical Therapy. Effective October 1, 2015
• L34429 Outpatient Speech Language Pathology. Effective October 1, 2015
• L35036 Therapy and Rehabilitation Services (PT, OT). Effective October 1, 2015 Revised March 9, 2022
• L35070 Speech-Language Pathology (SLP) Services: Communication Disorders. Effective October 1, 2015

Local Coverage Article (LCA)

• A52866 Billing and Coding: Speech Language Pathology. Effective October 1, 2015
• A53064 Billing and Coding: Outpatient Occupational Therapy. Effective October 1, 2015
• A53065 Billing and Coding: Outpatient Physical Therapy. Effective October 1, 2015
• A54111 Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders. Effective October 1, 2015
• A56566 Billing and Coding: Outpatient Physical and Occupational Therapy Services. Effective December 19, 2019
• A56868 Billing and Coding: Outpatient Speech Language Pathology. Effective August 15, 2019
• A57040 Billing and Coding: Speech-Language Pathology. Effective September 19, 2019
• A57067 Billing and Coding: Outpatient Physical and Occupational Therapy Services. Effective September 19, 2019
• A57703 Billing and Coding: Therapy and Rehabilitation Services. Effective November 14, 2019

Last Updated Jan 14, 2026