Re: Therapy Cap exceptions Diagnosis (are medical or tx ones?)

[Guest guest]

I'm glad you brought this up because we are bit confused on a related

issue. I'm reading the 2/15/06 CMS release and it states " For a

condition or complexity to qualify the beneficiary for an exception to

the caps, the therapy must be related to one of the listed conditions.

In addition to conditions, there are clinically complex situations that

can justify an automatic exception to the therapy caps for ANY condition

that necessitates skilled therapy services.

So we first need a condition diagnosis listed before we can also add and

refer to a complexity diagnosis also?

Just clarifying.

Thanks,

Lott

Lott Physical Therapy

Fairfield, TX

[Guest guest]

The list of ICD-9 codes that have automatic exception are in CMS Manual,

Pub. 100-04, Transmittal 853

Sara Baker

The Rehabilitation Institute of Kansas City

3011 Baltimore, Kansas City, MO 64108

[Guest guest]

You noted the process correctly---the cap exception is for any skilled

service. But be aware that skilled services are defined not by the reality

of a situation, but by the documentation of that reality.

During a recent seminar, some clever person mentioned that we should think

of the cap exception as " automated " rather than " automatic. " That says it.

The provider must prove necessity in the instance.

Dave Milano, PT, Director of Rehab Services

Laurel Health System

32-36 Central Ave.

Wellsboro, PA 16901

dmilano@...

RE: Therapy Cap exceptions Diagnosis (are medical

or tx ones?)

I'm glad you brought this up because we are bit confused on a related

issue. I'm reading the 2/15/06 CMS release and it states " For a

condition or complexity to qualify the beneficiary for an exception to

the caps, the therapy must be related to one of the listed conditions.

In addition to conditions, there are clinically complex situations that

can justify an automatic exception to the therapy caps for ANY condition

that necessitates skilled therapy services.

So we first need a condition diagnosis listed before we can also add and

refer to a complexity diagnosis also?

Just clarifying.

Thanks,

Lott

Lott Physical Therapy

Fairfield, TX

[Guest guest]

It seems as though Medicare is making a feeble attempt to act like they

care, by giving us one more rope to grab onto before we sink.

Personally, we jump through so many hoops as it is, that I don't think we

will even bother with exceptions. We will just discharge our patients when

they have reached their cap, end of story.

We cannot afford any additional man hours to try to comply with these

additional demands on a " maybe " chance that we will be reimbursed.

I feel that as long as we, as providers continue to play these games with

the insurance companies, that we deserve what we get, or should I say what

we " don't get. "

Other insurance plans are sure to follow, with their cap limitations because

Medicare has gotten away with it.

Diane

Valley Rehabilitation

On Mon, 27 Mar 2006 13:30:55 -0500, Milano, Dave wrote

> You noted the process correctly---the cap exception is for any

> skilled service. But be aware that skilled services are defined not

> by the reality of a situation, but by the documentation of that reality.

>

> During a recent seminar, some clever person mentioned that we should

> think of the cap exception as " automated " rather than " automatic. "

> That says it. The provider must prove necessity in the instance.

>

> Dave Milano, PT, Director of Rehab Services

> Laurel Health System

> 32-36 Central Ave.

> Wellsboro, PA 16901

>

> dmilano@...

>

> RE: Therapy Cap exceptions Diagnosis (are

> medical or tx ones?)

>

> I'm glad you brought this up because we are bit confused on a related

> issue. I'm reading the 2/15/06 CMS release and it states " For a

> condition or complexity to qualify the beneficiary for an exception

> to the caps, the therapy must be related to one of the listed conditions.

>

> In addition to conditions, there are clinically complex situations that

> can justify an automatic exception to the therapy caps for ANY condition

> that necessitates skilled therapy services.

>

> So we first need a condition diagnosis listed before we can also add

> and refer to a complexity diagnosis also?

>

> Just clarifying.

>

> Thanks,

> Lott

> Lott Physical Therapy

> Fairfield, TX

>

>

>

>

>

>

>

>

>

>

[Guest guest]

Diane,

How can you justify, as a therapist discharging a patient simply because the cap

has been met? If patient outcomes and ethics are a priority we need to jump

through these crazy hoops. Not fun, but still necessary.

Michele , PT

Rehab Manager

PBMC

Rockport,ME

>>> pt@... 03/27/06 04:54PM >>>

It seems as though Medicare is making a feeble attempt to act like they

care, by giving us one more rope to grab onto before we sink.

Personally, we jump through so many hoops as it is, that I don't think we

will even bother with exceptions. We will just discharge our patients when

they have reached their cap, end of story.

We cannot afford any additional man hours to try to comply with these

additional demands on a " maybe " chance that we will be reimbursed.

I feel that as long as we, as providers continue to play these games with

the insurance companies, that we deserve what we get, or should I say what

we " don't get. "

Other insurance plans are sure to follow, with their cap limitations because

Medicare has gotten away with it.

Diane

Valley Rehabilitation

On Mon, 27 Mar 2006 13:30:55 -0500, Milano, Dave wrote

> You noted the process correctly---the cap exception is for any

> skilled service. But be aware that skilled services are defined not

> by the reality of a situation, but by the documentation of that reality.

>

> During a recent seminar, some clever person mentioned that we should

> think of the cap exception as " automated " rather than " automatic. "

> That says it. The provider must prove necessity in the instance.

>

> Dave Milano, PT, Director of Rehab Services

> Laurel Health System

> 32-36 Central Ave.

> Wellsboro, PA 16901

>

> dmilano@...

>

> RE: Therapy Cap exceptions Diagnosis (are

> medical or tx ones?)

>

> I'm glad you brought this up because we are bit confused on a related

> issue. I'm reading the 2/15/06 CMS release and it states " For a

> condition or complexity to qualify the beneficiary for an exception

> to the caps, the therapy must be related to one of the listed conditions.

>

> In addition to conditions, there are clinically complex situations that

> can justify an automatic exception to the therapy caps for ANY condition

> that necessitates skilled therapy services.

>

> So we first need a condition diagnosis listed before we can also add

> and refer to a complexity diagnosis also?

>

> Just clarifying.

>

> Thanks,

> Lott

> Lott Physical Therapy

> Fairfield, TX

>

>

>

>

>

>

>

>

>

>

[Guest guest]

Diane,

I am afraid you are going to take a beating on this one, rather than

piling on about the ethics of this situation let me say that if you

D/C the pt. when they meet the cap rather than " jumping through the

hoops " you are telling CMS (Medicare) that further PT is no longer

medically necessary, they then compute the data and come up with

lower percentage of pts that would require further PT than is a

reality. For instance, the last time the cap was in place, CMS

determined that only 17% of Medicare participants would have needed

therapy in XS of the cap. We all know that this is a very low number

and was falsley derived by CMS because we as providers either

discharged the pt. as you suggest or simply treated them for free.

The only way that we can deal with this cap is to " jump throught the

hoops " make sure that we make CMS realize just how great the need is

and then be sure that we can document medical necessity and progress

towards functional goals with our continued care. At the very least,

if you are not willing to jump through the hoops you must refer those

who you feel need further care on to an outpt. hospital facitlity or

to another private practice who will go the distance necessary not

only for the pt. but for the profession as well.

E. s, PT, DPT, OCS

s Orthopedic & Spine Rehab, Inc

Bonita Springs, Fla

>

> Diane,

> How can you justify, as a therapist discharging a patient simply

because the cap has been met? If patient outcomes and ethics are a

priority we need to jump through these crazy hoops. Not fun, but

still necessary.

> Michele , PT

> Rehab Manager

> PBMC

> Rockport,ME

>

>

> >>> pt@... 03/27/06 04:54PM >>>

> It seems as though Medicare is making a feeble attempt to act like

they

> care, by giving us one more rope to grab onto before we sink.

>

> Personally, we jump through so many hoops as it is, that I don't

think we

> will even bother with exceptions. We will just discharge our

patients when

> they have reached their cap, end of story.

>

> We cannot afford any additional man hours to try to comply with

these

> additional demands on a " maybe " chance that we will be reimbursed.

>

> I feel that as long as we, as providers continue to play these

games with

> the insurance companies, that we deserve what we get, or should I

say what

> we " don't get. "

>

> Other insurance plans are sure to follow, with their cap

limitations because

> Medicare has gotten away with it.

>

> Diane

> Valley Rehabilitation

>

> On Mon, 27 Mar 2006 13:30:55 -0500, Milano, Dave wrote

> > You noted the process correctly---the cap exception is for any

> > skilled service. But be aware that skilled services are defined

not

> > by the reality of a situation, but by the documentation of that

reality.

> >

> > During a recent seminar, some clever person mentioned that we

should

> > think of the cap exception as " automated " rather

than " automatic. "

> > That says it. The provider must prove necessity in the instance.

> >

> > Dave Milano, PT, Director of Rehab Services

> > Laurel Health System

> > 32-36 Central Ave.

> > Wellsboro, PA 16901

> >

> > dmilano@...

> >

> > RE: Therapy Cap exceptions Diagnosis (are

> > medical or tx ones?)

> >

> > I'm glad you brought this up because we are bit confused on a

related

> > issue. I'm reading the 2/15/06 CMS release and it states " For a

> > condition or complexity to qualify the beneficiary for an

exception

> > to the caps, the therapy must be related to one of the listed

conditions.

> >

> > In addition to conditions, there are clinically complex

situations that

> > can justify an automatic exception to the therapy caps for ANY

condition

> > that necessitates skilled therapy services.

> >

> > So we first need a condition diagnosis listed before we can also

add

> > and refer to a complexity diagnosis also?

> >

> > Just clarifying.

> >

> > Thanks,

> > Lott

> > Lott Physical Therapy

> > Fairfield, TX

> >

> >

> >

> >

> >

> >

> >

> >

> >

> >