CMS Medicare Guidelines

CMS Medicare Guidelines for PM&R

Tags: compliance medicare cms policy

Key Medicare Resources

Local Coverage Determinations (LCDs)

• Specific to your Medicare Administrative Contractor (MAC)
• Search at: cms.gov/medicare-coverage-database
• Common LCDs for PM&R:
  • Therapy Services
  • Injections for Pain Management
  • EMG/NCS Testing
  • Spinal Interventions

National Coverage Determinations (NCDs)

• Apply nationwide across all Medicare jurisdictions
• Override LCDs when conflicts exist

Therapy Caps & Thresholds

Medicare Therapy Threshold (2024)

Therapy Type	Threshold
PT + SLP Combined	$2,330
OT	$2,330

Threshold vs. Cap

This is a threshold, not a cap. Services above threshold require KX modifier and documentation supporting medical necessity.

Incident-To Billing Requirements

Office Setting Only

Requirement	Detail
Setting	Office only (POS 11)
Supervision	Direct supervision (physician in office suite)
Plan of Care	Established by physician
Follow-up	Physician must see patient periodically

SNF/Hospital

Incident-to billing is NOT allowed in SNF, hospital, or facility settings.

Documentation Timelines

Document	Timeframe
Initial Evaluation	Before treatment begins
Plan of Care	Within 30 days of evaluation
Progress Reports	Every 10 visits or 30 days
Recertification	Every 90 days
Discharge Summary	Within 30 days of discharge

Medical Review Triggers

Targeted Probe & Educate (TPE)

• 3 rounds of review
• 20-40 claims per round
• Education provided after each round

Recovery Audit Contractors (RAC)

• Post-payment audits
• Focus on high-risk areas
• Can request medical records up to 3 years back

Appeals Process

1. Redetermination (120 days)
2. Reconsideration (180 days)
3. ALJ Hearing (60 days)
4. Medicare Appeals Council (60 days)
5. Federal Court (60 days)

Stay Updated

Medicare policies change frequently. Subscribe to your MAC’s email updates and check CMS.gov quarterly.

PM&R Coding MOC Medical Necessity in Rehab Therapy Modifiers