Cap Exception Process

[Guest guest]

Wow. Am I mistaken or did they actually make a well thought out exception

process.

I realize its still up to individual FI interpretation and individual

reviewer but a good start from CMS. I think CMS took a look at one of the

memos that gives position points against the cap. CMS knows the cap is a

bad idea and maybe they are trying to set a policy to address it. Our big

concern would still remain that the cap, if it remains, becomes a pattern

that expands in regulation, acceptance, & restriction with time.

Steve Passmore PT

Healthy Recruiting Tools

spass@...

FYI

The Centers for Medicare and Medicaid Services (CMS) has issued an exception

process to the Part B therapy caps that went into effect for Skilled Nursing

Facilities January 1. This is great news for Medicare recipients and the

rehabilitation industry! CMS has heard and responded positively to Congress'

demand that patients continue to have access to medically necessary therapy.

The exception process allows beneficiaries to obtain coverage for medically

necessary services if their treatment is expected to exceed the following

caps for 2006: $1,740 for physical and speech therapy and $1,740 for

occupational therapy.

The exception process places recipients into two categories:

Auto-exception

The vast majority of our patients will fall into this category, including

those who may have already reached their cap earlier this year. Patients

will be granted an exception without the need to submit any forms. Use of a

modifier code will delineate patients under auto-exception. We have attached

a list of the 26 ICD-9 codes that fall under this auto-exception process.

In addition there are other clinical complexities that can justify an

auto-exception to the therapy caps. Some of the major ones are:

Generalized musculoskeletal conditions affecting multiple sites in addition

to another primary disease or condition being treated,

Mental or cognitive disorders in addition to another primary disease or

condition being treated,

Patients who require PT and SLP services at the same time, and

Patients who experience a prior episode of therapy in the same calendar

year for a different primary disease or condition.

Manual exception

Any patient who falls outside of the auto-exception category will receive an

extension only after a written request is submitted to the Fiscal

Intermediary prior to recipients reaching their cap.

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