Therapy Cap Exception Request Form
THERAPY CAP EXCEPTIONS
On January 1, 2006, CMS implemented a payment limitation, or “therapy cap” for outpatient rehabilitation services. This applies to all outpatient part B therapy services except those rendered in hospital outpatient or emergency room settings. Outpatient rehabilitation services include physical therapy - including outpatient speech-language pathology for which there is a combined annual limit for 2006 of $1,740. Occupational therapy has a separate annual limit for 2006 of $1,740.
CMS recognizes that certain circumstances, conditions or complexities may justify payment for reasonable and necessary therapy services beyond the limiting cap. Therefore, contractors may, upon request, grant exceptions to therapy caps for services provided during calendar year 2006, if these services meet certain qualifications as medically necessary services.
Exception may be automatic or manual: An automatic exception requires:
That the beneficiary meets specific conditions and complexities listed in the Medicare Claims Processing Manual, Pub. 100-04, Chapter 5, (as revised by CR4364) for exception from the therapy cap; or,
That the beneficiary meets specific other criteria published by the Medicare contractor (GHI) that it believes, based on the strongest evidence available, will require a beneficiary to receive additional therapy visits beyond those payable under the therapy cap.
No specific documentation must be submitted to the contractor if the beneficiary qualifies for the automatic cap exception for an active condition when documentation justifies medically necessary services above the caps. However, the provider must maintain documentation of medical necessity in the beneficiary’s clinical records and justify the clinician’s decision that the beneficiary qualified for the automatic cap exception for medically necessary services. Providers must submit this documentation upon contractor request.
Provider/suppliers/beneficiaries may include, at their discretion, a summary that specifically addresses the justification for therapy cap exception.
If a case does not meet the conditions for an automatic exception, providers may request a manual exception for up to 15 days of therapy service for each discipline of occupational therapy, physical therapy, and speech language pathology. For manual exceptions, providers must submit sufficient supporting medical record documentation at the time of the request. A new request with documentation must be submitted each time the beneficiary is expected to require more therapy days than previously approved.
When a therapy cap exception has been approved, or meets all the guidelines for an automatic exception, providers must include a KX modifier on the claim identified as a therapy service with a GN, GO, GP modifier. This allows the approved therapy services to be paid, even though above the therapy cap financial limits.
Documentation:
GHI expects the following types of documentation to be submitted with all manual exceptions and in response to contractor requests for documentation supporting automatic exceptions:
- Evaluation and Certified Plan of Care - 1-2 documents. (An evaluation or re-evaluation must include a diagnosis, subjective and/or objective condition, and prognosis. This information may be included in or attached to a plan. Providers/suppliers/beneficiaries should accompany the request with the plan for the entire episode of care for that patient, including justification for any needed services beyond the 15 currently requested.)
- Certification - Physician/NPP approval of the plan required 30 days after initial treatment-or delayed certification.
- Clinician-signed Interval Progress Reports (when treatment exceeds 10 treatment days or 30 days) – These must be sufficient to explain the beneficiary’s current functional status and need for continued therapy with the request for therapy visits in excess of those payable under the therapy cap. This is not required to be provided daily in treatment encounter notes or for an incomplete interval when unexpected discontinuation of treatment occurs.
- Treatment Encounter Notes – The Treatment Encounter Note is acceptable if it records the name of the treatment; intervention, or activity provided; the time spent in services represented by timed codes; the total treatment time; and the identity of the individual providing the intervention. These may substitute for Progress Reports if they contain the requirements of interval progress reports at least once every 10 treatment days or once in the interval.
- For therapy caps exceptions purposes, records justifying services over the cap, either included in the above or as a separate document. Please see the revised Section 220.3 of the Medicare Claims Processing Manual located at www.cms.hhs.gov for more details about the types of documentation required and explanations of what that documentation should contain.
Submission of additional other items may be required at the contractor’s discretion.
Requests for therapy cap exception can be mailed to:
GHI Medicare
Program Evaluation
25 Broadway 12th Floor
New York, NY 10004
Attention: Therapy Cap Exceptions
Or faxed to:
(646)458-6764 Please indicate on the fax cover sheet the following: Attention: Therapy Cap Exceptions
Contractor Decision:
If determined to be medically necessary, GHI will grant additional treatment days for occupational therapy, physical therapy, and speech language pathology. It is preferable that the request for exception be received before the therapy cap is actually exceeded. Approval for additional therapy visits already provided may be possible when the request is accompanied by documentation supporting medical necessity of the services. Claims for services above the cap that are not deemed medically necessary will be denied as a benefit category denial.
If GHI does not make a decision within 10 business days of receipt of the request and documentation, then the decision for therapy cap exception is considered to be deemed approved as medically necessary for the number of future visits requested (not to exceed 15).
Notification of Decision:
Providers will be notified in writing if the request for the cap exception is approved or denied. The decision on the exception request is not an initial determination, and therefore is not appealable.
A Note of Caution:
CMS has identified a persistently high national error rate for physical therapy services, involving the overpayment of millions of dollars. Thus, CMS is wary of the potential for providers to take advantage of this “exceptions” process by submitting high volumes of claims that do not qualify or lack supporting documentation.
Although services may meet the criteria for exception from the cap due to condition or complexity, they are still subject to review to determine that the services are otherwise covered and appropriately provided. As previously stated, the exception is granted (either automatically or by manual exception) on the clinician’s assertion that there is documentation in the record justifying that the services meet the criteria for reasonable and necessary services. For example, the documentation must accurately represent the facts, and there shall be no evidence of abusive or inappropriate use of the process or the services by the provider/supplier.
An example of inappropriate use of the process is the routine application for exceptions after the cap has been exceeded. The routine use of the KX modifier on every claim for a patient that has an excepted condition or complexity, with regard to the impact of the condition on the need for services above the cap, is inappropriate. If GHI determines that a submitted exception to the limitation is inapplicable or has been disapproved or was approved based on fraud, misrepresentation or abuse, it is required to recoup any funds billed and paid in excess of the financial limitation.
Local Coverage Policy Still Applies It is important for providers to remember that, regardless of the cap or cap exception, existing GHI local policy, such as the “Physical Medicine and Rehabilitation” coverage decision (LCD), continue in full force. Claims and documentation must continue to adhere to the policy and all its sections: Indications, Limitations, Coding Guidelines, Documentation Requirements and Utilization Guidelines. Payment can be made ONLY for exceptions representing covered, reasonable, necessary and restorative. Services that exceed necessary and reasonable treatment, which represent maintenance or palliative care, or that do not require the skill of a therapist to be safe and effective, are never payable. Therapists, providers and suppliers must have the necessary training, licensing and credentials to perform therapy services according to existing local and national policy.
For further information and to view the list of conditions that qualify for automatic exceptions, please see:
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