News from CMS: Expiration of Therapy Cap Exceptions

[Guest guest]

From CMS:

Subject: News from CMS: Expiration of Therapy Cap

Exceptions

The exceptions to outpatient therapy caps expire on

June 30, 2008. Outpatient therapy service providers

should not submit claims with the KX modifier for

services furnished on or after July 1, 2008. To the

extent possible, CMS is working with Congress, health

care providers, and the beneficiary community to avoid

disruption in the delivery of health care services and

payment of outpatient physical therapy, occupational

therapy and speech-language pathology claims for

services furnished by physicians, non-physician

practitioners, and therapists paid under the physician

fee schedule, beginning July 1.

For physical therapy and speech language pathology

services combined, the limit on incurred expenses is

$1810. For occupational therapy services, the limit is

$1810. Deductible and coinsurance amounts applied to

therapy services count toward the amount accrued

before a cap is reached. Therapy cap accruals began on

January 1, 2008, and some patients may have reached

the annual limits by June 30, 2008.

Providers may access the accrued amount or remaining

amount of therapy services from the Medicare

beneficiary eligibility inquiry and response

transactions. Specifically:

· For CWF users, the system returns the “applied”

amount. See CR4115 at

http://www.cms.hhs.gov/transmittals/downloads//R759CP.pdf

· For users of the HETS 270/271, the system returns

the “remaining” amount. See the page 18 of the 270/271

user guide at

http://www.cms.hhs.gov/HETSHelp/Downloads/HETS%20270-271%20User%20Companion%20Gu\

ide.pdf

· The Medicare contractors’ Interactive Voice Response

units (IVR) return either the remaining or applied

amounts based upon contractor programming. For those

few contractors that do not provide this information

on their IVRs, providers can call the contractors’

customer service representatives.

For additional information, Providers and Suppliers

should also read the Medicare Claims Processing

Manual, chapter 5, section 10. 2 at

http://www.cms.hhs.gov/manuals/downloads/clm104c05TXT.pdf

Patients Who Have Reached Their Limit(s) on Outpatient

Therapy Services:

Note that patients who have reached their limit(s) on

outpatient therapy services, other than those who

reside in a Medicare-certified part of a skilled

nursing facility, may obtain medically necessary

therapy services that exceed the caps if the services

are furnished and billed by the outpatient department

of a hospital. In other settings, outpatient therapy

services in excess of the caps are not covered, and

the therapy provider may charge for those services. An

Advance Beneficiary Notice is recommended, but not

required for services that exceed therapy caps. An ABN

is available at the following link:

http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp#TopOfPage

(click on ABN-CMS-R-131 Form). In the box titled

" Reason Medicare will not pay " the following language

is suggested Medicare will not pay more than $1810 for

expenses incurred for physical therapy and

speech-language pathology services combined or for

occupational services in 2008.

Patients may be referred to this website for further

information:

http://www.medicare.gov/Publications/Pubs/pdf/10988.pdf

CMS will continue to be in communication with you with

further information about payment of Medicare

physician fee schedule claims. In addition, be on the

alert for more information about other legislative

provisions which may affect you.

Rick Gawenda, PT

President, Section on Health Policy & Administration

APTA